The figure⇓ shows the packaging of a “rice slice”, which a mother gave to her 23 month child, believing it to be free of any milk. The patient had an anaphylactic reaction shortly after ingesting a very small amount. On close inspection of the ingredients, casein is listed but not qualified as a milk protein.

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The child initially presented at 8 weeks of age with a cutaneous reaction to cows’ milk formula on her second exposure, having previously been breast fed. She had raised specific IgE level to milk and a positive skin prick test (3 mm wheal with 6 mm erythema). Thereafter she was managed with an extensively hydrolysed formula and the family were given advice to avoid all milk and its derivatives. They were prescribed antihistamine but not an adrenaline auto-injector.

This case illustrates the difficulty of managing allergy in real life. It is easy to see how a product described as a “delicious alternative to cheese” could be wrongly thought to be milk free unless the ingredients are closely scrutinised. Thirty per cent of children diagnosed as allergic have been shown to have a further exposure in the year after diagnosis.¹ A further difficult issue in clinical practice is when to prescribe adrenaline, especially for the youngest patients in whom there is no proprietary device in the correct dose for size.²