Conceived as a warning for allergic consumers, born and nurtured as a statement to dissuade potential litigation, the phrase “May contain traces of . . .” now threatens to become immortal as it enters the lexicon as a proxy for a blanket disclaimer. This situation developed as a response to the problem of hidden food allergens.

Immediate hypersensitivity to certain foods, with the potential for anaphylaxis and death, affects about 6% of children and 2% of adults.2 Characterised by sudden allergic symptoms on ingestion and confirmed by positive skin and/or radioallergosorbent tests, inadvertent ingestion of a food allergen may require self-injection with adrenaline using an EpiPen (self-injectable adrenaline device) and/or medical resuscitation. Food allergy causes about 25% of anaphylactic deaths in the United Kingdom.3 There is also the distressing scenario of administering and/or witnessing emergency treatment that affects everyone, including parents, friends, carers and schools.

“Hidden” allergens are hidden in the sense of being unrecognisable, such as egg in a pudding. In December 2002, Food Standards Australia New Zealand introduced changes to the Food Standards Code, making it mandatory that common food allergens and products derived from those allergens be labelled on packaged foods.4 Foods that are not labelled must have ingredient information available at the consumer’s request. Food allergens that must be declared include egg, milk, peanut, tree nuts, sesame, crustaceans, fish, soy, and cereals containing gluten.

There are rare sensitivities for which mandatory labelling does not apply, including anaphylaxis to certain spices5 or fruits.6 In this issue of the Journal, the article by Smith et al7 (page 219) describes the first reported Australian cases of anaphylaxis to lupin, and the authors submit that foods containing lupins, used increasingly in manufactured food products, should be subject to mandatory labelling.

Follow-up strategies after anaphylaxis include assessment in a specialist clinic, immunological and food analysis, provision of an EpiPen (now listed under the Pharmaceutical Benefits Scheme), practice with an EpiPen trainer, a written anaphylaxis action plan, a personal allergen identification medallion, access to useful websites (Box), and involvement of carers and schools. Education of children as well as their carers is crucial so that teenagers can walk away from childhood with skills to help keep them safe. There are simple principles to emphasise:

• Always carry an EpiPen

• Always read food labels

• Ask questions about food preparation (be aware of the risk of cross-contamination)

• No label/no eat

• No EpiPen/no eat

• Tell friends about a serious food allergy

• Tell friends if feeling unwell, especially after eating.

How are we to interpret the disclaimer “May contain traces of . . .”? “May contain” means the allergen is stored or processed close to the food product, and/or added to other food lines, but not purposely included in the product. We don’t know the chances of accidental contamination, which may be measurable if the same production line is used, but remote if the allergen is restricted to a separate building. The word “traces” implies extremely small amounts, but defining the allergenic potential of foods, and thus obtaining a threshold dose that triggers reactions in the majority of sensitised subjects, has proved difficult.8 While people with allergies welcomed the 2002 changes to the Food Standards Code, their diet is now more restricted because of the proliferation of these “may contain” precautionary statements. Manufacturers argue that the risks associated with cross-contamination of food ingredients “from paddock to plate”, despite good manufacturing practice, have led to the many variations of “may contain” warnings. This has reduced the already limited food choices of consumers with allergies and has led to a rise in unnecessary avoidance of many foods that may in fact be safe.

Since January 2003, Australia has had more than 50 food recalls for undeclared allergens.9 While many of the recalls have involved imported products, an alarming number have related to Australian-made foods recalled as a result of consumer complaints or government testing.

How can we improve the current situation? Recently published Australian guidelines recommend that allergen minimisation, rather than banning certain foods, is the appropriate strategy in schools.10 If a school “thinks” it has banned an allergen, a level of complacency may develop among teachers and childcare workers. But if one focuses on allergen minimisation, then it follows that foods that have peanut, for example, in the ingredient list should be left for consumption at home and not sold in the school canteen, but foods that are labelled “May contain traces of . . .” can be allowed at school for the non-allergic school population.

We must be alert to newly recognised hidden food allergens, such as the lupins identified by Smith et al.7 Consensus protocols are being developed to determine threshold doses of food allergens,11 and, in time, these may serve as a guide to more accurate labelling. Food manufacturers, food scientists, health professionals and consumer organisations must work towards reducing the number of precautionary statements. The Australian Food and Grocery Council now facilitates an Allergen Working Group, which draws together relevant stakeholders to focus on the needs of consumers with allergies. As Australia imports and exports both food ingredients and packaged foods, steps toward uniform regulations will assist consumers and the food industry alike. In time, with a cooperative approach, we may even find a smarter way of saying “May contain traces of . . .”.