Making clinical decisions when the stakes are high and the evidence unclear

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Abstract
Case study 1 Dylan, a 20 month old boy, was referred to a paediatric allergy clinic for assessment of his peanut allergy. At 12 months of age he developed facial contact urticaria to peanut butter, which spontaneously resolved without respiratory or other symptoms. Since then, he has not had further reactions or eaten peanuts, although the rest of the family often eat peanuts and nuts. Dylan is regularly cared for by his grandparents and does not attend a childcare centre. His skin prick tests show a 9 mm (≥ 3 mm is considered positive) reaction to peanut. The doctor recommended that he continue to avoid peanuts and be reviewed annually with skin prick testing. If the results remain positive without other clinical reactions, Dylan will be considered for a formal food challenge when he starts school. An emergency adrenaline (epinephrine) autoinjector (self or carer administered) was not recommended. Dylan's mother said, “I had heard about [autoinjectors] so I was waiting to hear what the specialist would say. I suppose that if you had to, you would give it, but I just can't see it. I hate seeing him have needles for any reason.” Footnotes References w1-12 are on bmj.com We thank the parents of Dylan and Jarred for contributing their stories to this article. Contributors and sources All authors conceived and planned the article, critically reviewed drafts, and approved the final version. WH wrote the first draft, which arose from her research on the handling of risk and uncertainty in clinical and policy decision making, as applied to food anaphylaxis in children. WH wrote the stories using the parents' words. She is the guarantor. WH was supported by grants from the Australian Allergy Foundation and the National Health and Medical Research Council of Australia ID297112. Competing interests AK's superannuation fund owns shares in Commonwealth Serum Laboratories, which distributes adrenaline autoinjectors (EpiPens) in Australia.

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