Allercy and Asthma Health
The Official Publication of AAN - MA

Summer Is NOT the Time To Relax When It Comes To Peanut Allergies


by Eileen Censullo, MBA, RRT, FAARC

It’s that time of year again when the kids are home from school for the summer. Moms are relieved that, for a while, there is a break from hectic schedules, homework, and worries of chronic medical conditions like asthma or allergies flaring up away from home. Moms with kids who have peanut allergies may be especially inclined to believe these allergies can be much more easily controlled at home. A recent study from Canada begs to differ. Researchers found children are actually at a greater risk of exposure to peanuts at home than they are in school, and too often, medical care is also lacking.

The study looked at more than 1,900 children with a diagnosis of peanut allergy to see how exposure occurs, how serious the outcomes of the exposure are, and what treatment is given. All of the children had suffered allergic reactions to peanuts in the past.

The average length of time in the study was 2.9 years, and over this time, 567 exposures occurred in 429 children. The researchers classified 11.3% of the reactions as severe and 50.1% as moderate.

Thirty-seven percent of the exposures happened in the child’s own home. Other people’s homes and restaurants accounted for 14.3% and 9.3%, respectively. Schools and daycares where peanuts are forbidden represented 4.9% of the cases. Interestingly, in schools and daycares where peanuts are allowed, exposure only happened 3% of the time.

Perhaps most disturbingly, only 42% of the severe peanut allergy reactions were evaluated by a medical professional, and almost one in six went totally untreated. For moderate reactions, the situation was much worse. Medical attention was delivered only 25% of the time.

Researchers did find that accidental exposures happened less and less often over the 2.9 years of the study, and they believe this was due to the children and the parents developing better avoidance strategies. Adolescents were at high risk due to their high-risk behavior.

Things to know

Clearly, more education is required on the importance of strict allergen avoidance and the need for prompt and correct management of symptoms. Now that summer has arrived and children may spend more time at home or visiting friends or relatives, here are some things we should all know. 

Peanuts are among the most common allergy-causing foods, and they often find their way into things you wouldn't imagine. Take chili, for example: it may be thickened with ground peanuts. The peanut isn’t actually a true nut – it’s a legume, which is in the same family as peas and lentils. But the proteins in peanuts are similar in structure to those in tree nuts. For this reason, people who are allergic to peanuts can also be allergic to tree nuts, such as almonds, Brazil nuts, walnuts, hazelnuts, macadamia nuts, pistachios, pecans, and cashews.

The body's immune system normally fights infection. But when someone is allergic to tree nuts or peanuts, the immune system overreacts to proteins in these foods. Every time the person eats (or, in some cases, handles) a peanut or tree nut, the body thinks the proteins are harmful invaders. The immune system responds by kicking into high gear to fend off the "invader." This causes an allergic reaction, in which chemicals like histamine are released in the body.

The release of these chemicals can cause someone to have some or all of the following problems: wheezing; trouble breathing; coughing; hoarseness; throat tightness; stomachache; vomiting; diarrhea; itchy, watery, or swollen eyes; hives; red spots; and swelling or a drop in blood pressure. Reactions to foods like peanuts and tree nuts can be different. It all depends on the person — and sometimes the same person can react differently at different times.

Beware of anaphylaxis

Nut and peanut allergies can lead to a severe reaction called anaphylaxis. Anaphylaxis may begin with some of the same symptoms as a less severe reaction, but then quickly worsen, leading someone to have trouble breathing, feel lightheaded, or to pass out. If it is not treated quickly, anaphylaxis can be life threatening.

Although a small amount of peanut protein can set off a severe reaction, it is rare that people will get an allergic reaction just from breathing in small particles of nuts or peanuts, since the protein has to be ingested to cause a reaction. Most foods with peanuts in them don't allow enough of the protein to escape into the air to cause a reaction. And just the smell of foods containing peanuts won't produce a reaction because the scent does not contain the protein.

In very rare cases, when people do react to airborne particles, it's usually in an enclosed area (like a restaurant or bar) where lots of peanuts are being cracked from their shells. If someone inhales and then swallows the protein, this can lead to a reaction when the protein gets digested.

Avoiding reactions

Although some people outgrow certain food allergies over time (like milk, egg, soy, and wheat allergies), peanut and tree nut allergies last a lifetime in many people.

The best way to prevent a reaction in someone with a nut allergy is to avoid peanuts and tree nuts. Avoiding nuts means more than just not eating them. It also means not eating any foods that might contain tree nuts or peanuts as ingredients.

The best way to be sure a food is nut free is to read the label. Manufacturers of foods sold in the United States must state on their labels whether foods contain peanuts or tree nuts. Check the ingredients list first.  Even dog food and treats can be dangerous if you are exposed to your pet’s saliva shortly after they are eaten.

After checking the ingredients list, look on the label for phrases like these: "may contain nuts,” or "produced on shared equipment with nuts or peanuts." People who are allergic to nuts have to avoid foods with these statements on the label. Although these foods might not use nut ingredients, the warnings are there to let people know the food may contain small traces of nuts. That can happen through something called "cross-contamination," when nuts get into a food product because it is made or served in a place that uses nuts in other foods.

High-risk foods

Some of the highest-risk foods for people with peanut or tree nut allergy include:

  • Cookies and baked goods. Even if baked goods don't contain nut ingredients, it is possible they came into contact with peanuts or tree nuts through cross-contamination. Unless you know exactly what went into a food and where it was made, it's safest to avoid store-bought or bakery cookies and other baked goods.
  • Candy. Candies made by small bakeries or manufacturers (or homemade candies) may contain nuts as a hidden ingredient. The safest plan is to eat only candies made by major manufacturers whose labels show they are safe.
  • Ice cream. Unfortunately, cross-contamination is common in ice cream parlors because of shared scoops. It's also a possibility in soft-serve ice cream, custard, water ice, or yogurt places because the same dispensing machine and utensils are often used for lots of different flavors. Instead, do as you would for candy: buy tubs of ice cream at the supermarket and be sure they're made by a large manufacturer and the labels indicate they're safe.
  • Asian, African, and other cuisine. African and Asian foods (especially Thai, Chinese, and Indian) often contain peanuts or tree nuts. Mexican and Mediterranean foods may also use nuts, so the risk of cross-contamination is high with these foods.
  • Sauces. Many cooks use peanuts or peanut butter to thicken chili and other sauces.

Always proceed with caution; even if you've eaten a food in the past, because manufacturers sometimes change their processes — for example, switching suppliers to a company that uses shared equipment.

Here are some other precautions you can take:

  • Be on the watch for cross-contamination that can happen on kitchen surfaces and utensils — everything from knives and cutting boards to the toaster. Make sure the knife another family member used to make peanut butter sandwiches is not used to butter your bread and that nut breads are not toasted in the same toaster you use.
  • Avoid cooked foods you didn't make yourself — anything with an unknown list of ingredients.
  • Tell everyone who handles the food you eat, from relatives to the restaurant, that you have a nut allergy. If the manager or owner of a restaurant is uncomfortable about your request for peanut- or nut-free food preparation, don't eat there.
  • Make school lunches and snacks at home where you can control the preparation.
  • Be sure your school knows about your allergy and has an action plan in place for you.
  • Keep rescue medicine (including epinephrine) on hand at all times — not in your locker, but in a pocket, purse, or school bag that's with you. Epinephrine comes in two types of easy-to-carry containers, one about the size of a large marker and the other about the size of a small cellphone. Your doctor or respiratory therapist will show you how to use it.
  • It's also a good idea to carry an over-the-counter antihistamine, as this can help treat mild allergy symptoms. Use antihistamines in addition to — not as a replacement for — the epinephrine shot in life-threatening reactions, and always use the epinephrine shot as the first treatment. Get emergency care after epinephrine is used, because a second reaction can happen up to four hours or even longer after the first reaction.

Better safe than sorry

Living with allergies can seem hard at times. But as more and more people are diagnosed with food allergies, businesses and restaurants are increasingly aware of the risks they face. If friends you or your child are visiting or eating lunch with don't know about your allergy, tell them in plenty of time to make some simple preparations -- such as not sharing your drink after eating that peanut butter sandwich or using the same knife to make your sandwiches. In short, communicate, be safe, and always carry your epinephrine.

Eileen Censullo is a respiratory therapist and member of the American Association for Respiratory Care who currently serves as vice president of quality and systems improvement at the American Heart Association in Philadelphia, PA.
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