Peanut Allergy in Children
Peanut allergy among children is a growing and serious medical issue all over the world. “Allergy to peanuts and tree nuts (TNs) is the leading cause of fatal and near-fatal food allergic reactions.” (Sicherer, Munoz-Furlong and Sampson) the increased incidence of peanut allergy (Grundy, Matthews and Bateman) (Sicherer, Munoz-Furlong and Sampson) combined with the fact that such allergies are becoming more reactive, i.e. creating sever and rapid reactions including but not limited to even believed first exposures eliciting anaphylaxis is creating a serious wave of concern among parents, physicians, schools, food producers and many other community stake holders. (Lack, Fox and Northstone)
Childhood peanut allergies commonly cause difficulties to breath, asthma, the constriction of airways, as well as itching and swelling. According to the statistical data, about 10 per cent of children who suffer from peanut allergies face a serious, multisystem allergic reaction, called anaphylactic shock that for some can even result in lethal outcome. In addition to all, sensitivity to peanuts very rarely lessens or fades away over time, therefore meaning that children do not often outgrow the dangerous disorder. (Clark)
The prevailing belief on the subject of increased prevalence and intensity of peanut allergies is that increased intake of peanut and peanut products by pregnant mothers is at the heart of the issue. Yet, the etiology of the increase is multi-causal and still in the preliminary research phases. (O’B Hourihane, Dean and Warner) (Zeiger) (McLean and Sheikh) (Lack, Fox and Northstone)
Allergy to peanuts is the most common cause of fatal and almost fatal food related anaphylaxis6 7 and is an increasingly common cause of referral to allergy clinics. The increase in prevalence of peanut allergy may simply reflect the general increase in atopic diseases. The apparent increase in cases may, however, be due at least in part to increased exposure to peanut allergens early in life8 or possibly before birth, as with other allergies. (O’B Hourihane, Dean and Warner 519)
Advice regarding how individuals and especially expectant mothers and caregivers of young children is still relatively conflicting, with some advising this subgroup to avoid peanuts and peanut products while pregnant and to avoid feeding such products to children, especially under the age of five, but again recommendations vary and a complete understanding of the issue is far from obtained. (McLean and Sheikh) (Zeiger) While other researchers are developing fundamental research trials that expose children with positive peanut allergy skin tests to a small dose of a peanut flour, (a sort of inoculation) orally in a controlled dose and environment, to determine if such a trial is safe and effective as a cure for peanut allergy. (Clark) This work will serve as an introduction to the issue of peanut allergy among children and help dispel some of the myths and illuminate the facts surrounding this growing and alarming issue as well as discus the affects of this allergy on children and their caregivers, when peanut allergy is diagnosed.
Peanut allergy diagnosis has more than doubled in the last decade. (Clark)
In fact, all allergic diseases in children — including foods allergies (most commonly peanuts, milk, egg, wheat, soy, tree nuts, fish and shellfish), environmental allergies, asthma, and eczema — have been increasing at similar rates over the last decade. One theory for this is the Hygiene Hypothesis, which suggests that because children now have fewer infections (due to improved hygiene), their immune systems are more likely to target other things such as items in the environment and diet, resulting in allergies. (Clark)
Peanut Allergy Affects of the Lives of Children and Caregivers
Serious peanut allergies are absolutely affective on those who are affected by this allergy. Peanuts, and derivatives of them are products that are found in a very large number of products on the market today and even when the peanut, peanut oil, peanut flour or other byproducts are not present in the product, products are often produced in environments that also process peanuts on the same equipment. Examples of these products is a seemingly endless list but many of them are common foods associated with childhood, such as premade breakfast cereals, snack crackers, trail mix snacks and literally hundreds of other commercial products. Though peanuts are not the most commonly used items in pre-made convenience packaged products they are frequently present in at least trace amounts in thousands of products people buy and eat every day and there is scientific evidence that even without ingestion peanut allergy can cause an exposure reaction even when the oil or peanut comes in contact with the skin.
A study from Mt. Sinai Medical Center in 2003 specifically examined those questions. Thirty children with severe peanut allergies were exposed to both skin contact and the smell of peanut butter. The study reached the following conclusions: a rash may occur where the skin is touched by peanut butter but a dangerous reaction will not result unless the peanut butter enters the mouth, nose, or eyes. the rash will get better when washed with soap and water, and when Benadryl is given. (Young)
Another issue with regard to more mild exposures has to do with the fact that it is a well documented fact that the greater the number of exposures to a dangerous allergen the greater the reaction. While some children might show a very mild reaction to an exposure, such as swollen eyes and/or a rash the following exposure might be far more serious and involve at least some breathing problems. (Smith) So, in the case of a potentially deadly allergy any exposure, even topical should be avoided. This puts significant pressure on children and those who care for them or whom they interact with outside and inside the home. One parent of a child who died of a peanut exposure stresses that she and her son were very careful about peanuts, going so far as to seriously limit the child’s diet and even allocating a peanut free table in his school cafeteria, but the parent also states that probably in a bid to reduce concern her son’s doctors never fully explained just how serious a peanut exposure could be. Another compounding issue associated with the case of the Smith boy is the facts that he also had asthma, a relatively common coexisting condition which some believe exacerbates anaphylaxis and its seriousness, when serious food allergies are present. (O’B Hourihane, Dean and Warner) (Clark) (Lack, Fox and Northstone) (Grundy, Matthews and Bateman) (Sicherer, Munoz-Furlong and Sampson)
Managing a chronic condition, like asthma can be a serious challenge in children but compounding it with a serious common food borne allergy can seem insurmountable. Still, Smith states that she would give anything in retrospect to have been more educated about the seriousness of her son’s condition. After one topical exposure, where a family member had eaten peanuts an hour prior and then wrestled with her son, a mild anaphylactic shock ensued and the child was admitted to an ER. At the ER the child was given an epi-pen, a fast acting epinephrine injection that can rapidly reverse a reaction, but his family was given little or no education about the medication, when to use it and generally about how serious his reactions could become. (Smith)
“I feel like I was cheated of the knowledge that I should have been given. I should have known that these reactions could get worse. They never told me that he could stop breathing from this. I wished they would have explained how serious this can be and how quickly things can happen. (Smith)
Other interviewed parents express the same concerns, i.e. The lack of real facts about peanut allergy and just how serious it is. (Peterson) it also must be noted that many children with peanut allergy, the most common of all food allergies among children and adults also have other food borne allergies including; egg, milk, corn, wheat, fish, shellfish and the list goes on. (Zeiger 6)
An interview with a pediatric allergy specialist offers a list of precautionary measures one should take if they intend to host a peanut allergic child in their home:
The first step is to make sure that no food containing peanuts or any peanut product is served to the peanut-allergic child. Remember that food can be easily contaminated. If a knife that has been used to spread peanut butter is then dipped in a jar of jelly, that jelly is no longer safe for a peanut-allergic child. If your family has eaten peanut butter or peanuts recently, clean tabletops and counters with soap and water. If you have young children who may have wandered around the house with peanut butter on their hands, clean their toys and other surfaces they may have touched. Be sure to ask the peanut-allergic child’s parents for specific instructions and any prescribed medicines in case of an accidental exposure and reaction. (Young)
This brief list of precautionary measures shows significant insight into the everyday challenges faced by children and caregivers when peanut allergy is present. Forethought is necessary as is the ability to educate those around you and in some cases such precaution may lead to limitations on the child’s activities, especially in cases where those who are ignorant of the seriousness of the issue discount and do not respond to offered education. Another mom who is managing a child with a peanut allergy stresses the two hardest things about having a child with this condition:
What has been the hardest part about dealing with your child’s peanut allergy for you? / Two things. First: Trust. Trusting that whoever is watching your child (be it at daycare or school or babysitting) REALLY understands the ramifications of her allergy. It doesn’t matter if it’s family or not, it’s hard to trust another person with your child’s care when they have a special need like this. I’m not worried about my daughter eating peanuts or peanut butter directly. I AM worried about her trusting an adult who doesn’t know how to read a label (or won’t bother to). / Second: Mortality. There’s nothing more sobering than facing your child’s mortality at an early age. Sure most parents deal with general fears about their kids getting hit by a car or talking to strangers. But having a child with a food allergy that involves anaphylaxis makes you think about your child dying. Alot. It isn’t fun. (Peterson)
Fundamental education regarding the seriousness of food borne allergies is an essential aspect of helping individuals with allergies and other stakeholders appropriately deal with food borne allergies, especially when the allergens are exceedingly common, like in the case of peanuts. Full parental and caregiver education about the seriousness of the disorder is also something that still seems to be lacking. (Smith) (Peterson)
Broad Education is the Key
Individuals frequently report the feeling that the condition was downplayed or not given significant time and attention when diagnosis was made and achieving the point of diagnosis was not always easy either, as often with children exposures are not always so clear and allergy testing might not be seen as an option of first resort. With serious allergies it is also considered difficult to test as skin prick test are the safest method but a less safe less controlled option, food challenge testing might be seen as a better option for a child because of the traumatic nature of the prick testing, but this may not really be the case. Food challenges are commonly suggested in literature and elsewhere when food allergies are suspected as the cause of certain symptoms, and yet with the seriousness of single exposures to some food allergies at home, ad hoc and difficult food challenge testing can be very dangerous. A brief explanation of each type of test is needed:
Prick test; is a topical testing process where a long list of potential allergens are topically applied to the skin with a minor abrasion or even a very small needle, in a recorded patterned grid, usually on a person’s forearm, though testing can be conducted elsewhere. The exposure of a minimal amount of the allergen is then reviewed by looking at the skin reaction and judging it by a predetermined scale of reaction seriousness. The test is then recorded and allergens are identified. Usually such tests are relatively conclusive and albeit minor can seem seriously traumatic for a child, but as has been stated they are done in a controlled environment with trained medical staff present. (Sicherer, Munoz-Furlong and Sampson) (O’B Hourihane, Dean and Warner)
Food challenge test; usually takes place over a longer period of time, and is often administered at home. The food challenge consists of exposing the child to a single new food for a set period of time, isolating new foods from others that have not yet been tested and when one produces symptoms of allergy removing it from the child’s diet. The record keeping can be minimal and the length of the testing can vary, as can the exposure of the child to other exacerbating allergens during the test phase, which completely challenges the observer and can of course be dangerous as single exposures by people with serious food borne allergies can cause breathing related reactions. (Sicherer, Munoz-Furlong and Sampson)
Finally, a child may simply be diagnosed with a food born allergy after a known exposure that has caused a mild to serious allergic reaction, but especially if such a reaction is indicative of the type of reaction that can progress to anaphylaxis, head and/or neck swelling or any trouble breathing. All of these diagnostic options are likely to elicit some data that will help in the diagnosis but either can be potentially dangerous and could also produce inconclusive results. The protocol of pediatric and emergency physicians has swayed in the direction of administering (or prescribing) epinephrine, and asking questions later or in some cases diagnosing or referring to an allergy specialist upon any suspicion of a serious food born allergy. Yet, these protocols are not universal and again are relatively new, isolated to pediatric doctors and triage doctors who are at the battle lines of the problem and see serious cases on an almost daily basis. One thing that is very important is that a parent or caregiver must become an advocate for a child with a peanut allergy and if they do not feel they are getting the right treatment or answers from a particular health care provider they may need to simply go to someone else. Any individual with a suspicion of a serious food born allergy should be taken to see a specialist, who will guide the individual and his or her caregivers through the process of gaining the knowledge needed to manage the allergy, including but not limited to explaining the seriousness in no uncertain terms and in teaching identification of serious progressive symptoms. A brief synopsis of recognizing allergic reaction is offered by Dr. Michael C. Young:
4. How can I tell if a child is having an allergic reaction? What should I do?
The most common reaction is a feeling of itchiness and a red rash, particularly around the mouth where the food comes in contact with the skin. If the rash and itchiness are self-limited and not associated with other symptoms, your doctor may recommend treatment with an antihistamine such as Benadryl. If the rash is widespread and other symptoms emerge, the reaction is considered systemic or anaphylactic. Swelling of the tongue and throat, difficulty breathing, abdominal pain, vomiting, and a change in the level of alertness are all danger signs of possible life-threatening anaphylaxis. A child displaying these symptoms needs immediate medical attention. If the child has a prescribed EpiPen, it should be used promptly. Once the EpiPen is used, the child must be brought to the nearest medical facility for observation as there is the possibility that a delayed reaction (up to 4 to 6 hours later) may occur, requiring additional treatment. (Young)
This synopsis offers a great starting point for global discussion about the issue and should be offered to everyone that an individual child, suspected of a food allergy is around. This should include, teachers, playmates, parents of classmates and anyone else who might unwittingly expose the child to the allergen. For many children there are second chances with regard to exposure to allergens but for others there are not and every means should be employed to ensure the safety of the child. Broader community awareness campaigns are also an important aspect of reducing mortality in these cases. (Smith) (Peterson) (Clark) (Young)
This work has offered significant insight into the seriousness and the increasing prevalence of peanut allergy among children. Issues associated with lifestyle affect as well as, recognition, diagnosis and management of the condition were fully explored. The causation of the disorder and the increasing incidence were discussed and at least one possible “cure” was discussed. Changing the manner that individuals affected and the broader community views the issue of peanut allergy is the key to reducing the number of premature deaths in children, which has been associated with it. Parents of children with the condition, as well as expert researchers and clinicians express that the seriousness of the problem has been downplayed and that this should be mitigated with broader and more specific education regarding the condition. There is no doubt that solving the riddle of the causes of this condition is going to take some time, if it ever occurs but in the mean time effectively managing the condition is absolutely essential.
Clark, Dr. Andrew. Interview: Childnen’s Peanut Allergy Cure on Its Way eNotAlone.com. http://www.enotalone.com/article/21156.html, 3 March 2010.
Grundy, Jane, et al. “Rising prevalence of allergy to peanut in children: Data from 2 sequential cohorts.” Journal of Allergy and Clinical Immunology 110.5 (2002): 784-789.
Lack, Gideon, et al. “Factors Associated with the Development of Peanut Allergy in Childhood.” The New England Journal of Medicine 348.11 (2003): 977-985.
McLean, Susannah and Aziz Sheikh. “Does avoidance of peanuts in early life reduce the risk of peanut allergy?” British Medical Journal (2010): 340, 424.
O’B Hourihane, J., T.D. Dean and J.O. Warner. “Peanut allergy in relation to heredity, maternal diet, and other atopic diseases: results of a questionnaire survey, skin prick testing, and food challenges.” British Journal of Medicine 313 (1996): 518-531.
Peterson, Gabrielle. Spotlight Interview: Gabrielle Peterson (Peanut Free Mama) Janeen. http://community.wegohealth.com/profiles/blogs/spotlight-interview-gabrielle, 30 June 2009.
Sicherer, Scott H., Anne Munoz-Furlong and Hugh Sampson. “Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: A 5-year follow-up study.” Journal of Allergy and Clinical Immunology (2003): 2026-2028.
Smith, Pamela. I Wish I Was the Parent Who Was Warned Gina Clowes. http://www.allergymoms.com/modules/wordpress/index.php?p=509, 16 April 2008.
Young, Dr. Michael C.Q&a: Peanut Allergies an Interview with Dr. Michael C. Young PBS. http://www-tc.pbskids.org/arthur/parentsteachers/lesson/health/pdf/Binky_Peanut_Allergy_QA.pdf, ND.
Zeiger, Robert S. “Food Allergen Avoidance in the Prevention of Food Allergy in Infants and Children.” Pediatrics 111 (2003): 1662-1671.
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