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Ming Tsai’s Food For Thought

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My journey with food allergies began when I opened my first restaurant, Blue Ginger, in 1998. I felt it was important that our kitchen be mindful of food allergies to ensure that all customers could safely dine with us. Little did I know that soon enough food allergies would become an enormous part of my everyday life. 

Just a few years after opening Blue Ginger, my oldest son was diagnosed with multiple food allergies; in fact, he was born severely allergic to soy, wheat, peanuts, tree nuts, dairy, shellfish, and eggs. At first, as a chef, I thought it was an unfunny joke from upstairs. But I soon realized it would be an invaluable lesson and opportunity. I quickly learned that trying to eat at restaurants with food allergies was a much larger task than I imagined. Even though I had established protocols in my restaurant for those with food allergies, most other restaurants didn’t take the same care. I can recall a few times where my family and I were turned away because the chef or restaurant did not want to accommodate us. There were a few occasions where my son was accidentally served a dish containing a small amount of one of his allergens, and within minutes he began exhibiting symptoms of an anaphylactic reaction. As a parent, it’s one the scariest experiences. Thankfully, my wife is a trained nurse, and we were able to spot the signs quickly and administer epinephrine right away. 

First implemented at Blue Ginger, and later at Blue Dragon (which is 100% peanut and tree nut free), we created a book that includes every dish on the menu and a comprehensive list of ingredients separated by dish components (i.e. proteins, starches, vegetables, sauces, and garnishes). This way, the patron and restaurant staff can easily determine which part of the dish has the allergen and omit the item from their order. For example, a customer with a peanut allergy would still be able to have the Chicken Satay with Peanut Sauce by opting for an alternate (and equally delicious) dipping sauce. 

Additionally, any ingredient processed and received from outside vendors is starred and the ingredients are indexed in our system (e.g., dried *egg* pasta). A highlighted ingredient indicates that it is one of the top eight food allergens: peanuts, tree nuts, wheat, soy, shellfish, fish, milk, or egg. Our protocols also ensure proper lines of communication between the front of house staff and the kitchen. Every manager, server, and bartender is trained to ensure all customers can safely dine with us. You can find an example of our documentation here.

My family’s experiences, and the knowledge that comes with being a restaurant owner and chef, inspired me to champion the first bill in Massachusetts to require all local restaurants to comply with food allergy awareness guidelines. It took four years working with the Massachusetts legislature to write Bill S. 2701, which was eventually signed into law in early 2009.  

I’m incredibly proud of the work that we’ve done in Massachusetts to help those with food allergies have a more positive restaurant experience. As a chef, restaurateur, and a food allergy parent, I’ve experienced this issue from multiple sides. From the customer perspective, it’s important to notify the restaurant when making the reservation, triple-check that the server understands the severity of the allergy, and do a final check when the food arrives at the table for any visible cross-contact with your allergen or mistakes. Food allergies are a two-way street. From the restaurant perspective, we need to have procedures in place to make sure customers can safely eat, but we also need to be made aware of any allergies and understand the severity so that we can accommodate. Over the years, I’ve developed a useful and effective way to better determine the severity of people’s food allergies. I ask, “Is using the same fryer okay?” The point we are getting at here is if shrimp is fried in a fryer, could the customer eat fries out of that same fryer? Depending on the answer we then have a better understanding as to the severity of the food allergy, which we use as a directive to the kitchen staff. 

Restaurants should care about food allergies not only because it keeps their patrons safe, but also because it’s smart business. The hospitality industry can be challenging, and meeting customer’s demands is always of the utmost importance. At the end of the day, we are all fighting for loyal customers. 

I guarantee you, if you serve a food allergy customer a delicious and safe meal, and they leave smiling, you’ll have a customer for life.

Peace and Good Eating, 

Chef Ming Tsai

 

Ming Tsai holds an equity stake in Allergy Amulet.

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Killer Beauty Regimens

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When we think about managing food allergies, we don’t tend to consider lipstick or lotion. But we should.

Walking down the aisle of my local co-op recently, I grabbed a tub of moisturizer labeled “tester” and applied a dab to my hand. I tried placing the scent, and when I couldn’t, turned the jar around and saw almond oil listed as the first ingredient. My stomach clenched, and a variant of “shoot” slipped from my mouth. I’m deathly allergic to tree nuts. I washed my hands immediately, and fortunately, I was fine. Historically, my worst skin exposure outcome is hives. However, given the unpredictability of allergic reactions, it’s still hard not to panic. 

You’d think after all these years and several close calls I’d be more careful; but when it comes to skincare and beauty products, I routinely let down my guard. I shouldn’t.

Did I sufficiently give you a fright? 

Good. Sometimes a little fear is a good thing. Especially when you’re talking about something as serious as an allergic reaction! 

For the food allergic, even moderate skin exposure can be serious. Creams, soaps, oils, make-up, lipstick, and balms can also lead to small amounts of ingestion, so it’s important for those with food allergies and their loved ones to vet these items with the same diligence they do foods. Don’t forget vitamins, teas, and herbal supplements, too! 

Beware the two S’s: spas and salons. 

Planning a massage, manicure, or haircut? Make sure you tell your massage therapist or stylist to avoid products containing your allergen. This is especially true if you’re allergic to nuts—you’d be surprised how many spas and salons use nut oils. Just last month while getting my haircut I was surrounded by advertisements for the salon’s newest cherry almond shampoos and conditioners. Suffice it to say, I steered clear of this product line. 😉 

FDA labeling laws and cosmetics.

Skincare and beauty products are not regulated in the same way that foods are for allergens—even if they contain a common allergenic ingredient! 

The Food Allergen Labeling and Consumer Protection Act (FALCPA), which we explore in an earlier blog, applies to FDA-regulated food products, not cosmetics and beauty products. Accordingly, these products do not need to adhere to FALCPA labeling requirements, although many brands list these ingredients anyway. Regardless, it’s worth taking note.

We hope this information hasn’t spooked you, although it is Halloween season! Rather, we hope this knowledge helps you stay informed and safe when managing your food allergies. So before you slather on some blood-red lipstick this All Hallow’s Eve, check that label!

Wishing you all a BOO-tiful Halloween! 👻🎃

- Abi and the Allergy Amulet Team 

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Take Two: The Importance of Carrying Two Epinephrine Auto-injectors

With Halloween around the bend, we wanted to share a quick PSA on the importance of carrying two epinephrine auto-injectors in case of an allergic reaction. 

Why? Let’s look at the facts.

In cases of severe anaphylaxis, one dose of epinephrine is often not enough. Up to 20% of people who receive an initial dose of epinephrine for anaphylaxis require a second injection. This can happen even without further exposure to the allergenic trigger! A second allergic reaction called biphasic anaphylaxis can occur between 1 to 72 hours (typically eight hours) after the initial reaction.

Despite these harrowing stats, most individuals do not carry two auto-injectors.

In a study of roughly 1,000 US patients and caregivers with epinephrine prescriptions, 82% said they do not carry two auto-injectors. Meanwhile, 75% of respondents reported previously administering epinephrine. Of those that sought emergency care, 45% did so because a second dose of epinephrine was unavailable. 

Education and awareness is also lacking. Only a quarter of respondents reported that they were advised to carry two auto-injectors.

But epinephrine is expensive.

We hear you. Epinephrine auto-injectors are not cheap, which can make it difficult to have multiple epinephrine auto-injectors on your person at all times.  

Fortunately, that’s starting to change. Increased market competition and PR scandals like the one that rocked Mylan have helped drive down the price. 

Additionally, below are some cost-saving options worth checking out. 

-      Check for discount codes and savings plans on manufacturer websites. 

-      Purchase generic epinephrine alternatives.

-      Explore mail-order pharmacy options (you may be able to receive a larger supply of medication at a lower co-pay amount if these benefits apply).

-      Price shop between local pharmacies—prices vary, especially between large chains and small pharmacies.

-      Ask your doctor about patient assistance programs. 

-      Switch to your insurance carrier’s “preferred” auto-injector (if applicable).

-      Double check that your pharmacy has applied all possible coupons at check out.

-      Ask your company’s HR department if they offer financial assistance to employees to cover prescriptions.

We hope you all have a SWEET and SAFE Halloween! And don’t forget to TAKE TWO!

-      Meg and the Allergy Amulet Team

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Food Allergies + Natural Disasters… A Different Kind of Storm

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As torrential floods from Hurricane Florence ripped through the Carolinas earlier this month, Madison, Wisconsin—home of the Allergy Amulet headquarters—was still reeling from record rainfall levels and flash floods. 

These events got us thinking: How should the food allergy community prepare for a natural disaster? 

First, there are great emergency kit checklists available through the American Red Cross and FEMA websites, which advise on supplies to have at the ready in case of an emergency. If you or your loved one has a food allergy, however, you have a few extra things to consider.

Tell me more.

At a minimum you should plan to have several days’ worth of allergy-friendly foods on hand that don’t require refrigeration, heating, and that don’t spoil easily. This might include canned vegetables, granola, or dried fruits and meats. Don’t forget several days’ worth of water, too! 

The American Red Cross recommends having a seven-day supply of any necessary medications. For food allergy families this could include your antihistamines as well as epinephrine, or any other doctor-recommended medications (e.g., inhaler). Depending on where you live, and what type of emergencies are most common, you may want to have these items already packed and stored in a convenient location. For example, if you live in an area prone to tornadoes, it’s likely that you have a basement, so you may want to store your emergency supplies down there.  

What if I need to evacuate?

Evacuating in the wake of a natural disaster can present unique challenges for those with food allergies. Shelters may not serve allergy-friendly meals, and even if they do, families may need to manage for cross-contact. Having allergy-friendly foods on hand and disinfectant wipes for hands and surfaces can help mitigate exposure risk. Make sure to also pack emergency action plans for children if you have them, insurance cards, and an emergency contact list with your medical providers!

Check expiration dates!

Don’t forget to review and update your emergency preparedness kit at least once a year, and make sure to check the expiration dates on your epinephrine and antihistamines. Spokin recently offered a feature on its app that helps you to manage epinephrine expiration dates.

We all hope that you never need your emergency supplies, but it’s a good idea to be prepared! 

- Susannah and the Allergy Amulet Team 

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Scientists Find Link Between Antacid & Antibiotic Exposure and Food Allergies & Asthma

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As someone who remembers (with disgust) that pink goo as a child (also known as the antibiotic amoxicillin), I read this headline in shock. Did that chalky bubble gum syrup make me more susceptible to developing food allergies and asthma?

Here’s what the scientists found. 

In a recent study published in JAMA Pediatrics, researchers looked at approximately 800,000 infants that had ingested antibiotics or antacids in their first six months of life. They found that those exposed were more likely to develop food allergies or asthma. 

Babies are routinely prescribed antacids for regurgitating food or experiencing acid reflux after a feeding. This is very common in infants, so you can appreciate why this study is sending shockwaves throughout the parenting community!

The research hones in on how antacids and antibiotics affect an infant’s microbiome—that place where trillions of bacteria help aid in digestion, fight infection, and regulate the immune system. We know that antibiotics kill the bad bacteria that make us sick, but they also wipe out the good stuff that keeps us healthy. Antacids similarly can help ease digestion, but a less acidic stomach can alter the bacterial composition of the intestine and reduce protein digestion

The microbiome has been a hotbed of research lately—especially in the food allergy field. As we’ve discussed in a previous post, one of the leading theories behind the rise in food allergies is the impact that chemicals and medications are having on our microbiome and gut health—especially at a young age. We’ve also previously written on gut health and the important role the microbiome plays in healthy immune function.  

“This does not mean that infants should never get antacids or antibiotics,” Dr. Claire McCarthy notes in response to the study. “Antibiotics can be lifesaving for infants with bacterial infections, and there are situations when antacids can be extremely useful.” She adds though that both medications are often overprescribed and encourages doctors to “ask if it is truly necessary [to prescribe these medications]—and whether there are any alternative treatments that might be tried.” The lead author of the study, Dr. Edward Mitre, also recommended in light of the findings that “antibiotics and acid-suppressive medications should only be used in situations of clear clinical benefit.”

The recent surge in research surrounding gut health and the microbiome is a welcome trend, and one that will hopefully lead us to more concrete answers surrounding the origin of food allergies and how to mitigate or eliminate them altogether. 

- Abi and the Allergy Amulet Team

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The 411 on the 504: School Allergy Plans Decoded

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Last month we covered the basics of kids and epinephrine. This month we’re bringing you the skinny on school management plans for your child’s food allergies.

Are you wondering about a 504? An IEP? Have we lost you? 

Don’t worry, we’ve got you covered. 

Setting Up the Plan

Most school districts have district-wide plans for food allergy management, treatment, and reaction prevention. Many states also offer suggestions for school districts on managing food allergies based on guidelines from the Centers for Disease Control and Prevention. To date, there is no federal regulation that standardizes these policies and procedures, so these policies vary between states (and often between school districts within each state). 

The first step in setting up an allergy management plan for your child is to reach out to your child’s school. Many schools will ask you and your child’s doctor to fill out an allergy and anaphylaxis emergency plan form, although this form can go by different names. This form covers what steps school staff should take in case the child is exposed to an allergen or if he/she exhibits symptoms of a reaction. The American Academy of Pediatrics published this template form for reference. Once submitted, the school nurse typically prepares an Individualized Healthcare Plan (IHP): an internal document that outlines the processes the school should follow in the event the child experiences an allergic reaction. 

Some parents go one step further and request a 504 plan. Section 504 is part of a federal civil rights law that protects individuals with disabilities and health conditions, including life-threatening food allergies. The law applies to all schools and programs that receive financial assistance from the U.S. Department of Education (so all public schools and some private schools). A 504 plan lays out how the school should prevent and respond to allergic events. If a 504 plan protocol is not followed, there are several dispute resolution options available for parents. 

To secure a 504 plan, a parent must contact the school district’s 504 coordinator, who works with school officials to determine if the child qualifies. This determination is based in part on medical history, so your doctor may need to provide the school with this information. If the child qualifies, the team will work together to determine what special accommodations and protocols must be followed. 

Notably, if your child has a disability and qualifies for an Individualized Education Plan (IEP), a separate 504 plan is not necessary. The child’s food allergy accommodations may be joined under their IEP. Also of note, in some non-religious private schools where 504 plans do not apply, parents may rely on the Americans with Disabilities Act (ADA) to ensure that the school implements a food allergy management plan for the child. 

School Policy Options

Since there are no national standards for food allergy protocols, policies vary widely between schools. 

According to a recent study surveying school nurses across the country, the most frequently reported policies include: training school staff to respond to allergic reactions and anaphylaxis, using epinephrine autoinjectors, and managing for cross-contact in cafeterias. Other policies commonly implemented include: community food allergy awareness events, designated lunch areas for children with food allergies, and food guidelines for classroom celebrations.

The least frequently reported policies were: allergen labeling information in cafeterias, food management policies for after-school activities, and school-provided stock epinephrine for field trips and off-campus outings. In light of the differences between school policies, parents should understand their school’s protocols before developing their child’s plan.

Words of Wisdom

Finally, we talked with a few food allergy parents in different school districts and asked them to share a few words of wisdom on these management plans:

- “Plans may be different within the same school system—as your child goes from elementary to middle to high school, you will want to revisit your plan. For example, once a child moves to a different school building, new protocols may be appropriate. Older children may also be allowed to self-carry epinephrine or antihistamines.”

- “Make sure your plan or school policies cover transportation to and from school if your child rides the school bus.”

- “Think about after-school plans for your older child, as middle and high school students often have plans with friends after school. For example: can they store their medicine in a school locker during the day–even if the school doesn’t allow self-carry–so that they are prepared to go to a friend’s house or activity directly after?”

We hope this rundown of plan options, food allergy management policies, and parenting wisdom helps you to better advocate for your child’s food allergy needs!

-      Susannah and the Allergy Amulet Team 

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The Nutty Nature of Nuts

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For years, patients diagnosed with a tree nut or peanut allergy have been told to avoid all nuts. But what if I told you that being allergic to one nut doesn’t necessarily mean you’re allergic to another? What if I also told you that avoiding nuts altogether could result in a higher risk of BECOMING allergic to nuts?

Nuts, right?

To make things even more confusing, it’s possible to be allergic to some tree nuts and not others (e.g., a patient could be allergic to all tree nuts except hazelnut and almond). Walnuts and pecans are almost 100% cross-reactive, so if you’re allergic to one, you’re almost certainly allergic to the other. The same is true of cashews and pistachios. But that’s pretty much where the similarities end. 

Often, if a patient has an allergic reaction to a peanut or a tree nut, their allergist will advise the patient to avoid all nuts. Why? The rationale is three-fold: 1) some tree nuts are cross-reactive with others; 2) nuts are often packaged and handled in a shared facility, making cross-contact more likely; and 3) it is often easier for a doctor to advise patients to avoid all nuts (including peanuts, which are technically a legume). 

Doctors have also generally recommended strict avoidance of all nuts after a peanut or tree nut allergy diagnosis because of the challenges in distinguishing between nuts. Otherwise, the patient would be expected to know the difference between all of the different types of nuts: almonds, brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios, and walnuts—both shelled and unshelled. Studies have also shown that allergy patients are only slightly worse at identifying tree nuts than their allergists. 

Patients would also have to trust that kitchen and waitstaff at restaurants could distinguish between the nuts (spoiler alert: many can’t). Additionally, it’s hard to find bags of tree nuts that don’t list warnings of possible cross-contact with other tree nuts or peanuts due to manufacturing practices. In order to determine which nuts a patient is allergic to and which ones are safe, one or more oral food challenges may be necessary. 

Because of this, recommending that a patient avoid all nuts has historically been deemed the more practical—and safer—approach to food allergy management. 

Then came the LEAP (Learning Early About Peanut) study.

The LEAP study suggested that kids who were at risk for developing a peanut allergy were significantly less likely to become allergic if they ate peanuts early and often. The study also showed that if a patient was unnecessarily avoiding peanuts they were more likely to become allergic to peanuts over time. This suggested that unnecessarily eliminating certain allergenic foods could increase a child’s risk of becoming allergic.

This study led to a seismic shift in the food allergy community’s understanding of food allergies and allergy management practices. Suddenly, blanket avoidance of all tree nuts and peanuts came with the potential risk of increasing an at-risk child’s chances of developing a food allergy. For this reason, it is important that allergists talk with their patients and/or the patient’s families after a peanut or tree nut diagnosis about the different approaches to managing food allergies and decide together what is in their best interest. 

The first option is the oldest approach: strict avoidance of all peanuts and tree nuts. Many patients and families feel safe with this approach. Total avoidance may lessen the fear of a reaction due to cross-contact. Accordingly, for many patients and/or families, avoidance is the right choice. Another option is to have the patient continue to avoid the foods they are allergic to (in this example certain tree nuts) and teach families how to safely eat the foods they are not allergic to. This process may involve a food challenge. Deciding to eat certain nuts when allergic to others does involve learning how to read labels to check for potential cross-contact, learning what the different nuts look like shelled and unshelled, and understanding that eating those nuts is something that should be done at home and not in restaurants. 

We still have a lot to learn about food allergies, but hopefully in time we’ll get better at managing, diagnosing, and treating them. In the meantime, for newly diagnosed food allergy patients, candid conversations are a good start. 

 

Brian Schroer, MD is on staff at Cleveland Clinic Children’s Hospital where he sees patients of all ages with allergic and food-related diseases. 

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Best Practices for Kids + Epinephrine

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I’m not quite sure how summer passed by so quickly. Is it really back-to-school season already?! As families gear up for the school year ahead, we thought it would be a great time to review current best practices for kids and epinephrine—something every parent should know even if your child has no food allergies! 

Here are a few things to remember as you prepare for your child’s fun (and safe!) return to school.

Educating Your School Tribe

It’s a good idea to get your child’s food allergies on the radar of their school caretakers before the year begins—especially if your child is changing schools. Contact their school nurse and teacher to plan for where the epinephrine will be stored and how it will be used in case of an emergency. You may also want to discuss how snacks and treats are handled in the classroom. Many schools have food allergy policies in place, but some protocols are at the teacher’s discretion. 

It doesn’t hurt to schedule a face-to-face with your child, teachers, and caregivers before school starts to talk through your food allergy game plan. As a bonus, this gives your child an opportunity to meet their teacher before the year begins and help them tackle some of those first-day jitters! 

Epi Dosing Options

There are currently three different epinephrine dosages available. For adults and kids who weigh more than 30 kilograms (~66 pounds), the recommended dose is 0.3 milligrams. For smaller kids weighing between 15 and 30 kilograms (~33-66 pounds), the recommended dose is 0.15 milligrams. Several brands offer both dosing options, including EpiPen, Adrenaclick, and Auvi-Q.  

For infants and toddlers who weigh between 7.5 and 15 kilograms (~16.5-33 pounds), Auvi-Q makes an auto-injector with a lower dosage (0.1 milligrams), which also features a smaller needle. 

Make sure to check with your doctor to determine the best option for your child! 

Safe Storage

Remember that epinephrine is temperature sensitive. The medication should be stored at room temperature and never in extreme hot or cold climates (e.g., car glove compartments). Some brands also recommend that users periodically check to ensure the liquid has not changed color. If the solution assumes a pinkish or brownish hue, this can indicate decreased effectiveness. Epinephrine is light sensitive too—so store your auto-injectors in cases!  

Parents should work with their child’s school or daycare provider to map out a plan for both on-site and off-site storage (e.g., field trips), to ensure availability and maximum effectiveness. 

Using Your Epinephrine

As explained in one of our earlier blog posts, the outer thigh is the best place to administer the injection, even through clothing if necessary. Most manufacturers offer videos on their websites to demonstrate how to use their product. These can be a great resource for new caregivers and anyone that should be prepared for an allergic emergency. Like CPR, administering epinephrine is a good skill for any parent to have in their arsenal.

Replacing Your Supply

Currently, most auto-injectors expire within 12 to 18 months. Make sure to check your epinephrine expiration dates and mark them in your calendar. A good rule of thumb is to always have two auto-injectors in close proximity to any food-allergic child in case one is defunct (and in some cases, two injections may be required!). 

As you replace old auto-injectors, remember that some manufacturers offer coupons or other financial assistance, especially for lower income families.  

While we hope you never have to use an epinephrine auto-injector, we share these reminders to keep all of our children safe as we send them off to the classroom! 

- Susannah and the Allergy Amulet Team  

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What Food Allergies Can Teach Our Kids

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Every now and again, I like to write about my personal experience as a mom managing food allergies. Parenting is no easy feat, but it’s especially tough when you're raising a child that could stop breathing if accidentally exposed to certain foods.   

Although peanut and tree nut allergies are not something I would have chosen for my daughter, there has been an upside to her having food allergies. For one, our family has to look more carefully at the ingredients we put into our bodies, which has made us healthier eaters. The greatest gifts, however, have come in the form of life skills and values my daughter has learned at a young age.

Below are a few that immediately come to mind. 

Diligence. Now that my daughter is entering kindergarten, she’s starting to take charge of carrying emergency medicines to and from activities and storing them appropriately. Increasingly, she’s having to brave the world without me. Whether at school, summer camp, or a birthday party, she knows it’s her responsibility to ask if a food is safe when I’m not there to help her read the label. 

What has she learned? To be detail oriented and persistent—qualities that will help her in countless facets of life. 

Compassion. We talk to our daughter often about things that make her unique, like food allergies and wearing glasses. I find these talks help her relate to the differences between people both physically and situationally. Last year we saw a homeless family outside of a local store asking for money. After she asked me a few questions to better understand the situation, she decided we should give them the snacks we brought in the car so that they wouldn’t be hungry. Cue my proud mama heart swelling! 

Compassion is one of those life skills that will serve her well as a child AND as an adult. 

Time Management. It takes time managing food allergies! Label reading and meal planning take a lot longer when you have to think about a food allergy. Our daughter completed OIT for her nut allergies in 2017, and while it’s now been a year since we finished, she still has a daily maintenance dose of several nuts and a mandatory hour-long rest period afterward. It can be hard to find time to squeeze in her maintenance dose and rest time each day (today it was sandwiched between summer school and a T-ball game!).

Showing her how we map out each day and carve out time to manage her food allergies has been a great lesson in time management that will serve her well as she enters “big kid school” this fall. 

Bravery. It can be hard to stand up for yourself, let alone when you’re a small child! Food allergies have nudged her to become her own self-advocate (and a food allergy advocate!). I’d like to think we’ve led by example as her champion and guardians all these years and I’m proud to see her now standing up for herself (and her health). 

I hope her bravery goes beyond self-advocacy. I hope her newfound courage leads her to try new things, persevere through adversity, and stand up for others in need.

We all have moments when food allergies feel defeating, inconvenient, and stressful. But for all the woes allergies bring, they can also be a gift. It all boils down to perspective. Adversity breeds strength, and I see that strength in my daughter more and more each day.

-      Meg and the Allergy Amulet Team

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FPIES: Not As Delicious As It Sounds

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From time to time, we like to write about the rarer forms of food allergy. We’ve covered  Eosinophilic EsophagitisOral Allergy Syndrome, and allergies to red meat and water! Today’s blog topic will cover another lesser-known, but very serious food allergy: Food Protein-Induced Enterocolitis Syndrome (FPIES for short). 

What is it?

FPIES is a non-IgE immune system reaction to food that affects the gastrointestinal (GI) tract. IgE stands for the antibody immunoglobulin E, and most allergic reactions (think top eight most common food allergies) involve this antibody. FPIES is cell-mediated, which results in a delayed allergic reaction.

Notably, unlike typical food allergies, FPIES does not show up on standard allergy tests.

Who does it affect?

FPIES reactions often show up in the first weeks or months of a child’s life. Sometimes the child may be a little bit older if they’ve been exclusively breastfed. First reactions often occur when introducing solid foods, such as infant formulas or cereals, which are typically made with dairy or soy.

What are the common trigger foods?

For infants that experience FPIES from solid foods, rice and oats are the most common triggers. Other reported triggers include, but are not limited to: milk, soy, barley, sweet potato, squash, green beans, peas, and poultry. 

Any food protein can be a trigger and some infants may be sensitive to other foods as well. As with any food allergy, some children may only react to 1-2 foods, while others may react to several. 

What are the symptoms?

FPIES can cause severe symptoms following ingestion of a trigger food. Classic FPIES symptoms include diarrhea, severe vomiting, and dehydration. These can lead to changes in body temperature, blood pressure, and lethargy. Upon ingestion of a trigger food, there is a characteristic delay of 2-3 hours before the onset of symptoms. 

Symptoms can range from mild (such as an increase in reflux and several days of runny stools) to life-threatening (shock). In several cases, after repeated vomiting, children often begin to vomit bile. Diarrhea typically follows and can last up to several days. It’s important to note that each child is unique and may experience their own range and severity of symptoms. 

Importantly, many infants who are eventually diagnosed with FPIES are initially suspected to have a severe infection or sepsis based on their symptoms. 

How is it diagnosed?

FPIES cannot be detected with traditional allergy testing methods, such as skin prick or blood tests that measures IgE antibodies. It is accordingly tough to diagnose.

Researchers are currently looking to atopy patch testing (APT) for its effectiveness in diagnosing FPIES. APT involves placing the trigger food in a metal cap, which is left on the skin for around 48 hours. The skin is then observed for symptoms in the days following removal.

Additionally, the outcome of APT may determine if the child is a potential candidate for an oral food challenge: the gold standard for food allergy diagnosis. A medical doctor, often an allergist and/or gastroenterologist, should be involved in the diagnosis of FPIES.

Is there a silver lining?

The good news is that FPIES usually resolves with time! Many children outgrow FPIES by age 3, allowing kids to introduce the offending foods back into their diet over time. With proper medical attention and a personalized dietary plan, children with FPIES can grow and thrive! 

- Meg and the Allergy Amulet Team

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