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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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What To Expect When You’re Expecting…An Oral Food Challenge

My daughter, moments after finishing her first oral food challenge.

My daughter, moments after finishing her first oral food challenge.

This topic is pretty fresh in my mind as my daughter underwent an oral food challenge to macadamia nuts last week. In case you’re not familiar with an oral food challenge (OFC), or haven’t experienced one yet, let us fill you in.

Today, oral food challenges are considered the gold standard for food allergy diagnosis in children and adults alike. Skin prick and blood tests aid in diagnosis, but they are prone to error—false positives are not uncommon. You can read more about food allergy diagnosis methods in our blog Food Allergies Today: An Expert Q & A.

There are typically three reasons why you might do an oral food challenge:

1. You or your child tested positively for a food allergy but have never actually eaten the food.

2. You or your child tested positively for a food allergy and have eaten the food before with no symptoms.

3. To see if you or your child has outgrown a known food allergy.

An oral food challenge is usually held at your allergist’s office over a few-hour period. The allergist administers tiny amounts of the potential allergen in gradually increasing doses over a set period of time (usually 3-6 hours). In my experience, the whole challenge start to finish lasts around 4 hours. Once the full serving is administered, the doctor will typically observe the patient for a couple hours to monitor for signs or symptoms of an allergic reaction. If symptoms occur at any point during an OFC, the challenge stops and symptoms are treated immediately.

Importantly, not everyone is a good candidate for an OFC. According to allergist Dr. Jordan Scott, “when asthma is flaring or when patients are ill, we don’t challenge.”

Let’s talk about what to expect. First, block off the day, because even if the OFC is expected to last only a few hours, the experience can be emotionally draining and stressful. Being prepared and understanding the purpose and procedure is incredibly important! Below you’ll find a list of things to prepare ahead of time so you can tackle the challenge head on. 

Ask your allergist what he/she needs you to bring. He may ask you to provide the food for the challenge, or his office may provide the food (we’ve done both). If you’re providing the food, make sure you’ve done your homework to ensure it’s not processed in a shared facility or processed on a shared line with something else you’re allergic to. For example, when we challenged sesame a couple years ago, we ensured the hummus we brought wasn’t processed in a shared facility with nuts: my daughter’s other allergen. We didn’t want cross-contact playing a factor.

Ask your allergist what you should stop doing. Ask your allergist what medicines you need to stop taking before the challenge. Our allergist requires that we stop giving our daughter her daily antihistamines for seasonal allergies a few days before the challenge, as that could mask reaction symptoms during the OFC. Additionally, she cannot take any asthma medicine that day. However, if asthma symptoms start flaring, there’s a chance they’ll want to play it safe and reschedule your challenge anyway—clear communication with your allergist is key!

Bring lots of activities for entertainment. If the trial is for a child, I’ve found that new activities, games, and library books always help to hold their attention longer. Having a favorite stuffed “friend” or something that the child associates with comfort is helpful too. If you’re an adult, a good book and your favorite digital gadgets will probably suffice!

Pack safe snacks. If the challenge goes well, you may be at the allergist’s office for several hours. However, the tiny doses of food your allergist administers aren’t likely to fill you up ☺. We like to bring some of our daughter’s favorite tried and true snacks that we know are safe (another way to avoid bringing cross-contact into the equation!). Since the challenge is at an allergist’s office, and there will likely be patients in the near vicinity with food allergies, it’s an added bonus if you can bring foods that are free from the most common allergens: peanuts, tree nuts, fish, shellfish, wheat, egg, milk, and soy. I also bring disinfectant wipes in case the food spills so that I can clean it up properly for the next allergic patient. Good food allergy etiquette is important!

Bring your emergency medications. While this may seem unnecessary (hello, you’re at the allergist’s office ☺), it’s important. There’s always a small chance of a delayed reaction, and if that happens on the way home, you’ll want to have your epinephrine and antihistamines at the ready.

Stay calm. If you’re a parent accompanying a child to an OFC, it helps to remain calm if your child experiences an allergic reaction. “If a reaction occurs, it is important for parents to remain calm because children can pick up on the anxiety and feed on that,” allergist Dr. John Lee advises. If your child experiences a reaction, Dr. Lee also suggests that parents avoid calling it a “failed challenge” in front of their child, noting that “this can make a child feel as if they’ve somehow failed, or done something wrong.”

Leave the siblings at home. If the food challenge is for your child, it’s smart to leave any siblings at home so you can stay focused—especially in the event of an allergic reaction. Best-case scenario, your child doesn’t have a reaction and it ends up being quality time with your babe. If you’re an adult, you’ll still want to bring someone with you for support and to make sure you get home safely.

Set a course of action/next steps. Once the challenge is complete, talk to your allergist about next steps. If the challenge went well, make sure you know how to proceed with exposure to the food moving forward. If it didn’t, they may recommend future testing/follow up, and possibly strict avoidance of the food.

I hope you find these tips helpful! After experiencing my daughter’s first oral food challenge, I felt far better equipped to take on the second. In case you’re wondering, she passed her OFC to macadamia nuts! This is one nutritious food we can add back into her diet. Hooray!

If you’re interested in discussing oral food challenges further, let me know. We’ve been through several, so I know the ropes pretty well!

- Meg and the Allergy Amulet Team 

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Cross-Contact or Cross-Contamination: What’s the Difference?

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I’ll be honest with you: distinguishing between cross-contact and cross-contamination used to throw me off. Many people in the food allergy community (my past-self included) often mistakenly use the terms interchangeably.  

The confusion is so widespread that even food manufacturers and allergists mix up the two. In fairness, cross-contact is a new(ish) term, so some have gotten into the habit of labeling everything involving inadvertent food exposure as cross-contamination. “I’ll be the first to admit that I don’t always use the terms correctly,” says allergist Dr. Jordan Scott. “Many of us were trained to use cross-contamination to refer to allergens inadvertently getting into another food source.”

To help clear up some of the confusion, we’re breaking down the difference between the two terms in this post.

Let’s start with some examples.

Cross-contact: This occurs when a food allergen in one food (let’s say milk protein in cheese) touches another food (let’s say a hamburger), and their proteins mix, transferring the allergen from one food to another. These amounts are often so small that they can’t be seen!

In this example, let’s assume I have a severe milk allergy. If the cheese touches the burger, cross-contact has occurred. Even if the cheese is removed from the burger, trace amounts of the milk allergen likely remain on the burger making it unsafe to eat and posing the risk of an allergic reaction.

It’s important to note that most food proteins (with few exceptions, like heat labile proteins) CANNOT be cooked out of foods, no matter how high the temperature. When our daughter underwent oral immunotherapy for her peanut allergy, we were given the option to bake the peanut flour into muffins for her to consume. We were told that the high oven temperature would not affect the protein structure of the peanut flour.

Cross-contamination: Cross-contamination occurs when a bacteria or virus is unintentionally transferred from one food product to another, making the food unsafe. The key mark of distinction is that cross-contamination generally refers to food contamination, not food allergens.

A couple examples: you cut raw chicken on a cutting board before you put it on the grill. You then cut peppers on that same cutting board. The raw chicken juice touches the peppers, therefore posing a risk for bacteria. Or say you purchase a cantaloupe that unknowingly has listeria. The knife used to dice up the melon is now a vehicle for cross-contamination. Unlike cross-contact, properly cooking contaminated foods generally CAN eliminate the food-borne offender.

Is it all making sense now? In short, when referring to food allergens, use cross-contact, and when referring to food-borne bacteria or viruses, use cross-contamination. Easy peasy.

We hope our explanation cleared up any confusion. Now that you’re a cross-contact pro, here’s a guide with tips on how to avoid cross-contact.

Want to discuss this topic further? Still confused? Feel free to reach out to me at mnohe@allergyamulet.com. I’m always game for a good food allergy chat!  :)

-       Meg and the Allergy Amulet Team

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OIT—Is It For Me?

Feeding your peanut-allergic child peanuts is not easy as a mother—I would know, I do it every day. Your instincts as a parent are to keep your child as far out of harm’s way as possible. But in today’s world, peanuts may be the best management tool we have for my peanut-allergic child.

Let me explain.

My daughter was born with a severe allergy to peanuts and tree nuts. For the first three years of her life, we strictly avoided these foods. She’s now four. Last April, we agreed to undergo an oral food challenge at her allergist’s office to find out if she was still allergic. Her peanut blood test numbers had dropped considerably—this blood test measures levels of Immunoglobulin E (IgE) to individual allergens in the body. IgE is the antibody that triggers food allergy symptoms. Plus, she hadn’t been exposed to peanut since she was a baby. Unfortunately, the oral food challenge outcome wasn’t as we hoped: after ingesting ¼ of a peanut, split into three gradually increasing doses over a 45-minute period, she experienced an anaphylactic event and we had to administer epinephrine. It was an emotional day, to say the least.

After discovering that she was still severely allergic to peanuts, we decided to explore oral immunotherapy: a method of food desensitization that involves re-introducing the immune system to the allergenic food in gradually increasing amounts over time, with the goal of eventual tolerance.

For our family, the results have been life changing. The same little girl that reacted to ¼ of a peanut now eats 12 peanuts daily with zero symptoms. But OIT is not necessarily for everyone, so I’d like to share our family’s journey and offer some insights into the process so that you can determine whether it’s a good fit for you or your child.

If your allergist doesn’t have a clear picture of your allergy severity, treatment may start with an oral food challenge. Once the individual has been identified as an OIT candidate, they are typically provided a juice-like beverage containing tiny amounts of the allergen. This beverage is consumed during the same two-hour period every day. Depending on how quickly a patient builds up a tolerance, your allergist may recommend coming in every week or two for an “updose”—an increase in the amount of allergen consumed. As the immune system grows more tolerant, the patient eventually moves to a powder form (which is typically sprinkled onto food), and finally to solids (e.g., whole nuts).

Importantly, OIT requires a considerable time commitment. Although updosing typically occurs every week or two, the allergen must be consumed every day to build and maintain tolerance. OIT also places constraints on physical activity. During OIT, the patient can only engage in calm, quiet activity half an hour before dosing, and at least two hours afterwards (during their observation period). This ensures that the immune system doesn’t get “revved up” unnecessarily and trigger an allergic reaction.

Is OIT perfect? Not quite. For the foreseeable future, my daughter must eat 12 peanuts with a two-hour observation period everyday. However, we can now choose the time frame each day, and expect the observation period to shorten over time. There’s also a measure of unpredictability. On two occasions, our daughter developed a couple hives after her prescribed dose, and we had to give her antihistamines. Other times, we had to lower her dose because she was sick, which can compromise the immune system. It is these situations, and the risk of producing a more serious adverse outcome, that discourages many allergists from taking up the practice. Indeed, OIT is still relatively controversial. Additionally, OIT treatments are still in their nascent stages and are not widely practiced, so there is less data and information available.

Importantly, not every food-allergic child or adult is a good candidate for OIT. For example, if a patient has severe environmental allergies, acute asthma, or eosinophilic esophagitis, they will not likely qualify for OIT. Additionally, OIT treatment is not available for all allergens—desensitization to peanuts, for example, is far more common practice than, say, shellfish.

If you think OIT may be of interest to your family, I’d encourage you to talk to your allergist and seek out additional information and guidance. You can also reach out to me at mnohe@allergyamulet.com for more on the parent perspective—I’m always up for a good food allergy chat!

- Meg, Director of Strategic Development

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