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cross-contact

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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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My Child Doesn’t Have a Food Allergy... But Her Friends Do

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When my family moved to a new neighborhood five years ago, we quickly learned that our new neighbors’ oldest son had a severe peanut allergy. Our children became fast friends, and the kids went back and forth between the two houses all the time. None of our three children have food allergies, so this was very new to us. To ensure that he was safe while under our care, we knew we had to get up to speed on how to keep him out of harm’s way (and well fed!).

Here are the top 10 tips we’ve learned, in case you find yourself in a similar situation:

1)    Ask the Question. Inviting a new friend over for a play date or sharing snacks at the park? Always ask the other parent or caregiver if their child has any food allergies. Allergy parents are often grateful if you bring it up!

2)    Read Labels. Get to know the ingredients of the snack foods you regularly buy. Which granola bars contain tree nuts? Which crackers are made in a facility that processes peanuts? At a minimum, know where to look on the packaging to find allergen info. I’m often surprised when a food I would have considered to be nut-free actually isn’t. We’ve created a cheat sheet for you to learn the rules of label reading!

3)    Keep the Original Packaging. It’s so much easier to check the ingredient list on a box of crackers if it is still in the original packaging. Often, similar products made by different companies have different allergy warnings and ingredients. 

4)    Have Allergen-Free Snacks on Hand. Consider offering fresh fruits, veggies, or cheese for kids who can eat dairy. We’ve found that parents of kids with allergies are happy to make suggestions for healthy and safe snacks that everyone can enjoy. As an added bonus, minimally processed foods are healthier anyway!

5)    Think About Cross-Contact. When you make a PB&J for your child, does the knife go in both jars? If so, that jam may contain peanuts. I try to use two different knives, but if we have a friend over with a peanut allergy, I open a new jar of jam rather than risk an allergic reaction.

6)    Keep Up the Hand Washing. We all know we should have kids wash hands before eating, but what about afterwards? If your kids eat a peanut butter sandwich, be mindful that their hands may have peanut residue on them, which could pose a risk to those with peanut allergies! Post-meal hand washing also helps keep those toys clean! 🙌  

7)    Think Outside the House. When we carpool with the neighbor that has a peanut allergy, I wipe down the car handles and other surfaces that our kids touch, especially since our family often eats in the car! Let’s be honest, don’t we all? 😉

8)    Make Birthday Parties Inclusive. Ask about food allergies on the invitation. For an electronic invite, you can list what you are planning to serve. We have a child in one of my kids’ friend groups with an egg allergy. His mom is always willing to bring alternative snacks and treats, so a heads up is appreciated in case she needs to plan ahead! 

9)    Know and Support Your School’s Rules. Our elementary school has some classrooms that are nut free, so we always pack nut-free snacks. The lunchrooms are generally nut friendly, with designated nut-free tables. If my child wants to eat with a friend who sits at the nut-free table, he also needs a nut-free lunch. It’s important to avoid undermining the school’s allergen policies. There are plenty of delicious food options for your child that will also keep their friends safe!

10)   Make it Easy on Older Kids. Older kids don’t want you hyper-managing their food choices, especially when they aren’t your children. Make it easy for teens and tweens to self-manage their food allergies by offering plenty of safe options and letting them choose. 

With these guidelines in place, we have been able to successfully navigate the food allergy terrain while keeping our children’s friends safe (and bellies full!).

- Susannah 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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