Peanut Allergy

Peanuts belong to the legume family of plants which also includes soybean as well as several other peas and beans. A recent study of 8000 children in 2007 found that 1.63% of children are allergic to peanuts. This compares to 1.5% in 2000 suggesting that the prevalence may be increasing over time. Peanuts contain multiple proteins that have now been identified to cause this allergy. These are named Ara h 1, Ara h 2, etc through Ara h 8. Persons allergic to the Ara h 2 are likely to also be allergic to other nuts, especially Brazil nuts. This is called cross-reactivity. How does someone become allergic to peanuts? An allergy to peanuts is like any other allergy in that the body produces an antibody called IgE which requires previous exposure in which the body becomes sensitized. This antibody causes release of histamine and other substances from a cell called a mast cell when this individual is again exposed to peanuts. These chemicals then cause the symptoms of the allergic response. What are the symptoms? In most cases the skin is the main site of the reactions (89% of cases). This can be itching, hives or swelling. Breathing symptoms are next (42% of the time) and can include swelling in the upper or lower airway. This can cause a feeling of constriction of the throat or wheezing (spasm of the bronchial airways). Persons with asthma may be more prone to this type of reaction and are at added risk of a more serious reaction. The gastrointestinal tract may be involved (26% of cases) with cramps, bloating or abdominal pain. The most serious type of reaction occurs when the cardiovascular system is involved (4% of the time). This can cause decreased blood pressure and possibly, shock. The more serious incidences of allergic reactions are called anaphylaxis. How is a peanut allergy diagnosed? This allergy is often evident without any testing at all. It is confirmed either by a blood test (called RAST or CAP) or a prick skin test done in the office. We may often use both methods as a more comprehensive way to follow the allergy over time. Natural history of peanut allergy Studies now show that only about 15% of peanut allergic children will outgrow this allergy. Therefore, acceptance of the need for long-term measures to deal with this allergy are essential.

How is a peanut allergy treated? The obvious mainstay of long term treatment is total avoidance of any exposure to peanut or peanut containing products. Below is a list of the measures I recommend as a minimum way to treat this allergy.

What I recommend for peanut allergic children

1. Total avoidance of peanuts or any foods that may contain peanuts including those in which the ingredient label states that they were processed on the same equipment as peanuts. I recommend that no peanut-containing products be present in the house of a child or adult with this allergy. 2. Read labels of foods to ensure the absence of peanuts. Federal law now requires that peanut be listed on any food label in which peanut may be present. 3. Notification of all persons who may prepare food for the child or care for the child in the absence of the parent of this allergy. This should include informing them of the seriousness of the peanut allergy so that they can take the same avoidance measures necessary. Also, there should always be someone readily available who can administer epinephrine if needed. I recommend that siblings of the allergic child also know how to administer the epinephrine, if they are old enough to properly do so. 4. Meeting with and discussion with school officials regarding the allergy is essential! Teachers should be fully aware of the allergy and injectable epinephrine should be available at the school at all times. There also must be someone who can properly administer it. Any teacher or school official of our patients who would like demonstration of how to correctly administer epinephrine can contact my office at 384-3711 and our nurse will gladly teach him/her to properly do this at no charge. 5. Ultimately, the child must know to never eat any foods in which the ingredients are not fully known and must never rely on the reassurance of other children that any foods such as cookies do not contain peanuts. This way of life should be started as soon as the diagnosis is made of a peanut allergy. We have a standard form called Anaphylaxis Action Plan which we will fill out to keep on record for any school or day care. This will outline specific treatment measures recommended. 6. Parents should register with and be familiar with the Food Allergy and Anaphylaxis Network (FAN) and their website, www.foodallergy.org and sign up for their newsletter. 7. I recommend to prepare a small kit that can be carried with the child in which the epinephrine (EpiPen, Twinject) and diphenhydramine (Benedryl) can be carried and be immediately available. Always be aware of the expiration dates of these medications and replace them when expired since they may lose potency. 8. If you plan to travel on a commercial airline, contact the airline ahead of time to notify them of the presence of a peanut allergic individual on that

flight to that they can take the proper precautions. Many airlines have stopped serving peanuts but not all have. 9. Consider contacting the Red Cross and take a course in Basic Life Support (BLS). You never know when you may need it for anyone, not just your child! Places to avoid I recommend peanut allergic individuals to totally avoid: 1. Asian restaurants 2. ice cream shops 3. bakeries 4. buffets 5. public water fountains, especially in schools 6. Be very careful of sauces, stews, soups and chili What about the future? Another measure we may need to discuss is the administration of an injected medicine called Xolair (anti-IgE antibody). This has the potential of blocking the antibody, IgE, that causes the histamine release. Right now it is only approved for severe asthma but may need to be discussed for severely peanut allergic children, especially those who also have asthma. The FDA is experimenting with peanut inbreeding to essentially breed out the proteins that cause allergy. This is ongoing research and may lead to help in reducing accidental exposures in the future. Current research is also ongoing attempting to desensitize allergic individuals to peanuts, possibly orally. This has met with mixed success so far but holds promise for the future. Safety issues are a major concern with this type of therapy. Other sources of information: Food Allergy and Anaphylaxis Network www.foodallergy.org. 1-800-929-4040 American Academy of Allergy, Asthma and Immunology www.aaaai.org American College of Allergy, Asthma and Immunology www.acaai.org Revised 10/4/2012