Dr. Sharma:  The ability of epinephrine to treat the many signs of anaphylaxis is rather amazing.

It acts on a number of receptors in the body to exert its effects. First, it causes constriction, or tightening, of the blood vessels, which decreases swelling and also helps to increase blood pressure.

It also increases the heart’s contraction and heart rate, which can help to prevent or reverse cardiovascular collapse. Epinephrine relaxes the muscles around the airways in the lungs, helping the airways to open up.

Finally, it prevents the release of additional allergic chemicals, which aids in stopping further progression of the reaction. No other medicine acts on so many body systems, which is why epinephrine is the drug of choice for anaphylaxis.

Dr. Sharma is an allergist, clinical researcher and Assistant Professor of Pediatrics. He is Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington D.C. and Director of the Food Allergy Program. He co-authors “The Food Allergy Experts” column in the American Edition of Allergic Living magazine. Questions submitted below will be considered for answer in the magazine.

Dr. Sharma
A.  Let’s take a closer look at your daughter’s latex allergy to help clarify this. She is allergic to latex because her immune system reacts to a particular protein in latex. That protein is actually very similar in structure to proteins found in several plant foods, such as banana, kiwi, avocado, papaya, chestnut, tomato, potato, and bell pepper. This is called “cross-reactivity.”

So, the immune system might “cross-react” to a plant food that is structurally similar to latex. Based on limited studies, it seems that one-third to one-half of people with latex allergy might have an allergic reaction to one of these plant foods, especially fresh fruits, which is why this is called “latex-fruit syndrome.”

That reaction risk is the reason avoidance of these fruits and vegetables is standard advice for latex allergy.

Dr. Sharma is an allergist, clinical researcher and Assistant Professor of Pediatrics. He is Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington D.C. and Director of the Food Allergy Program. He co-authors “The Food Allergy Experts” column in the American Edition of Allergic Living magazine. Questions submitted below will be considered for answer in the magazine.

The discussion around this article has become a wonderful opportunity to explore with our patients their concerns about the real risks of food allergy, their hopes for a cure, and their understanding of where things stand in that search for a cure. Since you may have some of the same questions, allow me to review some key perspectives and hopefully find common ground on which we can all agree.

Those living with food allergy are all too aware of the risks of accidental food allergen ingestion. However, we strive to provide our patients a balanced approach, where we encourage vigilance at reducing those risks, but work to prevent that from evolving into debilitating anxiety. This requires a clear understanding of the real risks of food allergy.

One area fraught with ambiguity for patients is food allergen labeling laws. The Food Allergen Labeling and Consumer Protection Act (FALCPA) does not permit any of the eight major food allergens to go unlabeled as ingredients, regardless of the quantity present. However, what is very troublesome to families is that FALCPA is silent on the issue of cross-contact.

Cross-contact can and does sometimes occur in manufacturing.  There is no guidance given to manufacturers as to when a precautionary label (often referred to as a “may contain” warning) should be included.  Fortunately, efforts are under way by the Food and Drug Administration (FDA) to help reform how manufacturers use these precautionary statements.

Another important point of discussion raised by the Times article is the true risk of anaphylaxis due to skin exposure to food allergens. In the Spring 2013 issue of Allergic Living, Dr. Scott Sicherer addresses this question (pages 24-25), explaining that anaphylaxis from skin exposure is very unlikely because the skin barrier prevents the protein from entering the blood system. So, for most with food allergy, playing a game with a ball that had briefly contacted an allergen would not be expected to pose a significant risk of anaphylaxis.

Also of concern to patients was the reference in the Times article to a mortality rate from food anaphylaxis of 1 per 1,000 for “severely allergic” children. It is critical that patients understand that this figure was derived by comparing the estimated number of food allergy deaths in the U.S. to the number of annual emergency department visits for food anaphylaxis. Another approach favored by many puts the risk at more than 100 times lower, or five to 10 per one million.  This approach has the advantage of making the comparison to the total food allergy population in the U.S.

Undoubtedly, even one death from food allergy is a tragedy because it could have been prevented. For those with food allergy, it is important to understand that this risk can be significantly decreased by exercising vigilance in avoiding food allergens and always having access to epinephrine.

Another area of discussion after the Times article revolved around the emotional toll that food allergies can take on families, particularly when severe allergic reactions have been experienced in the past. Our goal is always to help families work through their fears and arrive at a place where affected children feel safe and in charge of their allergies.

Certainly, the psycho-social impact of food allergy is real and, as research is beginning to demonstrate, often detrimental. But there is help, and fear should not be accepted as the norm for those with food allergy. For times when anxiety becomes overwhelming, a counselor, psychologist, or psychiatrist can teach specific coping mechanisms.

While no one would choose to have a food allergy, some of our young patients have gained great empowerment from their experience – a sense that if I can manage my food allergies, I can do anything. So, as the name “Allergic Living” epitomizes, a balanced approach is important to ensure that having a food allergy does not prevent one from truly living.

Next: Community’s Role in the Quest for a Cure

Dr. Hemant Sharma: This is a great question, and one that many parents of children with cow’s milk allergy have as they search for a suitable substitute for cow’s milk. Unfortunately, because goat’s milk protein is similar in structure to cow’s milk protein, more than 90 percent of  the time, the immune system will mistake the two and cause a reaction to goat’s milk or goat’s cheese in someone with a cow’s milk allergy. So goat’s milk is not a safe alternative to cow’s milk, and for the same reason, neither are sheep’s milk nor buffalo’s milk.

You can discuss with your child’s allergist what might be an acceptable cow’s milk substitute. An option for an infant would be an extensively hydrolyzed, cow’s milk-based formula, in which the cow’s milk protein is extensively broken down, making it less recognizable by the immune system and less likely to cause a reaction. Since these formulas are also good sources of nutrients, many allergists will recommend children on restricted diets remain on them beyond the age of one year.

Once ready to wean from a formula, options at that point might include soy milk or rice milk, assuming your child does not also have allergies to those foods. To be sure that all nutritional requirements are being met, it definitely is a good idea to discuss your options with your child’s allergist or a dietitian.

Dr. Sharma is an allergist, clinical researcher and Assistant Professor of Pediatrics. He is Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington D.C. and Director of the Food Allergy Program. He is also the site director for the National Institutes of Health Allergy and Immunology fellowship program. He writes “The Food Allergy Experts” column in the American Edition of Allergic Living magazine. Questions submitted below will be considered for answer in the magazine.