Dr. Scott Sicherer: Despite its name, coconut is not actually a nut, but a fruit. Regardless, the Food and Drug Administration considers it a tree nut, which is why it’s included in U.S. labeling laws.

It is difficult to assess the risk of coconut allergy among those with tree-nut allergies because allergic individuals may become wary of coconut and avoid it. Still, coconut allergy appears rare, and uncommon even among those with tree-nut allergies.

In a national registry of 5,149 people with peanut or tree-nut allergies, only four self-reported an allergy to coconut. And a more recent study of 40 children with positive tests or known allergy to peanuts or tree nuts showed no increased risks for having positive tests or allergy to coconut.

Your allergist would consider your personal allergy history in deciding whether to add coconut to your diet or to perform any testing. However, be aware that tests are often positive to coconut in people who could actually tolerate it, so a physician-supervised feeding test may be necessary for a conclusive answer.

When it comes to coconut oil, there is almost no medical literature on allergic reactions to it, which may reflect the likelihood that the processed forms of coconut oil contain little or no protein, although this has not been studied. Still, for those with verified coconut allergy, avoidance of coconut oil should be considered because it may have residual protein.

Finally, it’s important to note that people with peanut or tree-nut allergies who choose to eat coconut must be diligent to avoid cross-contact with avoided tree nuts or peanut.

Dr. Scott Sicherer is Chief of the Division of Allergy and Immunology of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai in New York. Together with Dr. Hemant Sharma, 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.

We do not have adequate studies to state the general risk of chickpea allergy among children with peanut allergy. Peanut is a legume and it shares similar proteins with many other beans. However, in a U.S. study performed many years ago, only 5 percent of children with a peanut allergy had allergic reactions to other beans tested.

A tricky problem is that if you use blood or skin tests to beans for a person with a peanut allergy, about half the time the tests are positive even though 95 percent of the patients can eat the beans. The tests are affected by immune responses to shared bean proteins that are not important when it comes to allergic reactions.

Studies of chickpea and lentil allergy emanating from Mediterranean countries do note a high correlation of allergic reactions among pea, chickpea and lentil. Over two-thirds of children reactive to one of these three, reacted to another of the three. However, peanut allergy was uncommon in these children.

It appears that if a child with peanut allergy has already been tolerating peas, there is a much lower chance of having allergy to chickpea. Conversely, if peas caused a reaction, the risk of chickpea and lentil allergy is quite high.

Individual advice may vary, but if chickpea was already eaten and tolerated, there would be no reason to avoid it because of a peanut allergy. Lastly, a positive allergy test to chickpea in a person with peanut allergy does not prove an allergy and a medically supervised feeding (e.g. a food challenge) may be warranted.

Dr. Scott Sicherer is Chief of the Division of Allergy and Immunology of the Jaffe Food Allergy Institute at the Mount Sinai School of Medicine in New York. Together with Dr. Hemant Sharma, 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.

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. Susan Waserman: Most food allergies start in childhood, but you’re right, they can develop at any time in a person’s life.

Factors that favour the development of food allergy in adults include sensitization to pollens and house dust mites, as well as occupational sensitization (which occurs when people who regularly handle and inhale food become sensitized to it due to repeated exposures).

As well, adults with birch pollen allergy may develop “oral allergy syndrome,” which leads those affected to experience itchy mouth when they eat certain raw fruits and vegetables. This is the result of cross-reactivity between the food and the pollen.

Interestingly, those sensitized to house dust mites may end up with shrimp allergy because both contain the protein tropomyosin.

Occupational sensitization is also associated with crab and pork allergies.

Dr. Susan Waserman is an allergist and Professor of Medicine in the Division of Allergy and Clinical Immunology at McMaster University in Hamilton, Ont. She is also a past president of the Canadian Society of Allergy and Clinical Immunology.

We welcome your question to Allergic Living’s Ask the Allergist. Thank you for understanding that the specialists aren’t able to answer every question received.

He was diagnosed with the food allergies when he was 9 months old, and has no recollection of getting sick from the foods. I think he is getting curious, trying to experiment, and I am worried about him at school. Do you have any suggestions about dealing with his curious nature?

Dr. Scott Sicherer: You are describing behaviors that represent age-appropriate natural curiosity and some element of “testing boundaries”. I recommend responding the same way you would if he attempted other dangerous actions such as running into the street or playing with electric sockets. In other words, take stronger actions to ensure he does not eat the avoided food, including extra supervision and placing temptations out of reach.

Reasoning with a 5-year-old about the consequences of the actions is not likely to be fruitful, although it is appropriate to say “Eating the food could make you sick and we don’t want you to get sick.”

Assuming a child is otherwise developmentally normal, positive reinforcement for appropriate behavior may be helpful, including verbal praise (“We are so proud of our big boy for not touching those cookies”) or a sticker chart (“Look, you got two stickers for twice not touching those cookies and eating your safe ones instead. Now you can choose a special toy to play with”).

One exercise you can try: Ask an adult friend to offer your son food and teach him to say, “No thanks, I have an allergy and my mom or dad has to make sure it is OK.” Provide positive reinforcement when he does a good job. Reading stories
about children with food allergies and pointing out how others have restrictions may help him understand and accept the differences, but also recognize that he is mostly doing the same things as others.

Next: Sending a curious food-allergic child to school

Dr. Scott Sicherer: The answer would depend upon the amount of protein in the steam, your personal degree of sensitivity, whether you have asthma, and the amount inhaled.

The amount inhaled is related to proximity, room size, ventilation and other factors. This issue has not been extensively studied.

One small study attempted to replicate reported allergic reactions to cooking vapors in food-allergic children with asthma by having the children in a 7- by 13-foot room while food was being cooked on a stovetop for 20 minutes. Reactions were replicated in five of nine children.

In those five children, the triggers were fish (three children), chickpea and buckwheat. The four negative tests were to milk (two), fish and egg. Among the five reactions, all the children had asthma symptoms and two also developed hives (chickpea and buckwheat).

Regarding your shellfish allergy, based on the study mentioned and studies of people with occupational asthma related to working with shellfish, it seems clear that shellfish protein can become airborne in steam and may trigger reactions. Therefore, steam coming from plates of hot shellfish could pose a risk.

Dr. Scott Sicherer is Chief of the Division of Allergy and Immunology of the Jaffe Food Allergy Institute at the Mount Sinai School of Medicine in New York. Together with Dr. Hemant Sharma, Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington, 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.

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.

Dr. Scott Sicherer: Being able to recognize the need for epinephrine and to actually self-inject in an emergency are beyond the capability of most children your son’s age. The readiness to self-administer requires the appropriate developmental level, understanding about symptoms of a reaction, and then the willingness to inject the epinephrine.

Before you consider the readiness of your child, speak with your allergist to be sure you are comfortable with recognizing symptoms and understand when and how to inject epinephrine. Since barriers to using the auto-injector include “needle phobia” and unfounded worries about side effects, have a discussion with the allergist about the safety of epinephrine, and perhaps practice with an old injector and an orange. Achieving your own comfort is the first step in preparing the right message to give to a child who will eventually take on this responsibility.

The notion of self-treatment can be taught early on, but granting full independence is a much more gradual process. For all children, I generally instruct that a responsible adult should be available to make treatment decisions and ultimately inject epinephrine. For teenagers, having their friends aware of the food allergy and how to inject epinephrine can add another layer of safety.

Gradually include your child in allergy management, with guidance from your doctor. Having him practice with an epinephrine self-injection trainer is a good first step. The road toward independence also includes having him play a part in reading labels on packaged foods, speaking up about allergy at restaurants, and eventually discussing when epinephrine would be required.

Dr. Sicherer is a practicing allergist, clinical researcher and Professor of Pediatrics. He is Chief of the Division of Allergy and Immunology, Jaffe Food Allergy Institute, at the Mount Sinai Medical School of Medicine in New York. He is also a member of the FAAN medical advisory board. Together with Dr. Hemant Sharma, Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington, he writes “The Food Allergy Experts” column in the American Edition of Allergic Living magazine.

To submit a question, write to ask@allergicliving.com. Write “The Food Allergy Experts” in the subject field, and keep your question brief.