On April 7, 2013, Adrian Gutierrez, an 8-year-old boy from Monmouth County, New Jersey, experienced a severe reaction and died in hospital. The reaction came over the boy on his family’s drive home from church, following a visit to a coffee shop. The boy’s mother suspects that Adrian, who was allergic to dairy and peanuts, may have accidentally sipped from his brother’s hot chocolate with milk. (Adrian had ordered a hot chocolate with  soy milk.)

One news report stated that an epinephrine auto-injector was administered to the boy. However, it is not clear whether the shot was given immediately after the reaction began, or  whether there was a significant delay. In the case of a severe allergic reaction, epinephrine should always be administered right away, as the drug can be less effective if a reaction has progressed.

On March 13, 2013, Maia Santarelli-Gallo, a 12-year-old girl from Burlington, Ontario (in Canada), appears to have experienced anaphylaxis during an outing to a shopping mall with her father and older sister. Local news reports suggest Maia had reacted to dairy and egg in the past, but her parents had been told she was intolerant rather than allergic, and she had never been prescribed an auto-injector. At this point, it is not definitively known what caused the reaction, but milk is suspected – since the last thing Maia ate was an ice cream cone.

Asked to comment on the girl’s fatal reaction, allergist Dr. Susan Waserman expressed profound concern to the local press. “It speaks to the need for proper diagnoses, proper education, how the family was told to handle this supposed food intolerance,” she said, adding that better support for the family would have led the girl to have an auto-injector. “The whole community feels terrible when we feel something like this,” she said.

On March 8, 2013, Cameron Groezinger-Fitzpatrick, a 19-year-old from Plymouth, Massachusetts, died from his peanut allergy while home from university for spring break. His family has said that a friend had offered him a cookie, which was supposed to be peanut-free but turned out to contain peanut butter.

According to ABC News, Cameron’s mother was told over the phone by a 911 operator not to administer an expired EpiPen which was in a nearby cupboard. Cameron’s current auto-injector couldn’t be found in time, as he had not finished unpacking for his visit.

“I didn’t know you can die from nut allergies. I feel foolish,” Robin Fitzpatrick, Cameron’s mother, told ABC News.

These tragic events reinforce the need for allergy education and having epinephrine always ready to access for those with food (and sting) allergies.

In more positive news, several states are beginning to see the importance of readily available epinephrine and are passing bills that allow doctors to prescribe “stock” auto-injectors to schools. These devices can used in emergencies for students who don’t have an auto-injector on school premises (in some cases, it may be a first allergic reaction).

Kentucky, Nevada, Oregon, Georgia and Tennessee have all seen recent progress in such bills in their state legislatures. In fact, Kentucky Governor Steve Beshear will be holding a formal ceremony to sign that state’ stock epinephrine bill into law on April 22, 2013.

Asthma can be tricky for a doctor to diagnose, especially in young kids. Symptoms can mimic other diseases and spirometry, the breathing test to diagnose asthma, requires the patient be able to breathe into a tube, which isn’t possible for most small children.

“The hypothesis has been that people with airway disease will have different metabolism compared to those without disease,” says Dr. Darryl Adamko, head of pediatric pulmonary medicine for the Saskatoon Health Region.

That is, the chemicals in their urine will have a unique compound that could be tested for. His team, based at the University of Alberta where he used to work, is using a technology called nuclear magnetic resonance (NMR) and they believe they have pinpointed what the metabolism of an asthmatic looks like in urine.

They are now working with groups in the United Kingdom and Canada to see how well testing urine for this compound predicts asthma. (Adamko is also testing the theory with COPD, bronchiolitis and allergic rhinitis.)

The researchers are still trying to recruit groups large enough for a robust study, but based on the early results, “it does look like it can differentiate asthma versus COPD or asthma versus no asthma,” says Adamko.

The pediatric respirologist hopes this test will do more than just diagnose. “As you get sicker, your metabolism changes,” he says. That means if someone comes into a clinic or hospital with asthma symptoms, a urine test could tell doctors whether the symptoms will get worse. While Adamko is optimistic his team will be successful, he says it’s at least five years before such a test is used in common practice.

First published in Allergic Living magazine.
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Dr. Watson: Parents are always concerned about introducing highly allergenic foods, especially if they or other children have food allergies. There is very little data in the medical literature to support any advice. You are correct that skin testing an individual who has never been exposed to a food doesn’t make much sense. False positive reactions occur up to 50 per cent of the time, so a positive test means little. The only rational is that if the test is negative, you can be relatively comfortable giving the first exposure at home, as the risk of a reaction is no greater than in the general population.

As a person with peanut allergy, you should not be the one feeding your son peanut. You can be close by. There are different options on how to introduce an allergen, but it’s generally recommended to start with a small amount of peanut butter on the lip. If that’s tolerated, then your son can try a small amount in his mouth. If he refuses to eat it, or if you are worried, don’t push him.

If he tolerates the peanut, he should eat it at least once per week, as the chance of developing an allergy to a food eaten regularly is less than if the food is eaten rarely. If the thought of this procedure keeps you awake at night, talk to your allergist about trying peanut in his or her office.

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.

Dr. Wade Watson is a pediatric allergist and Professor of Pediatrics at Dalhousie University. He is also the head of the Division of Allergy at the IWK Health Centre in Halifax.

See an allergist. If you don’t already have an allergist, go to your family doctor and ask to be referred to one; a good allergist is like a private investigator who can usually single out the culprit in no time. When it comes to food allergies, an accurate diagnosis is key, or else you risk giving the boot to foods that are just fine, and keeping the trouble-makers around.

Keep a journal. As soon as you suspect a food allergy, keep a careful journal of everything you eat, your activities, and any symptoms you experience. You may suspect that a particular food is causing your reactions, but it could be a different offender altogether – and your journal will help you and your allergist arrive at an accurate diagnosis. (Allergists consider the “reaction history” a key part of the process.)

Take the test. When you see your allergist, he or she will likely want to perform one or more tests to pinpoint your allergy. The following are the types of tests available.

1. The Skin-Prick Test

This is by far the most common allergy test, and is usually performed in the allergist’s office. A drop of a serum that contains the allergen is placed onto the patient’s forearm or back, and is then pricked with a small needle so the allergen goes slightly under the skin’s surface. (This is not at all the same sensation as getting an injection or blood test; it’s more like a small pin prick.)

If you are sensitized to an allergen and it is put under the skin, antibodies attack and create a small red bump called a hive – so if a hive forms where the serum was placed, it indicates a possible allergy.

It is important to note, however, that if a hive does form, it does not necessarily mean you will react when you eat the food. In fact, some studies have shown that only half of the people who have positive skin tests are actually allergic to the food, so a positive test is only one indicator of a possible allergy.

But the bigger the hive that forms, the more likely it is the person will react when he or she eats the food. (False negatives are also possible, but are uncommon.)

Need to Know

• It is important that you avoid taking antihistamines for at least 48 hours before the prick test, or the results may be inaccurate.

• Serious systemic reactions to the skin-prick test are possible – but extremely unusual. So skin-prick tests are considered a simple and safe tool in allergy diagnosis.

The skin-prick test replaced the traditional “scratch test”, in which a drop of serum was put on the skin and then scratched with a pin, because the scratch test put more allergen under the skin and came with a greater risk of a serious reaction.

2. Specific IgE Blood Test (RAST, UniCAP, ImmunoCAP)

Blood tests are a less common method of diagnosing allergy, because they are much more expensive and not necessarily more accurate – but they are sometimes used when a patient has a skin condition that makes prick testing difficult, when a serious allergy is suspected.

They are also often used to help confirm the results of a prick test.

For this test, a blood sample is taken then sent to a laboratory for testing. At the lab, the blood is put in contact with an allergen in a dish; if the patient is sensitized to that allergen, the antibodies in the blood will attach themselves to it.

A substance that recognizes those allergen-attached (IgE) antibodies is added, and then they are counted. The higher the number of those allergen-attached antibodies, the greater the likelihood the patient will react when exposed to that substance.

The downsides of the test are that they are considered less accurate, and they lead to more false negatives. In fact, if the test is negative, the patient still has a 15-20 per cent chance of being allergic to that substance.

Like the skin-prick tests, a positive test does not necessarily mean you’ll react when you eat the food. However, if a test comes back with a very high number of allergen-attached antibodies, there’s a greater likelihood a reaction will occur when the food is eaten.

3. Intradermal Test

An intradermal test is similar to a skin-prick test in that a small amount of an allergen is introduced to the skin, and if a hive forms, the test is considered positive. The main differences are that the serum is more diluted, and it is put more deeply under the skin’s surface, where it is more likely to react.

Intradermal tests aren’t used as often as they once were, because they can result in more serious reactions, and are usually only administered after a prick test has come back negative. They are most commonly used to test insect venoms and drugs, starting at very low concentrations, then working up slowly. They are rarely used for food testing.

This type of test is more sensitive, so can give clearer results – but they also tend to lead to more false positives. On the upside, there are fewer false negatives.

Anaphylaxis Note: It’s important to note that none of these tests (prick, intradermal, blood) can predict whether or not a person will go into anaphylaxis, the most serious form of allergic reaction. Some people assume that the more severe the reaction on the skin or in the blood, the greater the chance of anaphylaxis – but this is not statistically true.

I’ve been going back and forth on the subject since the day he was born. It might have even started before. But the question of when, if ever, to test Judah for nuts continues to plague me.

As a bottle-fed baby (forgive my surgically reduced boobs), my second born showed obvious signs of a milk allergy almost immediately. His vomiting, coiling, tensing up and inconsolable crying during and after every feeding, accompanied by major bouts of diarrhea, caused me to switch him to a soy-based formula before he was three weeks old.

When I saw a slight but noticeable change in his reaction, I stuck with it, 87 per cent convinced that it was a milk allergy. My pediatrician was right behind me.

He did, however, point out that Judah, who was by now a year old, could be facing any number of other issues. This was hopeful, if not convincing. I finally set up an appointment to take the little stinker to our allergist to be tested for cow’s milk allergy. This was almost eight months ago, and the week leading up to the appointment remains vivid in my memory. I struggled hard with that irreconcilable question over whether or not to test for nuts at the same time.

I wanted to know so badly that he that he wasn’t allergic to peanuts and tree nuts like his big brother Lucas, but I didn’t have – and don’t yet have – the emotional wherewithal to deal with the bad news. I’m just not ready. There’s also something blissful about keeping the possibility open to him being free of any nut allergies.

And what if I sensitize him? No allergist will deny that testing could do that. Granted some don’t subscribe to the theory, and current research suggests early exposure may in fact reduce the likelihood of sensitivity to key allergens. But that pendulum continues to swing. When Lucas was first diagnosed almost 3 1/2 years ago, our allergist preferred to wait out exposure for as long as possible, especially for someone who could be genetically predisposed.

So other than the prospect of discovering that little Judah is not allergic to the usual suspects, which would make me the happiest mother in Canada, why risk it?

This is a kid who lives in a nut-sterile world, who has more EpiPens and antihistamines at his disposal than you can possibly imagine (OK, if you’re reading this you can imagine). He’s not in daycare or school, and everyone around him is thoroughly trained to deal with an anaphylactic emergency.

I explained all this to our dear allergist, who looked at me quizzically as if he’d never heard this perspective before. The pomp in his voice was also starting to make me feel idiotic. So I gave him the old journalistic silent treatment, the one that gets people to talk more than they intend. Sure enough, all of a sudden he started to tell me that there is evidence to suggest early testing can cause sensitization, and that I have to do what makes me most comfortable.

He brought himself to agree that Judah lives a low-risk lifestyle, even though he’s considered high risk for anaphylaxis given Lucas’s group of life-threatening allergies. It seems that, with an allergic sibling, his chances of having a serious food allergy was greatly increased. And so I agreed to test him for milk and to decide after that how I felt about further testing. Honey was on side to do whatever I wanted for our little son, of course.

Prick, scratch, prick …. Within 30 seconds I saw the welts forming. Honey was holding Judah with his bare back toward me, and the doctor was by now out of the room. My eyes began to well up as the spots grew. That little shadow of hope that was keeping me afloat for so long was all of sudden replaced with this glaring, unequivocal reality. Right there in the centre of those blossoming blemishes, my presumptions had turned to scientific fact. No matter what I thought or felt before, it hurt like a stake in the heart.

Honey, was unfazed. “You knew it. You’ve known it all along,” he kept saying, which was cold comfort (and made me want to stick a stake in his mouth just to end the added torture he was inflicting on me).

The doctor returned with a sympathetic look on his face. Words weren’t necessary. He knew I knew. As a courtesy he asked if I had any further thoughts about testing for the nuts, to which I quickly responded, “absolutely not!” I didn’t have to confer with Honey nor would he dare contradict my position on our kids’ allergies, as it goes in our life. And that was the end of that.

We were booked for a follow up eight months later – at which time we could revisit the big question. That was last week’s appointment. We conveniently cancelled.

Still, there isn’t a week that goes by I don’t wonder, contemplate and even fantasize about getting the verdict on Judah. And just when I forget about it for a day, someone will ask, “is he allergic to nuts too?”

My answer? “We treat him like he is.”

A protein in the immune cells of newborns appears to hold the answer as to whether a baby will either be protected, or susceptible to the development of allergies later on,” Professor Tony Ferrante from the University of Adelaide said in a release.

He and other researchers discovered the allergy marker in 2007, and they have been working on developing a blood test ever since. The protein, called kinase C zeta, is found in much lower amounts in the children at risk of allergies.

Ferrante says the blood test is more reliable than other indicators, such as family history or IgE antibody levels.

Researchers also said there is evidence that fish oil supplements increase the level of the kinase C zeta protein, and may protect against developing allergies. They are studying pregnant women and those who have just given birth to solidify this theory.