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

In fact, three to five years after completing an OIT study, Johns Hopkins University researchers said that many participants were more reactive to cow’s milk than they had been early in the course of treatment.

The team presented results from a follow-up study involving 32 children from two clinical trials in which they were fed tiny, then increasingly larger amounts of milk. These patients completed the milk oral immunotherapy, then underwent an oral challenge test for tolerance and were sent home with individualized instructions for daily milk consumption.

It turned out that 38 percent of the test subjects (12 children) who were thought to be desensitized were having frequent symptoms from milk three to five years after the trial had ended, while 22 percent had occasional symptoms. Only 25 percent of the participants were able to consume milk without symptoms. (The other 16 percent had ceased having milk.)

In terms of the type of reactions being experienced, 31 percent reported systemic symptoms (characterized as more than an itchy mouth or stomach ache) and 19 percent had symptoms serious enough to require an epinephrine auto-injector.

At a news conference at the AAAAI meeting, Dr. Robert Wood, director of pediatric allergy and immunology at Johns Hopkins, did not mince words: “Some of the more dramatic failures had looked like absolute successes in the study. They were tolerating huge amounts of milk; they were about as close to ‘cured’ as we could imagine,” he said.

The study shows that 22 percent of the children had returned to either milk avoidance or minimal consumption of it. “The main thing that I’ve come to believe is that they were not as protected as we believed in that they self-restricted [consumption] because they didn’t like the side effects the milk was putting them through,” said Wood.

So have the researchers lost hope? Not at all. It appears more a case of figuring out where the research goes from here for some patients who lose newfound allergy protection easily.

“Learning something that’s disappointing is why it’s called research,” Wood noted about the study. As he told Allergic Living in an interview: “To go from where we were 10 years ago, which was to say that ‘we probably can’t give food to a highly allergic patient safely at all,’ to say now that some patients are having extremely good outcomes, this leaves us with encouragement that the long-term potential is very real.”

Dr. Wesley Burks, one of the leaders on OIT research from the University of North Carolina, summed it up well when he said: “There are a lot of encouraging results, but there’s also a lot of work to be done. This isn’t really ready for treatment – we’re not there yet.”

There are some intriguing bigger questions on where research will head to get “there”. Allergic Living will be examining these issues in the Summer edition in a special report on food allergy treatment research. We hope you and your family will find it enlightening.

Read more news from the AAAAI meeting here.

See Also: Parents Exposing Kids to Their Allergens

Known as sublingual immunotherapy, or SLIT, this treatment works by having study subjects take tiny, daily doses of an allergen – in this case, peanut – in steadily increasing amounts over an extended period of time.

The new study, published in the January edition of the Journal of Allergy and Clinical Immunology, involved 40 peanut-allergic patients between the ages of 12 and 37 in five U.S. cities. The subjects were randomly divided in half, with one group taking liquid drops containing peanut powder under the tongue and the other taking drops with a placebo.

After 44 weeks of the daily doses, 70 percent of those getting the peanut powder could tolerate at least 10 times more peanut in an oral food challenge before showing symptoms than they could have at the outset of the study. In a follow-up challenge at 68 weeks, they could tolerate about twice as much again. (Patients were also to be retested at 88 weeks.)

This suggests that longer treatment could lead to even better results. The end goal is to slowly build up tolerance until the individual is no longer sensitized to the allergen.

“It gives us hope that this type of therapy might be used in the future for some type of treatment,” Dr. Wesley Burks, lead author of the study and Chair of the Department of Pediatrics at The University of North Carolina, told Allergic Living.

But Burks is quick to acknowledge the hurdles that remain. First, the treatment was not effective for 30 percent of the subjects. He believes this has to do with finding the proper dosage for those individuals, which could be related to their specific immune and gastrointestinal systems.

He says it shows that more and larger studies are required before this type of treatment – currently only done with strict medical supervision – becomes widely available.

The second issue is that, after 44 weeks, the average amount of peanut one of the responding allergic patients could consume was still fairly small: 496 milligrams. That equates to about two peanuts (a single peanut typically contains 250 to 300 mg of protein).

The treatment “is not ready for practical day-to-day usage,” says Burks. “There is some efficacy, but it is not the right thing to do right now”.

Even if SLIT’s results are being measured in incremental successes, that is still significant and promising, especially when compared to the sole, current allergy treatment of strict avoidance of peanuts.

An anaphylactic reaction includes more than one of the body’s systems, such as the respiratory tract, gastrointestinal tract, the skin and cardiovascular symptom. Symptoms of an allergic reaction include tingling in the mouth, swelling of the tongue and throat, itchy skin or hives, difficulty breathing, abdominal cramping and vomiting. In a severe anaphylactic reaction, a person may experience a drop of blood pressure, loss of consciousness and even cardiac arrest and death.

One of the issues in managing peanut allergy is that symptoms can vary. A person may have had minor symptoms, only to suffer anaphylaxis on a subsequent exposure.

Because peanut allergy reactions can be severe, it is important that a person with this allergy carry an epinephrine auto-injector (EpiPen or Twinject) with them at all times. Peanut allergy is often considered a lifelong allergy, but research has shown up to 20 per cent of children may outgrow it by the time they reach school-age.*

*Source: 2010 FA primer. JACI

Prevalence

In the United States, the rate of peanut allergy in children increased by 3.5 times from 1997 to 2008, to a rate of 1.4 per cent. In Canada, it is estimated that 1.68 per cent of children and 0.71 per cent of adults have peanut allergy.

More on Peanut Allergy Statistics

Next Page: Not a Nut!

What is immunotherapy?

Immunotherapy is a form of treatment, commonly known as allergy shots, in which a patient with allergic rhinitis gets controlled exposure to allergens through injections. It will not be the first course of treatment. In immunotherapy, a doctor raises the allergen dose in your shots over a number of months and years – the intent is that as the dose rises, you become less sensitive to allergens.

Who should get allergy shots?

First, your allergist will take a history, do an examination including skin-prick tests to determine what you are allergic to, and then will prescribe medications. If you’re still suffering even with medication, allergy shots may be the next step. Candidates for this treatment are usually people who are no longer helped by allergy medications and those who have serious rhinitis symptoms for prolonged periods of time.

If you haven’t had allergies for long, you are more likely to be responsive and experience longer-lasting benefits. Children, however, should have had seasonal symptoms for at least two years before being considered candidates, says Dr. Eric Leith, an allergist based in Oakville, Ontario, and chair of the Canadian Allergy, Asthma and Immunology Foundation. The child should be old enough to understand what’s going on, he says, “and if a reaction occurs, they must be able to express that.”

Allergist Dr. Harold Kim says about 5 to 10 per cent of patients receiving immunotherapy have skin, breathing or gastrointestinal reactions. Only about 1 to 3 per cent have more severe reactions. While anaphylaxis is rare, “immunotherapy can be life-threatening,” cautions Leith. “You should be waiting in the doctor’s office for half an hour [after the treatment] to make sure you are not reacting.” If you have asthma, Leith stresses that it must be under control or the shots “may accentuate the asthma.”

How long does immunotherapy treatment last?

Immunotherapy can take years to carry out. Patients receive one to two shots a week of minimal amounts of their allergen for about six months, until they reach their “maintenance dose,” which means symptoms have improved. Then, a monthly dose is required to keep the allergies under control. Treatment can take up to five years, but the benefit of immunotherapy is that it may have a lasting effect even after the shots have stopped. Leith says there have been cases in which patients have seen their symptoms disappear completely.

Related:
• The Hay Fever Handbook
• 10 Ways to Beat the Pollen
• America’s Top 10 Spring Allergy Capitals

From the Spring 2006 issue of Allergic Living magazine.
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