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Nut and Peanut Allergy

First grade has been a difficult parenting year for Anne. Her 6-year-old son, Justin, began eating lunch in the cafeteria with hundreds of other students armed with their peanut butter sandwiches, peanut butter crackers, and all those hidden peanuts in their processed foods.

For Justin, who has an extremely severe allergy to peanuts, it means sitting at a separate table with other children who have food allergies. But Justin isn't alone: The U.S. Food and Drug Administration estimates that 6% of children younger than 3 years old have some kind of allergy to food, putting them at risk of an allergic reaction at home, or even more dangerously, away from home.

It seems ironic that one of the most popular, most readily available proteins causes one of the most pervasive and severe allergies among Americans.

What Are Nut and Peanut Allergies?
The most common allergy-causing foods are peanuts, tree nuts, milk, eggs, fish, shellfish, wheat, and soy, according to the Food Allergy and Anaphylaxis Network (FAAN). About 1.5 million people in the United States are allergic to peanuts (which are not a true nut, but a legume - in the same family as peas and lentils). Half of those allergic to peanuts are also allergic to tree nuts, such as almonds, walnuts, pecans, cashews, and often sunflower and sesame seeds. The American Academy of Allergy, Asthma, and Immunology estimates that up to 2 million, or 8%, of children in the United States are affected by food allergies, and that six foods account for 90% of those food allergy reactions in kids: milk, eggs, peanuts, wheat, soy, and tree nuts.

Food allergies occur when a person's immune system mistakenly believes that something he or she ate is harmful to the body. In an attempt to protect the body, the immune system produces antibodies called immunoglobulin E (IgE). Those antibodies then cause mast cells (which are allergy cells in the body) to release chemicals into the bloodstream, one of which is histamine. The histamine then acts on a person's eyes, nose, throat, lungs, skin, or gastrointestinal tract and causes the symptoms of the allergic reaction. Future exposure to that same allergen (things like nuts or pollen that you can be allergic to are known as allergens) will trigger this antibody response again. This means that every time that person eats that particular food, he or she will have an allergic reaction.

Unlike allergies to other foods like milk and eggs, children generally don't outgrow allergies to peanuts or nuts. But over time, they should become experienced at avoiding the foods that make them ill.

Signs and Symptoms
The first signs of an allergic reaction can be a runny nose, a skin rash all over the body, or a tingly tongue. The symptoms can quickly become more serious - including signs of anaphylaxis (a sudden, potentially severe allergic reaction involving various systems in the body), such as difficulty breathing, swelling of the throat or other parts of the body, a rapid drop in blood pressure, and dizziness or unconsciousness. Other possible symptoms include hives, tightness of the throat, a hoarse voice, nausea, vomiting, abdominal pain, diarrhea, and lightheadedness. To someone who has no allergies, seeing someone else experiencing anaphylaxis can be just as scary as it is for the allergic person. Anaphylaxis can happen just seconds after being exposed to a triggering substance. It can involve various areas of the body (such as the skin, respiratory tract, gastrointestinal tract, and cardiovascular system), and can be mild to fatal. The annual incidence of anaphylactic reactions is small - about 30 per 100,000 people - although people with asthma, eczema, or hay fever are at greater risk of experiencing them.

How Is a Nut or Peanut Allergy Diagnosed?
Obviously, babies can't tell their parents when their tummies hurt or their throats itch, so diagnosing food allergies early in a child's life can be difficult. Doctors therefore generally recommend that parents refrain from giving their children peanut butter or other peanut or nut products until after they're 2 years old. If there's a family history of food allergies, parents should wait until the child is 3. And many doctors recommend that their pregnant patients - especially those with food allergies - keep the lid on the peanut butter jar until after the baby's born and they're done nursing.

If your doctor suspects your child might have a peanut or nut allergy, he or she will probably refer you to an allergist or allergy specialist for further testing. The allergy specialist will ask you and your child questions, such as how often does your child have the reaction, how quickly do symptoms start after eating a particular food, and whether any family members have allergies or conditions like eczema and asthma.

Allergies are diagnosed using a skin test or blood test, depending on the age and condition of the patient. Initially, the suspected allergen is placed on the skin and the skin is pricked with a plastic toothpick-like instrument. If the child is allergic, a reaction (a welt that looks like a mosquito bite) will develop in 20 minutes. Skin testing can also be done by injecting the suspected allergen under the skin with a needle.

It's important that your child stop taking antiallergy medications (such as over-the-counter antihistamines) 2 to 3 days before a skin test because they can interfere with the results. Most cold medications, as well as some antidepressants, can also affect skin testing. Check with the allergist's office if you're unsure about what medications need to be stopped and for how long.

Some doctors may also take a blood test that will check for antibodies for specific allergens.

If the results of the skin or blood tests are still unclear, then in select cases, a food challenge may be needed for final diagnosis. During this test, your child might be given gradually increasing amounts of nuts or peanuts to eat, while being watched for symptoms by the doctor. This can only be performed in a clinic or hospital where access to immediate medical care and medications is available. And it should be avoided if your child has experienced a clear-cut anaphylactic reaction to nuts or peanuts in the past.

How Is It Treated?

There is no real cure for food allergies. The only real way to cope with them on a daily basis is to know the trigger foods and avoid them. So parents must educate their children early and often, not only about the allergy itself but also what reaction they will have if they eat the offending food. The task at hand is to stay vigilant about reading each and every food label and educating others, including relatives, caregivers, neighbors, and teachers.

In case of an emergency, doctors recommend that nut- and peanut-allergic adults and children 12 or 13 and older (depending on the maturity of the child) keep a shot of epinephrine with them in an easy-to-carry container that looks like a pen. Millions of parents across the country carry epinephrine everywhere they go.

With one injection into the thigh, epinephrine, or adrenaline, is administered to ease the allergic reaction. A prescription for epinephrine includes two auto-injections. Your child's doctor can give you instructions on how to use and store the epinephrine injection pen; it's essential that you familiarize yourself with the procedure.

If your child is 12 or older, make sure he or she keeps the pen readily available at all times. If the child is younger than 12, talk to the school nurse, your child's teacher, and your child's child-care provider about keeping one on hand in case of an emergency. Also make sure that epinephrine pens are available at your home, as well as at the homes of friends and family members. Your child's doctor may also encourage your child to wear a medical alert bracelet. It's also a good idea to carry an over-the-counter antihistamine, which can help alleviate allergy symptoms in some people. But antihistamines should not be used as a replacement for the epinephrine.

Kids who have had to take an epinephrine shot should go immediately to a medical facility or hospital emergency department, where additional treatment can be given if needed. Up to one third of anaphylactic reactions can have a second wave of symptoms several hours following the initial attack, so the child might need to be observed in a clinic or hospital for 4 to 8 hours following the reaction.

Caring for Your Child

It's important to be vigilant about your child's food allergies, even during simple, everyday activities. Here are some basic tips:

• Read food labels. Beginning in 2006, food makers are required to clearly state whether a product contains peanuts or tree nuts that could trigger an allergic reaction. The statement should be in or adjacent to the list of ingredients. (Keep in mind though, this rule only applies to foods labeled after the start of 2006. So some of the products that were made before then and are still on the shelves may not say anything about allergens.)
• Avoid cooked foods you didn't make yourself - anything with an unknown list of ingredients. Stay away from baking mixes, chilis, Asian dishes, and buffet restaurants where spoons go in and out of various bowls that may contain nuts or seeds.
• Avoid fried foods (especially in restaurants and fast-food places) that may be made with peanut oil or may contain hidden peanuts or nuts.
• Don't be cavalier about food allergies - tell everyone who handles the food your child eats, from waiters and waitresses to chefs and bakers. If the manager or owner of a restaurant is uncomfortable about your request for peanut- or nut-free food preparation, don't eat there.
• Encourage people not to feed your child. Make your own school lunches, as well as snacks and treats to take to parties, play dates, sleepovers, school functions, and other outings.
• Talk to the daycare supervisor or school principal before your child attends. Then talk to your child's classmates or send home a note explaining that your child has a severe allergy to peanuts or nuts. Ask parents to refrain from sending in snacks that have peanuts.
• Keep epinephrine accessible at all times - not in the glove compartment of your car, but with you, because seconds count during an anaphylaxis episode. It's a good idea to also keep epinephrine in your child's classroom (not just in the nurse's office), or with your child, depending on state laws.
• See a board-certified allergist or your child's doctor regularly.

Here are some other tips that might make life a little easier for you and your nut- or peanut-allergic child:

• Use - and encourage others to use - an antiseptic hand wash after meals.
• Consult with a dietitian to come up with safe but delicious meals and snacks.
• Carry a list of foods to watch out for in your backpack or bag.
• Talk to your child's teachers, relatives, caregivers, and close friends about the allergy. Teach them to recognize the signs of anaphylaxis and show them how to help your child.

Be sure to arm yourself with all of the other need-to-know info that will help keep your nut- or peanut-allergic child safe by checking out our Nut and Peanut Allergy Diet article, which contains a comprehensive list of ingredients and foods to avoid.