Contact & Inhalant Reactions Research Studies and Articles How close to steam would an allergic person have to be to react? Q. I’m allergic to both nuts and shellfish. While I understand that ‘smell’ of either of these won’t
cause a reaction, I’ve read that cooking steam can result in symptoms, perhaps even anaphylaxis.
But how close to steam would an allergic person have to be to react? For instance, if I’m in a
restaurant serving seafood, do steaming plates of food present a risk?
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.
ALLERGIC RESPONSE TO PEANUT INHALATION AND SKIN CONTACT 2002‐2003 Scott H. Sicherer, MD, PhD
Mount Sinai School of Medicine, New York, NY
ALLERGIC RESPONSE TO PEANUT INHALATION AND SKIN
CONTACT
2002-2003
A serious concern among parents of children with severe peanut allergy is that casual contact to peanut butter by skin contact or inhalation (smell)
could trigger a severe reaction. However, there were no specific studies to address this concern. With the support of the Geduld Family and FAI, Dr.
Sicherer and colleagues conducted a study to address this important issue. They selected 30 children with “severe” peanut allergy (high allergy tests to
peanut and/or prior reactions to casual exposure). Each child was exposed to 1/2 cup of peanut butter, held a foot from his nose for 10 minutes, and to
a pea-sized amount of peanut butter pressed onto his back for one minute. The peanut butter was masked to hide odor and a placebo (a harmless
substance that looked like peanut butter) was used to avoid bias. None of the children responded to the inhalation. A third experienced redness,
itching, or a single hive on the skin, but only in the exact spot touched by peanut. Based on the number of children studied, the researchers concluded
with 96% certainty that at least 90% of similarly allergic children would not react significantly to such exposures.
The results of this study were published in the Journal of Allergy and Clinical Immunology (JACI) in July 2003. In this article, the researchers point out
that: 1) the study result is limited to peanut butter, not other forms of peanut; 2) the amounts studied, which were chosen to simulate accidental
touching or being near someone eating a peanut butter sandwich, may be different from, for example, inhaling peanut dust on an airplane; 3) since
even tiny amounts of peanut butter, if ingested, could cause a severe reaction, no school policies or other policies in place should change; and 4) the
study cannot be used as evidence that there are no patients who may be more sensitive to touch or smell of peanut. The study should provide some
comfort to the majority of families affected by severe peanut allergy. It also provides practical guidelines for allergists to use in evaluating patients with
peanut allergy.
Read the abstract of the JACI article in the National Institutes of Health's PubMed database.
Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol.
2003 Jul;112(1):180-2.
Relevance of casual contact with peanut butter in children with
peanut allergy.
Simonte SJ, Ma S, Mofidi S, Sicherer SH.
Source
Department of Pediatrics, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
Abstract
BACKGROUND:
Casual skin contact or inhalation of peanut butter fumes is reported and feared to cause allergic reactions in highly sensitive children
with peanut allergy but has not been systematically studied.
OBJECTIVE:
We sought to determine the clinical relevance of exposure to peanut butter by means of inhalation and skin contact in children with
peanut allergy.
METHODS:
Children with significant peanut allergy (recent peanut-specific IgE antibody concentration >50 kIU/L or evidence of peanut-specific
IgE antibody and one of the following: clinical anaphylaxis, a reported inhalation-contact reaction, or positive double-blind, placebocontrolled oral challenge result to peanut) underwent double-blind, placebo-controlled, randomized exposures to peanut butter by
means of contact with intact skin (0.2 mL pressed flat for 1 minute) and inhalation (surface area of 6.3 square inches 12 inches from
the face for 10 minutes). Placebo challenges were performed by using soy butter mixed with histamine (contact), and scent was
masked with soy butter, tuna, and mint (inhalation).
RESULTS:
Thirty children underwent the challenges (median age, 7.7 years; median peanut IgE level, >100 kIU/L; 13 with prior history of
contact and 11 with inhalation reactions). None experienced a systemic or respiratory reaction. Erythema (3 subjects), pruritus
without erythema (5 subjects), and wheal-and-flare reactions (2 subjects) developed only at the site of skin contact with peanut
butter. From this number of participants, it can be stated with 96% confidence that at least 90% of highly sensitive children with
peanut allergy would not experience a systemic-respiratory reaction from casual exposure to peanut butter.
CONCLUSIONS:
Casual exposure to peanut butter is unlikely to elicit significant allergic reactions. The results cannot be generalized to larger
exposures or to contact with peanut in other forms (flour and roasted peanuts).
Frequency and significance of immediate contact reactions to peanut in peanut‐sensitive children. Clin Exp Allergy.
2007 Jun;37(6):839-45.
Frequency and significance of immediate contact reactions to
peanut in peanut-sensitive children.
Wainstein BK, Kashef S, Ziegler M, Jelley D, Ziegler JB.
Source
Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, NSW, Australia. [email protected]
Abstract
BACKGROUND:
Parents of atopic children frequently report, and are alarmed by, contact reactions to foods. Some schools restrict foods due to
concerns regarding possible systemic reactions following contact in allergic children.
OBJECTIVE:
We aimed to determine the frequency with which peanut-sensitive children exhibited contact sensitivity to peanut butter and to
assess the significance of such reactions.
METHODS:
One gram of peanut butter was applied directly to the skin of 281 children who were skin prick test (SPT) positive to peanut
(immediate skin application food test; I-SAFT). The test was considered positive if one or more weals were present when the patch
was removed after 15 min. A subset of children then underwent an open-label oral challenge with graded amounts of peanut protein.
RESULTS:
During 3515 clinic visits, 330 I-SAFT tests for peanut contact sensitivity were performed; 136 (41%) were positive. The mean SPT
diameter was 10 mm in the I-SAFT-positive children and 8.5 mm in the I-SAFT-negative children (t-test, P<0.0001). No child had a
systemic reaction following topical application of peanut butter. Eighty-four children had 85 oral challenges after blinded, placebocontrolled I-SAFT testing. Challenge was positive in 26/32 of those with a positive I-SAFT and negative in only 6/32. Challenge was
also positive in 26/53 but negative in 27/53 of those with a negative I-SAFT (sensitivity 50%, specificity 82%, chi2, P=0.003).
CONCLUSION:
A minority of children sensitized to peanut (positive SPT) develop localized urticaria from prolonged skin contact with peanut butter.
No tested subjects, including ones with systemic reactions upon oral challenge, developed a systemic reaction to prolonged skin
exposure to peanut. Therefore, systemic reactions resulting from this mode of contact with peanut butter appear highly unlikely.
Distribution of peanut allergen in the environment. J Allergy Clin Immunol.
2004 May;113(5):973-6.
Distribution of peanut allergen in the environment.
Perry TT, Conover-Walker MK, Pomés A, Chapman MD, Wood RA.
Source
Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
Abstract
BACKGROUND:
Patients with peanut allergy can have serious reactions to very small quantities of peanut allergen and often go to extreme
measures to avoid potential contact with this allergen.
OBJECTIVE:
The purpose of this study was to detect peanut allergen under various environmental conditions and examine the effectiveness of
cleaning agents for allergen removal.
METHODS:
A monoclonal-based ELISA for Arachis hypogaea allergen 1 (Ara h 1; range of detection, 30-2000 ng/mL) was used to assess
peanut contamination on cafeteria tables and other surfaces in schools, the presence of residual peanut protein after using various
cleaning products on hands and tabletops, and airborne peanut allergen during the consumption of several forms of peanut.
RESULTS:
After hand washing with liquid soap, bar soap, or commercial wipes, Ara h 1 was undetectable. Plain water and antibacterial hand
sanitizer left detectable Ara h 1 on 3 of 12 and 6 of 12 hands, respectively. Common household cleaning agents removed peanut
allergen from tabletops, except dishwashing liquid, which left Ara h 1 on 4 of 12 tables. Of the 6 area preschools and schools
evaluated, Ara h 1 was found on 1 of 13 water fountains, 0 of 22 desks, and 0 of 36 cafeteria tables. Airborne Ara h 1 was
undetectable in simulated real-life situations when participants consumed peanut butter, shelled peanuts, and unshelled peanuts.
CONCLUSION:
The major peanut allergen, Ara h 1, is relatively easily cleaned from hands and tabletops with common cleaning agents and does
not appear to be widely distributed in preschools and schools. We were not able to detect airborne allergen in many simulated
environments.
Food Hypersensitivity by Inhalation Food hypersensitivity by inhalation
Daniel A Ramirez† and Sami L Bahna*†


*Corresponding author: Sami L Bahna [email protected]
† Equal contributors
Author Affiliations
Allergy & Immunology Section, Louisiana State University Health Science Center in Shreveport, 1501 Kings
Highway, Shreveport, LA, USA
For all author emails, please log on.
Clinical and Molecular Allergy 2009, 7:4 doi:10.1186/1476-7961-7-4
The electronic version of this article is the complete one and can be found online
at:http://www.clinicalmolecularallergy.com/content/7/1/4
Received:
8 December 2008
Accepted:
20 February 2009
Published:
20 February 2009
© 2009 Ramirez and Bahna; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Abstract
Though not widely recognized, food hypersensitivity by inhalation can cause major morbidity in affected
individuals. The exposure is usually more obvious and often substantial in occupational environments but frequently
occurs in non-occupational settings, such as homes, schools, restaurants, grocery stores, and commercial flights. The
exposure can be trivial, as in mere smelling or being in the vicinity of the food. The clinical manifestations can vary
from a benign respiratory or cutaneous reaction to a systemic one that can be life-threatening. In addition to strict
avoidance, such highly-sensitive subjects should carry self-injectable epinephrine and wear
MedicAlert® identification. Asthma is a strong predisposing factor and should be well-controlled. It is of great
significance that food inhalation can cause de novo sensitization.
Assessing the Real Risk of Airborne Peanut by Robert Wood, MD in Food Allergy for Dummies People with severe peanut allergy often live in constant fear that they will react in the mere
presence of peanut. If you're one of these people, you have plenty of reason to fear--a
severe reaction can make you miserable and even threaten your life. But just how likely is
it that someone eating a peanut butter and jelly sandwich next to you poses a significant
threat? The risk is lower than you might think.
As I point out in Food Allergies For Dummies, airborne reactions to peanut protein in
peanut butter, candy bars, and even peanut butter crackers is very unlikely. The reason is
because the peanut protein, which is responsible for triggering a reaction, is usually
contained by some other ingredient in the food, such as chocolate or caramel. You may be
able to smell the peanut butter, but the odor is the result of something other than peanut
protein.
Caution: Although an airborne reaction from peanut contained in most foods is rare, you
may react if the person eating the food is in your face, talking and laughing, and essentially
spraying small droplets of peanut at you. You could also react if the person gets peanut on
her hands or on the table and it happens to contaminate the food you're eating. It's still a
good idea to keep a safe distance from the person and to follow other precautions I outline
in the book.
Airborne peanut reactions are much more common in situations with high concentrations of
peanut dust, such as in restaurants that serve peanuts in shells and encourage patrons to
toss the shells on the floor. In a roomful of peanut-cracking, peanut-chomping patrons
kicking up peanut dust, the risk of an airborne reaction is very high, indeed, and I strongly
advise that anyone with a peanut allergy avoid these situations.
ALLERGEN EXPOSURE THROUGH KISSING Scott H. Sicherer, MD
Mount Sinai School of Medicine, New York, NY
ALLERGEN EXPOSURE THROUGH KISSING
2005-2006
Dr. Sicherer and his colleagues undertook a study to investigate how long peanut protein typically remains in saliva after a meal of peanut butter, and
to develop ways to efficiently remove residual peanut protein from the mouth. They found that peanut residue gradually disappeared from the mouth,
reaching undetectable levels if participants waited a few hours and had a peanut-free meal. The researchers also tested five methods to remove
peanut butter, such as brushing teeth and chewing gum. These methods generally reduced the peanut to levels that were unlikely to cause a reaction.
However, some peanut was still detectable in several of the 30 participants. The researchers concluded that peanut-allergic patients require counseling
regarding the risks of kissing or sharing utensils.
Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol.
2007 Jul;120(1):171-6. Epub 2007 Jun 4.
Consumer attitudes and risks associated with packaged foods
having advisory labeling regarding the presence of peanuts.
Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL.
Source
Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, NE 68583-0919, USA.
Abstract
BACKGROUND:
Foods with advisory labeling (eg, "may contain") are increasingly prevalent. Consumers with food allergies might ignore advisory
labeling advice.
OBJECTIVE:
We sought to determine whether consumers with food allergy heeded advisory labels and whether products with advisory labels
contained detectable peanut allergen.
METHODS:
Surveys (n = 625 in 2003 and n = 645 in 2006) were conducted at Food Allergy & Anaphylaxis Network patient conferences. Food
products bearing advisory statements regarding peanuts were analyzed for the presence of peanut.
RESULTS:
Consumers were less likely to heed advisory labeling in 2006 (75%) compared with in 2003 (85%, P < .01); behavior varied
significantly according to the form of the statement. Peanut protein was detected in 10% (20/200) of total food products bearing
advisory statements, although clinically significant levels of peanut (>1 mg of peanut or >0.25 mg of peanut protein) were detected
in only 13 of 200 such products.
CONCLUSION:
Consumers with food allergy are increasingly ignoring advisory labeling. Because food products with advisory labeling do contain
detectable levels of peanuts, a risk exists to consumers choosing to eat such foods. The format of the labeling statement did not
influence the likelihood of finding detectable peanut, except for products listing peanuts as a minor ingredient, but did influence the
choices of consumers with food allergy.
CLINICAL IMPLICATIONS:
Allergic patients are taking risks by increasingly disregarding advisory labeling.
FOOD ALLERGEN LABELING 2007 Scott H. Sicherer, MD, PhD
Mount Sinai School of Medicine, New York, NY
FOOD ALLERGEN LABELING
2007
FAI was instrumental in the passage of the 2004 Food Labeling and Consumer Protection Act (FALCPA), which requires that food labels indicate,
in plain language, whether or not a product contains any of the eight major allergens. Since the law went into effect in January of 2006, FAI has
assisted the Food & Drug Administration (FDA) by conducting extensive national surveys of food labels to ensure that manufacturers are in
compliance. Dr. Sicherer is working with FAI to analyze the data from these surveys and to identify labeling problems and offer potential solutions.
A special concern is the “may contain” warning, which often appears on the labels of products that food-allergic consumers have eaten safely for years.
Some manufacturers use this provisional warning as a protection when allergen-free foods are made in the same factory or on the same machines as
products that contain allergens. An FAI survey of 20,241 food labels showed that 17% had “may contain” or similar warnings. Baked goods and
candies had especially high warning rates (over 40%). To further complicate matters, a survey of 1,000 products found that 19 different types of
terminology were used on advisory labels. This widespread use of provisional warnings and imprecise language causes confusion and limits
consumers’ choices. The results of this study are being prepared for publication.
In an additional study, conducted in cooperation with the highly respected Food Allergy Research and Resource Program at the University of
Nebraska, products with and without advisory labeling are being tested for milk, egg, and peanut content to determine the magnitude of contamination
of a variety of products. To date, tests have indicated that 5.3% of the products with advisory labels, and 1.9% without a warning or declaration of the
presence of an allergen, were contaminated. The contaminated foods that did not have advisory labeling were primarily from small manufacturers. The
results of this study also are being prepared for publication.
These studies are important because they examine the effectiveness of current labeling and help inform industry and government about needed
improvements. The preliminary study results were presented to the FDA in a public hearing on September 16, 2008, and will be helpful in shaping the
agency’s long-term plans to improve advisory labeling.
Food Allergy Labeling Not Always Accurate Food Allergy Labeling Not Always
Accurate
A small number of products contain allergens no
matter what ingredients are listed, study finds
March 16, 2009 RSS Feed Print
By Amanda Gardner
HealthDay Reporter
MONDAY, March 16 (HealthDay News) -- A small number of food products with a "may contain" label
actually do contain an allergen, while about 2 percent of foods products without such a claim also contain
allergens, new research shows.
But the offending products more often came from smaller companies, noted the authors of a study that is
scheduled to be presented Monday at the American Academy of Allergy, Asthma and Immunology's annual
meeting, in Washington, D.C.
"We didn't do an exhaustive survey of every product out there, but one thing we did notice is that products that
didn't have this labeling but did have detectable proteins came primarily from smaller companies," said study
senior author Dr. Scott H. Sicherer, an associate professor of pediatrics at the Jaffe Food Allergy Institute at Mount
Sinai School of Medicine in New York City. "So for what it's worth, we could presume that small companies don't
have as much oversight."
Still, Sicherer added, buying certain food products can be a game of roulette for people with allergies.
"If you're a patient with a food allergy, it's probably best to stick with the larger companies," agreed Dr. David
Resnick, director of allergy and immunology at Morgan Stanley Children's Hospital, New York Presbyterian Hospital,
in New York City.
Food allergies, which affect about 2 percent of adults and 5 percent of infants and young children in the United
States, can range from the merely irritating to the life-threatening.
"Not too many fatalities are reported with egg allergies, but with peanuts, that's where fatalities are more likely to
be reported," Resnick stated. "If you're buying food from a smaller company and have a serious allergy like a
peanut allergy, you have to be really cautious."
The Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA) required new labels on packaged foods
containing "major food allergens," which were defined as milk, eggs, fish, crustacean shellfish, tree nuts, wheat,
peanuts and soybeans, or any other ingredient that contains protein derived from one of these foods or food
groups.
Among other things, the labels had to include plain-English descriptions of ingredients and possible allergens. For
example, "milk" is used instead of "casein."
But the issue of "may contain"-type labels was not addressed. Such warnings can include "may contain peanuts,"
"processed on shared equipment," or "manufactured in a facility that processes peanuts or milk."
Consumers (and probably some experts) have been confused by this sort of labeling, which, said Sicherer, is not
regulated.
Of supermarket-sourced, randomly selected food products that had such labeling, 5.3 percent had detectable levels
of one of three allergens: egg, milk or peanut.
Among products tested that did not carry "may contain"-type labeling, 1.9 percent had detectable levels of one of
the allergens.
In all, 399 products were tested.
Although the researchers did not specifically look at this, about half of the 19 products containing an allergen might
prompt a reaction in sensitive people, Sicherer said.
The group also did not explore which food types or groups were more likely to contain allergens, but other
researchers reporting at the same meeting found that dark chocolates were a leading offender.
A food industry spokesman said that current labeling is guided by the best available science.
"Our members are committed to ensuring that food allergic consumers have the information they need on the food
label to make informed choices about whether or not a particular food item is appropriate for them to eat," said
Brian Kennedy, director of communications at the Washington, D.C.-based Grocery Manufacturers Association.
"That is why we support the use of science-based criteria by food and beverage companies in determining whether
or not a supplemental or 'may contain' allergen advisory on a food product label is necessary."
Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol.
2001 Jan;107(1):191-3.
Fatalities due to anaphylactic reactions to foods.
Bock SA, Muñoz-Furlong A, Sampson HA.
Source
Department of Pediatrics, National Jewish Medical and Research Center, Denver, CO, USA.
Abstract
Fatal anaphylactic reactions to foods are continuing to occur, and better characterization might lead to better prevention. The
objective of this report is to document the ongoing deaths and characterize these fatalities. We analyzed 32 fatal cases reported to a
national registry, which was established by the American Academy of Allergy, Asthma, and Immunology, with the assistance of the
Food Allergy and Anaphylaxis Network, and for which adequate data could be collected. Data were collected from multiple sources
including a structured questionnaire, which was used to determine the cause of death and associated factors. The 32 individuals
could be divided into 2 groups. Group 1 had sufficient data to identify peanut as the responsible food in 14 (67%) and tree nuts in 7
(33%) of cases. In group 2 subjects, 6 (55%) of the fatalities were probably due to peanut, 3 (27%) to tree nuts, and the other 2
cases were probably due to milk and fish (1 [9%] each). The sexes were equally affected; most victims were adolescents or young
adults, and all but 1 subject were known to have food allergy before the fatal event. In those subjects for whom data were available,
all but 1 was known to have asthma, and most of these individuals did not have epinephrine available at the time of their fatal
reaction. Fatalities due to ingestion of allergenic foods in susceptible individuals remain a major health problem. In this series,
peanuts and tree nuts accounted for more than 90% of the fatalities. Improved education of the profession, allergic individuals, and
the public will be necessary to stop these tragedies.
Further fa
atalities caused by anaphyylactic reactio
ons to food, 22001‐2006 Furtheer fatalitiees caused by anaph
hylactic reeactions tto food, 2001-2006
6

S. Allan Bock, MD
,

Anne Muñoz-Furlong, BA
,

Hugh A. Sampson, MD
published onlin
ne 20 February 2007
7.
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

Full Text
PDF
Reference
es
Article Outline
O
I.
II.
Re
eferences
Copyright
To the Editor:
3 individuals who died because of food-induced anaphyylaxis. The cases w
were accumulated iin a registry kept byy
In 2001 we reported a group of 32
1
he American Acade
emy of Allergy, Asthma & Immunology
y and The Food Alllergy and Anaphyla
axis Network. The
e registry, which do
oes not
members of th
represent a sy
ystematic or comple
ete accounting of all
a fatal food-induce
ed allergic reactionss in this country, ha
as been maintained
d continuously sincce the
initial report. We
W have done so to
o determine whethe
er there are any ch
hanges in the chara
acteristics of subse quent fatalities and
d to determine whe
ether
recommended
d interventions with
h self-injectable epinephrine have changed.
Additional sub
bjects have been re
ecorded prospective
ely in the registry between
b
2001 and A
August 2006. Inforrmation about the d
deaths has been co
ollected
1
using the sam
me questionnaire us
sed in the original re
eport. This report lists the details of tthe new data that h
have been collected. Briefly, the family
members of th
he individuals who died were contacte
ed, and standardize
ed information was collected by using
g a structured questtionnaire to determ
mine the
likelihood thatt a food caused the
e fatal reaction, the identity of the food
d suspected, the pre
esence or absence
e of asthma (and th
he status at the time
e of
death where possible),
p
previous history of reactions
s to the suspected food, location of th
he reaction, and wh
hether epinephrine was administered in a
timely mannerr. The cases includ
ded in this report fro
om the registry hav
ve been as criticallyy evaluated as posssible to include onlyy cases in which th
here is
high certainty that the death was
s caused by a seve
ere allergic reaction, there is high certa
ainty that the correct culprit has been identified, and wha
atever
history is available has been reviewed. We have tried to eliminate bias toward the most common culprit (pe
eanut) by these me
easures. We did exxclude
some reports with incomplete infformation or where there was uncertainty about a likely cculprit. It would havve been helpful if every individual had
d been
seen by an alllergist and had und
dergone a complete
e evaluation that included skin testing
g, serum antibody le
evels, and blind foo
od challenges. Diag
gnosis
was not made
e by allergists for all patients. Diagnos
stic criteria used (fo
or example, skin priick test, specific se
erum antibody levels, blind food challe
enges)
were not cons
sistent between hea
alth care providers for these patients. We do not have de
etailed information on the severity of previous allergic re
eactions
ed during the intervview reported the p
to foods (exce
ept, of course, that none were fatal) in
n these individuals. The history obtaine
presence of a know
wn
allergy and infformation about pre
evious reactions. Many
M
of those who died
d
had not previo
ously been in the h ospital for their rea
actions or needed
epinephrine. Some
S
of these families indicated that they had no idea th
hat these reactionss could be fatal. We
e acknowledge thatt we probably have
e a bias
toward overprrescription of self-in
njectable epinephrin
ne because we ten
nd to collect and be
e aware of more sevvere cases. Howevver, the unpredictab
bility of
response to a known food allergen, especially in ind
dividuals with asthm
ma and especially for the most predicctable culprits, makkes us comfortable with
this approach.
Thirty-one add
ditional subjects (Table I) were identiffied between 2001 and 2006. The indiividuals ranged from
m 5 to 50 years of age. There were 19 males
(61%). Peanut accounted for 17 deaths, tree nuts for
f 8, milk for 4, and
d shrimp for 2. All ssubjects for whom tthere are data had asthma, although the
severity and trreatment at the time of death are poorly documented be
ecause of a lack of a
available details. T
The lack of readily a
accessible epineph
hrine
remains substtantial with only 4 in
ndividuals (where the
t information was
s available) appearring to have had ep
pinephrine administtered in a timely ma
anner.
The known loc
cations where the deaths
d
occurred inc
cluded schools (3; including colleges)), homes (12; includ
ding homes of frien
nds), restaurants (8
8),
work/office se
etting (4), and camp
p (2).
Table I. Fo
ood fatalities 20
001-2006
Patient no. Agge (yy) M/F Date Culprit Asthma Previou
us history
Food Location Timely epinephrine Patient no. Age (y) M/F Date Culprit Asthma Previous history Food Location Timely epinephrine 1 32 M 3/11/2001 Nuts Yes Yes
Nut bowl
Restaurant
No
2 16 M 5/9/2001 Walnut Yes Yes
Chinese food
School, cooking class Probably 3 9 M 5/18/2001 Peanut Yes Yes
Cookie
School outing
No
4 24 F 11/26/2001 Peanut Yes Yes
Chinese food
Home
No
5 25 F 10/30/2001 Nut meats Yes Yes
Candy
Home of friends
No
6 16 M 11/5/2002 Milk Yes Yes
Bread
Home
Unk
7 31 M 12/13/2002 Peanut Yes Yes
Catered food
Office party
No
8 50 M 12/24/2002 Nut Yes Yes
Cookie
Home
No
9 12 F 3/14/2003 Peanut Unk Unk
Egg roll
Unk
Unk
10 18 M 6/21/2003 Peanut Unk Unk
Wrap
Unk
Unk
11 32 M 3/15/2003 Shrimp Yes Yes
Meal
Restaurant
No
12 29 M 6/13/2003 Peanut Yes Yes
Meal
Restaurant
No
13 29 M 4/24/2000 Almond Yes Yes
Candy
Office
Yes
14 17 F 12/26/1986 Nuts Yes Yes
Cookie
Home of friends
No
15 21 F 10/9/2003 Peanut Yes Yes
Brownie
College
No
16 18 M 1/20/2004 Shrimp roll Yes Unk
Shrimp roll
Restaurant
No
17 27 M 2/1/2004 Peanut Unk Yes
Baked clam
Home
No
18 17 M 2/8/2004 Hazelnut Yes Yes
Candy
Home of friends
No
19 17 F 4/6/2004 Peanut Yes Yes
Peanut butter Camp
No
20 34 F 5/29/2004 Peanut Unk Yes
Thai dish
Home
No
21 5 M 8/1/2004 Peanut Unk No
Peanuts
Home
No
Patient no. Age (y) M/F Date Culprit Asthma Previous history Food Location Timely epinephrine 22 9 M 7/22/2004 Milk Unk Unk
Milk
Camp
Yes
23 22 F 10/29/2004 Peanut Yes Yes
Dessert
Restaurant
No
24 14 F 1/22/2005 Peanut Yes Yes
Egg roll
Restaurant
No
25 36 M 3/21/2001 Peanut Yes Yes
Brownie
Work
No
26 17 M 3/5/2005 Milk/whey Yes Yes
Protein shake Home
No
27 7 F 3/2/2005 Milk Yes Yes
Chocolate mix Home
Unk
28 11 F 5/31/2005 Peanut Unk Yes
Candied apple Carnival
Unk
29 40 M 2/8/2006 Tree nut Unk Yes
Cookie
Work
Yes
30 13 F 4/13/2006 Peanut Yes Yes
Wrap
Fast food in mall
No
31 16 M 8/1/2006 Peanut Yes Yes
Cookie
Home of friends
No
F, Female; M, male; Unk, unknown.
Maintaining the registry enables us to compare the characteristics of these ongoing tragic deaths with the course and deficiencies in previously
observed cases and determine whether educational efforts have had any apparent effect on preventing these tragedies. Unfortunately, this group of
fatal reactions has striking similarities to the original group, but there are also some differences that may be important. The median age and sex
distribution are similar to the earlier group, with slightly more males in this group. However, there are more younger subjects (4 no more than 10 years
of age vs 1 in the original report), and more older individuals (7 at least 30 years of age vs 1 in the original report). Nevertheless, it is clear that the
greatest number of fatalities still occurs in adolescents and young adults. The foods primarily responsible for the deaths continue to be peanut and tree
nuts, with more instances of reactions to milk (4 in this group, vs 1 in the previous report). The location and circumstances of the food reactions are
similar as well, with ongoing examples of individuals with known food allergies consuming foods without asking about ingredients and then not having
the proper treatment available. Twelve of the 31 fatalities were caused by individuals with peanut or tree nut allergy consuming desserts (candy and
bakery products) prepared away from home, and without having properly inquired about the ingredients.
2
There are some similar reports in the literature. Moneret-Vautrin et al reviewed 107 cases registered by the Allergy Vigilance Network in 2002. In this
group there were 2 reported fatalities, one from “anaphylactic shock” caused by peanut in a 21-year-old man, and the other caused by soy in a child.
3
Pumphrey reported 37 food fatalities, and the foods incriminated had significant similarities to those reported here. The additional foods were
4
chickpea, banana, and nectarine, but peanut and tree nuts predominated. Colvar et al reported 9 children with severe reactions: 3 were fatal and 6
were “near-fatal.” Six subjects were known to be allergic to the food causing the reaction, and only 1 of 9 had never had a known food-allergic reaction.
5
In the 3 fatal cases, peanut was the likely culprit in 1 and cow's milk in the other 2. The 3 who died had a history of asthma. Uguz et al reported 112
allergic reactions to implicated foods in subjects responding to a questionnaire in the United Kingdom Anaphylaxis Campaign. Although there were no
fatalities reported in this group, the foods responsible for symptoms were similar to those in this report. In these reports, the foods culprits are similar,
the locations where reactions occur are similar, and the importance of asthma is emphasized as a risk factor.
Several lessons have been learned and reinforced by the information collected in this portion of the registry. We have cited support from the literature
where it exists for these lessons: (1) education of the medical profession to ask about food allergy, diagnose it, educate patients, and prescribe
6
epinephrine continues to be inadequate ; (2) patients' education regarding diagnosis, allergen avoidance, symptom recognition, and discrimination
7 8
between asthma flares and anaphylaxis remains very inadequate , ; (3) patients need to inquire in detail about ingredients and avoid eating desserts
and bakery goods, especially when away from home; (4) patients' knowledge of and compliance with the importance of carrying epinephrine needs
9
improvement ; (5) availability of epinephrine to emergency medical technicians and prompt dispatch of paramedics or emergency medical technicians
who can carry and administer epinephrine needs to be improved in many locales; (6) school education including food preparation and staff training
needs improvement; (7) public education about the potential fatal nature of food allergy needs to be disseminated; (8) restaurant education concerning
10
the importance of accurate labeling and the full and complete disclosure of food ingredients must be stressed to the industry ; and (9) evaluation by
an allergist with the identification of the specific food culprits, and detailed education of patients and their families and friends may be lifesaving.
In conclusion, the registry continues to receive reports of tragic fatalities caused by known food offenders. A lack of education at all levels, a lack of
preparedness of allergic individuals and their families to respond appropriately, and a lack of prompt reporting of the abrupt onset of serious allergic
symptoms appears unchanged from our previous report. We believe that a concerted national effort, similar to the National Heart, Lung, and Blood
11
Institute Guidelines on the Diagnosis and Management of Asthma,
problem.
is necessary to reverse the morbidity and mortality of this growing national
Peanut and tree nut allergic reactions in restaurants and other food establishments. J Allergy Clin Immunol.
2001 Nov;108(5):867-70.
Peanut and tree nut allergic reactions in restaurants and other
food establishments.
Furlong TJ, DeSimone J, Sicherer SH.
Source
Food Allergy and Anaphylaxis Network, Fairfax, Va, USA.
Abstract
BACKGROUND:
The clinical features of food-allergic reactions in restaurants and other food establishments have not been studied. Of the registrants
in the United States Peanut and Tree Nut Allergy Registry (PAR), 13.7% have reported reactions associated with such
establishments.
OBJECTIVE:
The purpose of this study was to determine the features of allergic reactions to peanut and tree nut in restaurant foods and foods
purchased at other private establishments (eg, ice cream shops and bakeries).
METHODS:
Telephone interviews were conducted through use of a structured questionnaire. Subjects/parental surrogates were randomly
selected from among the 706 PAR registrants who reported a reaction in a restaurant or other food establishment.
RESULTS:
Details were obtained for 156 episodes (29 first-time reactions) from 129 subjects/parental surrogates. Most reactions were caused
by peanut (67%) or tree nut (24%); for some reactions (9%), the cause was a combination of peanut and another nut or was
unknown. Symptoms began at a median of 5 minutes after exposure and were severe in 27% of reactions. Overall, 86% of reactions
were treated (antihistamines, 86%; epinephrine, 40%). Establishments commonly cited were Asian food restaurants (19%), ice
cream shops (14%), and bakeries/doughnut shops (13%). Among meal courses, desserts were a common cause (43%). Of 106
registrants with previously diagnosed allergy who ordered food specifically for ingestion by the allergic individual, only 45% gave
prior notification about the allergy to the establishment. For 83 (78%) of these 106 reactions, someone in the establishment knew
that the food contained peanut or tree nut as an ingredient; in 50% of these incidents, the food item was "hidden" (in sauces,
dressings, egg rolls, etc), visual identification being prevented. In 23 (22%) of the 106 cases, exposures were reported from
contamination caused primarily by shared cooking/serving supplies. In the remaining 21 subjects with previously diagnosed allergy,
reactions resulted from ingestion of food not intended for them, ingestion of food selected from buffet/food bars, or skin
contact/inhalation (residual food on tables, 2; peanut shells covering floors, 2; being within 2 feet of the cooking of the food, 1).
CONCLUSIONS:
Restaurants and other food establishments pose a number of dangers for peanut- and tree nut-allergic individuals, particularly with
respect to cross-contamination and unexpected ingredients in desserts and Asian food. Failure to establish a clear line of
communication between patron and establishment is a frequent cause of errors.
Self‐reported allergic reactions to peanut on commercial airliners. J Allergy Clin Immunol.
1999 Jul;104(1):186-9.
Self-reported allergic reactions to peanut on commercial
airliners.
Sicherer SH, Furlong TJ, DeSimone J, Sampson HA.
Source
Division of Pediatric Allergy/Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, USA.
Abstract
BACKGROUND:
Allergic reactions to food occurring on commercial airlines have not been systematically characterized.
OBJECTIVE:
We sought to describe the clinical characteristics of allergic reactions to peanuts on airplanes.
METHODS:
Participants in the National Registry of Peanut and Tree Nut Allergy who indicated an allergic reaction while on a commercial airliner
were interviewed by telephone.
RESULTS:
Sixty-two of 3704 National Registry of Peanut and Tree Nut Allergy participants indicated a reaction on an airplane; 42 of 48 patients
or parental surrogates contacted confirmed the reaction began on the airplane (median age of affected subject, 2 years; range, 6
months to 50 years). Of these, 35 reacted to peanuts (4 were uncertain of exposure) and 7 to tree nuts, although 3 of these 7
reacted to substances that may have also contained peanut. Exposures occurred by ingestion (20 subjects), skin contact (8
subjects), and inhalation (14 subjects). Reactions generally occurred within 10 minutes of exposure (32 of 42 subjects), and reaction
severity correlated with exposure route (ingestion > inhalation > skin). The causal food was generally served by the airline (37 of 42
subjects). Medications were given in flight to 19 patients (epinephrine to 5) and to an additional 14 at landing/gate return (including
epinephrine to 1 and intravenous medication to 2), totaling 79% treated. Flight crews were notified in 33% of reactions. During
inhalation reactions as a result of peanut allergy, greater than 25 passengers were estimated to be eating peanuts at the time of the
reaction. Initial symptoms generally involved the upper airway, with progression to the skin or further lower respiratory reactions (no
gastrointestinal symptoms).
CONCLUSIONS:
Allergic reactions to peanuts and tree nuts caused by accidental ingestion, skin contact, or inhalation occur during commercial
flights, but airline personnel are usually not notified. Reactions can be severe, requiring medications, including epinephrine.
The US Peanut and Tree Nut Allergy Registry: characteristics of reactions in schools and day care. J Pediatr.
2001 Apr;138(4):560-5.
The US Peanut and Tree Nut Allergy Registry: characteristics of
reactions in schools and day care.
Sicherer SH, Furlong TJ, DeSimone J, Sampson HA.
Source
Division of Pediatric Allergy/Immunology, Department of Pediatrics, Elliot and Roslyn Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York, New
York; and Food Allergy Network, Fairfax, Virginia.
Abstract
OBJECTIVE:
Severe food-allergic reactions occur in schools, but the features have not been described.
STUDY DESIGN:
Participants in the US Peanut and Tree Nut Allergy Registry (PAR) who indicated that their child experienced an allergic reaction in
school or day care were randomly selected for a telephone interview conducted with a structured questionnaire.
RESULTS:
Of 4586 participants in the PAR, 750 (16%) indicated a reaction in school or day care, and 100 subjects or parental surrogates
described 124 reactions to peanut (115) or tree nuts (9); 64% of the reactions occurred in day care or preschool, and the remainder
in elementary school or higher grades. Reactions were reported from ingestion (60%), skin contact/possible ingestion (24%), and
inhalation/possible skin contact or ingestion (16%). In the majority of reactions caused by inhalation, concomitant ingestion/skin
contact could not be ruled out. Various foods caused reactions by ingestion, but peanut butter craft projects were commonly
responsible for the skin contact (44%) or inhalation (41%) reactions. For 90% of reactions, medications were given (86%
antihistamines, 28% epinephrine). Epinephrine was given in school by teachers in 4 cases, nurses in 7, and parents or others in the
remainder. Treatment delays were attributed to delayed recognition of reactions, calling parents, not following emergency plans, and
an unsuccessful attempt to administer epinephrine.
CONCLUSIONS:
School personnel must be educated to recognize and treat food-allergic reactions. Awareness must be increased to avoid accidental
exposures, including exposure from peanut butter craft projects.