Allergy Basics

Educating oneself and your child is the first and most important step to take in understanding your child's food and environmental allergies. Regarding food allergies in particular, much information and mis-information exists. The following includes an overview of food and environmental allergies and information concerning a number of related issues, such as eczema and anaphylaxis. As you read and learn, please remember that every child is unique and situations differ from person to person. It is imperative to seek the advice of a knowledgeable physician as self-diagnosis and treatment is potentially dangerous. [Please call the American Academy of Allergy, Asthma and Immunology for a reference to a board-certified allergist. (800) 822-ASMA.]

1. Food Allergy Basics

Approximately 11 million Americans live with food allergies. Peanut allergy is the second most common food allergy (seafood being the most common) in children although the most significant, due to the potentially life threatening nature of the reaction. It occurs in approximately 1 in 50 children and is the most likely food to cause anaphylaxis resulting in death. Estimates indicate one death for every 200 episodes of anaphylaxis.


Heredity seems to be the prime reason some people have allergies and others do not. In the individual with a food allergy, the immune system produces increased amounts of immunoglobulin E antibody, or IgE. When these antibodies battle with food allergens, histamine and other chemicals are released as part of the body's immune reaction to these substances. These chemicals cause blood vessels to widen, smooth muscles to contract and affected skin areas to become red, itchy and swollen -in effect, causing an allergic response.

Food allergy most commonly becomes evident during infancy and preschool years, usually presenting as eczema, hives, vomiting, diarrhea, failure to thrive and anaphylaxis. Severe reactions can occur with even trace amounts of the food allergen, especially with peanuts. Serious reactions can also occur from skin contact, touching the eyes, and through inhalation of food particles. In young children, although the initial contact with the allergen may be on the hands or arms, the reaction can spread to other parts of the body through scratching and rubbing of the face and eyes.


Allergists test for diagnosis of allergies through skin and blood testing. With skin testing, the physician places a diluted amount of the extract of the suspected food on the skin through a puncture or scratch. Within 15 to 20 minutes, a positive reaction typically appears as a raised bump surrounded by redness. Currently, there are two types of blood tests: the radioallergosorbent test (commonly known as RAST) and ImmunoCAP, where the food allergen does not need to be introduced to the body for testing. If properly performed and interpreted, skin test and/or blood testing to foods are reliable and good screening tests for food allergy; nonetheless, true confirmation of a suspected food allergy requires an appropriately designed and monitored oral challenge.


There is no cure for food allergy. Strict avoidance of the allergy-causing food is the most secure methodology for preventing a reaction. Patients should be on guard for hidden ingredients in unsuspected foods such as in candy, baked goods, trail mixes, sauces, desserts or gravies. (see Precautions) In the event of an adverse reaction, studies have shown that early administration of epinephrine (EpiPen®), upon first presentation of symptoms, is the key to a patient's avoidance and survival of anaphylactic shock.


Most individuals who have had an allergic reaction to food ate something they thought was safe. And yet, the majority of patients and their parents do not have a written plan from their doctor for preventing and treating reactions. This can be a costly mistake.


1 “Peanut Allergy,” Allergy Unit, Royal Prince Alfred Hospital, Australia,
Velencia Soutter, Anne Swain, Robert Loblay
2 “Food Allergies: Advice from your Allergist,” ACAAI: American College of Allergy, Asthma, & Immunology
3 Soutter, Swain, and Loblay, “Peanut Allergy”


2. Precautions: Topline Summary

The Care Environment

  1. Totally avoid peanut butter and other significant peanut products in the care
    environment. This avoidance policy should extend to no peanut butter kept on the premises because of surface and other food contamination during preparation and consumption.
  2. Eat home-prepared food where possible. Always carry a supply of safe food when traveling for your child.
  3. Eating other nut products represents a risk as cross contamination and substitution often occurs and unrecognized allergies often exist.
  4. Avoid nuts and seed products such as tahini (sesame paste) in very young children with peanut allergies as they may have an unrecognized allergy to these foods or a new allergy may develop. In older children and adults this needs to be managed on an individual basis.
  5. Inform your doctor about your child's relevant food, drug and latex allergies.

Outside the Home

  1. Cautiously give your child processed foods and food prepared outside of the home as particularly chocolate, confectionery, unlabelled foods and restaurant fare always
    represent a risk.
  2. Read all labels very carefully when purchasing food (see safe food) as ingredients and manufacturing processes may change. Remember the “may contain… warning” is not very discriminating and gives no indication whether the risk is substantial or minimal.
  3. Advise family, party hosts and caterers well in advance of a gathering about your child's allergies and that the risk extends to contaminated cooking surfaces and
    serving bowls. Advise them about problem foods and safe alternatives.

In Case of a Reaction

  1. A MEDICALERT® bracelet that your child wears can provide vital information about the nature of the problem in an emergency.
  2. Always carry an EpiPen® (self-administrable adrenaline) and make sure that those who are with your child are aware of his/her allergies and the need to administer the EpiPen®. An adult caregiver should always assume responsibility for administering an EpiPen®.
  3. Educate all caregivers about the signs of an anaphylactic reaction and have an action plan in the event of an accidental contact reaction.
  4. Children (and adults) should never leave a group to go to the bathroom on their own if they have symptoms of a food allergy reaction.
  5. Keep a check on the expiration date of the EpiPen® and the color of the fluid in the barrel according to the manufacturer's instructions, as the adrenaline has a limited shelf life.
  6. Note that exposure to heat above 30°C may degrade the adrenaline; this means that adrenaline should not be carried in a car, too near the body in a pocket, or to the beach without adequate insulation.

4 “Food Allergies: Advice from your Allergist,” ACAAI: American College of Allergy, Asthma, & Immunology
5 Allergy Basics, Provided with permission from The Food Allergy & Anaphylaxis Network.
6 Soutter, Swain, and Loblay, “Peanut Allergy"
7 Ibid.


3. About Anaphylaxis

Anaphylaxis is an allergic emergency. It is a rapid, severe allergic reaction that occurs when a person is exposed to an allergen. When the allergen enters the bloodstream the body releases chemicals to “protect” itself from the allergen. These chemicals can cause dangerous symptoms, including breathing difficulty, swelling, dizziness, shock, and even death.

Common warning signs of anaphylaxis are as follows:

  • Tingling, itching or metallic taste within the mouth
  • Hives, swelling of mouth and/or throat
  • Vomiting, diarrhea, abdominal cramps
  • Difficulty breathing, feeling of impending doom, drop in blood pressure, loss of
    consciousness

Anaphylaxis is considered a medical emergency because death can occur within minutes; it requires immediate attention. The drug epinephrine is the preferred treatment for anaphylaxis and is available only by prescription. Given as an injection, via the EpiPen®, epinephrine rapidly constricts the blood vessels, relaxes the lung muscles to improve breathing, reverses swelling, and stimulates the heartbeat. The sooner anaphylaxis is treated, the greater the likelihood of survival. Therefore, you should be able to reach an EpiPen® within seconds whenever you are with a child with severe food allergies. Keep an EpiPen® with you at all times. It may be a good idea to store an EpiPen® unit wherever the child spends a lot of time, like at home, day care and school.


4. About Eczema8

(The following are directions for young patients with eczema. Use these notes as guidelines only. Please contact your allergist to amend the directions to suit your child's individual needs.)


Diet

  • Evaluation for offending food triggers is important!
  • Foods, especially milk, eggs, wheat, chocolate, oranges, nuts, peanuts and tomatoes are often a factor. In younger children, soy, and corn are also often factors.
  • An allergy elimination diet with a “serial oral re-challenge”-(reintroduction of one offending food at a time for a period of three to four days while carefully monitoring symptoms) may be necessary.
  • Children often outgrow food sensitivities. Be sure to discuss appropriate re-evaluation with your physician in order to avoid over-restricting your child's diet for
    longer than is really necessary.

Skin Care
Clothing

  • New articles of clothing for your child are best washed before worn.
  • Dreft detergent is preferable.
  • No fabric softeners or strong laundry soaps of any kind should be used.
  • Best to avoid dressing your child in wool, tight clothing, “rubberized” or elastic items, and sometimes polyester (especially bare or exposed stitches.)
  • Cotton clothing should be worn next to the skin.
  • Double rinse when doing your child's laundry (two or three rinse cycles).

Bath

  • For children with very dry skin, decrease water exposure to two-three times per week, and limit duration of water exposure to less than ten minutes at any given time.
  • Cetaphil bath substitute may be used (yes, one will smell clean and the skin will also actually be cleansed without the drying effects of water).
  • Best to bathe your child before or after supper, or at least one hour before bedtime. The skin is too warm immediately after a bath to get right into a nice, warm bed. Prurititis would result from doing so.
  • Bath water should not be too hot-this increases histamine release into the skin, and increases pruritis. Bath water should be tepid (room temp) or cool.
  • Do not use commercial alkaline soap. Hypoallergenic soap or sudsing agents (Aveeno- bar, Neutrogena, Basis) are preferable.
  • Avoid deodorant or perfumed soaps; they are very harsh.
  • If necessary, add emulsified oil or oatmeal colloid to the bath water.

Lubricants and Emollients

  • Be certain to make the application of an overall lubricant a routine part of your child's day.
  • The best emollient for any individual is often a trial and error process. Your physician, after examining the skin, will have a better idea of which lubricant might best suit your child's needs.
  • Ointments are used for thicker skins, while creams tend to be most beneficial for the mild-moderate eczema cases. Lotions often are ineffective as the skin “drinks” the lotion immediately, not allowing for maximal efficacy.
  • It is not unusual for a patient to have to change creams (“rotate” creams, much as you would alternate anti-histamines) to allow the skin to respond maximally to the prescribed treatment. Some work for a while, and then a substitute needs to be made.

Scratching

  • DON'T SCRATCH!
  • If your child is “itchy,” pat or slap gently. Do NOT scratch, as it destroys the top layer of the skin, and 1) allows for skin infection and 2) worsens the eczema!
  • You may use ice or cool compresses to relieve itching.
  • Avoid bath brushes.
  • Avoid “reflex” or “habit” scratching.
  • An anti-itch medicine is important if your child tempted to scratch.
  • Children should be given an anti-itch medicine before bedtime. Clean white socks may be affixed to a child's hands (once asleep), and prevents excoriation of the skin that may occur with overnight scratching.

Sunlight

  • In moderation, it may be beneficial.
  • Avoid sunburn!
  • Avoid excessive heat. Perspiration may irritate the eczema.
  • PABA-FREE sun lotions (screens) are recommended. Carefully test sunscreen lotions on a small area of the skin before applying generally.

Swimming

  • Avoid Jacuzzis, hot steam baths, and the sauna-they may worsen the eczema.
  • Swimming is beneficial for select patients. Showering immediately after chlorine
    exposure, and applying a lubricant all over the body immediately afterwards are
    definite musts.

Cosmetics

  • Avoid perfumes.
  • Use non-perfumed lipsticks.
  • Use very simple shampoos-Neutrogena is recommended.
  • Use hypoallergenic deodorants, avoid antibacterial deodorants.
  • Avoid acrylic nails and be very careful what agents are used on nails for manicure.

Medications
Oral medications may be used to help control eczema.

Anti-histamines

  • These are extremely helpful in reducing itching, promoting mild sedation, and perhaps protecting the skin from the action of the histamine.
  • These should NOT be applied in ointments (i.e. Caladryl) on the skin as they may cause allergic reactions.
  • These are particularly important to be used at night when subconscious scratching takes place.

Antibiotics

  • Oral antibiotics are indicated when the eczema becomes infected (often heralded by oozing, dark red or purulent lesions, scratching of scab marks, yellow crusting, painful lesions, and/or malodorous discharge from the affected areas.)
  • Should not be applied topically.

Lubrication

  • Water-washable creams and ointments, Vaseline, vegetable oils and a variety of other ointments may be recommended on an individual basis.
  • Best to avoid lanolin and paraben-containing medications.
  • Read all labels carefully.

Cortisone-like Medication

Topical

  • Used by most physicians as creams or ointments to severely affected areas except the face, mucous membranes and genitals, where special prescribing rules apply.
  • Systemic absorption is variable depending upon multiple factors (the condition of the skin at the time of application, whether the area is occluded after application, whether an emollient is pre-mixed with the steroid, what type of steroid is used, etc.) Systemic absorption can certainly be minimized-speak with your physician regarding specific recommendations which would be appropriate for your child's specific needs.

Oral

  • Occasionally oral steroids may be needed to decrease the inflammation of moderately severe eczema. Usually only a short course is necessary. The appropriate use of steroid by your physician may actually allow for less overall exposure to medication, and may increase subsequent control over the eczema.

FLARE-UPS (EXACERBATION OF ECZEMA) AND CHANGES:

  • Immediately report any severe flare-ups of eczema. Your physician needs to know when there is any significant change from the normal course of events!

Remember! Your physician is not a mind-reader. If the eczema is out of control, it is time to have the specialist re-evaluate to decide on a change of treatment “game plan.” Keep skin cool, calm, and comfortable-eczema is essentially an “itch that rashes”-DON'T SCRATCH!


8 “Treating Eczema”, by Catherine G. Fuller, M.D., Board Certified Asthma and Allergy.



5. Guide to Elimination and Challenge Diets

Elimination and challenge diets can be extremely helpful in understanding which food is responsible for an allergic reaction, as they are an effective way to determine food sensitivity. Offending foods should be eliminated! Although the number of foods in your child's diet may be limited, it is possible with imagination and ingenuity to prepare a tasty and interesting meal that your child will love. Food appeals to all the senses, so a colorful presentation is extremely important in stimulating the appetite. Please contact your physician before implementing an elimination or challenge diet. And, make sure you test for allergies twice a year, as children often grow out of allergies, and you do not want to over-restrict their food intake.