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Peanut Allergic Reaction Case Study

Peanut is one of eight allergens with specific labeling requirements under the Food Allergen Labeling and Consumer Protection Act of 2004. Under that law, manufacturers of packaged food products sold in the U.S. and containing peanuts as an ingredient must include the presence of peanuts, in clear language, on the ingredient label.

To avoid the risk of anaphylactic shock, people with a peanut allergy must be very careful about what they eat. Peanuts and peanut products are commonly found in candies, cereals and baked goods, such as cookies, cakes and pies. If you’re eating out, ask the restaurant staff about ingredients - for example, peanut butter may be an ingredient in a sauce or marinade. Be extra careful when eating Asian and Mexican food and other cuisines in which peanuts are commonly used. Even ice cream parlors may not be safe for people with a peanut allergy, since peanuts are a common topping.

Foods that don’t contain peanuts as an ingredient can be contaminated by peanuts in the manufacturing process or during food preparation. As a result, people with a peanut allergy should avoid products that bear precautionary statements on the label, such as “may contain peanuts” or “made in a factory that uses nut ingredients.” Note that the use of those advisory labels is voluntary, and not all manufacturers do so.

If you’re cooking from scratch, it’s easy to modify recipes to remove peanut ingredients and substitute ingredients that aren’t allergens, such as toasted oats, raisins or seeds. Some people who can’t tolerate peanuts or eat peanut butter can consume other nut or seed butters. Keep in mind that these products may be manufactured in a facility that also processes peanuts - so check the label carefully and contact the manufacturer with any questions.

Many individuals with an allergy to peanuts can safely consume foods made with highly refined peanut oil, which has been purified, refined, bleached and deodorized to remove the peanut protein from the oil. Unrefined peanut oil - often characterized as extruded, cold-pressed, aromatic, gourmet, expelled or expeller-pressed - still contains peanut protein and should be avoided. Some products may use the phrase “arachis oil” on their ingredient lists; that’s another term for peanut oil. If you have a peanut allergy, ask an allergist whether you should avoid all types of peanut oil.

While some people report symptoms such as skin rashes or chest tightness when they are around or smell peanut butter, a placebo-controlled trial of children exposed to open peanut butter containers documented no systemic reactions. Still, food particles containing peanut proteins can become airborne during the grinding or pulverization of peanuts, and inhaling peanut protein in this type of situation could cause an allergic reaction. In addition, odors may cause conditioned physical responses, such as a skin rash or a change in blood pressure.

Can peanut allergy be prevented?

In 2017, the National Institute for Allergy and Infectious Disease (NIAID) issued new updated guidelines in order to define high, moderate and low-risk infants for developing peanut allergy. The guidelines also address how to proceed with introduction based on risk in order to prevent the development of peanut allergy.

The updated guidelines are a breakthrough for the prevention of peanut allergy. Peanut allergy has become much more prevalent in recent years, and there is now a roadmap to prevent many new cases.

According to the new guidelines, an infant at high risk of developing peanut allergy is one with severe eczema and/or egg allergy. The guidelines recommend introduction of peanut-containing foods as early as 4-6 months for high-risk infants who have already started solid foods, after determining that it is safe to do so.

If a child is determined to be high risk, the new guidelines recommend evaluation by an allergy specialist, which may involve peanut allergy testing, followed by trying peanut for the first time in the specialist’s office. If a child is tested and found to have peanut sensitization, meaning they have a positive allergy test to peanut, from that positive test alone, the specialist still won’t know if they’re truly allergic. Peanut allergy is only diagnosed if there is both a positive test and a history of developing symptoms after eating peanut-containing foods. 

A positive test alone is a poor indicator of allergy, and studies have shown infants who have a peanut sensitivity aren’t necessarily allergic. The updated guidelines recommend that infants with a positive peanut skin test have peanut fed to them the first time in the specialist’s office. Some infants may have a large reaction to the skin test (8 mm or larger) which could indicate they are already peanut allergic.  An allergist may decide not to have the child try peanut at all if they have a very large reaction to the skin test. Instead, they might advise that the child avoid peanuts completely due to the strong chance of a pre-existing peanut allergy. Other allergists may still proceed with a peanut challenge after explaining the risks and benefits to the parents.

Moderate risk children – those with mild to moderate eczema who have already started solid foods – do not need an evaluation. These infants can have peanut-containing foods introduced at home by their parents starting around six months of age. Parents can always consult with their primary health care provider if they have questions on how to proceed. Low risk children with no eczema or egg allergy can be introduced to peanut-containing foods according to the family’s preference, also around 6 months.

Parents should know that most infants are either moderate- or low-risk for developing peanut allergies, and most can have peanut-containing foods introduced at home. Whole peanuts should never be given to infants as they are a choking hazard. More information can be found here, and also in the ACAAI video, “Introducing peanut-containing foods to prevent peanut allergy.”

A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

CASE 1 DIAGNOSIS: ALLERGY BULLYING

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient’s asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient’s school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [1]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff (2).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) (2) and an overall decrease in quality of life measures (1). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this (3). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents (1). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

  • www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

  • www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

  • www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

CLINICAL PEARLS

  • Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

  • Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

  • Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

REFERENCES

1. Shermesh E, Annunziato RA, Ambrose MA, et al. Child and parental reports of bullying in a consecutive sample of children with food allergy. Pediatrics. 2012;131:e10–e17.[PMC free article][PubMed]

2. Lieberman J, Weiss C, Fulong T, Sicherer M, Sicherer S. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2010;105:282–6.[PubMed]

3. Marrs T. Why do few food-allergic adolescents treat anaphylaxis with adrenaline. Pediatr Allergy Immunol. 2013;24:222–9.[PubMed]

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