Children who are allergic to food are found to be suffering from anxiety and are increasingly more lonely; One allergic child out of five never attends peers’ parties, while one in four always brings along “safe” food. The burden of food allergies and the risk they can escalate to life-threatening diseases is particularly heavy on children, whose normally active and sociable lifestyle can be severely limited and frustrated by the effort to keep them away from potentially dangerous food.
According to a study presented at the 2011 Food Allergy and Anaphylaxis Meeting by the European Academy of Allergy and Clinical Immunology (EAACI), held Feb 17-19 in Venice, Italy, 23 percent of allergic children are no longer curious to try new food to vary their diet, considered too monotonous by most of them. A child out of ten also gives up crucial physical activity for fear of anaphylactic shock triggered by exercise.
“About 17 percent of allergic children, regardless of their age, never go to a party or a picnic with friends, while 24 percent are forced to bring along something to eat,” says Prof. Maria Antonella Muraro, Chair of the EAACI Meeting. The study, headed by Prof. Muraro, was carried out by the Center for the study and treatment of allergies and food intolerances at the hospital of the University of Padua, Italy on 107 young patients and their mothers.
“Also, 5 to 15 per cent of cases of anaphylactic shock can be triggered by physical activity following the consumption of small amounts of allergenic food that would otherwise be harmless, so one allergic child out of ten also stops every kind of exercise,” Prof. Muraro added. “Allergies are often downplayed as a minor problem, but the life of an allergic person can be hell. Allergic children show to be more afraid of being sick and a higher level of anxiety about food than children with diabetes. The constant alarm surrounding them is taking a toll on their development and well-being.”
Another worrisome problem adding to the poor quality of life of allergic patients, especially the younger ones, is the need to carry life-saving devices at all times, such as epinephrine auto-injectors, “loaded” with enough drug to prevent death in case of severe anaphylactic shock. They are easy to use, light to carry and discreet, but one out of three patients still leaves home without them.
“Within 8 or 10 minutes the shot reverses the symptoms, ranging from urticaria to respiratory distress, cardiovascular collapse and gastrointestinal problems including vomiting and diarrhoea,” explains Prof. Muraro. “It can cause minor side effects, such as irritability or tremors that end as soon as the adrenaline is processed by the body, generally within a couple of hours. Patients should not be scared, even those who have a heart disease: the possible side effects are negligible in comparison to the opportunity to save your life.”
There is no scientific evidence that complementary therapies or kits sold through websites can identify allergies, the UK NHS watchdog NICE says. It says sites for services such as hair analysis use plausible stories but are not backed up by scientific evidence. It is publishing new guidance to help doctors in England and Wales identify when a child may have allergy problems. NICE says some parents end up turning to alternative therapies after a perceived lack of help from their GPs.
It is estimated that one in 20 young children has a food allergy. Dr Adam Fox, an allergy specialist based at the Evelina Children's Hospital in London, says not all children suffer immediate and obvious symptoms. “Food allergies can actually be extremely subtle. Lots of children have eczema, colic or spit up more food than usual. For some of those children the underlying problem is an allergy to something within their diet.”
The guidelines include detailed advice about how to recognise symptoms and when to refer to specialists. Dr Fox, who helped write the guidelines for National Institute for Health and Clinical Excellence (NICE), says he often sees parents in his specialist clinic who have wasted money on complementary or alternative tests.
The review by NICE looked for any scientific research of the usefulness of approaches including hair analysis and Vega testing, which uses mild electric currents, or kinesiology, in diagnosing allergies in children. “The websites are very well put together, the stories behind them are plausible, but we were unable to find any evidence to support them,” says Dr Fox. He says there are two types of testing used in NHS clinics – skin prick and blood sample – which are backed by scientific research. NICE is warning that parents sometimes turn to alternative tests when they have failed to convince their family doctor to listen to their concerns.
It took Alison Berthelson more than two years to get an allergy diagnosis for her first son Harris. She had been to the local surgery several times when he suffered rashes and stomach upsets without any particular cause being identified. After Harris ate a small piece of chocolate containing nuts he suffered a more extreme reaction, becoming agitated, with an extreme rash covering his entire body. The out-of-hours GP gave her son a medicine to reduce swelling, but did not send him on to hospital as an emergency. “It was really very terrifying, terrifying at the time because we didn't know what was happening, and terrifying later when we did know what had happened and how lucky we were.” A new GP correctly diagnosed possible food allergies, and sent Harris for testing at a specialist NHS clinic. He now has to avoid nuts, sesame and some other ingredients used in prepared foods.
Allergies on rise The number of children suffering from food allergies appears to be increasing, although experts are at a loss to understand exactly why. Family doctors are now more likely to see very young children suffering allergic reactions. Dr Joanne Walsh, a GP involved in drafting the advice, says she now sees several children a week with suspected allergic reactions. Some are babies just a couple of weeks old. By gradually eliminating, and reintroducing different foods, she can help parents manage the allergy without the need for hospital visits. “There's nothing more rewarding than a parent coming back and saying it's like having a different child.”
Eating more fruits and vegetables may not protect children from developing allergies, according to a large Swedish study that questions earlier hints of benefit. Fruits and vegetables are rich in antioxidants, which are thought to reduce airway inflammation. So recent studies reporting less asthma, wheezing and hay fever among children who consumed more produce appeared to make sense.
But not all research has found that link, and the studies that did may have had a surprising flaw, said Helen Rosenlund of Karolinska Institutet in Stockholm, who led the new study. She said some proteins in fruits like apples and pears resemble the pollen parts that trigger hay fever, meaning that kids might react to both. In other words, existing allergies may have caused them to eat around the produce, rather than the other way around. “This could confuse research findings,” explained Rosenlund, “falsely suggesting that diets with fewer fruits and vegetables result in more allergic disease.”
To find out if this was the case, Rosenlund and her colleagues looked at data on nearly 2,500 eight-year-olds who had participated since birth in a larger Swedish study. Based on blood tests and questionnaires filled out by parents, the researchers found that seven percent of the children had asthma. The rates of hay fever and skin rashes were more than twice as high. The average child ate between one and two servings of fruit, and between two and three servings of vegetables each day.
At first glance, some produce did seem helpful: Kids with the biggest appetite for fruit had less than two-thirds the odds of developing hay fever than those who ate the least amount. Apples, pears and carrots appeared to be particularly helpful, the researchers report in the Journal of Allergy and Clinical Immunology, but there was no such link for vegetables overall. However, it turned out that half the children with hay fever were sensitive to birch tree pollen, one of the pollens known to resemble the proteins in apples and carrots. And sure enough, after the team repeated their analysis excluding the 122 kids with food-related allergy symptoms, the hay fever link disappeared as well. “Fruits do not seem to offer protection against allergic if diet modifications are considered,” say Rosenlund.
The researchers say more studies are needed, particularly in other parts of the world that may have a different variety of allergy triggers, or allergens. And they advise those studies should not forget to look at how allergies might influence what participants eat. “Studying diet it is not so easy when it comes to the relation with allergic disease,” Rosenlund said, “because it is such a complex disease pattern.”
SOURCE: bit.ly/g3DpI7 The Journal of Allergy and Clinical Immunology, online January 10, 2011.
Food allergies, by some accounts, affect about 4 percent of adults and 5 percent of children under the age of 6 in the United States, though this study raises questions about the reliability of such figures.
Food allergies can cause a variety of problems, ranging from mild skin rashes or nausea to a life-threatening, whole-body reaction known as anaphylaxis. The allergies can also have serious effects on patients' social interactions, school and work attendance, family economics and overall quality of life. “It's a life-defining diagnosis in a way,” said Chafen.
The National Institute of Allergy and Infectious Diseases is working on new clinical practice guidelines and, as part of its efforts, enlisted Chafen and her colleagues to review the current evidence on food allergies.
The researchers started their work by sifting through thousands of scientific papers, published between 1988 and 2009, that focused on the four foods — milk, eggs, fish and peanut and tree nuts — responsible for more than half of all allergies. They ultimately reviewed 72 studies, including one meta-analysis on prevalence, 18 studies on diagnosis, 28 studies on management, and four meta-analyses and 21 additional studies on prevention.
When examining the literature, the researchers found there was no universal definition of “food allergy,” in spite of NIAID's defining it as an “adverse immune response” that is “distinct from other adverse responses” such as a food intolerance. In fact, 82 percent of the studies provided their own definition of food allergy.
“This validates the idea that there exists a great deal of complexity and confusion in the field of food allergy, even at the level of the medical literature,” said co-author Marc Riedl, MD, MS, section head of clinical immunology and allergy at UCLA.
Along the same lines, there was a lack of uniformity for criteria in making a diagnosis. The current gold standard is the food challenge, during which a physician gives a patient a sample of the suspected offending food, sometimes in capsule form, and then monitors for allergic reaction. However, this test requires specialized personnel, is expensive and has a risk of anaphylaxis. Office-based tests were used to diagnose many patients; these include a skin-prick test, during which a dilute extract of the potential allergen is placed on the skin, and a blood test that determines the presence of food-specific allergic antibodies known as IgE.
As the researchers discuss in their paper, the concern with the latter two tests is that they're not definitive: Patients with non-specific symptoms, such as a rash or digestive troubles, and positive skin-prick or blood tests actually have less than a 50 percent chance of having a food allergy. In order to make a proper diagnosis, they pointed out, physicians need to evaluate the data within the context of a patient's history and have a great understanding of symptoms consistent with true food allergy.
What this means, then, is there is a potential for the overdiagnosis of food allergy.
“I frequently see patients in my clinical practice who have food intolerance, but have previously had inadequate or inappropriate evaluation and been told they have a 'food allergy',” said Riedl. “This causes a great deal of unnecessary anxiety and concern for the patient.”
Previous studies have tried to determine whether the skin-prick or blood test is superior over the other, but in reviewing the evidence, Chafen and her colleagues found “no statistical superiority in either test.” They also found generally inconclusive results from 10 previous studies in which the tests were combined, in an effort to improve diagnostic accuracy.
“I was very surprised,” said Chafen. “I'm a general internist and I thought diagnostic strategies were more-studied.”
In terms of treatment, Chafen said expert opinion is that an elimination diet — having the patient stop consuming the food that causes the allergic reaction — is the most common. Although the approach is a common-sense one (“If a patient breaks out in hives repeatedly after drinking milk, it's your instinct as a physician to say, 'Don't drink milk,'” Chafen said), the researchers found the treatment hasn't been well-studied.
It would be unethical to conduct controlled studies of elimination diets for patients with serious, life-threatening allergic reactions, but as pointed out in the paper, there are few studies of this approach on patients with relatively minor symptoms.
“In these instances, the benefits of an elimination diet are uncertain based on published evidence and potential benefits need to be weighed against the potential nutritional risks of such a diet, particularly in children,” the researchers wrote.
Chafen and her colleagues also found that immunotherapy, a treatment in which the body's immune system is altered by administering increasing doses of the allergen over time, appeared to be effective at eliminating symptoms in the short term. Immunotherapy isn't a licensed method for allergy treatment, but the researchers urged more study on its long-term effect and safety.
In all, the researchers concluded, the food-allergy field is in need of uniformity in the criteria for what constitutes an allergy and a set of evidence-based guidelines upon which to make this diagnosis. NIAID, which put together an expert panel and has reviewed the group's analysis, is planning to finalize such guidelines later this summer.
As for Chafen, who sees patients with potential food allergies, these findings have encouraged her to rely more on specialists to help clinch a diagnosis. “People need to be seen by someone with a deep understanding of diagnostic tests and criteria,” she said. “The distinction between food intolerance and food allergy is really important.”
The study was funded by NIAID. Other Stanford authors on the study are Dena Bravata, MD, a PCOR affiliate; and Vandana Sundaram, MPH, assistant director of research for CHP/PCOR. Paul Shekelle, MD, PhD, with the RAND Corp.'s Southern California Evidence-Based Practice Center and the West Los Angeles VA Medical Center, is the senior author.
Tips for Managing Food Allergy
Get a professional diagnosis. Don't try to diagnose a food allergy yourself. If you suspect that your child has a food allergy, discuss this with your doctor. He or she can advise you accordingly and may refer you to an allergist for additional testing and treatment if needed. You should work with your doctor and/or allergist to develop an action plan for managing the allergy through indicating which foods your child should avoid, and possibly prescribing medication, such as an antihistamine or, for severe reactions, self-injectable epinephrine (EpiPen® or Twinject®).
Pass around the plan. Give your child's food allergy action plan to people who regularly see your child, including relatives, caregivers and their friends' parents.
See an Accredited Practicing Dietitian. An APD like Nastaran can help you and your child identify foods and ingredients to avoid, and develop an eating plan to ensure your child gets all the nutrients needed to grow and develop properly. For example, if your child is allergic to milk, the dietitian will recommend other calcium-containing foods and beverages.
Always read food labels. Always read food labels to see if the product contains any of the eight major allergens, or other ingredients your child is allergic to. Since food and beverage companies continually make improvements, read the label every time you purchase a product. Teach your child how to read labels, too.
Get support at school. Meet with staff at your child's school to review and distribute your child's food allergy action plan. At minimum, involve your child's primary teacher, the school nurse (if there is one), and key food service staff. Make sure all supervisory staff your child sees during the school day and during after-school activities have a copy of the plan. It is highly recommended that school administrators, teachers, and even food service staff are aware of the food allergy action plan in the absence of a school nurse.
Be cafeteria cautious. Go over the school lunch menu with your child to identify foods to avoid. Work with food service staff to plan substitutions or pack a lunch for your child to take to school. Remind your child not to share or trade food with others and make sure they know which staff can help if they have questions about a food, or if they have a reaction to a food. Be sure your school food service staff has copies of the School Foodservice and Food Allergies information sheet and review it with them when you talk to them about your child's food allergies.
Ask questions when eating out. Most life-threatening allergic reactions to foods occur when eating away from the home. Explain your child's situation and needs clearly to your host or food server—and teach your child to do the same when you're not with them. If necessary, ask to speak with the chef or manager. Some fast food restaurants provide a list of the ingredients in their menu items, as well as information on whether any of the eight major allergens are present.
Keep an allergy-safe kitchen. Rather than singling out your food-allergic child, prepare allergy-free recipes the whole family will enjoy.
Make peers “allergy allies.” Encourage your child to talk openly with friends and classmates about their allergy, what foods they must avoid, and what could happen to them if they don't. Suggest that your child enlist their friends in helping them “stay on the alert” for foods in question so they won't get sick.
Most importantly, be ready for emergencies. Teach your child the possible symptoms of a serious allergic reaction (anaphylaxis), such as difficulty breathing or swallowing, or tingling in the hands, feet, lips or scalp. If they experience symptoms after eating a food, make sure they know to immediately call 0-0-0 and, if prescribed by your allergist, use their medication to treat the reaction. If possible, have your child wear a medical alert bracelet or necklace that identifies the specific allergy. Every few months, “role play” an allergic reaction to make sure your child knows what to do.
For more information and resources on managing food allergies see Nastaran or your doctor.
Source: International Food Information Council