Thursday, Feb. 26, 2009
By Alice Park
Susan Fradin has nightmares about Cheerios. Specifically, the Honey Nut variety. Her son Noah is allergic to peanuts and almonds, and her nighttime torment began during his first trip to sleepaway camp, when he was 9. Fradin, a former publicist in Los Angeles, worried that her son would eat cereal he shouldn't and go into anaphylactic shock. "I woke up in the middle of the night thinking, What if he eats Honey Nut Cheerios thinking they are regular Cheerios?" she says.
Yes, Fradin is one of those incredibly anxious parents who would prefer that her son never so much as lay eyes on a Mr. Peanut logo ever again. Noah's allergist at UCLA, Dr. Gary Rachelefsky, who has treated him since babyhood, describes her as initially "one of the most fearful mothers I ever came into contact with." She's calmer these days, but her concerns are not unfounded. A few months before Noah went off to camp, she woke up one night to find him covered in hives, coughing and gasping, and she had to jam a syringe full of epinephrine into his thigh to help him breathe. "It was horrendous," says Fradin. (See 9 kid foods to avoid.)
Noah is now 16 and a surprisingly well-adjusted member of what might be called the Allergy Generation. In addition to peanuts, he is allergic to lentils, beans, peas, tree nuts, sesame and shellfish. The Fradins and the 3 million other families in the U.S. with food-allergic children have to navigate not only the complexities of the grocery aisle but also the growing skepticism among those who wonder if the sudden rise in food allergies is due more to hysteria than to histamines. A waiter, for example, may not grasp the seriousness behind Noah's endless questions about the menu. "I just need to spend a little more time ordering and talk about how I could die," he says.
As more and more schools set up peanut-free zones and as food manufacturers add warning labels that their products might contain particles of peanuts, soy or other allergens, the abundance of caution is starting to trigger a backlash. Given all the attention paid in recent years to food allergies, the number of people in the U.S. who die from them--15 to 20 a year--is relatively small. More people die each year from bee stings. "But we don't remove flowers from schools or playgrounds," Dr. Nicholas Christakis, a professor of medical sociology at Harvard Medical School, commented recently in the British Medical Journal. When asked about his editorial, which he wrote after his son's school bus had to be evacuated because someone spotted a peanut on board, he said, "We should be having a sober-minded, public-health debate, and instead the overresponse to food allergies is preposterous."
Christakis notes that peanut and other food allergies are a real problem; it's the community reaction to them that is getting out of hand. According to the Centers for Disease Control and Prevention (CDC), the percentage of U.S. children under 18 with a reported food allergy jumped 18% from 1997 to 2007, and the number of children hospitalized for food allergies has nearly quadrupled in recent years. So forget pet dander and pollen. "In this day and age, allergy in pediatrics is all about food, food, food," says Dr. Allen Lapey, a pediatrician at Massachusetts General Hospital. Each year, 30,000 people in the U.S. are rushed to the emergency room suffering from an allergic reaction to food. And while these allergies are rising among all major racial and ethnic groups, they are climbing fastest among Hispanic children, according to new data from the CDC.
See the top 10 food trends of 2008.
Read "The Peanut Butter Sandwich Under Threat."
The trend is not an entirely American phenomenon. European nations have posted increases similar to the one in the U.S., and in a study of the relatively confined residents of Britain's Isle of Wight, rates of peanut allergies among toddlers doubled from 1989 to 1994. While prevalence in Asian countries, where peanuts are a popular dietary add-in, remains low, experts warn that could simply be the result of spottier awareness, diagnosis and reporting of allergic reactions in those nations. (Read "Allergies Nothing to Sneeze At.")
What's behind the rise in food allergies? Has a generation of kids, or their moms, been exposed to things in the environment or in their diets that could make them more sensitive to certain food proteins? Perhaps. Allergies are the direct result of too much IgE, an immune-system component that serves as the body's supersonar for detecting any foreign and potentially harmful proteins. To signal the need to annihilate these invaders, IgE attaches like antennae to the surface of cells that release histamines and other inflammatory agents. In mild cases, the result is a rash and hives. In others, blood pressure drops and fluid builds up in tissues, leading to swelling. Airways can constrict, triggering coughing and eventually respiratory distress and even death. Once a massive IgE cascade is activated, only a shot of the hormone epinephrine, a.k.a. adrenaline, can stop a hypersensitive immune system from killing the body it set out to protect.
So why are children making so much IgE these days? Part of the fault may lie in modern medical practices: with antibiotics and immunizations to protect against micro-organisms and parasites, children's immune systems may be getting weaker and even bored, with little or nothing to fight. This theory was first posited 20 years ago by a British epidemiologist who noticed that children with more siblings had less hay fever than kids in smaller (and presumably less snot- and germ-laden) families. It could explain the climbing incidence of all allergies--not just those to foods--as well as asthma. Sanitation can't demystify the entire trend, but the so-called hygiene hypothesis remains the leading answer to baffled parents' questions.
For families like the Fradins, however, knowing the why of food allergies is less important than knowing whether their children will be affected--and how. (Noah has a brother who has no food allergies.) Because allergic reactions to food can vary, even within the same person, allergists often shrug when it comes to advising parents about forecasting anything about their child's next reaction. "We really have no test that can tell us who is apt to have a severe, life-threatening reaction and who is more like the vast majority who will never have that kind of reaction," says Dr. Hugh Sampson, director of the Jaffe Food Allergy Institute at the Mount Sinai School of Medicine in New York City.
Even the act of diagnosing allergies has become a source of confusion. Increasing reliance in recent years on a blood-based test instead of the classic skin-prick screening means that not just allergists but also pediatricians can find out if children are carrying IgE antibodies for certain foods. But some positive tests may be false alarms that lead families to spend a lot of energy avoiding common foods that their kids can actually tolerate.
See pictures of what makes you eat more food.
Read "Tips for Hosting an Allergic Child."
Given the uncertainty in the medical world, it's easy to understand the frenzy outside the doctor's office. Too often parents of newly diagnosed children aren't given enough information about when and even how to inject the lifesaving epinephrine. "Our allergist said, 'Here you go. Here's a prescription and see you in a year,'" says Dena Friedel, an Ohio mom whose daughter was diagnosed with a peanut allergy when she was 2. When her daughter had a reaction several months later, Friedel didn't know when to use the syringe and called 911 instead. The EMT told her she had made the right decision, but when they reached the hospital, "the doctor yelled at me and said I should have used the EpiPen," she says. "I was so confused and overwhelmed." (See the most common hospital mishaps.)
Reports in 2005 of a peanut-allergic girl who died from anaphylactic shock after kissing her boyfriend, who had eaten some peanut butter hours beforehand, raised alarms that the slightest exposure could prove fatal. It turned out that the girl also had asthma, a dangerous combination, since the lungs of asthmatics are more prone to swelling and shutting down when aggravated. Contact--in kissing, for example--through mucous membranes can also heighten the chances of an attack. For the most part, touching a food allergen is not a problem unless you then rub your eyes or stick your fingers into your mouth--both of which young children are fond of doing. Even so, parents' worries about the mere possibility of inhaling peanut dust prompted airlines to stop serving the popular flight snack. There has been no such treatment for passengers with milk or egg allergies, which are more common but also more likely to be outgrown. Moreover, smaller amounts of peanut protein can trigger allergic reactions in those who are sensitive, and peanuts are also more likely to result in fatalities than are other food allergens.
Still, very few people with a peanut allergy die from it. In fact, a 2003 study led by Dr. Scott Sicherer, a Mount Sinai pediatrician, showed that 90% of peanut-allergic children who got peanut butter on their skin developed nothing more than a red rash; none developed a systemic reaction in which their airways swelled up. The same went for smelling peanuts. Thirty peanut-allergic children were asked to sniff peanut butter and a placebo paste for 10 minutes each, and none developed a reaction to the peanut butter. Only one child had difficulty breathing--and that was after sniffing the fake peanut butter.
Such studies are starting to suggest a more nuanced way of handling the peanut problem in schools and other places. "You are probably better off teaching the faculty how to manage food allergies than making the classroom or school a peanut-free zone," says Dr. Sean McGhee, a pediatrician at Mattel Children's Hospital at UCLA. "To my knowledge, there aren't any studies where peanut-free zones decrease the incidence of anaphylaxis."
In some instances, peanut-free zones seem downright silly. Upon request, Delta and Northwest airlines will set up a peanut-free buffer zone spanning three rows in front of and behind an allergic passenger. (Why three rows instead of four or five?) Foodmakers have also gone a little overboard. In 2006 a federal law started requiring companies to use plain language to note the presence in their products of any of eight major allergens: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat and soybeans. But concern about liability claims led manufacturers to voluntarily supplement these labels with alerts on products that were made in the same facility or on the same machinery as food containing any of the eight allergens. The result is ubiquitous warnings about possible cross-contamination, which have made the labels essentially useless.
See the top 10 medical breakthroughs of 2008.
Read "Why We Buy the Products We Buy."
"You find yourself having to take a chance," says Noah, who continues to eat his favorite brand of pretzels even though it now carries the warning "Produced in a facility that handles peanut butter." And he's not alone. A study by Sicherer in 2007 found that 75% of food-allergic people ignored these labels when shopping, unsure exactly how great the danger of cross-contamination was. The same study also found that 1 in 10 products tested actually contained the allergen noted in the warning on the packaging.
In an effort to make food labels more useful, the Food and Drug Administration is considering a new standard that would give consumers a better sense of how much cross-contamination may have actually occurred. After holding hearings on these advisory labels last fall, the agency is now studying systems like Australia's VITAL program, in which companies voluntarily rank the risk of cross-contamination on a scale of low to moderate to high. Meanwhile, Massachusetts last year became the first state to pass legislation requiring training for restaurant staff in safe food-allergy practices to avoid cross-contamination in the kitchen. (Read "Fighting over Peanuts.")
But until more rigorous standards are in place, eating continues to be a game of Russian roulette for the food-allergic. Which is why some researchers are trying to find a better way to treat allergies than simply advising their patients to avoid certain foods. In a new strategy called oral immunotherapy, doctors try to retrain the immune system by hitting it with the offending protein enough times, in increasing doses, that the body's defenses eventually relent and accept the protein as friend rather than foe. "It's the first generation of treatment that would make people less or even no longer allergic," says Dr. Wesley Burks, chief of pediatric allergy and immunology at Duke University Medical Center. On average, children treated this way for a year are able to tolerate the protein equivalent of 15 peanuts, while the untreated group developed allergic reactions after 1 ˝ peanuts. For parents, allowing their kids to participate in the study was a leap of faith. "Doing this was the lesser of two evils," says Kimberly Carter, a Virginia resident whose daughter Hannah, 5, received a peanut-allergy diagnosis at a year old. "I was sure that at some point in her life, she was going to ingest peanuts, and there was a good chance she was going to die." Hannah recently had no adverse reaction after she downed chocolate pudding mixed with 5,000 mg of peanut protein--the equivalent of a dozen peanuts.
Hannah is now on a one-month reprieve from her daily pudding treatments; in four weeks, she will be challenged again with the same 5,000-mg dose of peanut flour. If she does not have a reaction, Burks will deem her "peanut tolerant" and allergy-free. If that happens, she will be among the first generation to conquer a food allergy. And perhaps it will be this scientific success that will provide the ultimate antidote to the hype and hyperbole. "We want people to understand what they have to do in case of an allergic reaction, but we don't want them to be so scared that they totally shelter allergic children, because that is not realistic," says Sampson. "It's a hard line to walk."
Read "The Year in Medicine 2008: From A to Z."
Read "Costly Peanut Plenty."
[This article contains a complex diagram. Please see hardcopy of magazine or PDF.]
How Food Allergies Can Affect The Body
When a hypersensitive immune system attacts proteins in peanuts or other foods that are harmless to most people, allergic reactions vary from a mild rash to anaphylactic shock, which can be fatal
1 Peanuts are first introduced to the immune system
2 The body reacts to peanut proteins by generating IgE antibodies
3 During the next encounter with peanuts, the antibodies attach to mast cells
4 IgE signals these cells to flood the body with histamines and other chemicals
Allergic reactions can include:
Histamines cause eyes and nose to run
The activated immune system triggers eczema and hives
Blood vessels become leaky, lowering blood pressure
Inflammation in the lungs can lead to difficulty breathing
Food allergies are becoming more common ...
Average hospital discharges per year of children with any diagnosis related to food allergies
... but cause fewer deaths than other hazards
Food allergies 18
Lightning strikes 48
Stings (hornets, wasps or bees) 82
Accidental drowning 3,976
Accidental poisoning 23,618
Flu and pneumonia 63,001 Sources: National Center for Health Statistics; Centers for Disease Control and Prevention