I am often asked what else can be done to help one’s child with food allergies.  I truly believe that the more you know, the more empowered you can be to help your child lead as happy and as normal a life as possible.  Below are some commonly asked questions that I hope will be helpful to you and your family, ranging from the psychological effects of food allergies in children to the latest clinical research in food allergies and how you can get involved!

How can my child help to prevent a food allergic reaction?

Once children become verbal, they can let others know that they have a food allergy.  When offered food, the children in my family with food allergies will let the person offering the food know that they have a food allergy.  They typically do not share or take food from other children or adults because even the most well-meaning person may not realize that the chocolate chip cookie they offered was contaminated with peanut butter from the peanut butter cookies they had made at the same time while using  the same spatula.  This has unfortunately happened to many a peanut allergic child.

How does a food allergy affect my child psychologically?

One study showed that having a food allergy was similar to having Type I diabetes in children.  It is important to recognize that children may feel frustrated by their food allergies as they may not be able to enjoy all the different foods that their friends and family are eating.  Some families may decide if their child is milk allergic to have a birthday cake made without milk.  Or if they go to a birthday party, a special and treasured muffin or cake is made for the food allergic child so that he or she does not feel like he or she is missing out.

How can I tell if my child is being bullied or teased because of his or her food allergy?

In one study 24% of children (and 35% five years and older) with food allergies were victims of bullying, teasing, or harassment.  For 86% of these children, the teasing, harassment and bullying occurred numerous times at school. Unfortunately, one-fifth of food allergy-related bullying involved school staff.

The children were both verbally teased and physically threatened with the food to which they are allergic. Two-thirds of the children felt sad, depressed, embarrassed and/or humiliated because of the teasing and bullying.

As a parent, you should regularly ask your child whether anyone is giving them a hard time about their food allergy.  If your child seems sad, depressed or withdrawn, you should ask them what is causing them to feel this way and get them help if needed.  Child psychologists can be very helpful in this regard. School staff should adopt a zero tolerance policy for bullying and have in place a plan for quickly dealing with bullying and teasing.  You can also engage your pediatrician and allergist to educate the school staff, parents, and children about food allergies.

Should my child wear a Medic Alert bracelet?

Absolutely.  Medic Alert bracelets are important to wear in case your child is having an allergic reaction and cannot communicate because of breathing or blood pressure problems.

We recommend that the bracelet state the following:

“Food Allergy -> Epinephrine and call 911.”  Make sure to add your contact number (e.g. cell phone number) if there is room.

Medic Alert and Lauren’s Hope make very attractive Medic Alert bracelets that are customizable to all ages.

Should I hold off on introducing certain foods to my children to prevent food allergies?

The evidence is not clear that delaying the introduction of certain foods will decrease the odds for developing food allergies. Research is currently being done to determine whether early introduction of peanuts into a child’s diet affects the development of food allergies. No results have yet been published, but when they become available they will be widely shared.

Besides strict avoidance and epinephrine are there any other treatments for food allergies?

People are becoming desensitized to food allergens by ingesting small daily, incrementally increasing doses of food allergen.  This has proven effective and relatively safe, but should only be done in a research trial.  Other treatments currently under research investigation are a traditional Chinese medication, Xolair (an anti-allergy antibody medication), recombinant food proteins, and ingestion of eggs of a parasite called whipworm.

If you are interested in food allergy research trials for your child, please look at clinicaltrials.gov.

How can I meet other families who have children with food allergies?

There are often many local support groups in the area who meet to help each other.  One such resource to help you find a support group is found on foodallergy.org.  You can also ask your allergist for tips for finding other families or support groups that may be helpful to you.

What are other resources for parents whose children have food allergies?

1. Food Allergy and Anaphylaxis Network – an excellent resource for everyone with food allergies.  They send out e-mail alerts about contaminated food products and a newsletter with very informative articles by food allergy experts.  The website also contains books, videos, and other teaching tools to educate children with food allergies as well as schools and workplaces about food allergies.  This is a must-see!
2. “Food Allergies for Dummies” by Robert Wood MD Allergist.  An excellent and detailed book for people with food allergies.
3. How to Manage Your Child’s Life-Threatening Food Allergies – Practical Tips for Everyday Life by Linda Marienhoff Coss.  Containing more than 200 pages of tips on how to manage a child’s food allergy, this book includes hundreds of easy-to-read tips, numerous checklists, sample forms, and real-life examples.
4. The Parent’s Guide to Food Allergies by Marianne S. Barber with Maryanne Bartoszek Scott, M.D., and Elinor Greenberg, Ph. D.  This book provides an extensive exploration of all aspects of food allergy management in day-to-day life. An invaluable resource for those struggling with a new diagnosis.
5. Caring for Your Child with Severe Food Allergies by Lisa Cipriano Collins, M.A., M.F.T. This informative book offers pertinent facts to help families cope with the emotional aspects of raising a child who has severe food allergies. Parents will learn both how to reduce risk while encouraging normal emotional development and how to address the needs of the child as well as the rest of the family.

As parents and caregivers, you can protect your child with food allergies by learning how to read food labels, prepare safe meals, and discuss with others your child’s food allergy to keep your child healthy.

How do I Read Food Labels?

• In the United States, all packaged foods must clearly identify eight specified food allergy sources: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, and soy. However, this does not apply to packaged meats, chicken, and egg products.
• How packaged foods are made can change at any time, so it is very important to read the label each time to avoid an allergic reaction, even if your child has eaten that food safely for years.
• Standard of care is to have a nutritionist review with you and your family how to read food labels as the food allergen can be listed in both the ingredient list AND/OR the “Contains” statement.  See example below.  Also, technical or nonspecific names for food allergens that one may not be familiar with also may be listed (example casein = a milk protein).  Finally a nutritionist can be helpful in making sure your child’s diet is nutritionally adequate.
• Allergens other than those listed above may still be listed on food labels with unclear names (eg, garlic or sesame seed may be listed as a spice, natural flavor, or even an artificial flavor). If you are unsure whether the food contains a potential allergen, call the manufacturer to clarify the ingredients.
• Labels may state “may contain,” “processed in a facility with,” “manufactured on shared equipment with,” etc. The law does not specify which type of label should be used.  Unfortunately, none of these statements reflect the level of risk to your child.  For example, a bread that states “may contain nuts” is not more or less likely to cause an allergic reaction than a bread that states “manufactured on shared equipment with nuts.”  Most allergists, including myself, recommend avoiding foods with these labels as it is not possible to know the risk to your child.  Although this may restrict your child’s food choices, it is also the most likely way to keep your child safe.

How can I make sure that the food I prepare is safe for my food allergic child?

• Some families decide to avoid having the food in the home if one person is allergic.  For example, if one child has a peanut allergy, the family makes the home “nut free.” Other families continue to have the allergenic food in the home but are careful to avoid giving the food to their allergic child.
• If the food is introduced into the home, it is very important to avoid cross contamination by thoroughly cleaning utensils, dishes, cutting boards, cookware, storage containers, and other food preparation materials before serving your food allergic child a “safe” meal.  For example, if a child without food allergies uses a knife to prepare a peanut butter jelly sandwich, it is possible to accidentally contaminate the jelly jar with peanut butter.  The child with peanut allergy could then eat the jelly and have a food allergic reaction.
• Using a dishwasher or liquid soap and water is generally enough to remove the food allergen from dishes and other food preparation materials.
• To remove peanut allergen from tabletops, commercial wipes (such as Lysol sanitizing wipes) or household cleaners (such as Formula 409 or Target Brand cleaner with bleach) are effective.
• Plain water or alcohol based sanitizers (such as Purell) does not remove peanut protein from the hands.  Bar or liquid soap with water however are effective in removing peanut protein from the hands.

How can I make sure my food allergic child is safe at restaurants?

Eating out can be difficult for children with food allergies.  Here are some tips to make it safer:

• Let the restaurant chef and/or manager who is directly responsible for the food know about your child’s food allergy (rather than the waiter).  Inform them that it is a not just a dislike of the food.
• Carry a restaurant card with your child and verbally make sure they understand the card.  An example of a restaurant card can be found below and at Interactive Chef Card. These cards can be printed on brightly colored cardboard stock paper, laminated, and kept in your wallet.

• Always check with the chef that the food you have ordered for your child does not contain the food allergen.  Ingredients on the menu should not be trusted at face value.  If the chef or server is not sure about the ingredients, avoid the food.
• Buffets and salad bars should probably be avoided given the high risk of cross contamination.

What should I do In Case of an Allergic Reaction?

A food allergic reaction can be a frightening experience.  Below I hope to help guide and empower you to be able to know the most effective way to treat an allergic reaction should your child have one.

How common are food allergic reactions?

Studies have shown that the rate of food allergic reactions is greater than 15% per year per child.  One study even showed that there is a 1 in 2 or 50% chance that your child will have an accidental ingestion leading to a food allergic reaction per year.

This happens because it not always easy to know if a packaged food or restaurant meal contains a food allergen.  As a result, it is very important to know how to treat an unexpected allergic reaction.

What should I do in case my child has an allergic reaction?

It is important that your doctor complete a food allergy action plan for your child that goes over exactly what to do in case of an allergic reaction.  Your doctor can tailor the food allergy action plan specifically to your child based off your child’s history of reactions and special circumstances.  These food allergy action plans can be found at foodallergy.com.  You should review the food allergy action plan with your child’s school, as well as with family members and baby sitters so that they know exactly what to do in case of an allergic reaction.

The general recommendation for food allergic reactions is to give injectable epinephrine and call 911 unless your child is only having mild itchiness or hives.  Epinephrine is the only life-saving medication in a food allergic reaction.  When in doubt, give epinephrine.  The benefits of giving it to prevent life-threatening complications in nearly all circumstances outweigh the risks of side effects (including fast heart rate, dizziness, shakiness, and/or nausea).  Moreover, these side effects go away as epinephrine is a hormone naturally produced and broken down by the body.

Should I carry one or two dose of Epinephrine with me?

In 10-20% of allergic reactions, a second dose of epinephrine is needed to treat the allergic reaction.  Therefore it is very important to carry two doses with you at all times.

What if I am scared to use the Epinephrine?

If you are too scared to give the epinephrine make sure that family and friends know how to use it.  You can give it to them to administer to your child if she or he is having an allergic reaction.

We recommend practicing how to use epinephrine with a training device with your doctor or nurse in their office as well as by watching the training videos that accompany the device at home. There are many different brands of epinephrine including Auvi Q (which verbally gives you directions on how to use the medication), Epipen Twin Paks, etc.  You should use the brand that you feel most comfortable with and is the most convenient for you to carry.  The more you practice with the device and train others on how to use it the more comfortable you will feel.  I also recommend using the real device on an orange or melon as the feel of the training device is slightly different than that of the actual injector.

Giving injectable epinephrine can be less painful than receiving a vaccine and will within seconds to minutes help stop or slow down the allergic reaction.  Some children have told me how surprised they were at how little it hurt and were grateful that they could breathe again or no longer have tummy pain.  Every child though has a different pain threshold and some may cry when it is administered, which is normal.  Please talk to your doctor if you have concerns about using epinephrine.

How do I take care of my the epinephrine?

It should be carried with your child at all times.  Avoid extremes of temperature (e.g. glove compartment of a car on a hot day) as this can degrade the epinephrine.  Avoid direct sunlight exposure.  If the clear white boxed opening on the EpiPen turns colors or becomes cloudy, the epinephrine is no longer effective.  EpiPen Twin Packs should be refilled every year.  Please make an appointment with your doctor when your EpiPens need to be refilled.  With old or expired EpiPens we recommend that you practice with them on melons or oranges and train family members and friends to do so as well.

What if I only have an expired epinephrine on me when my child has an allergic reaction?

Use it.  It is better than not receiving any epinephrine at all.  One study has shown that expired epinephrine still may contain an effective amount of epinephrine.

What is the role of antihistamines such as Zyrtec or Benadryl in treatment food allergic reactions?

Antihistamines such as liquid or chewable Zyrtec (generic name = cetirizine) or Benadryl (generic name = diphenhydramine) only help relieve itching or hives and may take up to 20-30 minutes to start working.  Antihistamines do not help breathing problems, airway swelling, stomach problems, or reverse low blood pressure.  As a result they are considered second-line treatment for food allergic reactions.  Epinephrine should always be used first unless the reaction is only mild itching or hives.

I am often asked as an allergist how can I tell if a child is having a food allergic reaction.  It is not always easy to tell and thus it is important to know all the possible symptoms of a reaction.  Being able to recognize the symptoms early on can prevent your child from having worsening and potentially life-threatening symptoms.

What are the symptoms of a food allergic reaction?

Children have unique ways of describing their experiences and perceptions, and allergic reactions are no exception. Precious time is lost when adults do not immediately recognize that a reaction is occurring or don’t understand what a child is telling them.

Some children, especially very young ones, put their hands in their mouths or pull or scratch at their tongues in response to a reaction. Also, children’s voices may change (e.g., become hoarse or squeaky), and they may slur their words.

The following are examples of the words a child might use to describe a reaction:

• “This food’s too spicy.”
• “My tongue is hot [or burning].”
• “It feels like something’s poking my tongue.”
• “My tongue [or mouth] is tingling [or burning].”
• “My tongue [or mouth] itches.”
• “It [my tongue] feels like there is hair on it.”
• “My mouth feels funny.”
• “There’s a frog in my throat.”
• “There’s something stuck in my throat.”
• “My tongue feels full [or heavy].”
• “My lips feel tight.”
• “It feels like there are bugs in there.” (to describe itchy ears)
• “It [my throat] feels thick.”
• “It feels like a bump is on the back of my tongue [throat].”

How can you tell the difference between a food allergic reaction and an asthma attack?  What do you treat first?

• Asthma and a food allergic reaction can look very similar, especially when there are only respiratory symptoms with a food allergic reaction.  This occurs in about 20% of cases when no skin or gastrointestinal symptoms are present to suggest a food allergic reaction versus an asthmatic one.  It is important to take into account the context of the symptoms.  If for example you know you have eaten at home with only safe foods, then the symptoms are less likely to be a food allergic reaction than if you were eating out or at a party.
• The beauty of epinephrine is that it is a great drug for both asthma and food allergic reactions, so you can never go wrong giving the epinephrine when there is any doubt.

What is the treatment for food allergies?

It is important to strictly avoid the food allergen and to carry an injectable medication known as epinephrine with your child at all times.  This treatment is the standard of care.  Many families ask how strict should they be in avoiding the food allergen.  Even a tiny amount of a food allergen can trigger a life-threatening allergic reaction.  Food allergies cause about 100-150 deaths per year.  As a result, strict avoidance is the most likely way to keep your child safe.

Having a child with food allergies can be a life-changing experience both for the child as well as everyone that takes care of him or her.  I know first-hand having children in my family with food allergies.  It has given me a passion to help children with food allergies through education, patient care, and research.  This is the first of a five part series over the next week in which we will discuss food allergies.  We will discuss commonly asked questions about food allergies and tips on how to keep your child safe and healthy.  I wish we had enough time and blog space to discuss each and every one of the more than 170 foods that have been reported to cause food allergies but since we don’t I hope that the general tips and answers to the many questions that I have been asked by families like yours over the years will be helpful to you.  Thanks so much for reading.  I would love to hear your stories, questions, and comments!

What is a food allergy?

A food allergy is a reaction in which one’s immune system thinks of a particular food as a foreign invader.  Typical symptoms include itchy red skin, coughing, vomiting, sneezing, and watery red eyes.  These symptoms are pathways that the body uses to try and remove the food allergen from the body (with vomiting is the most clear example of how your body expels the food allergen from the body).  Typical allergic reactions occur within minutes to an hour upon exposure to the food.

Allergic reactions typically happen after eating the food allergen.  It can also occur in other situations such as:

• Touching the food allergen which typically causes red, itchy skin
• Rubbing the food allergen into the eye which can cause swollen, red, watery eyes
• Breathing in the food allergen particles in the air (as a result of steaming, boiling, frying, grating, shedding, or grinding) which can cause difficulty breathing and coughing in highly sensitive children.  As a result, children who are highly sensitive should avoid situations in which there is a risk of food allergen inhalation. (Note the peanut allergen from peanut butter does not easily become airborne, but it may become airborne from peanut flour or “dusty” roasted peanuts.)

How can I tell if my child has a food allergy?

The definition of a food allergy is an adverse reaction mediated by the immune system that occurs reproducibly upon exposure to the food.  However, it is sometimes difficult to tell if your child has a food allergy or not.  For instance, some people who eat or drink milk products then develop bloating and gas.  This may be because they cannot break down a sugar in milk products called lactose.  In such a case, the bacteria in the gut ferment this sugar and cause gas and bloating.  This condition is known as lactose intolerance.  Lactose intolerance is not considered a food allergy but rather a food intolerance.  It can be helped with products such as Lactaid, an enzyme that breaks down lactose in your body, which can be taken before you eat or drink milk products to prevent symptoms. If you are not sure if your child has a food allergy, it is best to talk to your child’s pediatrician.  He or she can also refer your child to an allergist for testing.

How are food allergies diagnosed?

The most important way in which a food allergy is diagnosed is by your child’s history.  If the history is consistent with food allergy, your doctor may order allergy skin and/or blood tests to confirm the allergy.  If there is doubt about whether the symptoms represent food allergy or not, then a food challenge may be performed.   If your child has a food allergy, it is important that your child be seen by a board certified allergist for consultation and at least yearly follow-up appointments.

How common are food allergies?

It is estimated that up to 8% of children and up to 3-4% of adults have food allergies.

What are the most common food allergens?

Milk, soy, wheat, eggs, peanuts, tree nuts, fish, and shellfish cause over 90% of all food allergies.  However over 170 foods have been reported in the literature to cause food allergic reactions.

What caused my child’s food allergy?

A combination of genetic and environmental factors.  It is estimated that children who are born to parents who have allergies are 60% likely to develop some kind of allergy, whether it be eczema, hayfever, food allergies, or allergic asthma.  If only one parent is affected, the child has a 40% risk of being allergic.

Furthermore, in identical twins, if one is allergic to peanut, the other twin has a 67% chance of also being allergic. In siblings, if one sibling is allergic to peanut, the other sibling has a 7% risk.

One of the environmental factors hypothesized to affect the development of allergies is an environment that is “too clean.” This “hygiene hypothesis” posits that when the child’s environment is too clean, the immune system doesn’t have enough “work” to do and it may cause the immune system to skew towards an allergic predisposition since there are very few viruses and parasites to attack. There are many theories as to why food allergies are on the rise, but we do not know with 100% certainty why the number of children with food allergies is increasing.