Warning: May Contain Peanuts

labelCurrent treatment options for food allergy are limited. Chinese herbal therapy may prevent reactions. Oral desensitization may one day provide a more permanent cure. Unfortunately, neither treatment is available today. Instead, patients and parents are instructed to avoid a food (or group of foods) without error.

When eating out, you must rely on the kitchen staff. When eating at home, you must rely on the ingredient list provided by the manufacturer. These food labels may be inaccurate or difficult to interpret.

Reading a label is an acquired skill. In order to be successful, parents need to know the benefits and limitations of current labeling laws. Most important is the Food Allergen Labeling and Consumer Protection ACT (FALCPA); passed in 2004 and in effect since 2006. This law requires labels to plainly state, in clear english, if they contain a major food allergen. The major food allergens are milk, egg, fish, crustacean shellfish, peanut, tree nuts, wheat and soy). These ingredients must be listed if they are present in any amount, even in colors, flavors or spice blends. Additionally, the manufacturer must list the specific nut and/or seafood that is used. The food name can be found in one of two places;

1. Within the ingredient list; i.e. “natural flavoring (egg)”.

2. An adjacent “contains” statement; i.e. “Contains egg.” These are usually in bold type.

Passing this law was a step in the right direction. Unfortunately, there remain limitations;

• Only 8 foods groups are required. If you are allergic something else (i.e. sesame seed), it may not be included in the “contains” statement. If you are sensitive to something else (i.e. gluten or preservatives), it will not be included. You must read the full ingredient list.

• Alcoholic beverages, meat, poultry, and certain egg products are not regulated.

• Advisory labels for possible cross contamination are voluntary and inconsistent. Examples include, “May contain traces of peanut,” “Processed on equipment that also processes peanuts,” or “Made in a facility that processes peanuts.”

FALCPA requirements do not apply to potential or unintentional presence of major food allergens in foods resulting from ‘cross-contact’ situations during manufacturing, e.g. because of shared equipment or processing lines. It is left to the discretion of the company if they would like to include a warning statement. The wording of such statements is also left to the company. There are no parameters. This lack of consistency lowers the value of all statements. Their high prevalence and ambiguity leads consumers to doubt their legitimacy. In the end, warning statements are often ignored.

The warning statement is only valuable if can convey the risk of contamination and help parents to make informed decisions. Useful information would include, the probability that the product contains peanut and the amount of peanut that may be present. Several studies have analyzed foods in order to answer these questions. A study from Ireland, looking at 38 food products with a nut statement, found detectable peanut in 5% of foods. The amount of nut protein varied from 0.14 to 0.52 mg per serving (or less than 1/100 of a peanut).  A more recent US study found that 8.6% of foods with a peanut advisory contained a detectable level of peanut protein. Nutrition bars contained the highest levels. Other high risk foods include chocolate candies, cookies and baking mixes.

The problem is not limited to peanuts and tree nuts. In a 2010 study of milk, egg, and peanut; the highest level of contamination was for milk (10.2%). Overall 5.3% of foods with an advisory label were contaminated. The levels of milk found were within the range that may cause a reaction. On the other hand, peanut levels were low. It was estimated that the level of peanut contamination would cause a reaction in only 5% of peanut allergic children, making the overall risk of reaction less than 1%.

The amount of protein that may cause a reaction (threshold) varies dramatically in different children. This makes label standards difficult. The Australian Allergen Bureau have been using investigation and statistics to overcome this obstacle. A Voluntary Incidental Trace Allergen Labeling (VITAL) program was developed to make a single simple standardized precautionary statement available to assist food producers in presenting allergen advice consistently for allergic consumers. VITAL not only assists food producers in assessing the potential impact of allergen cross contact in each of their products but also specifies a particular precautionary allergen statement to be used according to the level of cross contact identified. The initial goal was to label foods with peanut levels higher than 1.5 mg, the amount likely to cause a reaction in 5% of peanut allergic children. With VITAL 2.0, the level drops to 0.2 mg, only 1% of peanut allergic children will react at this level. Additionally, VITAL 2.0 provides manufactures with an action grid containing 24 total foods.

Recommendations that are not specific are not helpful. At this point, the safest course is to avoid any food that declares the major allergen. Parents must read labels ALL of the time. Ingredients can change. In the end, if you are unsure whether or not a product could be contaminated, you should call the manufacturer to ask about their ingredients and manufacturing practices.

Discovery Channel presents “An Emerging Epidemic: Food Allergies in America.”

FARE

FARE (Food Allergy Research & Eductation) has teamed up with The Discovery Channel to produce a new documentary about food allergies called “An Emerging Epidemic: Food Allergies in America.” The hour-long documentary, narrated by Steve Carell, explores what it is like to live with life-threatening food allergies, how families and individuals managing food allergies are working to raise awareness in their communities, and the vital research underway to find effective treatments and a cure.

Watch the full documentary online>

The documentary debuted on Saturday, September 7 and will air again on Saturday, September 21 at 8 a.m. ET/PT. The documentary will also be available for viewing online at www.discoverychannelpatienteducation.com and available for download on iTunes.

Egg Allergy & 2013-14 Influenza Vaccination

flukidThe CDC recently published vaccine recommendations for the 2013-4 influenza season (http://www.cdc.gov/flu/about/season/index.htm). Special attention is given to those patients with a history of egg allergy.

Influenza vaccine is grown in embryonated chicken eggs and contains residual amounts of ovalbumin, a major egg allergen. For patients with egg allergy, even small amounts of this protein can trigger an allergic reaction. This risk must be considered before vaccination . On the other hand, Influenza infection poses a significant risk itself. There are approximately 300,000 hospitalizations annually, including more than 20,000 in children younger than 5. Children with asthma are most vulnerable. This is concerning given the increased incidence of asthma in children with egg allergy.

Due to fear of allergic reaction, flu shots were previously withheld from all children with egg allergy. In order to assess risk, allergists began skin testing children with the influenza vaccination.  In 1977 physicians began immunizing those egg allergic children with a negative influenza skin test. About ten years later another group pushed further. This time, children with a positive skin test were successfully vaccinated using a multi-step protocol. The most recent studies (including those with H1N1 vaccine) have found the real risk of reaction to be exceptionally low. One recent study, vaccinated 143 children with documented severe egg allergy. No children had a significant allergic reaction take place. This data is prompting change. Beginning with the 2011-2012 season, the AAP, CDC/ACIP, and NIAID specifically recommend that patients with egg allergy receive the trivalent inactivated influenza vaccine (TIV) with some precautions.

Here is a quick summary of the most recent CDC recommendations:

1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine.

– Vaccine should be administered by a healthcare provider who is familiar with the potential manifestations of egg allergy; and

– Vaccine recipients should be observed for at least 30 minutes for signs of a reaction after administration of each vaccine dose .

2. Persons who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention may receive egg-free vaccines, if aged 18 through 49 years and there are no other contraindications. If egg-free vaccines are not available or the the receipient is not within the indicated age range, such persons should be referred to a physician with expertise in the management of allergic conditions for further risk assessment before recipient of vaccine.

– All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available.

3. For individuals who have no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previously performed allergy testing, consultation with a physician with expertise in the management of allergic conditions should be obtained prior to vaccination.

4. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to future receipt of the vaccine.

Beyond the recommendations:

– Egg-free vaccines may be used for persons aged 18-49 years who have no other contraindications.  In 2012, the FDA approved Flucelvax, the first influenza vaccine produced without egg. A second vaccine, FluBlok, was approved in 2013.

– Skin testing is NO longer routinely necessary for patients with egg allergy. However, skin testing with the vaccine IS still appropriate when evaluating a patient with a history of reaction to the influenza vaccine itself, as opposed to a history of reaction to egg.

– Studies have shown ovalbumin (egg) content up to 1.2 ug/ml to be well tolerated. Most available vaccines have significantly less.

– Although intranasal vaccine (FluMist) contains one of the lowest absolute amounts of ovalbumin per dose, there are no data on its administration to patients with egg allergy. Thus, injectable vaccine only should be used for patients with egg allergy.

 

Can Diet Cure Chronic Hives?

Food dish

Food dishFat, Sick and Nearly Dead is a 2010 documentary which follows the journey of Australian Joe Cross (http://www.fatsickandnearlydead.com). Joe traveled the country during a 60 day juice fast. Nothing but liquid nutrition. His purpose; cure disease, reduce dependence on medications and lose weight. Joe has chronic hives (urticaria). He relies on multiple medications, including oral steroids, to control symptoms. Throughout the trip he undergoes a miraculous transformation. The number of pills and pounds continue to drop.

Should everyone expect these results? Probably not. A documentary film is not sound medical evidence. In this film, there is only one subject. There is no comparison group. Most importantly, hives frequently come and go on their own without reason.

A German study published in 2010 investigated diet manipulation for the treatment of chronic hives. Patients eliminated all processed foods, artificial substances, food additives, dyes, antibiotics, preservatives, phenols and natural foods rich in aromatic compounds such as tomatoes. What is most interesting, patients avoided the majority of Joe’s diet – NO fruit. The results were mixed; 34% benefited from the diet and 24% deteriorated while on the diet. Responders took on average 3 or more weeks to respond.

These doctors believe that artificial preservatives and dyes in modern processed foods (and aromatic compounds in some natural foods) act as pseudoallergens, substances causing allergy symptoms via non-allergic mechanisms. These foods trigger the release of histamine and subsequent hives without an allergic immune response. This suggests another possible link, those foods with high levels of histamine (http://chronichives.com/useful-information/histamine-restricted-diet).

An Italian group put patients on an oligo-antigenic and histamine-free diet for 21 days. They excluded foods with artificial coloring (esp. tartrazine), fermented foods, benzoates, Butylated hydroxyanisole (BHA) and butylated hydoxytoluene (BHT). Patients in this study had a significant improvement in symptoms. However, there were only 10 patients. Additionally, patients in a similar study out of Canada showed less substantial improvement.

Other foods under investigation for chronic urticaria include; MSG, parabens and aspartame. Alcohol and spices both can cause vasodilation (widening of the blood vessels) and hives in  patients with chronic urticaria. Unfortunately, hives continue to occur after elimination.

Overall, there is little scientific evidence to support elimination diets for the treatment of hives. We do not routinely advise patients to adopt a pseudoallergen free diet. However, there are patients who do not respond well to medications, who require multiple medications or are experiencing significant side effects. For this group, there is little risk in trying an elimination diet. Patients should be motivated. Patients should eliminate a large group of foods; although foods can be added one at a time (after hives have resolved), it is unlikely to help if they are removed one at a time. Most important, prolonged diet changes require the supervision of a doctor or nutritionist.