What a Food Allergy can Look Like

[Deebs]

This is my PSA for the day, inspired by the baby eating thread (about what babies eat, not eating your own babies)...

Scrub-Jay - I'm counting on you to chime in, but wanted to have a starting point because this is something NONE of my pediatricians explained to me, even though I voiced concerns that my children would have allergies because DH and I both have allergies.

Allergic reactions to food can happen immediately or a couple of hours after the ingestion of a food. Reactions can be eczema (which looks a lot like a viral rash - it's pretty much over the entire body in infants and young children, looking very little like eczema in adults), vomiting, diarrhea, swelling, hives, trouble breathing, or a rash around the mouth.

I know that Scrub-Jay is a big believer in having benedryl in the house (and knowing the proper dose), and I agree, but I also know the emergency physician in my house would say call 911 and go to the ED, unless the reaction is one that is more over time and slowly progressing. Even if benedryl seems to control the reaction, and allergic reaction in an infant or young child with a sudden onset is a medical emergency (and if you feel "bad" remember the people calling 911 for a foot that itches, because they're lonely, or because they ran out of their favorite ice cream. I assure you a child in distress is well worth the paramedic's time). Plus, sometimes symptoms are masked by treatment and then the allergy can flare back up. It's best if this happens in a hospital, right?

Eggs, milk, peanuts, wheat, soy, tree nuts (like walnuts, Brazil nuts, and cashews), fish (such as tuna, salmon, and cod), and shellfish (like lobster, shrimp, and crab) are the most common food allergens and over 80% (again S-J correct me if my numbers are dated) of food allergies are to those foods. However, your child can be allergic to pretty much any food.

And now, I'm adding my own tangent because DH lost a child to choking that scared the crap out of both of us, and it's food related. This was a child who was three years old, began choking in front of her parents who IMMEDIATELY did everything "right" and the child still couldn't be revived...so
Whole grapes, hot dogs and hard candy; dry foods that are hard to chew (popcorn, raw carrots, sunflower seeds and nuts) or sticky or tough foods (peanut butter, chewing gum, marshmallows) and large pieces of meat are all chokers. If you give your kids those food, cut them up and make sure you're right there while they're eating. Kids tend to outgrow the worst choking risks when they're around elementary school aged (which as a parent seems so OLD to have to worry about food anymore).

FULL DISCLOSURE: I AM NOT A PHYSICIAN, NOR DO I PLAY ONE ON TV. I'M JUST A LONELY MEDSPOUSE ON A FRIDAY NIGHT, TRYING TO HELP A SISTER (OR BROTHER) OUT. I DO THINK I COULD PLAY A DOCTOR ON TV IF THE OPPORTUNITY WERE TO ARISE. JUST SAYIN'.

[Chrisada]

I'm the crazy parent who still cuts up grapes for my five year old. My friend's aunt died when she was small from choking on a grape. I never forgot that story.

[v-girl]

I'm very much not an expert, but just have a small addition to this. If you do jarred babyfood and get the mixed foods (beef stew, chicken & veggies, etc.), check each ingredient to see if your child has had them all previously. This was how we discovered our son's allergy to tomatoes. He did outgrow that allergy (thankfully), but we had 2-3 years of ordering a separate pizza for the kid.

[scrub-jay]

I'm excited to add more, but not on my phone! I have much to add, but I think the EM in your house is absolutely correct about calling 911 immediately!! Having Benadryl around is a tool, but you should only give it if directed to AND on the way to the ED. A child can easily have a biphasic (up to hours later) reaction requiring epinephrine, steroids, or other treatment, but Benadryl can buy time DEPENDING ON THE SEVERITY. There are situations where epinephrine (EpiPen) is essential, even on a 1st exposure. I should emphasize ED treatment more D, you make an excellent point. I like Benadryl around bc if it happens the first time, you aren't going to have an prescribed EpiPen Jr. around and the advice nurse/ped on the phone might suggest Benadryl before paramedics arrive (or before you go in) and if you don't have it around at all...your toolkit is more limited. Can I steal your disclosure? I love it!!

[alison]

Fawk! I just gave my dd a bowl of grapes! And gave them to madeintaiwan's kids the other day, too! And dd got mini carrots in her stroller. Fawkityfawkfawk!

Thank you for writing this!

[Deebs]

V - The reason I started this thread is that I completely think this is something that is not at all intuitive, and parents aren't taught. I have learned so much more from my friends who have severely allergic kids than my own children's' pediatricians. I also learned so much in probably a one hour discussion with an allergist who really took the time to educate me.

S-J - IRL, people ask me how I know things. Well, pushing my DH and his two best friends through med school (helping them all, I think I may have studied more myself than a single one of them), getting my MPH, and then reviewing all of the death records of a hospital taught me so much. Not much of that really fits cleanly onto a resume, but I think my disclosure works. Use at will!

Alison - Nothing happened, so it doesn't matter. The good news on grapes is that they can be torn in half in a pinch, or easily cut. Carrots - just cut them into smaller sticks and make sure you're sitting with her while she eats. My youngest went through a week long period where I assume she was going through some developmental change, and I was whipping her out of her highchair, flipping her, and whacking her back at every.single.meal. The kid choked on everything. I'm not a crazy over-protective parent, but I really believe that when you know better, you do better.

My kids are TERRIFIED of popcorn now (but love it). When this patient came in, DH called me from work crying, and told me to throw all of the popcorn in the house away. In that moment, my kids were in another room, by themselves, eating popcorn. Now, the older two get all excited to stay up after the two year old and have some popcorn. We also have a good supply of Pirate's Booty at any given time to fill in for popcorn.

[GreyhoundsRUs]

Thank you for posting this! I'm going to re-read it in the morning, but it's exactly what I was looking for!

[scrub-jay]

Okay, on a computer now. Childhood food allergies are a huge problem; approximately 6-8% of children in the U.S. have at least one food allergy, impacting children under 3 more frequently (Waddell, 2011). Roughly 30,000 ER visits and 150 deaths every year are attributable to food allergies (United States Food and Drug Administration [FDA], 2011). This is a problem now, but it is also growing, the prevalence in food allergies increased nearly 20% and the prevalence of peanut allergies in children has tripled in the past decade (Branum & Lukacs, 2008; FAAN, n.d.). This is a huge and underrepresented public health issue.

Deebs is correct that eight foods (dairy, eggs, treenuts, peanuts, fish, shellfish, soy, and wheat) are responsible for the majority of the food allergic reactions, but the statistic has been increased to 90% responsible (FAAN). (Side note on treenuts: The FDA began including coconuts into the treenut grouping in 2006 even though it is technically a seed.) However, it is important to remember that the other 10% of allergens could be ANYTHING. I’ve met people with instant anaphylactic reactions to asparagus and others to carrots (these examples were adults.) It is important to always be vigilant for symptoms. An adult or a child can develop an allergy at any point, even after eating the food for YEARS (or months for a child). I honestly wish this were emphasized more by pediatricians when discussing solids introduction because they really seem to make it sound like if a reaction doesn’t happen in 3 days, it won’t happen.

Deebs is also correct in the common symptoms, I really like how the Food Allergy and Anaphylaxis Network (FAAN) outlines it:

GI: vomiting, nausea, diarrhea, abdominal pain
Skin: hives (sometimes just around mouth/face and other times full body), swelling, atopic dermatitis (eczema)
Eyes: swelling, itching, watering
Respiratory: wheezing, coughing, swelling of lips/throat (laryngeal edema), runny nose
Multisystem generalized: Anaphylaxis, can include symptoms above, loss of consciousness, drop in blood pressure, difficulty breathing (classic symptom for anaphylaxis)

It is very important to contact a physician (or 911) that if you see any of these signs because although you see hives, you may not be able to recognize the drop in blood pressure (for example). A child may just seem “off” as they enter shock due to anaphylaxis. Anaphylaxis requires epinephrine and as biphasic (later stage) reactions may occur, it is important to get to the ER quickly. Deebs is spot-on, please don’t self-diagnose and treat. Benadryl can only help mild symptoms whereas epinephrine/steroids/airway management/etc are necessary for the more serious reactions. I still think Benadryl is useful to have on hand under physician instruction, but it can’t touch anaphylaxis.

After the reaction, a parent may or may not be able to recognize what caused the reaction. MANY reintroduce those foods slowly to see which one elicited the reaction – this is NOT the right response. Food allergies may dramatically increase in severity, even upon second exposure. Never ever “challenge test” a child unless under the direct supervision of a physician. The correct response: avoid all possible foods that could have caused the reaction, set up an appointment with your pediatrician who should then give you a referral to an allergist. A good allergist is worth his or her weight in gold. They know WAY more than a pediatrician on the topic and they can identify life-threatening food allergies in a safe environment.

The above is generally in reference to IgE-mediated (type 1 immediate) allergies. These are not to be confused with food intolerances (such as lactose) which are not considered to be life-threatening.

I can keep going… and if anyone cares for the references for the any of the above, I’ll be happy to provide them. Any questions?

Disclaimer: I am not a physician either, but I am driven to educate the world about the life-threatening food allergies.

Very useful (and easy to read) food allergy website: http://www.foodallergy.org (Home of the Food Allergy Anaphylaxis Network or FAAN)

Other references (I've got so many more if anyone is actually interested)
Branum A. M. & Lukacs S. L. (2008, October). Food allergy among US children: Trends in prevalence and hospitalizations. National Center for Health Statistics Data Brief, 10. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db10.pdf
United States Food and Drug Administration [FDA]. (2011, October 25). Food allergies: What you need to know. Retrieved from http://www.fda.gov/Food/ResourcesFor.../ucm079311.htm.
Waddell, L. (2011, July). Living with food allergy. Journal of Family Health Care, 21(4), 21-28.

[scrub-jay]

Deebs - Thank you for also bringing up choking in children, it is so easy to forget the danger in everyday foods (and even more so if you are concentrating on avoiding known food allergens). Excellent point. And, I aspire to your amount of knowledge and comfort with public health! As for popcorn, I took an American Red Cross babysitting class when I was 10 (maybe) and one of the biggest take-home messages I got was: NEVER GIVE POPCORN WHILE BABYSITTING!! I've carried that with me forevermore.

[madeintaiwan]

Popcorn, candy, grapes, hot dogs, carrots. DS1 is such a terrible eater and was mainly nursed until he was over 2.5 because my PICU nurse MIL scared the crap out of us with ALL of her PICU child dies from choking horror stories. My mother still peels the skin off of grapes for us. It is my understanding that it is the skin that is a choking hazard. Good thread.

[peggyfromwastate]

I want to share my first story with anaphylaxis. The twins were about 18 months old, I was giving them lunch, and I let them try mustard for the first time. Ds didn't react right away, but I did notice it soon enough to know it was mustard. He had swelling around his mouth, very itchy eyes, and was just off. I wasn't sure what was going on. He'd had a lot of asthma issues to that point and we were doing nebulizer treatments 3-4 times a day. I thought allergies-- but I DID NOT think anaphylaxis. I called my Peds office. No one was there but I was hooked thru to an idiot receptionist who told me that everyone was at lunch and that I could call back in 50 minutes. I said-- " he could be dead in 50 minutes" and hung up. Then I called my dad bc He was an ER doc for about 30 years. I was tracking Stevens respiratory rate and while he was breathing shallowly, he was still breathing. He was just swollen.

Anyway, my dad kept me on the phone and advised that I continue checking his respiratory rate and not to call 911 unless he stopped breathing. I know this is not what I'd do now-- I'd definitely call 911 and ask questions later, but I was not going to strap ds into a car seat where I couldn't see him to drive him to the er and I also wasn't going to openly defy the advice of my dad. That's just where I was at that point.

Ds did outgrow the mustard allergy eventually (by age 6 I think)- we did complete food avoidance.

At age 20 months He was seen by an allergist and tested for various allergens. He reacted strongly to mustard, but they did not test him on peanut at the time bc his little back was too small for so many scratch tests. They just did mustard and the controls and 1 weed or something--

When we moved for med school about 6 months later ds was tested again-- this time peanuts and mustard and the controls. The allergist said with one known food allergy it was reasonable to test for the most common--- something along those lines. He reacted strongly to both but VERY strongly to peanuts. And he'd never rated peanuts before. Only been exposed thru dh eating peanut butter then sometime later kissing ds on the cheek. Ds would get a little welt there. I don't like peanut butter-- so I never really offered it to the kiddos.

Anyway-- we had an anaphylactic reaction to peanuts one time too. Very similar situation to the mustard but we were actually out of town (at a funeral) at the time and my dad was with us and checked ds's vitals constantly. I had the epi and should've given it to him... But again, I deferred to my dad's opinion.

So I've dodged the bullet twice which is more than any anaphylactic kid should expect. Ds carries sn epi and I do too at all times. Next time I see swelling anywhere I'm not hesitating.

As far as Benadryl, I'm not a big fan. I have some on hand but I feel like the way ds has anaphylaxis I don't want to mask any of that-- I know Benadryl won't stop all the swelling. Some people are using Benadryl in a school setting as a first defense-- I don't want them to have Benadryl on hand bc I want them to just go straight to epi. A girl died
last year from a known peanut allergy on the playground in the metro dc area. It was in the news. The nurse station only had paperwork for Benadryl, which sadly would have done nothing to save this little girl.

[scrub-jay]

Thank you for sharing your story, I can identify so much with so many elements. I wanted to add though, if the little girl you were talking about was Ammaria Johnson, she was a known peanut allergy and her mother claims the school refused to maintain the prescribed EpiPen. Whether or not this is true, it has initiated federal legislation to allow schools to maintain EpiPens for anaphylactic reactions. I don't have the reference handy, but 25% of kids will have their first food anaphylactic reaction while at school, and many of those will have never been diagnosed with food allergies previously. Benadryl is actually NOT recommended for many peanut-allergy kids because peanuts are known to be the most severe and likely anaphylactic of the known allergens. Of course, this call is made by the prescribing allergist.

[moonlight]

Deebs - Thank you for also bringing up choking in children, it is so easy to forget the danger in everyday foods (and even more so if you are concentrating on avoiding known food allergens). Excellent point. And, I aspire to your amount of knowledge and comfort with public health! As for popcorn, I took an American Red Cross babysitting class when I was 10 (maybe) and one of the biggest take-home messages I got was: NEVER GIVE POPCORN WHILE BABYSITTING!! I've carried that with me forevermore.

Yes thank you. I didn't think about other meats. I always think of hotdogs. Today DD wouldn't eat the chicken in the chicken pot pie I had made. Thinking back, the pieces were way too big for her. I finished them off for her. She loves almonds. what should I do about those? Crush them up or something?

When she was a younger toddler she was allergic to strawberries. Just a small rash around the mouth and on the face. She even threw up a couple times. She seems fine with strawberries now. DH thinks I'm a tad crazy but I think she's allergic to zucchini. He made a all veggie casserole 5+ months ago and she got this rash all over her body. We couldn't figure it out because she's had all the other veggies many many times before except for the zucchini. Last week I gave her one of those canned veggie soups for lunch. Boom. She got the rash all over her truck area. Same looking rash. I read the ingredients... there it was, zucchini! The rash is almost gone now. Should I take her in to the Pedi?

[scrub-jay]

Moonlight- I would, allergies can be mild rash-mild rash-anaphylaxis, they don't play fair. I think monitoring by an allergist is essential and having an EpiPen rx is important, better to have it and never need it, than need it and not have it. Trunk/body hives is often considered to be more serious than facial hives. Strawberries are very high in histamine and often mimic true food allergies, but the multiple system involvement (skin hives & GI vomiting) concerns me. If I were in your shoes, I'd be religiously avoiding zucchini and scheduling an appointment w/an allergist (or ped if you need a referral).

[peggyfromwastate]

Thank you for sharing your story, I can identify so much with so many elements. I wanted to add though, if the little girl you were talking about was Ammaria Johnson, she was a known peanut allergy and her mother claims the school refused to maintain the prescribed EpiPen. Whether or not this is true, it has initiated federal legislation to allow schools to maintain EpiPens for anaphylactic reactions. I don't have the reference handy, but 25% of kids will have their first food anaphylactic reaction while at school, and many of those will have never been diagnosed with food allergies previously. Benadryl is actually NOT recommended for many peanut-allergy kids because peanuts are known to be the most severe and likely anaphylactic of the known allergens. Of course, this call is made by the prescribing allergist.

That's the story. This was PG county I believe. The girl was on the playground and ate a candy if I recall.

The story did refer to the school not providing epipens. I'm sorry but the ALLERGIST and PEDIATRICIAN of this little girl should have been on the hook for not clearly explaining the need for an epi for this little girl to the mother, and pushing her to provide an epi to the school for use in anaphylaxis When you go to the school with your meds, if they push back, you push back harder and mention ADA protection. Sucks that you have to go that far but u do. I did for the insulin-- not for epipens. I did get pushback when I insisted that the playground aides carry epipens out to recess with them. This meant they needed to purchase fanny packs for rescue meds and general first aid items.

I think the single mom of this kid in PG was not educated well enough in her daughters allergy. The Dr didn't push the epipen requirement, the school nurses only would do Benadryl bc thats what the mom probided. I can not fault the mom-- she's deferring to "expert" opinion on the management of her daughters allergy. She wasn't well educated on this. I do not really think I would let the school have a general use epipen and count on that to save my kid with a known allergy. Makes sense for first time anaphylactic reactions, but still. This little girl needed an epi on site and it's not the schools fault that she did not have one.

It was just sickening all around.

SJ I'm very glad to hear changes are coming... But really THIS should never have happened. Never.