What is a food allergy?
- A food allergy occurs when the immune system mistakenly attacks a food protein. Ingestion of the offending food can trigger the sudden release of chemicals, including histamine, resulting in symptoms of an allergic reaction.
- The symptoms can be mild (rashes, hives, itching, and/or swelling) or severe (trouble breathing, wheezing, and/or loss of consciousness).
- A food allergy can be life‐threatening.
- Food intolerance, unlike a food allergy, does not involve the immune system and is not life‐threatening. Symptoms of food intolerance can include abdominal cramps, bloating, and diarrhea.
- There is no cure for food allergy. Strict avoidance of the offending allergen is the only way to prevent a reaction.
- The severity of a person’s allergic reactions to food cannot be predicted from previous reactions. Someone whose reactions have been mild in the past might react more severely during a next episode.
- Some skin exposures can cause local hives. The smell of a food does not cause an allergic reaction, but breathing in cooking vapors or powdered, crushed, or dust forms of an allergen has been reported by some to induce a reaction. These types of reactions are typically mild, but in rare cases people have reported experiencing severe reactions.
- Food allergy is a serious medical condition affecting up to 15 million people in the United States, including 1 in 13 children. The reasons for the recent sharp increase in food allergy are not clearly understood by scientists.
- Although an individual can be allergic to any food, 8 foods account for 90% of all food‐allergic reactions in the United States: milk, eggs, peanuts, tree nuts (almonds, brazil nuts, cashews, chestnuts, coconuts, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios, and walnuts), wheat, soy, fish, and shellfish.
- Children typically outgrow allergies to milk, egg, wheat, and soy. However, peanut, tree nut, fish, and shellfish allergies are usually lifelong.
- Studies show that more than 35% of children over the age of 5 have been bullied, teased or harassed because of their food allergy.
What is anaphylaxis?
- Anaphylaxis is a serious allergic reaction that is rapid in onset and can result in death. It is a systemic (whole body) reaction that may involve multiple body systems.
- Anaphylaxis can occur from minutes to several hours after exposure to the allergen.
- It is most often caused by allergic reactions to food, insect stings, medications, and latex. Food allergy is the leading cause of anaphylaxis outside of the hospital setting.
- Annually, in the US, there are 300 deaths from penicillin allergy, 150 deaths from food allergy, and 50 deaths from insect stings.
- Anaphylaxis can only be treated by epinephrine injected intramuscularly and must be treated immediately.
- It is critical to recognize the symptoms of a severe allergic reaction / anaphylaxis and respond quickly.
Potential symptoms of a life-threatening reaction may include:
Hives / rash
Swelling (tongue, lips, eyelids)
Swelling of the throat / difficulty swallowing
Difficulty breathing / shortness of breath
Increased heart rate
Low blood pressure
Loss of consciousness
Metallic taste or tingling in the mouth
- Factors that can influence the severity of a reaction include: the dose of the allergen, other concurrent illness like fever or asthma exacerbation, medications (ibuprofen, aspirin, beta blockers, ACE inhibitors), exercise, alcohol, hormones.
- 80% of patients who experience anaphylaxis have some type of skin or mucous membrane symptom (e.g. itchiness, hives, swelling, flushing). An anaphylactic reaction usually begins with skin symptoms and then rapidly evolves into a systemic reaction that involves other organ systems. However, 20% of patients do not have skin symptoms at all when they experience an anaphylactic reaction.
- Approximately 15% of people undergoing acute allergic reactions experience biphasic anaphylaxis, in which the initial symptoms are followed by a delayed second wave of symptoms 1 to 8 hours later.
- Due to continued absorption of the allergen from the GI tract and/or release of additional chemical mediators
- Increases severity of reaction and risk for fatal outcome
- Most reactions occur within 4 hours but some occur up to 72 hours after initial reaction
- Following any anaphylactic reaction, medical observation is required for 4 to 8 hours
- Predictors of biphasic allergic reactions include:
- A delay of more than 90 minutes in either: the administration of epinephrine to the child experiencing a severe reaction or delay in presentation to an emergency department. (The time frame is from the onset of the initial allergic reaction.)
- Wide (or high) pulse pressure during evaluation at hospital.
- More than one dose of epinephrine needing to be administered during the initial allergic reaction.
- Breathing distress that requires inhaled albuterol (salbutamol) in the emergency department.
- A higher incidence in children between 6 and 9 years old.
- Every food allergy reaction has the potential for developing into a life-threatening reaction. Several factors may also increase the risk for fatal anaphylaxis:
- Not receiving treatment with epinephrine or not receiving it in time
- History of previous anaphylaxis, especially biphasic anaphylaxis
- Having a peanut and/or tree nut allergy
- History of asthma
- Upright posture (see below under “Treatment for anaphylaxis”)
- Misdiagnosis of symptoms (e.g. asthma exacerbation, choking, panic attack/anxiety, fainting, heart attack, seizure, stroke instead of anaphylaxis)
- Carelessness about avoiding allergen(s)
- Treatment for anaphylaxis:
- Recognize signs and symptoms of anaphylaxis.
- Administer epinephrine by intramuscular injection immediately.
- Call 911 and request an ambulance with epinephrine*.
- Lay person flat with legs raised**. If breathing is difficult or they are vomiting, let them sit up or lie on their side.
- If symptoms do not improve or symptoms return, more doses of epinephrine can be given 5 minutes or more after the last dose.
- If reaction is severe and not improving, assess for breathing – you may need to perform CPR.
- Transport person to nearest hospital for continued treatment, monitoring, and follow up, even if symptoms resolve.
*Be sure to notify the 911 dispatcher that you need an ALS (Advanced Life Support) ambulance with epinephrine to treat anaphylaxis. Otherwise, they may dispatch a BLS (Basic Life Support) team who may not be carrying epinephrine or be trained to use it.
**It is important to keep the person lying down. Sitting up or standing might cause a dangerous sudden drop in their blood pressure.
♦Click here for a PowerPoint presentation from our June 2015 meeting – “Anaphylaxis – Be Prepared, Not Panicked” by Dr. Karen Andrews
♦Click here for a PowerPoint presentation from our October 2015 EMS training – “What Every EMT Should Know About Anaphylaxis: The Updated Guidelines” (Anaphylaxis Community Experts and Dr. Eric Caplan)
- Epinephrine is the only drug treatment for anaphylaxis. It is the ONLY drug that antagonizes the effects of all anaphylaxis mediators!
- Available by prescription as an auto‐injectable device (e.g. EpiPen®, Adrenaclick™, Auvi-Q™).
- Given for symptoms that extend beyond the skin such as swelling, choking, obstruction of breathing, wheezing, dizziness, vomiting, diarrhea, abdominal pain, rapidly progressing hives spreading in a generalized manner.
- Epinephrine is safe to use! Like adrenaline, it increases heart rate and blood pressure, reverses bronchospasm, and stops wheezing. Drug effects occur within seconds and are life-saving.
- Always carry 2 epinephrine doses at all times everywhere you go! One epinephrine dose lasts 20-30 minutes at most. If symptoms have not responded to the 1st injection, a 2nd injection can be given after 5 minutes. 30-35% of anaphylactic reactions may require a second dose of epinephrine.
- After using epinephrine and whenever someone experiences an anaphylactic reaction, they must be immediately transported to a hospital because additional treatment with a combination of epinephrine, antihistamines, and steroids may be necessary. Medical observation for 4 to 8 hours is necessary to monitor for biphasic anaphylaxis.
♦Five recommendations for reducing risk of thigh injury when using an EpiPen:
- The person’s leg should be immobilized.
- The action of administering epinephrine and site of delivery should be as well controlled as possible.
- The needle should remain inserted in the thigh for as short a time as possible.
- The needle should be strong enough that it does not bend during use.
- The needle should never be reinserted.
Preventing an allergic reaction:
Even a trace amount of food allergen may cause a severe reaction, so it is critical that the food allergen is strictly avoided. Here are some tips for strict avoidance:
- Diligently read ALL food labels every time
- Know what to look for on the label
- Understand food allergen statements
- Avoid any foods that do not have labels
- Check labels on non-food products as well
- Be aware of potential risks within the environment
- Know the sources of cross contamination to prevent exposure
- Ask questions
- Always bring safe snacks
- But always carry two doses of epinephrine, no matter what!
Reading the Labels:
“When in doubt, chicken out!”
“If you can’t read it, don’t eat it!”
- Manufacturers are required to list ingredients on the label.
- The Food Allergen Labeling and Consumer Protection Act (FALCPA) is a federal law that requires food manufacturers to disclose in plain English on ingredient labels the presence of the 8 major food allergens in the product: milk, egg, wheat, soy, peanuts, tree nuts, fish, and shellfish. Presence of the food protein can be listed as “contains milk” or the ingredient followed by the food source (e.g. “natural flavors (peanut, almond)”).
- There are many foods & products that are not covered by FDA allergen labeling laws, so it is still important to know how to read a label for allergen ingredients. Products exempt from plain English labeling rules include: foods that are not regulated by the FDA, cosmetics and personal care products, prescription and over‐the‐counter medications or supplements, pet food, toys and crafts. The FDA has exempted peanut oil from being labeled as an allergen, though it still must be avoided.
- Check out FARE’s helpful How to Read a Label Information Sheet.
- Advisory statements such as “may contain traces of…” or “manufactured in a facility that processes…” are voluntary and vary among companies.
- Read the ingredient list / package label every time to check for the presence of food allergens. Never rely on visual inspection or taste of a food to determine if it contains allergens.
- If a product has an allergen statement such as “contains wheat”, do not only read the allergen statement; you still need to read the entire ingredients list!
- Food manufacturing and production methods do change, so you must read the label even if the product was previously confirmed to be safe or consumed safely. Ingredients can also vary from one manufacturing plant to another.
- Low-fat/reduced fat versions of foods, snack-sizes, or the same foods in different types of containers (e.g. shelf-stable carton vs. can) can have different ingredients.
- Limit processed foods as much as possible as these have a greater potential for containing undisclosed or hidden ingredients. Be cautious with food manufactured outside of the United States; some other countries have less stringent product labeling requirements.
- Cross-contamination of food preparation, manufacturing, and packaging equipment is a serious concern, so many Allergists recommend that you avoid products with voluntary allergen statements such as “may contain peanuts”, “processed in facility that processes wheat”, “may contain traces of soy”, etc.
- Depending on your food allergy, you may need to avoid multiple ingredient foods with no label (e.g. foods from a bakery/ice cream display case or salad bar or buffet table). You may also need to avoid items from a bulk bins or bulk barrels.
- Be extremely cautious of foods that you did not make. Well-intentioned friends and family may not have read the ingredient labels while cooking or baking. They may not understand the danger of cross-contact or that trace amounts of an invisible allergen can cause a severe reaction.
- When in doubt about the label, consult FARE, call/email the manufacturer, or check the manufacturer’s website.
- If you are not sure if the food contains allergens and can’t confirm that that it doesn’t, don’t take the risk – don’t eat it, don’t feed it!
- Be prepared for a serious allergic reaction anyway and carry two doses of epinephrine at all times as there is still always a risk for accidental ingestion.
Cross-contact occurs when an allergen is unintentionally transferred from a food/item containing the allergen to a food/item that did not contain the allergen. Example: a knife that was used to spread peanut butter is wiped off before being used to spread jelly. Some ways to prevent cross-contact include:
- Wash hands well with soap & hot water or hand wipes before eating or touching the face (note that plain water and alcohol-based hand sanitizers are not effective at removing allergens from the skin, according to a study published in the Journal of Allergy and Clinical Immunology).
- Do not share utensils, dishware, cups, water bottles, beverages or food.
- Wash dishes, utensils, & cookware, and clean tables, counters, & eating surfaces thoroughly with bleach, commercial cleaners or commercial wipes. (Liquid dish soap is not as effective as commercial cleaners at removing allergens from surfaces, according to a study published in the Journal of Allergy and Clinical Immunology). It is best to use bleach. Do not leave any residue with potential allergens.
- Be aware that cooking/heating the food will not remove the allergen or reduce the chance of an allergic reaction.
- Consider other surfaces that may have allergens like chairs, hand railings, or playground equipment. Sponges, dishrags, sanitizing buckets, and aprons can also be sources of allergen exposure.
- Saliva from other people and pets can also contain the allergen if recently eaten.
- Be cognizant of what other people are eating around you.
- Beware of the potential for accidental exposures around young children. While skin contact usually (but not always!) only causes minor reactions, young children often put their fingers in their mouths which can result in potentially more severe reactions.
- Be aware that non-food items may contain food allergens. This includes but is not limited to: arts and crafts, bird feeders, pet food, medications, supplements, cosmetics, soaps, and body/hand lotions.
- Do not be afraid to ask questions to make sure the item is safe.
Food Allergy Basics Works Cited:
-Algurashi, W. et al. “Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis.” Annals of Allergy, Asthma & Immunology 2015.
-Brown, Julie C. et al. “Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children.” Annals of Emergency Medicine 2015.
-“Food Allergy Facts and Statistics for the U.S.” Food Allergy Research & Education (FARE). 29 January 2021 <https://www.foodallergy.org/resources/facts-and-statistics>.
-“From Confusion to Confidence: KFA’s Starter Guide to Parenting a Child with a Food Allergy.” Kids With Food Allergies. 2009-2010. 05 October 2013 <http://www.kidswithfoodallergies.org/guide_to_parenting_child_with_food_allergy.html>.
-“Managing Food Allergies in the School Setting: Guidance for Parents.” The Food Allergy and Anaphylaxis Network (FAAN). 05 October 2013 <http://www.foodallergy.org/document.doc?id=123>.
-Perry, T. et al. “Distribution of Peanut Allergen in the Environment.” Journal of Allergy and Clinical Immunology 2004; 113: 973-976.
-Pistiner, Michael. “Practical Food Allergy Management: A Quick Guide.” Kids With Food Allergies. July 2013. 06 October 2013 <www.kidswithfoodallergies.org/handout.html>.
-Pistiner, Michael. “Food Allergy Babysitting and Drop-Off Form.” Kids With Food Allergies. Ed. John Lee. June 2013. 06 October 2013 <http://www.kidswithfoodallergies.org/babysitter_form.html>.
-Young, Michael C. The Peanut Allergy Answer Book, Second Edition. Beverly, MA: Fair Winds Press, 2006.