FOOD ALLERGY AWARENESS

ARE YOU AWARE?

MICHELE A. FAGAN, EFDA, RDH, BS

Food allergies - they are nothing to sneeze at! When you think of the word allergy, you may think of that pesky pollen that is around in the spring and summer months. It causes a person with seasonal allergies to react with the symptoms of sneezing, a runny nose, and red, itchy, swollen eyes. However, a person with food allergies differs from one who may suffer from seasonal allergies. While seasonal allergies are uncomfortable and annoying, they are only temporary. Food allergies are the ones that can be life-threatening and are not seasonal.

Food allergies have to be dealt with on a daily basis. People with food allergies have to choose their foods carefully so they do not have a harmful reaction. It is not because they are picky eaters, nor do they have particular food preferences. The food allergic person, or the parent of a food allergic child, must make an assessment of every morsel of food they eat or drink ... every day of their lives. They must ask questions about food ingredients at every event outside their home involving food. They have to question every restaurant, every school cafeteria, and every house party they attend. In a home or a restaurant there can be cross-contamination of cooking pans, utensils, and baking trays. For example, just because someone offers the peanut allergic person a nut-free homemade cookie doesn't necessarily mean it is truly nut-free. It may have traces of peanut butter in it if the previous batch of cookies that were baked on the same tray had peanut butter or any kind of nuts in them. You have to ask the person who baked them if the cookie tray or spatula previously came in contact with any peanut butter or nuts.

The same holds true in a restaurant where cooking oils or food particles can remain on cookware. In a restaurant, do not hesitate to ask to speak to a chef if the server cannot answer your questions with absolute certainty regarding allergens. For the supermarket, every trip involves reading all labels ... all the time. Someone with a food allergy can never assume a food or drink is safe, even if it is something they had before, because companies may change manufacturers or ingredients at any time. This is why one must be vigilant about reading labels. Just one bite or one taste can be detrimental to the person with food allergies.

Allergic reactions to food can range from mild to severe, and there is no predicting when and how it is going to occur. It can occur within minutes or up to two hours after ingestion. A severe reaction to food allergies can literally take the allergic person's breath away (anaphylaxis). Anaphylaxis is a sudden, severe, potentially fatal, systemic reaction that can involve various areas of the body, such as the skin, respiratory tract, gastrointestinal tract, and cardiovascular system.

As the parent of a child with a severe peanut allergy, I know firsthand of the vigilance of food avoidance that must be carried out every day. I also know the fears and concerns of sending your food allergic child to school or to someone's home. I have been on a quest the past six years to learn more about food allergies and to educate others since my son was diagnosed. I also have a brother who at age 41 was just recently diagnosed with allergies to peanuts, shellfish, and egg whites. As a health-care professional, I am also encouraged to share what I have learned with others. This is a problem that has been increasing over the years across the nation. Perhaps you, too, have a food allergy or deal with one with a family member or friend. This information is not limited to just parents, teachers, and health-care workers. It can be shared with all people of all ages. Food allergies do not discriminate. They can occur at any age from childhood to adult onset. According to Robert A. Wood, MD, director of allergy and immunology at Johns Hopkins Children's Center in Maryland, "Once an allergic reaction to food occurs, there is no way to know how bad it will be; hence the worry and fear of living with a food allergy." Dr. Wood has firsthand experience with food allergies, not only as a researcher, but he also has a peanut allergy.

FOOD ALLERGY BASICS

A food allergy occurs when a person's immune system identifies proteins in a food as an allergen and begins to produce disease-fighting antibodies called immunoglobulin E (or IgE) against that food (e.g., nuts or milk). These antibodies attach themselves to mast cells in the body, and when the person again eats the allergenic food, the proteins from it become attached to the IgE antibodies. This causes the mast cells to release histamine and other powerful chemicals. It is these chemicals that cause the symptoms of allergy. The body responds in this way in an effort to expel the protein invader from your body.

ARE YOU PREPARED?

As health-care professionals, we must remain aware of our patients' medical histories. I recently had a patient with a medical history that read: Allergies: peanut, tree nut, shellfish, latex, apples, and strawberries. I thought to myself, when I started in the dental field close to 30 years ago, there were only two allergies we focused on - latex and penicillin. Now, we have many more considerations when it comes to dealing with a patient who has allergies. Although food allergies have been on the rise in the past 10 years, scientific research still does not have an answer as to why it is happening. Here are some questions to consider when treating patients:

• Would you know to ask about food allergies?
• Do you know what is in the products you recommend to your patients every day?
• Do you know to ask your allergic patients if they carry a self-injectable epinephrine device (Epi-Pen, Epi-Pen Jr., Twinject)? Do you know how to administer it?

Epinephrine is the first line treatment medication for a severe allergic reaction. People diagnosed with food allergies should have self-injectable epinephrine prescribed and carry it with them at all times. They should also wear an identification bracelet describing the allergy. Oral health-care professionals should be aware of the location of the patients' epinephrine. They should also know that it needs to be injected intramuscularly on the top side of the thigh and held there for 10 seconds. This type of injection is the quickest route for epinephrine to work. It can be injected right through clothing. This is to be done immediately and then call 911 for emergency medical assistance. The epinephrine is used to open up the airways so breathing can take place more easily. It strengthens the heartbeat and the ability of the blood to transport to all parts of the body. It should be noted that epinephrine may not always be effective in severe cases, which is why you must call emergency medical services. Epinephrine may be repeated five to 20 minutes after the initial dose.

THE MAGNITUDE OF THE PROBLEM

According to the American Academy of Allergy, Asthma, & Immunology, (www.aaaai.org) there are approximately 15 million Americans who suffer from food allergies. The number afflicted has risen over the past 10 years. Many of these allergies can be fatal. The top eight major allergens are milk, eggs, soy, wheat, peanuts, tree nuts (walnut, pecans, almonds, cashews, and pistachios), shellfish, and fish. According to Scott Sicherer, MD, clinical researcher at the Jaffe Food Allergy Institute and chief of the Division of Allergy and Immunology in the Mount Sinai School of Medicine's Department of Pediatrics, N.Y., "We see allergies to all sorts of foods. In fact, there are more than 170 foods that can cause an allergic reaction. We are seeing an increasing number who are allergic to raw fruits and vegetables as well as various beans and seeds, and more and more children who are allergic to poultry and meats." He also states that in a 2010 study of food allergies, rates of childhood peanut allergies - one of the most common and most dangerous allergies - has more than tripled between 1997 and 2008. The Centers for Disease Control and Prevention reported that the increase in food allergies has been seen in children under 18 years old, and estimates that these children experience more than 300,000 ambulatory care visits per year related to food allergy.

To make life a little bit easier for those with food allergies, the Food Allergen Labeling and Consumer Protection Act (FALCPA) became effective in January 2006. It ensures that people can easily and accurately identify ingredients that may cause a reaction. Under this law, allergen declaration must be in plain English. Though more than 170 foods have been identified as triggering food allergies, this law is limited to the eight major food allergens, which account for 90% of food allergies in the United States. You may see allergen alert statements such as may contain or processed in a facility ... followed by a particular allergen. Treat that statement as if it says it does have the allergen. Those alerts are posted to make you aware that there can be even a trace amount of allergen in a product. It is important to avoid those foods.

IS IT A FOOD ALLERGY OR INTOLERANCE?

A food allergy is an immune system response. It occurs when the body mistakes an ingredient in food - usually a protein - as harmful and creates a defense system (antibodies) to fight it. Food allergy symptoms develop when the antibodies are battling the "invading" food.

Food intolerance is a digestive system response rather than an immune system response. It occurs when something in food irritates a person's digestive system, or when a person is unable to properly digest or break down the food. As listed in the following chart, there are a variety of symptoms in both food allergies and intolerances. Not everyone will get all the symptoms, and reactions can vary widely from mild to severe.

FOOD ALLERGENS IN DENTAL PRODUCTS

Are you aware that there may be food allergens in the dental products we use or recommend for our patients? You can always refer to websites, or call the manufacturer if you have any questions about ingredients. Here are some examples:

• Recaldent is a milk derivative (may be listed as casein) - found in GC America's MI paste, toothpastes, and some forms of Trident gum.
• Polishing paste - contains gluten (causes gastrointestinal disorder)
• Fluorides - can contain gluten or nut oils
• Topical anesthesia - contains fruit flavorings
• Propofol - general anesthesia that contains egg protein
• Cements - eugenol is derived from oil of cloves
• Nitrous oxide - does not specifically contain egg, but it has a substance that is molecularly structured like eggs and reactions have been reported

FOOD ALLERGENS IN NONFOODS

Another point of awareness is for products that are nonfoods, but that may contain food allergens. Be sure to read labels on everyday products even if they are not edible.

• Soaps and hand sanitizers - may contain soy, milk, and nut oils
• Shampoos and other hair care products and dyes - can contain wheat, almond, and other nut oils and soy protein
• Hand and body lotions - may contain coconut, tree nut, or sesame and arachis (which is derived from peanut)
• Suntan lotion - can contain arachidyl glucoside and arachidyl alcohol (arachis refers to peanut)
• Makeup - also may include wheat and sesame oil
• Medications and supplements - gel cap formulations may contain soy, peanut oil, or canola oil
• Adhesives - many glues and other adhesives contain wheat, including envelopes, stamps, and stickers you have to lick to moisten the adhesive
• Play-Doh - contains wheat
• Fruit and vegetable rinses - many contain starch, which can come from wheat, potato, corn, and rice
• Stuffed toys or chairs - some of the stuffing in bean bag chairs or stuffed animals can include the shells of ground peanuts or tree nuts
• Pet food and bird seed - can contain wheat, peanut, milk, and eggs
• Landscaping soil - may contain peanut hulls
• Rolling pins - some may have been treated with nut oil

RESEARCH AND RESOURCES

Research - Currently, researchers at both Johns Hopkins and Duke University are testing both sublingual (under the tongue) immunotherapy and oral immunotherapy (allergen is swallowed). Some findings indicate that children with severe milk allergies who received a longer schedule of sublingual immunotherapy and then moved on to oral immunotherapy had fewer respiratory reactions along with decreased use of certain medications. Dr. Robert A. Wood presented these findings at the 2012 Annual Meeting of the American Academy of Allergy, Asthma, & Immunology. He reported that some of these therapies improve the safety of the allergen, although they did not eliminate all of the symptoms. This study shows that for some children - especially those with more frequent or severe reactions to oral immunotherapy - beginning treatment with sublingual immunotherapy might be beneficial. Dr. Wood stated, "We continue to search for the best approach for the treatment of food allergy."

A press release on April 12, 2012, from the Mount Sinai School of Medicine reports that David A. Koch, a philanthropist and executive vice president of Koch Industries, has donated $10 million to the Jaffe Food Allergy Institute at the Mount Sinai Medical Center in Manhattan, New York. Mr. Koch is a major advocate for medical research and has long supported research into food allergies. This donation is to be used for a program that will be a hub for drug discovery and vaccine development related to food allergy, and build upon promising work already underway at the Institute. The donation will also be used to further the Institute's recruitment of leading researchers dedicated to the discovery of new food allergy therapeutics.

Resources - A worldwide resource for information and advocacy on food allergies is known as FAAN (The Food Allergy & Anaphylaxis Network). It was founded in 1991 and is the world leader in information, resources, and programs for food allergy, a potentially life-threatening medical condition that afflicts approximately 15 million Americans. FAAN is a nonprofit organization based in Fairfax, Virginia. There are approximately 25,000 members in the United States, Canada, and 58 other countries. The organization is dedicated to increasing public awareness of food allergy and its consequences, educating people about the condition, and advancing research on behalf of all those affected by food allergies. FAAN provides information and educational resources about food allergy to patients, their families, school health professionals, pharmaceutical companies, the food industry, and government officials. For more information, you can visit FAAN at www.foodallergy.org.

In January 2011, President Obama signed into law the Food Safety Modernization Act, also called the "Food Safety Bill," The Food Allergy and Anaphylaxis Management Act (FAAMA) were included in this bill as well. Under this bill, the federal government has set up voluntary national guidelines to help schools across the nation better manage students with food allergies.

Food allergies are complex. They are not to be taken lightly. It can be frustrating for those living with them on a daily basis. It is also scary to think that there are people who just don't understand or "get it" that it is crucial for those afflicted with food allergies to live a life of total avoidance of certain foods. If the allergic person should ingest something that causes an allergic reaction, it can be as lethal as a bottle of poison to their system.

There is no cure for food allergies. Food touches so many areas of our lives. It is important to remind family members, teachers, and caregivers the importance of reading labels. Strict avoidance is vital. The motto for all those dealing with food allergies is: Education and awareness is the key. Are you aware? Your caution can save an allergic person's life. As the members of FAAN say, "Be a P.A.L. - Protect A Life from food allergies." I invite you to be a P.A.L. too.

Author's note: A very special thank you to my mentor, Patti DiGangi, RDH, BS, for "challenging me beyond my routine."

REFERENCES

1. Barclay L, Vega C. New Pediatric Guidelines for Self-Injecting Epinephrine for Anaphylaxis Treatment. http.www.medscape.com/view article/554150-print. Accessed Aug. 2, 2007.
2. David A. Koch donates $10 Million to Mount Sinai's Jaffe Food Allergy Institute. http.www.mssm.edu/research/programs/jaffe-food-allergy-institute. Accessed Apr. 12, 2012.
3. DiGangi P. Food Allergies Can Kill - Are You Prepared? 2006. http//rdhpennnet.com/display-article/280324/56/ARTCL/none/none/Food-Allergies-Can-Kill-are-you-prepared?/. Accessed Mar. 3, 2007.
4. Food Allergy News; Food Allergy & Anaphylaxis Network Newsletter; Oct.-Nov. 2011; (21)1.
5. Food Allergy & Anaphylaxis Network. http://www.foodallergy.org.
6. Food Allergies vs. Food Intolerances. http:www.webmd.com/allergies/foods-allergy-intolerances. Accessed Mar. 8, 2012.
7. GC America. http:gcamerica.com. http:mi-paste.com.
8. Infectious Diseases in Children; Treatment of Food Allergies Showing Progress. Accessed Mar. 4, 2012.
9. Laliberte R. Rethinking food allergies. Women's Day Magazine, Jan. 2011; 74(3).
10. Living the Allergic Life ... to the Fullest! Allergies at the Dental Office. http://allergyfree.wordpress.com/2010/04/16/allergies-the-dental-office. Accessed Jan.15, 2012.
11. Recaldent - an important ingredient for strong teeth. http://www.recaldent.com/p-faqs.asp.
12. Sicherer S, Sharma H. Allergic living. The Food Allergy Experts. Fall 2011; 1(3).
13. Wachs R. Food Allergy Connection. www.foodallergyconnection.org.
14. Wood R. http://drrobertwood.com/allergens-in-non-food-items.html. Accessed Apr. 1, 2012.

MICHELE A. FAGAN, EFDA, RDH, BS, has experience in the dental field as both a dental hygienist and expanded functions dental assistant. She is currently practicing dental hygiene in private practice in Philadelphia, Pa. She also has served as adjunct faculty at both Manor College in Jenkintown, Pa., and Harcum College in Bryn Mawr, Pa. Her role as a mom of a 10-year-old son, who has a severe peanut allergy, keeps her busy as an advocate for food allergies.