To Eat or Not to Eat?
So many people today are affected by different types of adverse food reactions. Adverse food reactions are abnormal responses to a certain food that might cause allergic or non-allergic hypersensitivity and reaction (Stapel, 793). These reactions have been growing phenomenally in the last ten to twenty years, especially in the United States. There is much confusion and many variables to consider when it comes to food allergies and anaphylactic response. A reaction that is so severe and can be deadly is known as anaphylaxis. Many people are not fully aware of what goes on biologically when a person is having an anaphylactic reaction. It is important to be educated on what happens when a person is going through a life threatening reaction.
The number of people with food intolerances has been growing rapidly in the last decade; however, not many people realize the significant differences between the two types of reactions: allergies and intolerances. It can be critical to learn and know these differences. There are two types of antibodies that affect these reactions, IgE and IgG. There are also several different types of testing for food allergies and intolerances. The differences in the results of those tests can be confusing. Different opinions are given on which form of testing gives the best results. After allergy testing, medication is prescribed to the patient. The two most common forms of medication are epinephrine (or some type of adrenaline medication) and an antihistamine. Many patients are afraid to use epinephrine in the event of an emergency; because of the effects the epinephrine has when used in a case of anaphylaxis. Is epinephrine truly safe to use? Do antihistamines work just as well in a case of anaphylaxis? Several government programs and events have been implemented to help children and the parents of students with food allergies, feel safer and more prepared in a school setting. What are other ways children with severe anaphylaxis can be helped?
There is much controversy involved in these subjects related to food allergies and anaphylaxis. In order to ensure the safety of people with food allergies (and even people who can be at risk) these subjects need to be clarified and taught to everyone. Doctors and specialists say different things and people often ask themselves, “Who is right?” “Which way is the best way to go?” Since there are so many variable when considering medication, allergy testing, and so forth, it is extremely important to be aware of all the options and then take the correct course of action.
A food allergy is defined as an immune system response to a certain food protein (FARE). The body sees that specific protein as a threat and starts attacking. The most common food allergens are peanuts, cow’s milk, shellfish, tree nuts, eggs, fish, wheat, and soy (Gupta, 17). Anaphylaxis is a severe and possibly fatal allergic reaction that occurs almost immediately after coming in contact with a certain allergen (Gupta, 17). Anaphylaxis affects the skin, gastrointestinal, respiratory, and cardiovascular system (FARE). The skin starts to become itchy. A person can end up with hives all over their body, including the face, inside the mouth, and the throat. When a skin reaction occurs, a person’s skin begins to swell, because all the blood is rushing from the brain to the skin. This makes it painful to touch anything. It also makes it difficult to receive treatment once a person is sent to the emergency room.
Typically, when someone is having an anaphylactic reaction to a food, that food was consumed orally. The body rejects that food, and so the gastrointestinal system begins to do the same. A person may experience stomach cramps, nausea, vomiting, and diarrhea. This, in a way, can help a person, because then the substance they are allergic to is no longer in the body. The cardiovascular system is also sometimes affected; only in extreme cases. The blood pressure drops drastically, and often times the body will start to seize, in an attempt to force all the blood back to your brain.
A study was done on people who were sent to the hospital because they were having an allergic reaction to something. They asked the patients to say whether they had a respiratory reaction, a cardiovascular reaction, or both. 13.9% of the patients said they experienced just respiratory problems. 25.4% said they just experienced cardiovascular problems. 60.7% said they had experienced both (Beyer, 1452). It is important to know what signs and symptoms to watch for, because anaphylaxis is so deadly and quick.
Often times, people are experiencing anaphylaxis and they don’t even know it. Another survey was done on people who were hospitalized for food reactions, and 71% of them experienced anaphylaxis without even realizing what anaphylaxis meant. (Gupta, 21) Sometimes people will experience recurrent symptoms, this is when after someone has had their anaphylactic attack, they calm down for a little while, but 30-60 minutes later that person will start to experience the symptoms over again. The symptoms are sometimes worse the second time around. Recurrent symptoms happen in around 6%-11% of children and 23% of adults with food allergies that are involved in an event of anaphylaxis (Gupta, 19).
Many people confuse food intolerances with food allergies. Food intolerances do not involve the immune system. They occur when a person has sensitivity to food. Food intolerances will not cause a life threatening reaction.
The reason why there are different reactions is because of the different antibodies that are activated. The Immunoglobin E (IgE) antibodies are what cause anaphylactic reactions. The Immunoglobin G (IgG) or more specifically the Immunoglobin G4 (IgG4) antibodies are the cause for food sensitivities or intolerances. The IgE antibodies attach themselves to cells in the skin, lungs, and the gastrointestinal system (AAAAI). The immune system sees these antibodies as a threat, and begins attacking them. This explains why the skin, lungs, gastrointestinal system are all affected during anaphylaxis. IgE antibodies also release histamines and other mediators (Healthscope). IgE symptoms include abdominal cramping, diarrhea, skin rashes, hives, swelling, wheezing, and potentially anaphylaxis (Healthscope). Not all cases of IgE allergies end in anaphylaxis. If the subject isn’t as allergic to the allergen or if medication is provided immediately, these symptoms will die down faster.
IgG antibodies have a dramatically different reaction than IgE antibodies. Instead of attaching to the cell, they attach directly to the food source when entering the blood stream (Healthscope). Since they do not attack the body itself, the immune system does not respond. However, there are still symptoms when IgG antibodies are active. Symptoms of presently active IgG antibodies include: abdominal bloating, migraines, depression, mood swings, asthma, skin conditions (such as Eczema), and behavioral problems in children. These symptoms are not deadly, but are important to watch out for and make sure people affected do not suffer from these conditions.
So, what are the differences between IgE and IgG antibodies? The reaction time for IgE antibodies is insanely faster than IgG antibodies (Healthscope). If a person eats a food allergen, their IgE antibodies will immediately begin to attach to their cells, typically starting in the skin or the lungs. Their antibodies stay attached to their cells for a long period of time, until they reach the cardiovascular system and begin to affect the heart. With IgG antibodies, they will attach to the food, but it takes a while for the food proteins to get into the blood stream. The response time takes longer and can depend on the person. The IgE reactions are normally permanent, rarely does a person stop reacting to a food allergy after a period of time. However, with intolerances and IgG antibodies, after time, a person can begin eating that certain food item (Healthscope).
The testing for IgE and IgG are extremely different, but commonly mistaken for the other. The different types of testing for food allergies include skin testing, blood testing and food challenges (FARE).
Skin testing is commonly used for anaphylactic allergies and to test for the appearance of IgE antibodies. The three most common forms of skin testing are the skin prick test, intradermal test, and the patch skin test (Henochowicz). All of these tests have to be performed in a qualified Allergist’s office. These can all be used for different foods and are all effective.
The skin prick test is performed by placing the substance on a person’s skin, and then the skin is pricked. The person being tested then waits for fifteen to twenty minutes. Welts (also called wheals) appear if the person is allergic to that substance. If welts appear, then the Allergist will measure them to see how sensitive a person is to a certain allergen. The larger the welt, the higher the sensitivity there is to that allergen. If no welt appears, then this commonly means you are not allergic to anything, and will be recommended to look at other medical options for the person’s symptoms. Sometimes a person can receive symptoms from allergy testing such as itching, stuffy nose, watery or red eyes, and skin rash (Henochowicz). The skin prick test is the most common form of allergy testing. It is normally reliable and accurate, in rare cases however, false positives or false negatives have occurred.
The intradermal skin test is where a small amount of allergen substance is injected slightly below the skin and then observed for any adverse reaction (Henochowicz). This again, is done in an Allergist’s office under qualified supervision. False positives appeared frequently when performing intradermal testing for food allergies, and so typically doctors will recommend the skin prick because they provide more accurate results. Injecting the allergen can be very risky and dangerous for people who have experienced anaphylaxis, whereas that risk is lowered a great deal with the skin prick test. The intradermal testing is most commonly performed for people with insect venom or drug allergies (Henochowicz).
The last form of skin testing is the patch skin test. The possible allergen (in the form of a patch) is taped to the person for 48-72 hours (Henochowicz). If you are allergic, a rash or allergic skin reaction will occur. This is common testing for more skin related allergies, rather than anaphylaxis (Henochowicz). If no symptoms occur, then the person will be recommended to a dermatologist who will test for other skin conditions not related to food allergies. Food allergies do not commonly occur when coming in contact with skin, but it can depends on the person’s immune system. If the person is naturally bothered by things touching their skin, food will often react.
The only absolutely secure form of testing for anaphylactic food allergy is a food challenge (Stapel, 793). A food challenge is when a patient eats a pure form of an apprehensive food allergen (Anaphylaxis Campaign, 1). Patients often question whether or not food challenges are safe. Food challenges are safe, as long as it is done under supervision and in a medical facility (Anaphylaxis Campaign, 1). For safety reasons, food challenges are never performed at home under any circumstances. They are performed in a hospital or a specialist’s clinic, under professional supervision and where medication is available in case of an emergency (Anaphylaxis Campaign, 1). Food challenges are typically completed for a scenario where both blood and skin tests have failed to present answers (Anaphylaxis Campaign, 1). There are two main types of food challenges, an open challenge and a blind challenge (Anaphylaxis Campaign, 1). An open challenge is simply where a patient eats the most raw or pure form of the allergen, knowing that this is the food they are eating. A blind challenge is where they present multiple food dishes; one contains the suspected allergen in it. Blind food challenges are done for a couple reasons. One reason is because the patient is afraid of eating something and it causing a serious reaction. Another is because sometimes reactions are believed to be psychological problems rather than physical. An option is chosen solely based on the preference of the patient.
Food challenges can be potentially life threatening, because of this there are certain steps that must take place during and after the test. If one step is missed, a person must stop the test, and wait to perform it again in several months to a year, just to ensure patient safety. Before the test is performed, the patient is examined by a doctor or specialist, to ensure that the patient is healthy enough to perform the exams, and that there won’t be other factors at play for a reaction. Professionals also must make sure they have all their equipment needed if the patient suffers from a reaction (Anaphylaxis Campaign, 1). The equipment may include medication, oxygen, and so forth. The patient then proceeds to eat a small amount of the suspected allergen. There is a six to eight dosage of the allergen, waiting fifteen minutes between each (Anaphylaxis Campaign, 1). After the patient is done eating, the staff and patient wait four hours to see if any reaction has occurred.
A positive reaction means the patient is allergic to that substance and will receive help immediately. If no reaction occurs, the patient is not allergic to the substance tested (Anaphylaxis Campaign, 1). If a person tests positive after a food challenge, then they will simply not eat the allergen anymore. If the food challenge results are negative, then the person needs to eat the allergen once a day for a week after the test, and then proceed to eat the allergen three times per week for a year (Anaphylaxis Campaign, 1). This is merely a precaution and safety, in case there was some other factor that causes the person to test negative. After that, if no reaction has occurred, then the patient can eat the food as often as they want (Anaphylaxis Campaign, 1). Doctors recommend keeping emergency medication on hand for at least three months (Anaphylaxis Campaign, 2).
Another type of food allergy testing is the blood testing, which is used more for food intolerances rather than anaphylactic food allergies. Even though some doctors do recommend blood tests, there is a lot of question related to this type of testing. In the 1970’s, scientists discovered the release of antihistamines, IgG antibodies, and how they acted (Stapel, 794). They saw that the antibodies attached to the food while it was in your blood stream, rather than the cells in your body. This was interesting because they had only seen antibodies attacking the body’s cells. Their main goal was to discover the relationship between food inhalant allergies and hay fever (allergy to plants), as well as test for food intolerances. There are certain foods that can connect to different hay fever inhalant allergies. The food intolerance results were very questionable. There has been a long standing debate over IgG antibody release, and whether or not blood tests can accurately give the patient results on food intolerances or food allergy.
Different studies have shown throughout time that there is no firm evidence that supports blood testing. A group of thirteen laboratory workers were asked to do both IgE allergy tests (skin testing) and IgG allergy testing (blood testing). All thirteen workers tested for a positive sensitivity for at least one common food allergen with the blood testing (Stapel, 795). This shows that everyone, to some degree, has sensitivity to a food protein. However, it can be low enough to where the person does not experience many, if any, symptoms. The workers skin test results were completely different than the blood test results (Stapel, 795).
What does this mean? “Positive IgG4 tests to foods… do not indicate the presence of food allergy, but are probably reflecting prolonged exposure to food components” (Stapel, 795). The workers’ positive results were most likely due to over exposure to that certain food protein, such as wheat, peanuts, or dairy. Those are all things people consume often and can test positive for because of how much they consume those food items. Does this mean people with food allergies should not pay for blood tests? When considering anaphylaxis, a person should choose skin testing over blood testing. Blood testing is not a reliable way to test for anaphylactic food allergies. If a patient is looking for a food intolerance issue, then yes these tests can be helpful. Celiac patients often use IgG blood testing. Celiac disease is a gluten intolerance that can affect the entirety of a person’s life (FARE). Celiac disease does not involve anaphylaxis, but often times can cause very serious damage to a person’s health and well-being. Even though celiac patients use blood testing, it still isn’t the most accurate form of testing, and often gives people false positives and false negatives (Stapel, 764).
There is no other form of testing for celiac other than doing a recommended elimination diet. In elimination diets, a person who experiences issues with food intolerances eliminates several common food allergens or foods they feel are suspicious from their diet (FARE). After a couple weeks or months, patients begin to add food items one at a time and keep track of how they feel (FARE). This will help pinpoint the specific sensitivity that is causing problems. Another method is to simply not eat a certain food for two to four weeks, and watch if the symptoms disappear. (FARE) If symptoms disappear, then the person has found their intolerance. This process is repeated with another food item.
What is the best form of testing? That is a difficult question to answer because doctors and specialists all have a different opinion of what is helpful and what is not. However, in the case of anaphylactic allergies, a food challenge will give the most confident results. However specialists struggle to perform food challenges because it is risky and can be dangerous if not done correctly. The skin prick test then is the best form of testing for anaphylactic food allergies, because it is safe and rarely inaccurate. For non-anaphylactic intolerances, blood testing can sometimes be useful, but an elimination diet can give you fairly good results as well.
What happens after testing? If a patient tests positive for IgE testing, the patient will be prescribed medication and told to stay away from that food allergen at all costs. There are two main types of medications for helping anaphylaxis and allergy symptoms, epinephrine and antihistamines.
Epinephrine is an adrenaline drug. It is the only treatment for anaphylaxis. Even though epinephrine helps with anaphylaxis, it does not cure it. If a person is experiencing anaphylaxis and chooses to administer epinephrine, they still need to rush to the hospital for further treatment. An adrenaline drug like epinephrine helps raise the blood pressure, increase oxygenation, raise blood glucose levels, and it helps the body fight against the allergic reaction (Simons, 1).
Epinephrine can come in the form of an auto injector, in case of an emergency; the mostly commonly used form is the EpiPen. The auto injector works so the patient or someone close to the patient can inject epinephrine which can keep the reaction at a lower level before they reach the hospital for more treatment. The container is full of a liquid form of epinephrine, with a tiny needle at one end (FARE). There is a safety release one pulls out, so the fluid cannot leak out or someone does not accidently inject themselves (FARE). The needle must be administered into the upper thigh, the fluid then travels straight to the heart where it helps keep the cardiovascular system from being affected by the anaphylactic response (FARE). Since anaphylaxis is so deadly and risky, no studies have really been done of how exactly epinephrine helps a person experiencing anaphylaxis (Simons, 6).
There is much controversy regarding whether or not epinephrine should be used on a person experiencing anaphylactic shock. A study was done on people who were hospitalized with cases of anaphylaxis (Gupta, 21). 83% of people who were hospitalized did not use any form of epinephrine (Gupta, 21). People are afraid to use EpiPens or other forms of epinephrine because they do not know much about them. However, doctors, specialists, and hospital staff usually recommend they carry an auto injector with them at all times. A study was done in Chicago and showed that 55% patients were prescribed some form of an epinephrine auto injector (Gupta, 19).
There are mainly benefits to EpiPens, but there are some disadvantages to them as well. The main benefit is that it can save someone’s life, and also keep a person’s allergic reaction from becoming too serious and deadly. The epinephrine helps perform vasoconstriction, which is the body’s natural form of raising the blood pressure, which usually comes in the form of a seizure (Simons, 5). Since the epinephrine takes care of the vasoconstriction for the body, patients typically do not lose consciousness or begin to seize when epinephrine is administered (Simons, 5). The side effects of the epinephrine include headaches, heart palpitations, anxiety, dizziness and so forth. (Simons, 2) This isn’t a huge concern, when discussing a matter of life or death, but it is definitely something people need to be educated on. None of side effects will be deadly, unless epinephrine is given in an overdose (Simons, 5). However, auto injectors are measured in a specific amount, so that over dosage does not happen, unless patient is given two to four shots (Simons, 5).
Epinephrine is safe to use, and highly recommended by the majority of doctors and specialists. There are adverse effects of using the auto injector, but when someone’s life is at stake, the side effects are not the major concern. Sadly, only around 61% of people with serious food allergies carry their EpiPen and only to specific places (Gupta, 21). The most common places are while traveling and to restaurants (Gupta, 21). EpiPens need to be carried everywhere. An allergic reaction can occur anywhere, and patients need to be prepared at any time.
Another common form of medication for helping food allergy reactions is antihistamines. Histamines carry messages to different cells by attaching themselves to special receptors on the cells surface (Gislason, 1). This is similar to how the IgE and IgG antibodies act. Histamine symptoms include headaches, lower blood pressure, skin irritation, stomach pain, cramping, respiratory difficultly such as asthma, and anxiety (Gislason, 1). Histamines normally are not the cause of anaphylaxis. There are two types of histamines, H1 receptors and H2 receptors (Gislason, 1). H1 receptors produce the allergic reaction, and cause allergy symptoms such as asthma and hay fever (Gislason, 1). H2 receptors have to do with the digestive system; they increase the amount of secretion of stomach acid (Gislason, 1). Antihistamines are the medications that block the messengers so that the histamines are not received (Gislason, 2). H1 blockers are the more commonly used for helping with food allergies. Common H1 antihistamines include Benadryl, Chlortripalon, Atarax, Claritin, Seldane, and Hismal (Gislason, 3).
Antihistamines can help with non-life threatening food allergies. However, antihistamines should not be used as a replacement for epinephrine or other adrenaline medications (Sheikh, 831). If anaphylaxis is occurring in a patient, antihistamines will not help a person’s body. A person with severe food allergies will go into anaphylactic shock within five to thirty minutes of eating that particular food (Sheikh, 830). Typical antihistamines are much slower than adrenaline medication, taking about one to two hours to absorb into the body (Sheikh, 832). By this point, the patient may already be dead by the time the antihistamines begin to work. Antihistamines can really help a patient after the attack has already occurred, as well as on a daily basis to help keep their body calm and prevent further severe reactions. Hospital staffs give antihistamines to their patients after the attack is over, along with steroids and sometimes epinephrine.
It is a dangerous and frightening world for people who suffer from food allergies. There are many variables and a reaction could happen at any point in time. It is much more difficult on young children, who are usually naïve when it comes to food allergies and their involvement in school. One in thirteen children in the US has food allergies; this corresponds to two students per classroom (Gupta, 22). This can be a huge issue if teachers and other students are not prepared. Not knowing about food allergies can potentially cost a young child their life if neither the student nor anyone else is prepared for anaphylactic responses to food.
In January of 2011, President Barack Obama signed the Food Allergy and Anaphylaxis Management Act (Gupta, 22). This was approved by Congress, in order to help students, teachers, and school staff to be educated and prepared for food allergies and anaphylaxis. This act provided education for kindergarten, elementary, and secondary school workers (Food and Drug Administration, 87). Less than a year after the document was signed and approved, the Secretary of Education developed guidelines to help schools manage children with anaphylactic food allergies (Food and Drug Administration, 88).
These guidelines require the school to have documentation from the student’s physician or specialist, which includes diagnosis of anaphylaxis, identification of child’s food allergen, records of any prior anaphylactic responses, list of medications, a detailed emergency treatment procedures, signs and symptoms child experiences (Food and Drug Administration, 88). These documents should also state whether or not the child is able to administer medication when necessary (Food and Drug Administration, 88). The school will then be provided a list of substitute meals for the students with a food allergy (Food and Drug Administration, 88). School staff, parent, and student will create an individual emergency plan that is specific to the student’s needs (Food and Drug Administration, 90). Different steps will be taken to make sure the risk of anaphylaxis is as low as possible (Food and Drug Administration, 90). A certain number of staff, not including the school nurse, will be trained and educated on food allergies and how to administer epinephrine as well as know the official plan for students experiencing anaphylaxis (Food and Drug Administration, 91). Some students carry their own auto injector with them, but the school is required to have a number of injectors on campus, in a safe and secure location (Food and Drug Administration. 94). Schools can apply for Grant funding to help pay for teachers and staff to attend local training, along with paying for the auto injectors and extra lunch items (Food and Drug Administration, 93). The Secretary of Education will approve the Grants that he/she chooses (Food and Drug Administration, 95). Schools can receive up to $50,000 for two years (Food and Drug Administration, 95).
When this program began in 2011, these were voluntary options for schools that had one or more students with food allergies. However, 25% of children’s first reactions took place at their school (Gupta, 22). The School Access to Emergency Epinephrine Act began in 2013 (Gupta, 22). There were not many changes involved in this act; however the voluntary guidelines that were stated in the Food Allergy and Anaphylaxis Management Act are now mandatory and required by every school system in the United States (Food and Drug Administration, 1). This provides students with a safer way of attending a public school system, and gives relief to parents, students, and school staff. School staff, along with the nurses can be prepared for an anaphylactic response in a child, which can help save a child’s life.
A newer way to help keep children safe from food allergens are service dogs. When people normally think of service dogs, they think of dogs that help blind people, people with epilepsy, and so forth. However, dogs are now being trained to smell and track certain food allergens in order to protect children with severe allergies that will cause anaphylaxis just from being airborne. When these service dogs first started being trained, many people felt like the dogs weren’t doing as well as they hoped. As time went on, training these dogs has developed. Hundreds of kids are now safer because of these dogs. A mother of a girl with a trained service dog said, “The dog is just one way we can help our daughter have a more normal life” (CBS8). Businesses, schools, and so forth, are harder to convince that these service are necessary for their children. They struggle to believe that food allergies are considered to be a disability according to the United States government. The different government programs that have taken place have helped this, and these dogs are now being more accepted in different situations. “Our goal is for the dog to be with her everywhere she goes,” the mother said. “I don’t expect people to change their world for us, but I do expect them to allow us to protect our child in the way we need to” (CBS8). These dogs help save lives, just like any other service dog. It’s truly incredible what they can accomplish.
Food allergies are a broad and vast phenomenon for many people. Many people hear a variety of ideas on what the best route is for themselves or their families. This causes mistakes to happen, because of a lack of education. It is important to analyze all the options that are out there, and then pursue the one that is felt to be the best option by the patient. Food allergies are so dangerous that mistakes cannot afford to happen, and could potentially cost someone their life. Education is not only important for people already suffering from food allergies, but for everyone. Food allergies and anaphylactic reactions occur without warning and very suddenly. Everyone is at risk for allergies. Since anaphylactic reactions are deadly within such a small amount of time, it is vital that everyone is prepared and educated. Such a short amount of time can affect the rest of a person’s life.
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