No Nuts! Dealing with Nut Allergies

Dr. Brown is an assistant professor of pharmacy practice at Palm Beach Atlantic University, Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida. Mr. Thornby is a PharmD candidate at Palm Beach Atlantic University.

The number of people with peanut allergies is on the rise. There are between 1.5 million and 3 million Americans who have peanut and/or tree nut allergies. Each year 50 to 100 fatal allergic reactions occur in people who unintentionally eat peanuts. Why do some people have allergies to peanuts whereas others do not?

A peanut allergy involves the immune system reacting to the proteins found in peanuts. People who have peanut allergies may have additional allergies, especially to other foods. This is because the allergens (the parts of the peanut that a person is allergic to) found in peanuts also are found in beans (eg, soy, green beans, and peas), seeds (eg, sesame, sunflower), and tree nuts (eg, almond, cashew, hazelnut, pecan, and walnut). For people with a peanut allergy, only 5% or less will have an allergy to beans as well. On the other hand, 25% to 50% are also allergic to at least 1 tree nut.

How to Determine If You Have an Allergy

It is important to see a doctor who specializes in food allergies to determine your individual risks. To make sure you are diagnosed properly, you may have to undergo a series of questions, blood tests, and a skin-prick test.

Exposure to even small amounts of peanuts may cause anaphylaxis (an-uh-fuh-lak-sis), or a severe allergic reaction. Symptoms such as itching, redness, swelling, shortness of breath, wheezing, nausea, abdominal pain, lightheadedness, or loss of consciousness may occur and usually begins within minutes after exposure to a peanut or peanut-containing product.

It is possible, however, to experience a delayed reaction, if symptoms do not appear immediately. Touching peanuts may result in hives, or areas of itchy and red skin, which may spread across your body. An allergic reaction also can occur if you inhale dust from peanut flour or mist from peanut oil cooking spray. Examples of peanut-containing products are listed in the Table.

Avoiding an Allergic Reaction

Avoidance is the best way to reduce your chances of experiencing a severe allergic reaction. It is important to read all food labels to look for peanut-containing products. Also, when dining out, ask the server about the types of oils in which the entrees are cooked. If your child has a peanut allergy, you?should inform and educate school personnel, parents of your child?s friends, and other caregivers about foods the child needs to avoid.

Both children and adults are advised to wear a medical alert bracelet or necklace. This alert should list the specific allergy and possible reaction symptoms, and provide first aid instructions for others during an emergency.

Treating a Serious Allergic Reaction

Table

Peanut-containing Food Products

• Peanut butter
• Peanut flour
• Ground or mixed nuts
• Baked goods, such as cookies and pastries
• Ice cream and frozen desserts
• Energy bars
• Salad dressing
• Cereals and granola
• Grain breads
• Peanut oil
• Marzipan

The emergency treatment during a severe allergic reaction involves several steps. First, an injection of epinephrine (EpiPen or EpiPen Jr) should be given to reduce the severity of the reaction. Second, taking liquid diphenhydramine (Benadryl) at a dose of 5 mg for every 10 lb of body weight, up to a maximum dose of 75 mg, also is recommended. Third, if not already done, emergency services should be contacted.

A visit to the emergency room is necessary because additional treatment may be needed. While at the hospital, the patient may be given medication such as albuterol in the form of a nebulizer, or special breathing machine, to open up your airways, as well as additional epinephrine injections and intravenous fluids.

After a severe reaction, you should be observed by medical personnel for at least 4 hours, as some patients may have another reaction that can be delayed for several hours. These secondary reactions are very dangerous and require immediate treatment. Upon leaving the emergency room, you may be given prescriptions for antihistamines (eg, diphenhydramine) and corticosteroids (eg, prednisone), which should be taken as the doctor prescribes. It is important to follow up with your primary care physician within 3 days.

EpiPen and EpiPen Jr

These injections, also known as auto-injectors, are designed to provide a quick dose of epinephrine for patients during severe allergic reactions. The EpiPen 0.3 mg is for patients weighing 66 lb or more. The EpiPen Jr 0.15 mg is for patients between 33 and 66 lb. The injection should begin to work quickly after it has been given. Some patients may feel a rapid heartbeat, slight nervousness, sweating, dizziness, and headache from the injection.

The EpiPen or EpiPen Jr should be kept nearby and ready for use at all times. The manufacturer recommends that you store these injections at room temperature, and they should never be exposed to extreme temperatures, such as in your vehicle?s glove compartment. The injection should be stored in the container provided to protect the medication from light. An expiration date will be printed on each product (eg, ?DEC 08? = December 31, 2008). The EpiPen should be replaced before the expiration date, even if you did not use it. A window on the outside of the pen allows you to see the solution on the inside. If the solution is discolored or contains solid particles, you should replace the injection.

Make an Action Plan

Make sure your child knows what symptoms to look for and how to ask for help if he or she has an allergic reaction. All individuals with peanut allergies should develop an action plan with their medical provider detailing what should occur once they have been exposed to any peanut-containing product. Once the action plan is complete, copies should be made available for easy access.

How to Use the EpiPen

A short film on how to use the EpiPen is available at www.epipen.com/howtouse.aspx.

• Unscrew the yellow or green cap from the carrying case, and remove the auto-injector from its storage tube.
• Grasp the unit with the black tip pointing downward.
• Form a fist around the unit with the black tip pointing downward.
• With your other hand, pull off the gray safety release.
• Hold the black tip near the outer thigh.
• Swing and jab firmly into the outer thigh until it clicks so that the unit is making a 90? angle to the thigh. (The auto-injector is designed to work through clothing.)
• Hold firmly against the thigh for approximately 10 seconds. (The injection is now complete, and the window on the auto-injector will show red.)
• Remove the unit from the thigh, and massage the injection area for 10 seconds.
• If you have not already done so, call 911, and seek immediate medical attention.
• Place the used injector, needle-end first, into the storage tube, and screw the cap of the storage tube back on completely, and take it with you to the hospital emergency room.