Peanut - Confex

Food Triggers:
The Degree of Avoidance
Marion Groetch, MS, RDN
[email protected]
Director of Nutrition Services, Jaffe Food Allergy Institute
Icahn School of Medicine
American Academy of Allergy, Asthma and Immunology www.aaaai.org Objectives
•  Identify ingredients that require avoidance
•  Identify ingredients that are typically tolerated
•  Understand the meaning of precautionary statements
•  Understand the risk of cross reactive food proteins
Major Allergens in the US
• 
• 
• 
• 
• 
• 
• 
• 
Milk
Egg
Wheat
Soy
Peanut
Tree nut
Fish
Crustacean shellfish
US
Major
Milk
Allergens Egg
Wheat
Soy
Peanut
Tree nut
Fish
Crustacean
shellfish
EU
Australia
Canada
Milk
Egg
Gluten-containing
grains
Soy
Peanut
Tree nut
Fish
Crustacean
shellfish
Sesame
Mollusks
Lupine
Celery
Mustard
Milk
Egg
Glutencontaining
grains
Soy
Peanut
Tree nut
Fish
Crustacean
shellfish
Sesame
Milk
Egg
Glutencontaining
grains
Soy
Peanut
Tree nut
Fish
Crustacean
shellfish
Sesame
Mollusks
Mustard
Minor Allergens
§  Do not require full disclosure on product
labels.
§  Vague ingredient terms:
Natural flavoring, coloring, spice, or
processing aid.
Allergen Sensitivity
•  Allergen contamination may be present in
manufactured foods
•  Tolerance varies widely across the sensitized
population.
•  Studies indicate that less than a milligram of
milk, egg, or peanut, can induce symptoms in
some highly sensitive individuals, while others
may not experience a reaction until more than
10 grams have been ingested.
Taylor SL, Crevel RWR, Sheffield D, Kabourek J, Baumert, J. Threshold dose for peanut: Risk
characterization based upon published results of peanut allergic individuals. Food Chem.
Toxicol. (2009), doi:10.1016/j.fct.2009.02.011
Difficulties in Establishing Thresholds
•  Safety assessment-based approach
• §  No
MilkObserved Adverse Effect Level (NOAEL)
•  Milk
•  Lowest
Egg
Observed Adverse Effect Level (LOAEL)
•  § Egg
•  Wheat
Wheat
•  • Once
a NOAEL is established, does industry have
•  Soy
the
ability to test for these levels of allergens in
•  Soy
•  Peanut
their
products?
•  Peanut
Cross contact
•  Precautionary labeling such as
–  May contain…
–  Manufactured in a facility…
–  Manufactured on shared equipment…
•  Voluntary and unregulated
8
Precautionary Labels
The NIAID guidelines suggest
avoiding any product that has a
precautionary label for your
allergen.
When is strict avoidance potentially
unnecessary?
•  Certain types of mild allergy may not require
strict avoidance, such as pollen-food related
syndrome.
•  In certain patients with milk or egg allergy who
have been challenge-proven to tolerate baked
milk and egg ingredients.
A survey on the management of pollen-food allergy syndrome in allergy practices.
Sicherer SH, Nowak-Wegrzyn AJ Allergy Clin Immunol. 2003;112(4):784
Changing paradigms
§  Baked-Milk study
•  ~ 75% of milk-allergic children tolerate baked milk
•  Accelerates tolerance (16-fold vs. avoidance)
§  Baked-Egg study
•  ~75% of egg-allergic children tolerate baked egg
•  Accelerates tolerance (15-fold vs. avoidance)
Nowak-Wegrzyn, Groetch. Let them eat cake. Ann Allergy Asthma Immunol
109 (2012) 287–288
To Avoid or Not to Avoid
§  Patient with milk allergy who tolerates baked milk?
•  Do we avoid products with precautionary labels for
milk?
•  Read labels carefully for un-baked milk
To Avoid or Not to Avoid
To Avoid or Not to Avoid
•  A patient with corn allergy?
–  Corn oil or corn syrup?
•  A patient with soy allergy?
–  Soy oil or soy lecithin?
•  A patient with peanut allergy?
–  Peanut oil?
Crevel, Kerkhoff, Konig. Allergenicity of refined vegetable
oils. Food and Chemical Toxicology. 2000;38:385-393.
To Avoid or Not to Avoid
•  Label does not tell you how the oil
was processed
•  Peanut oil
§  Crude oils: Expeller pressed, un-refined,
gourmet - AVOID
§  Refined- Not considered an allergen
Sicherer SH. Clinical implications of cross-reactive food allergens.
JACI 2001;108:881-890
To Avoid or Not to Avoid
•  A patient w/ Sesame allergy
–  Sesame oil?
•  A patient w/ Egg allergy
–  Egg white or egg yolk?
Sicherer SH. Clinical implications of cross-reactive food allergens.
JACI 2001;108:881-890
To Avoid or Not to Avoid
A patient with Cow’s Milk Allergy
•  Goat milk or sheep milk?
A patient w/ Peanut allergy?
•  Tree nuts or other Legumes?
Sicherer SH. Clinical implications of cross-reactive food allergens.
JACI 2001;108:881-890
Breastfeeding- Is maternal
avoidance necessary?
•  Immunologically active proteins can be found in breast milk.
•  Anaphylaxis can occur in the infant to breast milk from
maternally ingested allergen.
•  Chronic symptoms may also occur.
•  The amount present is variable.
•  If the infant with allergy does not have any symptoms to the
breast milk with an unrestricted maternal diet, then
avoidance is not necessary.
•  Maternal avoidance is rarely required for FPIES.
Contact allergy
•  Assessed the significance of contact sensitivity to peanut
butter in children sensitized to peanut.
•  1 g peanut butter applied directly to the skin for 15
minutes of children (n=281) who were SPT positive to
peanut.
•  A subset of children (N=85) underwent open-label oral
challenge to confirm peanut allergy.
Wainstein, B. K., Kashef, S., Ziegler, M., et.al. Frequency and significance of immediate contact reactions to
peanut in peanut-sensitive children. Clinical & Experimental Allergy 2007, 37: 839–845.
19
Contact allergy
•  A minority of children sensitized to peanut develop
localized urticaria from prolonged skin contact with
peanut butter.
•  No tested subjects, including ones with systemic
reactions upon oral challenge, developed a systemic
reaction to prolonged skin exposure to peanut.
Wainstein, B. K., Kashef, S., Ziegler, M., et.al. Frequency and significance of immediate contact reactions to
peanut in peanut-sensitive children. Clinical & Experimental Allergy 2007, 37: 839–845.
Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact with peanut butter in children with
peanut allergy. The Journal of allergy and clinical immunology. 2003 Jul;112(1):180-2..
20
Contact allergy
HOWEVER….
If peanut butter gets onto the hands and is unintentionally
placed into the mouth or rubbed in the eyes, this is more
akin to an ingestion rather than skin contact.
Wainstein, B. K., Kashef, S., Ziegler, M., et.al. Frequency and significance
of immediate contact reactions to peanut in peanut-sensitive children.
Clinical & Experimental Allergy 2007, 37: 839–845.
21
Airborne allergens
•  DBPC study (n=30) of children with history of severe
reaction to peanut ingestion were challenged by close
proximity/smelling peanut butter
•  A six inch square area of peanut butter hidden with
sheer gauze was placed 12 inches from face for 10
minutes.
•  No child experienced symptoms from proximity/smelling
of peanut butter
•  One subject experienced throat symptoms during
exposure to placebo
Relevance of casual contact with peanut butter in children with peanut allergy.
Simonte SJ, Ma S, Mofidi S, Sicherer SH. J Allergy Clin Immunol. 2003;112(1):180.
22
Airborne samples
•  Simulated environments when peanut might be eaten in
a preschool or school environment: peanut butter
sandwiches, open jars of peanut butter, packages of
shelled peanuts, shelling peanuts.
•  Ara h 1 was undetectable under all simulated
environmental settings.
Perry TT, Conover-Walker MK, Pomes A, et al. Distribution of peanut allergen in the
environment. The Journal of allergy and clinical immunology. 2004 May;113(5):973-6. JACI
2004;113:973-6
However…May depend on the degree
of exposure
•  Reactions to airborne peanut protein have been reported
in relation to commercial airliners, when many packets of
roasted peanuts are opened simultaneously.
•  Peanut dust may become airborne
•  Filters in these commercial airlines contain measurable
amounts of peanut protein.
Jones RT, Stark D, Sussman G,Yunginger JW. Recovery of peanut allergens
from ventilation filters of commercial airliners [abstract]. J Allergy
Clin Immunol 1996;97:423.
Airborne allergens
“Scent vs. Aerosolized”
•  Fragrance and scents from food result in contact with
airborne volatile organic compounds (VOC)- not known
to cause allergic reactions
•  During cooking or processing of foods, inhalation of
actual food protein particles may occur (aerosolization).
•  Inhalation contact with aerosolized food has been shown
to be capable of inducing asthmatic or respiratory
reactions in highly sensitive individuals.
Roberts G, Golder N, Lack G. Bronchial challenges with aerosolized food in
asthmatic, food-allergic children. Allergy. 2002;57(8):713.
25
Medications
•  Common food ingredients in medications- soy
lecithin and lactose
•  Lactose- pharmaceutical grade lactose is
considered to contain very little protein
•  Reactions to lactose in dry powder inhalers has
been documented.
Nowak-Wegrzyn A, Shapiro GG, Beyer K, Bardina L, Sampson HA.
Contamination of dry powder inhalers for asthma with milk proteins containing lactose.
J Allergy Clin Immunol. 2004;113(3):558.
Other items not covered under
FALCPA
• 
• 
• 
• 
• 
Cosmetics
Shampoos and lotions and toothpaste
Toiletry items
Pet foods
Any food item not regulated by the FDA such as
fresh meats and produce (regulated by USDA)

Download Report