Peanutty thoughts for today

The peanut. It’s a microcosm for many of today’s fears that sweep up parents and children and leave them so anxious that no amount of precautions are enough to help them feel safe. An article in the current issue of the British Medical Journal suggested that efforts to protect children with peanut allergies have become a cycle of escalating reactions, unsupported by the science, and are making fears worse. The author’s rather confrontational approach understandably received a lot of negative and emotional responses from concerned parents. But they also, sadly, illustrated the very fears he was trying to help put into perspective. The responses to his article also showed how many misconceptions about peanut allergies are widely believed.

It’s hard to have a calm discussion about peanut allergies at most forums without the issue quickly disintegrating into a choice between a PB&J and the death of a child. Accurate information is somehow seen as a threat to children with allergies. If the risk of death isn’t heightened to the max, doctors and scientists are accused by parents of trying to hurt their children. Fear is a powerful thing, not just as a news item to generate ratings or to sell programs and products, but when it becomes part of us. Trying to find the line between unproductive fear and constructive precautions is hard, but the facts can be a good place to start.

Sound information is not minimizing the seriousness of anaphylactic allergic reactions, but it can help bring a little perspective to decision-making in order to best protect all children and do what’s best for them.

The responses to the BMJ article, however, have been completely understandable, given the information that most of us, professionals and consumers alike, hear all the time. Even from the most seemingly trusted sources, we’re given only part of the story — with critical information left out — and that fuels misunderstandings and worries.

The same week that BMJ article made the news, the latest issue of Food Insight arrived. This publication of the International Food Information Council Foundation is sent to food, nutrition and health professionals and journalists. The very first sentences of its feature story said that more children than ever are living with food allergies. “In fact, the percentage of young children diagnosed with peanut allergies nearly doubled from 1997 to 2002. According to the Food Allergy & Anaphylaxis Network (FAAN), approximately 3 million children currently suffer from a food allergy.”

The Centers for Disease Control and Prevention also issued a new report with its own scary-sounding statistics that have been widely reported. The CDC’s National Center for Health Statistics Data Brief on trends in food allergies among U.S. children came out in October. From 1997 to 2007, it announced, the prevalence of reported food allergy increased 18% among young people under age 18, with 3.9% of young persons (about 3 million children) reported to have a food or digestive allergy.

These reports might seem to be saying that more children today have diagnosed food allergies, but that is not what they are actually reporting. The studies behind these claims were surveys, all of which found that the percentage of parents who report they believe their children have food allergies has increased over the past decade.

But these reports have also neglected to reveal that repeated studies have found that 5 times more parents report their children have food allergies than actually do when tested in double-blind, placebo-controlled food challenges; and as many as 12 times more report food allergies in their infants and children than actually have food allergies when given skin prick testing. The discrepancy between perceived and actual food allergies is growing.

With that introduction, let’s all take a deep breath and see what the research can tell us.

Epidemic hysteria

We’ll start with a quick look at the article that set off the latest firestorm. Writing in the BMJ, Dr. Nicholas Christakis, M.D., Ph.D., MPH, professor of medical sociology at Harvard Medical School, said that the increasingly extreme reactions of school officials over peanut allergies, and their “draconian efforts” to completely eliminate exposures, far exceed the magnitude of the actual threat. He said there is no scientific evidence that the restrictive efforts being imposed are effective or warrant the costs. More importantly, he said they are making things worse. Relating an anecdote in an elementary school attended by his own children, he said that school fund raisers selling candy mandated that parents could only pick up their orders of sealed tins from a loading dock to avoid the candy with nuts entering the school and potentially coming in contact with children.

“This decision came on the heels of another recent event,” he wrote. “A peanut was spotted on the floor of a school bus, whereupon the bus was evacuated and cleaned (I am tempted to say decontaminated), even though it was full of 10 year olds who, unlike 2 year olds, could actually be told not to eat food off the floor.” I wasn’t able to find a news story or published article to confirm this anecdote, but his verifiable points were that the number of schools adopting “nut free” school campuses are growing, as are the number of schools banning homebaked foods to avoid students coming into any contact at all with a potential allergen.

He equated the growing panic over peanut allergies to mass psychogenic illness, also called “epidemic hysteria.” That’s the social network phenomenon where a cascade of healthy people develop anxiety about a perceived danger, and being around others who are anxious serves to heighten one’s own sense of fear. In other words, fear is contagious, not necessarily the actual thing being feared. He said this comparison is helpful in two ways. First, total nut avoidance may not actually reduce risks for allergies, as a new British study suggested. Second, well-intentioned efforts to reduce exposure to the perceived cause actually fans the flames of a food fear because they signal to people that the danger is real, encourages even more people to worry, and fuels perceptions of an epidemic. This then encourages more parents to look for and test for a problem in their children, “thus detecting mild and meaningless ‘allergies’ to nuts.”

Sidebar. This article actually demonstrated another fact no one caught: Even scientists and professionals can be guilty of the very same over-reaction as parents are being accused of. It’s easy to apply sound scientific reason, be perfectly logical and see the fallacies of hype over an epidemic when it’s something one doesn’t believe in or have any vested interests in. But that same objectivity and reason goes out the window when it’s about a fear and epidemic that one believes. This refers, of course, to another contagious epidemic hysteria promoted by Dr. Christakis earlier this year. In that one, instead of peanut allergies, it was obesity. Apply his observations in the preceding three paragraphs to the obesity epidemic hysteria — it gives a very different and more helpful take on the ‘contagion theory’ of obesity.

In attempting to provide balance, he said that only 150* people (children and adults) die each year from all food allergies combined, which compares to 10,000 traumatic brain injuries from sports; 2,000 drownings; and 1,300 deaths from gun accidents. Yet, we don’t hear calls to end sports, he said. And considerably more children die just walking or being driven to school each year. The issue not whether nut allergies exist or can be serious, he said, it’s about balanced, reasonable accommodations for the few children with documented serious allergies.

Most importantly, the recommended treatment to stop the spread of any epidemic hysteria is to provide calming, reassuring facts, he said. “Honesty is the best policy.”

With that sound advice, we’ll turn to the research on the prevalence of peanut allergies in children and try to find the facts.

Peanut allergies doubled?

According to the Food Allergy and Anaphylaxis Network, over the past five years, peanut allergies in young children have doubled and food allergy is a “growing public health concern in the U.S.” The source of FAAN’s oft-cited claim is a 2003 study by pediatricians at Mount Sinai School of Medicine in New York, published in the Journal of Allergy and Clinical Immunology. In 1997 and 2002, they conducted a random telephone survey of a nationwide representative sample of nearly 5,000 households. Self-reported cases of peanut or tree nut allergies among adults were unchanged from 1997 to 2002, but the percentage of adults who reported that their children had a tree nut allergy increased from 0.6% to 1.2% and those who said their children had a peanut allergy increased from 0.4% to 0.8%.

The pediatric researchers concluded that reports of peanut allergies among children had doubled, but remain extremely rare. But none of these reported cases were confirmed clinically. Despite reported severity and frequency of allergies, however, the authors also found that more than a quarter of the parents had never sought evaluation for their children and fewer than half of those who had were actually found to have an allergy doctors felt significant enough to prescribe self-injectable epinephrine. No one knows what is driving the increase, but some doctors think it’s increasing media hype and parental fears, rather than some unknown threat to children increasing true allergies.

The new CDC report, citing an increase in reported food and digestive allergies over the past decade, also reminds us that we always need to ask how any statistic is defined. Definitions are everything. In this case, a “reported food allergy” was based on the National Health Interview Survey, asking parents:

Pediatric allergies rarer than parents believe

Researchers have been reporting for more than a decade that there is a large discrepancy between perceived food allergies and actual, clinically-diagnosed allergies. The prevalence of true food allergies among the general public is about 2%, while the number of Americans who believe they have a food allergy is considerably higher, by about eight times. In a 1996 issue of the Journal of Allergy and Clinical Immunology, researchers at the Food Allergy Center in Lynbrook, New York, reported that a representative sampling of American households were surveyed in 1989, 1992 and 1993. In contrast to the approximate 2% prevalence confirmed clinically, they said a total of 16.2%, 16.6% and 13.9% reported that at least one person in their household had a food allergy. Individuals who believed they were allergic to foods were more likely to be female, even though double-blind, placebo-controlled food challenges found no such demographic differences, they said.

A number of studies have examined the incidence of food allergies and hypersensitivity in children as reported by their parents compared to clinically-diagnosed incidences. Research by Dr. Taraneh Dean and colleagues at the University of Portsmouth recently conducted a series of careful studies of overall food hypersentivities in babies and children.

In one study published in the May 2006 issue of the Journal of Allergy and Clinical Immunology, they followed a group of 969 pairs of parents and babies, evaluating the infants at 3, 6, 9 and 12 months of age. By age 1, more than half (54%) of the infants were avoiding some food because their parents believed they had bad reactions, mostly to milk, wheat, nuts, eggs or additives. The researchers tested each child using double-blind, placebo-controlled food challenges [the gold standard] to diagnose food hypersensitivity, and did skin prick tests [a peanut allergy diagnosis can be confirmed by detecting peanut specific IgE via a prick test or fluoroenzyme immunoassay, although false positives are common, meaning about 60% of children with positive skin pricks don’t have allergies when tested with food challenges].

They found that only 0.9% to 2.5% of the babies had clinically confirmed food hypersensitivity (including everything from milk, eggs, fish, peanuts, sesame to wheat), with a cumulative incidence by age one of 1.2% confirmed by double-blind, placebo-controlled food challenge tests. Six percent of the babies had outgrown their food sensitivities by age one.

The rate of parent-perceived food hypersensitivity (54%) is considerably higher than objectively assessed cases (1.2%), they said. The researchers concluded that these findings “emphasize the need for accurate diagnosis to prevent infants being on unnecessarily restricted diets, which may be associated with inadequate nutrition in this important period of growth and development.”

Similar research was conducted on 1,532 school children. Parents and children reported that 15.7% and 18.7% of 11- and 15-year olds, respectively, had a food hypersensitivity and were avoiding some food because they believed they had bad reactions when they were exposed to those foods. The researchers clinically tested all of the children using open food challenges [as opposed to the more accurate double-blind, placebo-controlled studies] and skin prick tests. Still, they found the prevalence of food hypersensitivity was only 2.3%.

Dr. Taraneh Dean said: “We were surprised that such a high proportion of people in this age group perceived they had a problem. What this study suggests is that there is a public perception of an increase in food hypersensitivity syndrome, which is not borne out by objective clinical assessment.” Parental concerns far surpass the reality of food hypersensitivities.

Besides the physical health and nutritional effects of disproportionate food fears, when dangers from food allergies are exaggerated, they can affect young people in ways that are almost never talked about. A food allergy diagnosis should never be made on a child lightly, said Dr. Darshak Sanghavi, an assistant professor of pediatrics at the University of Massachusetts Medical School. “In a 2003 study, children told they were peanut allergic had more anxiety and felt more physically restricted than children with juvenile diabetes.,” he said.

One mother of an allergic child gave her perspective, writing in Harper’s Magazine earlier this year:

There is no question that food allergies are real. Yet instead of creating the healthy, happy children shown here, exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not uncommon. Recent surveys have also shown that children thought to have food allergies feel more overwhelmed by anxiety, more limited in what they believe they can safely accomplish, than even children with diabetes and rheumatological disease. One study documented how food-allergic youths become terror-stricken when inside places like supermarkets and restaurants, since they know that allergens are nearby. Such psychological distress is exacerbated by parents, who report keeping their children away from birthday parties and sending them to school in "No Nuts" T-shirts. Having been fed a steady diet of fear for more than two decades, we have become, it appears, what we eat. — Meredith Broussard

Protecting children

To protect children with severe allergies to peanuts or any allergen, no one disagrees that school food service personnel, teachers and school nurses need to be educated and trained to protect an allergic child; know what to do should an anaphylactic reaction occur; and have policies in place. Parents with severe allergies need to notify schools, provide the school with written instructions from the child’s doctor and signed by the parents for administering medication (such as an Epi-pen). Children old enough to self-administer epinephrine should carry their own kits.

“Despite their best attempts to avoid peanuts and carefully read labels, the average person with true peanut allergy still gets a reaction every three to five years,” said Dr. Sanghavi. “Affected children should never be without an EpiPen and someone who knows how to use it.”

While schools can help reduce exposure for vulnerable children, “it is difficult to achieve complete avoidance of all allergenic foods because there can be hidden or accidentally introduced sources,” said the American Academy of Allergy, Asthma & Immunology. “Accidental food ingestion can occur despite avoidance measures.”

It’s natural for the parent of a child with a severe peanut allergy to want a school campus scrubbed of every peanut in order to prevent their child from coming into contact with a potential allergen. But that’s never been shown to be an effective way to protect children. Also, it’s not just peanuts, said Mr. Jim Sanborn, with the School Board in Waconia, Minnesota, and a father of five. “If we removed all of the top eight foods that cause 90% of the allergies, we would be left with almost nothing to feed the kids for lunch. What kinds of nutritious meals can you make with no bread, no eggs, no pasta, no milk, no cheese, and no fish?” Peanuts are such an inexpensive source of quality protein for growing children, some have also objected to banning peanuts and peanut butter for the 99% of children who don’t have a problem, especially during a recession when many families are struggling to provide nutritious lunches for the kids.

According to Mr. Sanborn, recognizing that severe peanut allergies are rare isn’t to minimize the seriousness of any potential allergic reaction. But it’s challenging in the current climate of peanut fear to try and temper the discussion and implement a sound school policy to best reduce risks for all children.

“A ban doesn’t solve the problem,” he said. No matter how expansive, it is impossible to guarantee that kids wouldn’t come into contact with an allergen somewhere. Do we inspect every lunch box and article of clothing and kids' hands at the school door? He believed a more sensible approach for any child with a health issue is an individualized one, tailored to their needs, just as is done for children with diabetes or asthma, rather than go to extremes. “I can’t keep a kid from falling off a bike, but I can make them wear a helmet. That, to me, is a more acceptable solution than banning bicycles.”

Some of the extreme measures desired by anxious parents also aren’t warranted by the best medical and scientific evidence. As was recently covered here in depth, even a highly sensitive child with the most serious allergy to peanuts won’t have an allergic reaction through airborne exposures or breathing the smell of peanuts while someone else eats a PB&J sandwich. Dr. Michael C. Young, M.D., assistant clinical professor of pediatrics, allergy and clinical immunology at Harvard Medical School in Boston, is a peanut allergy expert and helped to develop the first food allergy policy for Massachusetts schools and authored The Peanut Allergy Answer Book. As he said: “It is important to examine the scientific basis of these ideas before accepting them as fact.”

“There is also the widely held belief that peanut residue found on surfaces such as sports equipment, toys, doorknobs, and washroom faucets can result in anaphylaxis,” he said. His extensive research has found anecdotal reports of contact skin reactions in sensitive children but there are no cases of anaphylaxis. It’s long been known that allergy-like symptoms can occur if someone believes they’ve been in contact with an allergen, but those aren’t true life-threatening anaphylactic reactions, either. “There is no evidence that casual contact and minor exposure from inhalation or skin contact, have an additive or cumulative effect, resulting in a worsening of the overall allergy.” This knowledge, that the most risky exposure remains direct ingestion, should allay anxiety, he said.

A few days ago, one mother wrote that when her child was first diagnosed with food allergies, she would have been livid, too, reading an editorial suggesting that deaths from food allergies are extremely rare and that reactions to protect children from peanuts in schools appear to be an overreaction. She understands how many of these parents are feeling, saying:

When my daughter was first diagnosed, I thought peanuts should be banned from all of her environments, including daycare and extended family's homes. The information I had at the time paralyzed me with fear. Now that we've lived with food allergies for awhile, I have a different perspective. Peanuts are a part of everyday life, and isn't it my job as a parent to help my children learn how to manage their food allergy in everyday life? I can't control their environment forever, but I can equip them with common sense about food safety.

Reading this editorial actually made me feel kind of embarrassed. Was I the parent who completely overreacted? Did I make people think that I needed a peanut-detector dog? (if there is even such a thing!) I wish I had my perspective now back when my child was first diagnosed. I'd be a little more relaxed but still vigilant. I'd educate and work as partners with people instead of request a removal of all peanut products…

This is where it’s helpful to band together with other parents dealing with child food allergies. We can lend perspective to those who have a more recent diagnosis, and we can learn from those more veteran than us...

Hopefully, good information and perspective can help concerned parents as they try to find the best balance for their child between constructive precautions and unproductive, and potentially harmful, responses to fear.

© 2008 Sandy Szwarc

* This figure from FAAN has been heatedly contested. It was calculated using a retrospective study of deaths from 1983 to 1987 in Olmsted County in Minnesota, which had reported one death from anaphylaxis in five years (not from food). Never the less, a researcher at Jaffe Food Allergy Institute extrapolated the prevalence of anaphylaxis deaths to the entire country and guessed that up to 55% of them could come from food allergens and then assumed about two-thirds of those were peanut-related, to arrive at 100-150 deaths a year. The American Academy of Allergy, Asthma & Immunology, in its latest position paper, uses the same study to report about 100 food-related anaphylactic deaths each year in the U.S.

Food allergy deaths have only been tracked by the CDC since 1998, using death certificates coded using ICD-10 classifications (the 10^th edition of the International Statistical Classification of Diseases). ICD-10 hasn’t yet been universally adopted, which makes the accuracy of its figure unreliable. It reports that of 2.5 million deaths among all ages in the U.S. in 2005, 11 people died from a food allergy in 2005, with the number from peanuts unknown.

Perhaps the most accurate population data on peanut-related deaths among children comes from the UK. Its national death statistics and pediatric surveillance system has recorded death statistics for nearly all children and it reported that only one child, a 15-year old, died from a peanut allergy between 1990 and 2000.

The point being, regardless of the precise figure, peanut allergy-related deaths are extremely rare.