Food Allergy Counseling

Food Allergy Counseling
Sloane Miller, MFA, MSW, LMSW, Psychotherapist; Specialist in Food Allergy Management, Speaking At Mylan Specialty / EpiPen Event (© Noel Malcolm 2013)

Monday, August 29, 2016

Interview: Dr Chitra Dinakar & Dr Jay Portnoy, Proximity Food Challenges

Recently, the journal of the American College of Allergy, Asthma and Immunology published a letter in their Annals of Allergy, Asthma and Immunology from Chitra Dinakar, MD 
and Jay M Portnoy, MD of Children’s Mercy Hospitals in Kansas City, MO. In it, they describe the scores of patients they see with one overriding concern: fear of casual contact with their allergen. To that end they combed through the existing literature and created a simple solution to calm the fears of their patients with food allergy fears: proximity food challenge tests. I had an opportunity to interview them via email. Please read the below.

As always, consult with your medical health care provider for your needs and DO NOT DO THIS AT HOME unless directed by your medical health care provider.


Allergic Girl: What prompted your team to create the "Proximity Food Challenge Test"?

Dr Chitra Dinakar & Dr Jay Portnoy (MD): We observed that many children/individuals/families with food allergies appeared to be in a state of worry, not knowing when accidental contact with the trigger allergen will set off the dreaded, life-threatening anaphylactic reactions. They were experiencing significant impairment in their quality of life, with many of them making multiple adjustments and accommodations in the way they interacted at school and work, often resorting to sitting all by themselves at peanut-free tables (and allergen-free tables), and going to extraordinary lengths to avoid social situations where there might be exposure/casual contact with the suspected allergen. 

It was not hard to understand why they were doing it: published literature is conflicting, with some earlier reports suggesting a heightened risk of reaction on contact or inhalation of food allergens (e.g., peanuts) in public places such as airplanes and baseball games.

However, reassuringly, contrary to those reports, some recent studies (including those from our center), indicate that the risk of a severe reaction is largely related to ingestion or contact of the allergen with mucus membranes (and rarely, inhalation, such as with shellfish and aerosolized peanut dust), and not with casual contact on intact skin. Therefore, in order to address the concerns regarding the possibility of airborne and contact food sensitivity in individual patients, we developed the Proximity Food Challenge test at our center. This test helps them understand, in a safe and monitored setting, what to expect with similar exposure in a real world environment in the future.

AG: What is a "Proximity Food Challenge Test"?

Dinakar/Portnoy: In order to help children/individuals attending the food allergy clinics at Children’s Mercy Hospital determine the degree of sensitivity to casual airborne or skin exposure, (and based on the 2014 Food Allergy Practice Parameter Update recommendation to “Teach patients that ingestion, rather than casual exposure through the skin or close proximity to an allergen, is almost the only route for triggering severe allergic/anaphylactic reactions), we started offering the option of undergoing "Proximity Food Challenge Test".

Our approach, containing the key elements of the protocol described in a study by Simone et al, is adapted to be conducted in an office setting equipped to handle anaphylaxis. After obtaining verbal consent, the provider opens a jar containing the suspect allergen, often peanut (since it is the most feared) in the room. While conversing, the peanut butter jar is then brought increasingly closer to the child. If there is no reaction, a dab is applied on the patient’s arm, and the patient monitored. Five minutes later, the food allergen is washed off with soap and water.  In situations where there is heightened anxiety secondary to the perception of occurrence of a previous reaction, an attempt to mimic the scenario may be undertaken in a double-blind, placebo controlled fashion.

In our experience, the Proximity Food Challenge has helped alleviate fears of the families and enabled the child to integrate in the social network at school and in the community.

AG: Incredible! In your letter you state that “…misinformation regarding the triggers of anaphylaxis is widespread.” What are three of the most prevalent myths you hear in your practice at Children’s Mercy Hospitals and please correct them!

Dinakar/Portnoy: Myth 1: casual contact (through the air, on skin contact or just being in the presence of a trigger) will cause anaphylaxis that could be life-threatening.

This is a myth and is not true. In general, the food allergen needs to be absorbed into the body to cause a reaction. In other words, one has to eat a food or have it touch mucus membranes (e.g., inside of the eyes, nose) or broken skin (e.g., individuals with open sores, eczematous lesions) to have systemic symptoms and anaphylaxis. Other types of exposure can cause skin rashes and swelling of eyes, lips, fingers etc (and of course, can be extremely anxiety provoking), but typically does not cause anaphylaxis. Rarely, inhalation of aerosolized food allergen (as when shellfish is being cooked, or peanuts are shelled) can cause systemic symptoms.

Myth 2: Ingestion of a food you are allergic to will always cause life-threatening anaphylaxis.

In real life, most food reactions involve itchy mouth, rashes, hives, swelling of lips and tongue, or vomiting. Many commonly reported reactions to fresh vegetables and fruits are due to the plant proteins cross-reacting with pollens in the air (food-pollen syndrome), and is typically limited to symptoms around the mouth and throat and are not anaphylactic. 

However, reactions can progress to anaphylaxis and be life-threatening, therefore taking reasonable precautions to prevent exposure, and treat reactions, is strongly recommended.

Myth 3: Epinephrine is a dangerous treatment.

In fact, we all produce epinephrine. It is a natural hormone that is made in our adrenal glands (adrenal comes from the Latin for “near the kidney”. Renal = kidney. The adrenal is near the kidneys). Epinephrine, (commonly known as “adrenalin”), is naturally produced in our body when we get excited, or do a burst of physical activity. Epinephrine is therefore a safe drug that is extremely effective. Unfortunately, many folks prefer giving antihistamines such as Benadryl instead of epinephrine because of their fear that epinephrine is a dangerous treatment. This may be appropriate for very mild reactions only. If 2 body systems are involved or the patient is having difficulty breathing or low blood pressure, epinephrine should be given first. The sooner the better. If you wait too long (eg: more than 6 minutes) it will not work as well.

AG: Much of the currently published literature about allergens and casual contact involves peanuts, exclusively. For many with anaphylactic allergies to the other top allergens (tree nuts, dairy, eggs, wheat, soy, fish & shellfish), they worry that the studies about peanuts do not apply to them. How can they be reassured that studies about one allergen are safely extrapolated and apply to their needs/real risks?

MD: Casual contact with peanut does not cause anaphylaxis. That is also true for the other foods. The only exception is crustaceans (a subgroup of shellfish which also includes mollusks and cephalopods). Crustaceans like shrimp, lobster and crab, are often prepared by boiling. The vapors can carry allergens into the air so it is possible to have mild reactions in a seafood restaurant that prepares food that way. Also being within breathing distance when peanuts are being shelled, or any process that causes breakdown of the allergen and dispersal in the air, can potentially cause anaphylaxis.

AG: Proximity food challenges are an incredible idea and one that I hope spreads to other centers for excellence. Until that time, will you be expanding that idea/teaching it to other allergy/immunology practices?

MD: We are trying to spread the message. The first step is with this publication. When ideas are published after meticulous peer scientific review, they are accepted better by the medical community. We have already received encouraging positive feedback from a few colleagues regarding this manuscript.  We will try to spread the message at educational sessions at local, regional and national meetings. We have also written about this in Missouri Medicine.  Hopefully, the message will find its way to the lay community through blogs such as yours (thank you very much for your initiative!). Patients who have undergone this procedure have been very grateful for the lightening of their anxiety burden. Hopefully, they will also help spread the message and will advocate to food allergy support groups about the advantages of seeking this type of testing.

AG: How can patients advocate for themselves and ask for their allergist to implement this idea?

MD: Patients should ask the doctors to help them determine if casual contact is a trigger for their child. They should be aware that this will help them and their child integrate better in activities of daily living and in their social/cultural fabric. They should mention that they read about the proximity challenge being performed at other centers and request that the doctors contact us/read the article/read your blog to find out more information. It is a very simple procedure, and apart from being time-laborious, is not very hard to perform. Patients will most certainly find that the peace of mind they gain after the test is done is well worth their efforts.

AG: For anyone with food allergies feeling confused about allergist recommendations regarding avoiding contact with their allergens and how to do so without avoiding one’s life, how would you suggest they engage their allergist in a conversation about real risk versus low-to-no risk situations?

MD: I would suggest that they explain to the allergist that they would like to identify the types of exposure that are not life-threatening for their child/individual in order to better fit in at school/home/work settings. Getting this help from their allergist will help alleviate some of their anxiety.

AG: For allergists reading this, how would you suggest they better help / communicate real risk to patients?

MD: I think the allergist may want to consider bringing up the possibility during the clinic visit, and discuss the pros and cons of performing these challenges.


Thank you, Chitra Dinakar, MD 
and Jay M Portnoy, MD!

Wednesday, August 24, 2016

Recipe: Bread & Butter Pickles, Allergen-Free

Bread & Butter Pickles are my favorite pickle, they’re sweet and vinegar-y, perfect for any burger or just as a sweet pickle-y snack. I deleted the spices in the recipe, not because of any personal allergen concern but because I didn’t have those spices in the house (and didn't feel like buying a big jar for a one time use). Even without the spice profile, the pickles tasted perfect, exactly like store-bought. And without seeds, it definitely makes the recipe allergen free for you seed/mustard-allergic folks.


Recipe: Bread & Butter Pickles, Allergen-Free
Gently adapted from Smitten Kitchen

Makes 4 cups of pickles

1 pound Kirby cucumbers, washed, skins left on and sliced 1/4-inch thick
1 large shallot (or 1 medium sweet onion), thinly sliced

1/8 cup Morton’s Kosher Coarse salt (if you are using a different salt, READ THIS POST from Smitten Kitchen)
1/2 cup Sugar in the Raw
1/2 cup distilled white vinegar

In a medium bowl, combine the cucumbers, shallots and salt. Mix well. Cover and pop in the fridge for two hours. In a pot, bring sugar, vinegar to a boil. Drain cucumbers and shallots. Add to vinegar mixture and bring almost back to a boil. Remove from heat and cool. You can store the pickles in an airtight container for up to three weeks in the fridge (they will NOT last that long though). They will begin tasting pickled in just a couple hours.

Monday, August 22, 2016

News: Canadian Transportation Agency Looks at Airborne Food Allergy Risk in Flight

UPDATE: September 16, 2016 - from Allergic Living magazine - Analysis: Canadian Airlines Report Misses the Mark on In-Flight Allergy Risks

UPDATE: August 29, 2016 -  From Food Allergy Canada  - New report from the Canadian Transportation Agency on air travel and food allergies


This article came out a few weeks back on the CBC: "No proof to back most peanut plane fears inquiry finds"

In it, "Former Conservative transportation minister Lisa Raitt directed the Canadian Transportation Agency to look into passenger allergies to nuts in 2015 following directives released in response to a series of passenger complaints.” 

They asked American allergist Dr Matthew Greenhawt to look into the matter.

(Dr Greenhawt has been exploring the issues of whether or not airborne allergens do indeed increase the chances of a severe allergic reaction mid-air and gave several medical quotes to my book, Allergic Girl: Adventures in Living Well with Food Allergies (Wiley, 2011))


From the CBC article:

“The risk analysis report was prepared by University of Colorado allergist and immunologist Dr. Matthew Greenhawt.

He says that while there is "general public concern" about the risks of inhalation or exposure through residue, the small number of studies that exist don't support the fear.

"The data that does exist has consistently shown that: a) peanut dust does not aerosolize; b) peanut butter contains no protein in its vapours; and c) surfaces can be effectively cleaned of any allergic residue and, moreover, there is minimal risk of anything more than a local irritation reaction from casual skin contact with the allergen," the inquiry says.

Greenhawt cites a study done in 2004 which was "unable to detect any circulating airborne allergen particles on filters worn at the level of the patient's neck after 15 bags of whole peanuts were shelled and then walked on in a small room, both with and without air ventilation."

Another study involved 29 participants with severe peanut allergies who were subjected to three ounces of peanut butter held 12 inches away from their noses. Researchers also smeared a small amount of peanut butter on their skin.

None of them had respiratory symptoms or systemic allergic reactions. But three patients developed localized redness on their skin.”


You can read the entire article here: "No proof to back most peanut plane fears inquiry finds - British Columbia - CBC News"

As always, consult with your personal board certified medical care consultant.

UPDATE: A reader suggested Dr Robert Wood has a different opinion from Dr Greenhawt and the literature. Here's a quote from a FARE interview in 2013 with Dr Robert Wood about airborne allergens:

FARE: For people with peanut or tree nut allergies, how dangerous are ball games, airplanes, and other places with lots of nuts?

Dr Wood: As a general rule, because ingestion is the main root of exposure that poses risk, being around nuts is not going to be dangerous. Now, airborne reactions can occur. They will typically only happen though if the nuts are being disturbed in a way that will create a dust and if you are in a very confined space. So if you think about how that might happen, you will definitely get more peanut allergen in the air if you’re cracking open nuts, especially if you’re throwing nuts on the floor and walking on the shells. Each of those activities may create some dust that does contain allergen. If you’re in a contained space – if you’re in the waiting area of a restaurant and everyone is cracking open nuts, and the floor of that waiting area has an inch-thick peanut shell on it – that is a place that you could have a dangerous airborne reaction. That same amount of peanut at a ball game, though, virtually never causes problems. In the outdoor air, it’s very rare to see true airborne reactions. Now on airplanes, if everyone was cracking open nuts, airplanes would be a scary place. But the truth is that just by opening bags of peanuts, there’s very little peanut allergen getting into the air. We can’t say that it’s a zero risk situation. I can’t say that ball games are zero risk; I can say they’re very low risk. For me and my peanut allergy, I don’t worry about ball games or flying at all. I have no concern about it whatsoever. If my patients want to avoid ballgames or be on peanut-free flights, I don’t say that’s wrong. Although I think that normalizing life as much as possible and finding a cooperative airline that won’t serve peanuts, at least for peace of mind, may be a reasonable approach to be less anxious and still enjoy a family trip or vacation.

Wednesday, August 17, 2016

Recipe: Blueberry Corn Drop Scone, Gluten-Free, Nut-Free

Blueberries and corn. Didn’t think they go together in a scone but they totally do and it tastes like pure summer in a biscuit. Smother them with some cinnamon sugar butter and wowsers, what an afternoon treat. So easy. So good. So simple. Gluten-Free, tree nut-free, peanut-free, seafood-free and soy-free.

Blueberry Corn Drop Scone, Gluten-Free, Tree Nut-Free
(Biscuit recipe adapted from Betty Crocker)

2 1/3 cups Gluten-free Bisquick
1/2 cup sugar in the raw
1/3 cup organic butter
3/4 cup organic milk
3 eggs
1 cup blueberries, washed and dried and de-stemed
1 ear of fresh corn, boiled and kernelled

Heat oven to 425°F. In large bowl, place Bisquick mix and sugar. Cut in butter with fork or pastry cutter until particles are size of small peas. Stir in milk and eggs until soft dough forms. Fold in blueberries and corn. Drop mixture onto ungreased cookie sheet by six large spoonfuls. Sprinkle tops with remaining sugar. Bake 13 to 16 minutes or until golden brown. Serve warm. Makes 6.

Cinnamon Sugar Butter
To 1 tablespoon softened butter, add sugar and cinnamon to taste and stir until delectably spreadable.

Wednesday, August 10, 2016

Recipe: Two-Ingredient Ice Cream, Gluten-Free, Tree Nut-Free

I had seen a recipe for no churn, two-ingredient ice cream all over the internet at least two summers ago: Nigella Lawson, The Kitchn, Food52 and Tasting Table. Here’s a quick and easy video, too.

I’m lactose intolerant, which means no heavy cream in my life but I really, really wanted to try this. So with my Lactaid pills at the ready, I gave it as go and oh my goodness, wow!

As every recipe states, it could not be easier and I love the control you have over ingredients. 

Sweetened condensed milk (just milk and sugar) and heavy cream (I used an organic brand that had only cream as the ingredient), mix them up, add some vanilla and oh my goodness, it’s like Haagen Daaz, that you made! No fancy machine needed, ingredients you can get at any store, any where et voila!


Recipe:Two-Ingredient Ice Cream, Gluten-Free, Tree Nut-Free

1 pint (two cups) of heavy whipping cream (use safe for you brand)
1 fourteen ounce can sweetened condensed milk (use safe for you brand)
1 teaspoon of vanilla (or any flavor you like)

Whip the cream into soft peaks. Fold in the condensed milk. Mix thoroughly until completely combined and no streaks. Add flavor. Pour mixture into a container with a cover. Lay saran wrap directly on top of the mixture to ensure no air gets in and close container with its lid. Freeze 6-8 hours or overnight. And then try not to eat it all at once.

Friday, August 05, 2016

Allergic Girl Blog, Sponsored Posts

I’m always looking for things that will make our lives tastier and more fun; expand our experiences and deepen our joy. I will continue to post across my social media channels in that vein; with honestly, with clarity and with integrity. 

In my tenth blogging year, I’m striking out and trying something new: sponsored posts on my social media platforms (TwitterFacebook, Instagram and/or my newsletter).

Regarding the FTC blogger endorsement guidelines from 2009 (updated in 2015) and my post in October 2009 about how I uphold those regulations, all that I wrote remains true. 


Sponsored posts will be clearly marked and in accordance with FTC rules.

Sponsored posts will be about products/services you’ve read posts me using for years, products/services I love, products in my cupboard right now; basically, things I buy for myself.

Sponsored posts will be about products/services that suit my food allergy, allergy, asthma, eczema needs. You will always need to check with companies directly for their safety for you and your needs. And, as always, if there’s any question about a medical diagnosis, please check with your personal medical health professional.

Now, let’s get our yum on!