Interview: Dr. Dave Stukus on Food Allergies, Physical Intimacy

Kissing and food allergies. I’ve thought about this a lot and written about it a ton, on my blog and in my book, Allergic Girl (Wiley, 2011). (You can actually just buy that chapter from my publisher here.)

As I’m single and dating, it comes up with every new date: the talk, the real risks, my anaphylaxis action plan, what they can do to help, what they should eat and should avoid. 

I can’t lie, having this conversation, sometimes weekly, is exhausting. But kissing someone and then having a reaction (which has happened to me twice within the last decade) is less enticing so I have The Talk each and every time it’s appropriate to do so.

Have you noticed, there is very little written on the topic from researchers or allergists. Crazy!

So, I asked colleague David R.Stukus, MD about reasonable precautions, risks and how to move forward with getting your kiss on.  Dr. Dave and I talked about food allergies and causal contact in the past and you can read that here. 

**Please note: different life stages and different ages have different informational needs regarding physical intimacy. I am writing this blog from an adult’s perspective (mine) for and about other adults (ages 18 and up) about food allergens and intimate contact. I’m assuming everyone has their emergency medications on hand, knows how to use them, has an anaphylaxis action plan and has access to an allergist to explore their personal concerns. 

Additionally, even though I'm writing this post from my viewpoint, this blog post is for everyone, regardless of sexual orientation or gender identity. Every person needs to get their kiss on safely.**

***

Sloane Miller: Let’s talk about casual contact first. What are the real risks if someone has eaten your allergen and immediately shakes your hand? Kisses you on the cheek? Kisses your hand? Touches your eye or lips?

Dr. Dave Stukus: First, there are multiple variables involved here that can change with each encounter and may affect everyone differently.

Overall, risk of anaphylaxis (for our purposes, defined as: a severe, rapidly progressive allergic reaction affecting more than one organ system) from casual exposures such as these is very low, regardless of allergen involved.

Casual contact may cause localized symptoms such as hives or swelling, which are almost always relatively mild, short lived, and rarely progress to anaphylaxis.

I hear stories all the time from parents/grandparents who eat their child’s allergen, kiss them on the cheek, and cause hives/rash in that area. I’ve never encountered anyone who had severe symptoms from this and there are no reports in the medical literature that I am aware of, either.

SM: What about for adults, where saliva exchange is part of being intimate?

Dr. Dave: If someone has recently eaten a meal containing an allergen, and then exchanges saliva through intimate kissing, it could cause a reaction, including possible anaphylaxis given that the oral mucosal surfaces are involved, along with potential ingestion. As we'll discuss, there are a lot of variables at play, any of which could change if/what reaction takes place. 

As for someone handling your allergen then touching your eyes or lips, transferring of allergen to the eyes or lips has the potential to cause swelling in these areas, which are already prone to swelling due to lack of much subcutaneous fat/tissue. It may appear very dramatic to have your eye swell, but this also rarely progresses to a more severe reaction.

I’m certainly not advocating that people with food allergies go out of their way to put themselves in these situations, but I strongly encourage people to not be overly afraid of these situations, either.

As always, take reasonable precautions to prevent contact with known food allergens and have immediate access to treatment in case a severe reaction should occur. ​

Reasonable precautions will be discussed below but include communication with all partners regarding your food allergies and asking them to not eat your food allergens during the meal prior to your potential intimacy, regardless of when that occurs (no allergen at lunch if afternoon/evening plans take place, for instance). 

​Most importantly, everyone with food allergies should discuss this with their personal allergist, who can offer the best individual advice. This is an area open to interpretation, opinion, and evaluation of risks - no easy or clear cut answers are available. People may completely disagree with my approach and recommendations, which is perfectly ok - but others may find this advice helpful and adopt into their own management strategies. What works for one person may not apply to anyone else and that is absolutely ok. 

SM: Generally speaking: what do you suggest are best practices to maintain romantic spontaneity whilst staying safe?

Dr. Dave: I strongly encourage active discussions with any and all romantic partners (or potential partners) regarding your food allergies. Ideally, this will occur early as it will affect most social encounters such as dining out or going to a party. Partners should be aware of exactly what foods you are allergic, what types of symptoms you may experience if you come into contact with those allergens, and also help train them on what to do in an emergency, including when and how to use your epinephrine autoinjector.

In regards to asking your partner to avoid your allergen(s), it helps to have a good understanding of risks from casual exposure.

The vast majority of people I care for with food allergies have their food allergens inside their home, go out to restaurants, and attend all desired social functions. They absolutely read labels, communicate with food handlers, and have their epinephrine available but there is rarely a need for complete and strict removal from an environmental or casual exposure standpoint. This is important information to share with romantic partners as they rarely if ever need to adopt the same strict avoidance requirements for themselves. We’ll talk about kissing and intercourse below…

SM: There is one study that looked at peanut protein in saliva, done over ten years ago with a small sample of people (38 subjects) about one allergen (peanuts). It’s the one study to which everyone (doctors and patient advocates) refers. This one: http://www.jacionline.org/article/s0091-6749(06)01192-4/fulltext.  What are your takeaways from this study?

Dr. Dave: This is a fascinating and important study that looked at persistence of detectable peanut allergen in saliva after meals containing peanut. Some big takeaways to consider: 1. Mouthwash and even tooth brushing may not be a reliable method to remove peanut protein from in between teeth and saliva. 2. Peanut was undetectable in every participant a few hours later and after consuming a non-peanut meal.

While this study was small, it employed great techniques for measuring peanut allergen to an extremely minute level. I see this as very helpful in providing guidance but not the end all be all in regards to this issue.

SM: So, in your opinion, can one study, with a tiny sample of people, about one allergen, really be extrapolated for all allergens, to all, or most people, with food allergies and anaphylaxis?

Dr. Dave: As with any research study, you have to be very careful before extrapolating or applying results to other situations. However, there is also a lack of evidence demonstrating harm from this scenario as well. When considering risk, there are many factors to consider. Is the risk realistic? Is it even plausible? Is this something that can potentially but rarely happen or is this something that is expected to happen? While we can’t extrapolate data from one small study to all scenarios/allergens, we can take educated guesses and apply principles that are likely going to consistently apply to other situations. Of course, exceptions will always exist.

To dive a bit deeper, it makes a lot of sense that other food allergens will no longer remain in saliva several hours after eating a non-allergen meal. Saliva contains enzymes which can help break down proteins. The act of chewing produces even more saliva to help wash out the crevices in between teeth/gum lines. We are constantly producing saliva and/or drinking throughout the day, which also helps to remove food proteins over time. There is no biologically plausible reason to expect a food allergen, regardless of source, to remain in someone’s saliva a day or two after eating, especially if they’ve been eating/drinking since their meal.  

SM: But why is it four hours after eating an allergen-filled meal (as the study suggests) and then eating an non-allergen filled meal in order to rid the mouth of peanut protein? Why not three hours or two hours or five hours?

Dr. Dave: Exactly – we cannot get hung up on details from one small study. ​if we replicated this study 100 times, I’m sure variations would occur. Keep in mind that the 4 hours covered everyone involved, many subjects were free of allergen before then. Can you imagine the food allergy community setting a timer after their partner last ate and waiting for that ‘ding’ before locking lips?

SM: Yes, I can, which is why I’m asking!

Dr. Dave: We have to be careful to avoid applying precision to a very imprecise situation. ​Some people operate much better by applying 'rules' to certain situations. If so, then they may wish to adopt a specific predetermined period of time and communicate that to their partner. 

Bottom line, no one can clearly state that you have to wait xx number of minutes or hours from meal time to kissing - we simply don't have enough evidence to make it that clear cut. 

SM: So again, what is reasonable? What is common sense here for adults?

Dr. Dave: Common sense can include having your partner avoid your allergen during the meal prior to any possible make out session. This would ensure they ate an allergen free meal prior to kissing, which should remove any allergen from their saliva through the process of eating, drinking, chewing and swallowing. 

However, everyone has their own comfort level and should adopt precautions that they are most comfortable with; some may ask partners to avoid all day during the day of intimacy to reduce risk even further, or even remove completely if they like spontaneity or have frequent intimacy (good for them, by the way). 

On the flip side, there are many people with food allergies have never had a problem in this scenario and have never asked their partner to avoid their food allergens for themselves. 

As with any strategy, it is not one size fits all. You cannot make something like this, with so many variables, black or white - everyone should feel comfortable with their own individual plan, which should freely change over time based upon experience. 

SM: What if your partner ate a food that was labeled as ‘may contain’ or ‘processed in a facility’? 

Dr. Dave: There’s probably no need to go to that extreme​ especially since these labels are voluntary. Bottom line is – it is very reasonable for someone with food allergy to have their partner avoid eating their known allergen for 3-4 hours prior to potential intimacy and ideally eat an allergen free meal as well. 

But it is likely unnecessary to have their partner remove that food from their own diet or avoid for days prior to kissing. People are likely being exposed in this manner all the time and they don’t know it because it’s not causing any problems.

SM: What about personal secretions (vaginal fluids and semen)? What are the real risks for a reaction (mild, moderate, severe or anaphylactic) during oral to genital contact? What does the literature state? What are best measures?

Dr. Dave: There are isolated, very rare, case reports of anaphylaxis or local reactions in the vagina caused by allergens being passed through semen. I am not aware of the reverse transfer from women to men or in any same sex encounters. I approach this similar to the advice I give regarding kissing. This is a rare occurrence and practical measures should be employed. I will be shocked if I ever meet a patient that experiences this during my career.

SM: Can we go back to" may contain" labels on foods? Those labels are set by individual manufacturers and are not regulated by the FDA (unlike FALCPA which is). So, foods labels “may contain” could contain an allergen or be completely free of allergens. Best case scenario: should your partner avoid those as well?

Dr. Dave: There are some who debate whether people with actual food allergies need to avoid these items. Since they are not regulated and protein levels are not monitored, we have no idea what they mean. It would be a bit extreme to have a romantic partner avoid these as well. However, if someone has known to have reacted to these products or prefers to adopt conservative management strategies to mitigate risk as much as possible, then it would be reasonable to apply the same recommendations of having your partner avoid these products for 3-4 hours prior to intimacy and have an allergen free meal in between.

SM: What do you suggest are the best, easiest to be compliant with “dating rules”?

Dr. Dave: I recommend not medicalizing intimacy. Intimacy is so important for all of us during our short time on this planet. We need to connect with others, feel loved, share our love, and most importantly feel safe. I realize that some people are very anxious and at times overcome with fear regarding the “what if” scenarios which we encounter all day every day. However, when taking what we know about food allergy reactions, risks involved, and how successful people can be in employing avoidance measures into their lives, this is one area where I truly hope people with food allergies can enjoy themselves. I strongly encourage active, open dialogues with all partners from the get go to discuss aspects of living with food allergy.

Thank you, Dr. Dave!

David R.Stukus, MD

Associate Professor of Pediatrics

Division of Allergy/Immunology

NationwideChildren’s Hospital and The Ohio State University College of Medicine

Columbus, Ohio

Dr. Dave is a board certified pediatric allergist/immunologist who practices at Nationwide Children's Hospital in Columbus, Ohio. He serves as Chair/Vice Chair and member of several committees through both the American College and Academy of Allergy Asthma and Immunology and was an invited member of the NIAID expert panel for the recently published guidelines regarding early introduction of peanut.

Dr. Dave is active on social media through his Twitter handle @AllergyKidsDoc where he dispels common myths and disseminates evidence based information. He is also a regular contributor to patient education through published articles on Nationwide Children's Hospital blog 700 Childrens, Huffington Post, US News and World Report, and KevinMD.