{"id":157,"date":"2014-08-26T20:09:47","date_gmt":"2014-08-26T20:09:47","guid":{"rendered":"http:\/\/wp-dev.its.vanderbilt.edu\/vanderbiltmedicine\/?p=157"},"modified":"2021-08-11T19:42:13","modified_gmt":"2021-08-11T19:42:13","slug":"off-limits","status":"publish","type":"post","link":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/off-limits\/","title":{"rendered":"Off Limits"},"content":{"rendered":"
\"Photo<\/a>
Photo by Pete McArthur<\/figcaption><\/figure>\n

 <\/p>\n

Noelle Kerlin is wary of food like some 2 \u00bd year olds are fearful of strangers, the dark or growling dogs\u2014every bite has the potential for harm. She\u2019s learned at a very young age that food can be her enemy.<\/p>\n

The tiny blonde with a headful of curls is allergic to more than 30 foods\u2014all milk options (cow, soy, almond), wheat, rice, oats, corn, chicken, bananas, pineapple, watermelon, peaches, cheese, eggs, etc. Potatoes are the only carbohydrate she can eat.<\/p>\n

\u201cShe cried most of the first 18 months of life. Now she can tell us her belly hurts,\u201dsaid Kristi Kerlin, Noelle\u2019s mother. \u201cAt some point she knew \u2018food doesn\u2019t make me feel good\u2019 so now she doesn\u2019t have much interest in food. We lock up our medicine cabinets and our cleaning supplies. With kids with food allergies, you feel like you need to lock up your food too.\u201d<\/p>\n

Noelle\u2019s reactions to allergens are varied\u2014she\u2019s broken out in quarter-sized hives, and foods have made her throat itch and her eyes red-rimmed. She vomits, has diarrhea, and because of the diarrhea, has severe diaper rashes.<\/p>\n

Since her diet is so limited she drinks 24 ounces a day of an elemental formula for children with milk allergies that supplies all of her nutrients.<\/p>\n

\"Noelle<\/a>
Noelle Kerlin. Photo by Daniel Dubois.<\/figcaption><\/figure>\n

Because of her allergies, she has been diagnosed with eosinophilic esophagitis, when a type of white blood cell builds up in the esophagus as a reaction to foods, allergens or acid reflux. It will require lifelong management. Luckily her reactions have not included anaphylaxis, a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to allergens. Anaphylaxis results in lowered blood pressure and dilated blood vessels. In severe cases a person can go into shock and it can be fatal. Many people who have severe allergies keep an autoinjector (EpiPen \u00ae) on hand to deliver a measured dose of epinephrine (also known as adrenaline) in case of anaphylaxis.<\/p>\n

\u201cNoelle goes everywhere with an EpiPen and Benadryl. I was very ignorant about food allergies two years ago,\u201d Kristi said. \u201cSome people think that having a food allergy isn\u2019t a big deal and that moms (of children with food allergies) are high strung. Yes we are. Our kids\u2019 lives are at stake. We try not to let it rule our life, but it\u2019s hard. You can forget spontaneity. She can\u2019t even play with Play-Doh because it has wheat in it.\u201d<\/p>\n

The Kerlins, who have two other children without food allergies, have learned where they can go to eat out. Chick Fil-A French fries are cooked separately from chicken, so they\u2019re safe, and some local chefs will prepare food safely for Noelle.<\/p>\n

\u201cAnybody who keeps her has to know how to use the EpiPen. There\u2019s a small group of people we trust,\u201d Kristi said. \u201cWe have an action plan filed at her preschool. If she breaks out in a rash or vomits, she gets Benadryl and then they call us. If she has breathing difficulty, she gets a shot with the EpiPen, they will call Vanderbilt and then us.\u201d<\/p>\n

 <\/p>\n

Are food allergies increasing?<\/strong><\/p>\n

A food allergy is an abnormal response to a food, triggered by the body\u2019s immune system. The immune system responds to the food as if it were a threat.<\/p>\n

Called the \u201cSuper 8,\u201d the most common allergenic foods are: milk, eggs, peanuts, tree nuts (such as almonds, cashews, walnuts), fish (such as bass, cod, flounder), shellfish (such as crab, lobster, shrimp), soy\u00a0and wheat. They account for an estimated 90 percent of food allergic reactions.<\/p>\n

According to Food Allergy Research and Education (FARE), about 1.5 million Americans have food allergies. They affect 1 in every 13 children under 18 in the U. S.\u2014or about two in every classroom. Experts differ on whether there is strong evidence that food allergies are increasing.<\/p>\n

The Centers for Disease Control and Prevention says that the number of children with food allergies rose 18 percent from 1997 to 2007. But Marshall Plaut, M.D., chief of Food Allergy, Atopic Dermability and Allergic Mechanisms with the National Institute of Allergy and Infectious Diseases (NIAID) with the National Institutes of Health, says the evidence of increase \u201cmay be correct, but it is relatively anecdotal.\u201d<\/p>\n

\u201cWe just don\u2019t know. We believe the problem is increasing, but we just aren\u2019t sure,\u201d he said.<\/p>\n

Many believe that hygiene, or extreme cleanliness, might be partly to blame for allergies in industrialized nations, Plaut said.<\/p>\n

The \u201chygiene hypothesis\u201d states that excessive cleanliness in our anti-bacterial society interrupts the normal development of the immune system, and this change leads to an increase in allergies. In other words, a very clean lifestyle has eliminated many of the types and quantity of germs the immune system needs to develop into a less\u00a0allergic system.<\/p>\n

But there\u2019s also a theory that other environmental factors, like pollution and added chemicals in our diet, are involved.<\/p>\n

\"Stacy<\/a>
Stacy Dorris, M.D. Photo by Daniel Dubois.<\/figcaption><\/figure>\n

\u201cIt\u2019s a very interesting theory,\u201d said Stacy Dorris, M.D., assistant professor of Pediatrics and a pediatric allergist at Vanderbilt University Medical Center. \u201cWe\u2019re too clean in one direction\u2014we don\u2019t get the big serious childhood diseases we used to get\u2014and on the flipside, we have more environmental insults\u2014air pollutants and chemicals in our diet\u2014that are probably skewing our immune system toward an allergic profile. Probably it\u2019s a combination of the two.\u201d<\/p>\n

But Dorris said it\u2019s important to keep food allergy occurrence rates in perspective.<\/p>\n

According to a FARE-funded study, only about 1 percent of all young children in the U.S. have a peanut allergy, one of the most common and life-threatening food allergies.<\/p>\n

\u201cIt\u2019s still a very unusual disease. You hear a lot about it in the media, and about peanut-free schools, that sort of thing, but it\u2019s still a very unusual condition. And many food allergies can be outgrown.\u201d<\/p>\n

According to FARE:<\/p>\n

\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Peanut and tree nut allergies, which tend to develop in childhood, are usually lifelong.<\/p>\n

\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Cow\u2019s milk, egg and soy allergies typically begin in childhood and eventually may be outgrown. However, in the past, most children outgrew these allergies by school age. A recent study, conducted by researchers at Johns Hopkins University School of Medicine, indicated that children are taking longer to outgrow milk and egg allergies. Fortunately, the majority are allergy-free by age 16.<\/p>\n

\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Fish and shellfish allergies also tend to be lifelong. More than 6.5 million adults are allergic to finned fish and shellfish.<\/p>\n

\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Children with multiple food allergies outgrow their allergies less frequently, and these children often have associated severe eczema, asthma and rhinitis.<\/p>\n

Food allergies can develop out of the blue at any time in life because the immune system is \u201cincredibly dynamic and constantly in motion,\u201d Dorris said.<\/p>\n

The severity also varies, Dorris points out. One child may break out in hives, when another can experience the life-threatening anaphylaxis.<\/p>\n

Dorris also has personal experience with food allergies\u2014her 4-year-old daughter, Andie, has been allergic to peanuts since she was 1.<\/p>\n

About a year ago, Andie went to work with her father on a snow day and took a bite of a protein bar containing peanuts that she pulled out her father\u2019s assistant\u2019s drawer.<\/p>\n

\u201cEven a couple of hours after Benadryl, her lips were swollen, she had hives on her face, and her ears were swollen twice their normal size,\u201d Dorris recalls. \u201cLater she had diarrhea. This was after one bite.\u201d<\/p>\n

 <\/p>\n

One bite is all it takes<\/strong><\/p>\n

Nine-year-old Christopher Clauss of Columbia, Tennessee, was\u00a0diagnosed with an allergy to peanuts, tree nuts and eggs when he was about 1.\u00a0 \u201cBut we avoid all nuts,\u201d said Eric Clauss, Christopher\u2019s father, a paramedic and nurse, who along with Christopher\u2019s older sister, has food allergies. \u201cIt\u2019s what you don\u2019t know that\u2019s scary, and sometimes you just don\u2019t know,\u201d he said, adding that the family looks at all foods as potential allergens.<\/p>\n

\"Eric<\/a>
Christopher Clauss. Photo by Daniel Dubois.<\/figcaption><\/figure>\n

When he was 4 Christopher ate cheese, which he had safely eaten before. He quickly developed an all-over body rash. \u201cOur routine was to give him Benadryl, but his reaction continued,\u201d Eric said.<\/p>\n

Within moments Christopher\u2019s breathing became labored. He was experiencing anaphylaxis and was nearly unconscious. \u201cIt was that fast. Although I am prepared for something like that as a nurse, you\u2019re not when it\u2019s your son.\u201d<\/p>\n

Eric stuck Christopher with an EpiPen, and his condition rapidly improved within a minute or so, then he drove him to Vanderbilt, about an hour away.\u00a0 In hindsight, that wasn\u2019t a good idea, Eric said. The dose of epinephrine may wear off fairly quickly and severely allergic patients can need a second dose. Luckily, Christopher did not.<\/p>\n

Eric said Christopher\u2019s anaphylactic episode was \u201cterrifying.\u201d<\/p>\n

\u201cHe sounded like he was trying to breathe through a straw. He was starving for air and you could see his chest muscles working so hard. He made a high-pitched screeching sound. He sounded like a crying seal.\u201d<\/p>\n

At the Pediatric Emergency Department at Monroe Carell Jr.\u00a0Children\u2019s Hospital at Vanderbilt Christopher was given steroids by IV and monitored for six hours. Two years later he was back with another severe reaction.<\/p>\n

Eric has instructed Christopher\u2019s teachers about how to administer the EpiPen. Last year, the Tennessee State Legislature passed a bill requiring public and private schools to have at least two EpiPens on hand to treat students in the event of a severe allergic reaction.<\/p>\n

\u201cThe most challenging thing for us is when he\u2019s with others,\u201d Eric said. \u201cWe don\u2019t know what happened with the cheese incident, and that\u2019s scary. There could have been something on the slicer where it was sliced or it could have been a preservative. To this day we don\u2019t know.\u201d<\/p>\n

There\u2019s a ritual when Christopher eats a new food. He takes a tiny bite of food and waits about five minutes to see if he has a reaction. Usually his mouth \u201cfeels funny\u201d or his stomach hurts if he\u2019s allergic. If he starts to react, he doesn\u2019t eat any more, and he brushes his teeth to get rid of food particles.<\/p>\n

Eric said dealing with food allergies is simply a part of life for Christopher and his family. \u201cWe\u2019ve told him there are certain things you have to deal with in life, and this is one of them. It could be a\u00a0lot worse.\u201d<\/p>\n

\"Jane<\/a>
Jane Choi, M.D. Photo by Susan Urmy.<\/figcaption><\/figure>\n

Jane Choi, M.D., a Vanderbilt adult allergist, said the number of patients with food allergies in her practice has increased. They are seeing new types of allergies\u2014a red meat allergy brought on by a tick bite (see sidebar) and also exercise-induced food allergies.<\/p>\n

Choi recommends that her allergy patients carry two EpiPens with them at all times in case a severe reaction requires an additional dose, or if the first one misfires.<\/p>\n

Patients with suspected food allergies are asked to keep a food diary and event log to help the allergist narrow down what might be causing an allergic reaction.<\/p>\n

\u201cIn addition to being a physician, you also have to be a detective,\u201d said Choi, who had an anaphylactic reaction to cashews when she was an allergy fellow at Johns Hopkins. Although she had eaten cashews before, she ate more than usual between seeing patients. She collapsed while examining a patient.<\/p>\n

\u201cSometimes you have a very astute patient who has diagnosed themselves by the process of evaluation, but other times it would be helpful to be a fly on the wall to see what\u2019s going on in their lives.\u201d<\/p>\n

 <\/p>\n

Detective Work<\/strong><\/p>\n

Louise Mawn, M.D., a busy Vanderbilt eye surgeon and the mother of four children, ages 8 – 14, credits her Vanderbilt primary care physician Jan Price, M.D., with sifting through Mawn\u2019s debilitating symptoms and suspecting a food allergy.<\/p>\n

In 2012, Mawn was convinced she had a serious illness because of the severity of her symptoms. \u201cI had a whole cornucopia of symptoms,\u201d she recalls, including a lump in her throat, extreme fatigue, swelling of her face and eyelids and stomach upset.<\/p>\n

\"Louise<\/a>
Louise Mawn, M.D., had debilitating symptoms and feared she had a serious illness. Thanks to the diligence of her physician, they discovered she is allergic to food preservatives. Photo by Daniel Dubois.<\/figcaption><\/figure>\n

The lump in her throat ended up being the base of her swollen tongue. It was all she could do to show up early in the morning for work and stay awake until early evening when her family was fed.<\/p>\n

Price sent her to a rheumatologist and a gastroenterologist to rule out other illnesses, with visits to the Vanderbilt Allergy, Sinus and\u00a0Allergy Program (ASAP) sprinkled in between. With the help of Adam Cates, a nurse practitioner at ASAP, her allergens were narrowed down and she was finally diagnosed with an allergy to food preservatives, like sulfites and nitrites.<\/p>\n

The diagnosis came after a frightening trip to an out-of-town medical conference where she was convinced she was going to lose her airway.<\/p>\n

The allergist sent her home with a weeklong elimination diet of black tea, white rice and grilled chicken. After eliminating the preservatives from her diet, her symptoms disappeared. \u201cI never went back to the allergist to have it honed down (about specific preservatives) because as soon as I stopped eating preserved foods, I was better. All my symptoms went away like magic.\u201d<\/p>\n

The diagnosis resulted in a huge lifestyle change for Mawn, particularly because the family\u2019s normal diet consisted of many processed and fast foods that she could get on the table quickly. \u201cThe microwave was the most critical appliance in my kitchen,\u201d she said.<\/p>\n

Mawn\u2019s husband and children now help prepare healthy, preservative-free meals. \u201cWe prefer to eat at home. It\u2019s easier and it\u2019s safer,\u201d she said, adding that she doesn\u2019t bemoan her diagnosis.<\/p>\n

\u201cIt seems to me I got off scot-free,\u201d Mawn said. \u201cI thought I had\u00a0a serious disease. I thought I was going to be leaving those four small children. I feel like I\u2019m the luckiest person alive to have all those\u00a0symptoms and to have it simply be that I can\u2019t eat food that nobody\u2019s supposed to eat anyway. I can\u2019t have a Coke? OK. What\u2019s in a Coke\u00a0that any of us should have? Human beings are not supposed to eat chemically named foods. They\u2019re supposed to eat carrots and squash and lettuce and apples.\u201d<\/p>\n

Mawn is grateful for Price\u2019s careful \u201cNancy Drew-like meticulous investigation\u201d into her symptoms. \u201cWhen she suggested I might have\u00a0a food allergy, I laughed. I felt like I was humoring her by going to the allergy appointment.\u00a0 I said \u2018at the age of 48 I have a food allergy?<\/p>\n

Are you kidding me?\u2019 But Dr. Price, with the help of ASAP, put it\u00a0all together.\u201d<\/p>\n

\u00a0<\/strong><\/p>\n

What\u2019s ahead?<\/strong><\/p>\n

NIAID\u2019s Plaut said one of the most promising NIH-funded research projects focuses on whether the timing of when foods are introduced to infants makes a difference in the development of an allergy.<\/p>\n

\u201cThe popular theory has been that you avoid an allergy by avoiding the food, when, in fact, it may be the exact opposite of what we should do,\u201d he said.<\/p>\n

The NIH-funded LEAP study (Learning Early about Peanut\u00a0Allergy) took place in London, where the standard of care, like that\u00a0in the United States, has been to avoid peanuts in early childhood.<\/p>\n

Recently the standard of care in the U.S. has changed so there is no\u00a0recommendation for either avoiding or eating peanuts because it\u2019s unclear that avoiding them is helpful. The LEAP clinical research study aims to determine the best strategy for preventing peanut allergy in young children since the majority of children have their first reaction to peanuts between 14 and 24 months of age. Children suffering from eczema or who are allergic to eggs are the highest risk.<\/p>\n

The LEAP study looked at 640 children who were enrolled in the study when they were between 4 months and 10 months of age. The children were randomized into two groups\u2014one that avoided peanut-containing foods until age 5, and another that received an age-appropriate peanut snack at least three times a week beginning when they entered the study. The study, which ended in late May, monitored children until age 5 to see which method\u2014avoidance or consumption\u2014works best for preventing peanut allergy. The results will soon be available.<\/p>\n

Other research is aimed at treatment, since there is currently no effective therapy for food allergies beyond food allergen avoidance and rapid medical treatment for allergic reactions to accidental exposures.<\/p>\n

One NIH-funded research study is looking at oral immunotherapy (OIT) in which patients with food allergies are fed small incremental amounts of that food. They are built up over the course of several months to a maintenance dose and then therapy is continued at home. The goal is to desensitize the patient so that the food doesn\u2019t cause an allergic reaction anymore.<\/p>\n

There are three types of allergen-specific immunotherapy that are currently being investigated in NIH-funded studies in the United States: oral, sublingual (under tongue), and epicutaneous (patch) immunotherapy. These therapies are in various stages of clinical investigation.<\/p>\n

\u201cBecause these studies got under way beginning only a few years ago, we\u00a0 don\u2019t have a lot of data yet about the effectiveness of these methods,\u201d Plaut said. \u201cWe have more promising data on oral therapy than the other two. But we just don\u2019t know about long-term benefits.\u201d<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

According to Food Allergy Research and Education, about 1.5 million Americans have food allergies. They affect 1 in every 13 children under 18 in the U. S.\u2014or about two in every classroom. Those who have them must approach food with a great deal of caution.<\/p>\n","protected":false},"author":216,"featured_media":158,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":false,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"_links_to":"","_links_to_target":""},"categories":[14,22],"tags":[],"class_list":["post-157","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-vm-features","category-vm-summer-2014"],"acf":[],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/cdn.vanderbilt.edu\/t2-main\/medschool-prd\/wp-content\/uploads\/sites\/82\/2014\/08\/allergiesleadart.jpg","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/pcDnub-2x","_links":{"self":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/157","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/users\/216"}],"replies":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/comments?post=157"}],"version-history":[{"count":1,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/157\/revisions"}],"predecessor-version":[{"id":3195,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/157\/revisions\/3195"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media\/158"}],"wp:attachment":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media?parent=157"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/categories?post=157"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/tags?post=157"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}