Aw, Nuts!

“Mommy, my mouth hurts”.  My 2 year old daughter was just finishing up her dessert (7-Layer bars from Cook’s Illustrated – they’re awesome) and my first thought was that she’d bitten her tongue. A quick look in her mouth turned up nothing and I didn’t give it a second thought. She got up from the table and went to play. About 30 minutes later, she projectile vomited all over my husband. While cleaning up, we found a few hives on her body. At this point my pediatrician brain kicked in – she was likely having an allergic reaction: one of those divine layers in the dessert bars was walnuts.

Food allergies affect up to 15 million people in the United States.  It is estimated that 4-6 percent of children have a food allergy.  While many allergies, like my daughter’s, are first diagnosed in young childhood, allergies can appear in older children as well as adults.  It is also possible for both children and adults to develop an allergy to foods they’ve eaten many times before.

The eight foods responsible for the majority of allergic reactions are:

  • Cow’s milk
  • Eggs
  • Fish
  • Peanuts (actually part of the legume family)
  • Shellfish
  • Soy
  • Tree Nuts
  • Wheat

There are currently lots of terms circulating relating to foods – sensitivity, intolerance, allergy, and they are often used interchangeably.  In reality these are all different. Technically, an intolerance means that your body is not able to digest a specific substance (think lactose intolerance), while a sensitivity can mean that you have an unpleasant reaction to a food like acid reflux. A food allergy, though, is a specific immune response to a particular food. This may produce different symptoms, which are listed below, but in each case, your body is treating the food as a threat and producing immunoglobulin E (IgE) antibodies. These antibodies travel to cells that release histamine and other chemicals which then cause the symptoms of an allergic reaction.

Symptoms of a food allergy typically begin within minutes of eating the trigger food but there could be a gap of an hour or two between eating the food and noticing symptoms.  These symptoms can range in severity and affect different parts of the body.  Food allergy symptoms include:

  • SKIN: Hives or red itchy skin
  • EYES/NOSE: Stuffy/itchy nose, watery eyes, sneezing
  • MOUTH: Itchy mouth, swelling of lips or tongue
  • THROAT: Hoarseness, tightness, trouble breathing/swallowing
  • LUNGS: Repetitive cough, wheeze, chest tightness, difficulty breathing
  • GUT: Vomiting, abdominal pain, diarrhea
  • HEART: Dizziness, feeling faint, pale, blue, weak pulse, confused

A mild reaction might include: an itchy mouth, a few hives around the    mouth or face, or mild nausea or discomfort.  A more severe reaction (anaphylaxis) typically includes symptoms from multiple organ symptoms such as hives and difficulty breathing or hoarse voice and vomiting.  In young children the first signs of an allergic reaction can be subtle and difficult for the child to describe.  Infants may put their hands in their mouths or pull on their tongues.  A young child might say things like:

  • “My tongue is hot.”
  • “It feels like something’s poking my tongue.”
  • “My mouth feels funny.”
  • “There’s something stuck in my throat.”
  • “My lips feel tight.”
  • “It (my throat) feels thick”
  • “My mouth hurts.” – this was my daughter’s first complaint.

What do you do if your child appears to be having an allergic reaction?  Call your pediatrician. If your child is having difficulty breathing or appears limp or pale – call 911.   Your pediatrician will likely recommend a dose of Benadryl (diphenhydramine) which is an antihistamine and a great first step in treating an allergic reaction.  For mild reactions, this may be all your child needs.  For more severe reactions you will be directed to the emergency room where there are a host of other medications and support given to treat an allergic reaction.  What did I do? I called my pediatrician.  Thankfully, my daughter’s symptoms resolved with Benadryl and close monitoring by doctor mom.

The next step is to follow up with an allergist.  An allergist will likely go over your child’s food and medical history in detail – what types of foods your child has eaten recently, how often, history of asthma, relatives with allergies, etc. Then, if warranted, she will likely test your child for the suspected allergen as well as those that are related to it. This will include both a blood test and a skin test.  In my daughter’s case, we found that she was allergic to most tree nuts, not just walnuts.

We left the allergist’s office with an Epi Pen Jr. (which is epinephrine – a life saving medication to be used in cases of severe reactions) and an Allergy Action Plan which spells out what to do in case of an allergic reaction.  It is important to share these plans with school, daycare and anyone who cares for your child.   We also received a lot of education about how to look at food labels, talk to restaurants as well as alerting us to less obvious sources of tree nuts (barbeque sauce we might have guessed, but Maraschino Cherries? Who knew?).

Will my daughter outgrow her tree nut allergy?  It’s hard to know for sure but there’s a good possibility that she will not.  Most children outgrow allergies to cow’s milk, egg, soy and wheat – even if they’ve had a history of a severe reaction.  Fish, shellfish, tree nut and peanut allergies are much more likely to persist through adulthood.  Repeat allergy testing with the allergist can help you learn whether your child’s food allergies are resolving. Never do challenge testing yourself! Past severity of an allergic reaction does not always tell you what will happen next time. Itchy mouth and hives can progress to a life threatening reaction.

Being a parent of a child with a food allergy can be a challenge, especially in the beginning as you navigate school, daycare, birthday parties, pot lucks, play dates and restaurants.  We only need to watch out for tree nuts but some parents have multiple allergens to worry about and it can be stressful.  But I think with time being vigilant becomes part of your routine.  You learn to frequent the restaurants that are great about giving allergy information and preventing cross contamination.  Japanese is great for us – no nuts!  You also learn to avoid certain establishments based on your child’s allergy.  We stay away from bakeries and tree nut laden cuisines like Thai and Indian.  Birthdays were a bit of a disaster for us in the beginning. Cakes are often made in bakeries where there are lots of tree nuts around.  My daughter cried and felt left out when we told her no birthday cake.  We quickly learned to bring alternatives with us (M&M’s or Oreo’s).  She now knows that any time there is a situation where she feels left out, there’s always a special treat to look forward to.

As my daughter has gotten older, she’s now 5, she has become an active participant in making sure her environment is safe.  “Get me away from these nuts!” she’ll exclaim as we pass by the nuts at the grocery store. If she’s offered food at a restaurant or at someone’s house, she immediately asks if it contains nuts. Next year she starts kindergarten and this makes me a little nervous. Unlike her preschool, the public school she will be attending is not nut free.  But with her developing awareness of her allergy and hopefully good communication with her teacher and those involved in her care at school (and likely a 504 plan), it should be a success. 

If you have questions about food allergies, calling your pediatrician is a great place to start.

 

Sources:

AAAAI.org – American Academy of Allergy Asthma and Immunology

www.foodallergy.org – Food Allergy Research & Education

ACAAI.org American College of Allergy, Asthma and Immunology

 

Written by: Jessica Grygotis, MD

Image Source: foodallergyfoundation.org

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