Allergy Shmallergy

Simplifying life for families with food allergies.

Food Allergies on the Big Screen February 12, 2018

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Sony Pictures and the creators of the upcoming movie “Peter Rabbit” are facing a backlash from parents across the globe after it was revealed that the rabbits use a gardener’s food allergy to attack and impair him.

 

Food allergies are among several disabilities that are used as cheap gags in movies and on TV.  Sometimes, such as in the movie “Hitch” and on the TV show “Modern Family,” they garner laughs because the symptoms of anaphylaxis are so severe and fast-acting that they take the audience by surprise.  Sometimes they are used to show weakness or to emphasize low social status, like nerdiness.  In a recent Party City ad slated to run during this year’s Super Bowl, having a food allergy was deemed “gross” to convey it as annoying.

 

What makes the “Peter Rabbit” use of food allergies particularly distasteful is that 2017 was speckled with stories of food allergy bullying across the world; including the arrest of two young teenagers who knowingly used a peer’s food allergy against her sending her into anaphylaxis and at least one death – that of a 13 year old at the hands of his classmates who had snuck cheese into his sandwich at lunch.

 

The exclamation point on the “Peter Rabbit” case is that the rabbits reportedly state that food allergies are “made up for attention.”  Unfortunately, this plays on some people’s already-formed perception of food allergies and undercuts how serious they truly are.

 

The use of food allergies to prompt laughter reinforces stereotypes, spreads misinformation and strengthens the idea that food allergies are a choice meant for self-importance or as an inconvenience to others.  The use of food allergies in children’s media prays on the worst fears of children with food allergies and their families.  [1 in 13 kids in the United States have food allergies – that’s nearly 20 kids – and about 80 family members – in every screening of “Peter Rabbit” who live with the anxieties of the very severe consequences that just a small crumb of an allergen can trigger.]  These children are watching their nightmare come to life on the big screen.

 

The food allergy community is accustomed to hearing food allergies become the butt of a joke. Jokes, as distasteful as they are to some, may have their place in adult-oriented films and television shows (as is the case with the movie “Hitch” and “Horrible Bosses”).  But when it’s placed in children’s programming, it becomes unacceptable.  Exposure to such imagery, dialogue and attitudes during such a formative time in their lives can affect young audiences with food allergies (and influence those without) both psychologically and socially.  It can scare and scar those with food allergies.  And, showing it “even in a cartoonish, slapstick way” (as Sony describes it in their apology) teaches others that food allergies are not to be taken seriously.  By watching “Peter Rabbit,” kids are learning that using someone’s food allergy against them is both humorous and without consequence.  Meanwhile, children with food allergies are watching – horrified – while the audience jovially cheers the rabbits on. It’s amazing that storylines, such as this one, pass through vast numbers of people for approval without being questioned for their impact on children.

 

Thankfully, Sony has issued an apology recognizing the insensitivity of the “Peter Rabbit” material.  Let’s hope that other production companies learn from this lesson.  Apologizing after the fact is the easiest thing in the world.  How can we ensure that this doesn’t happen in the first place?

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Nut or Not? Food Allergy Facts and Myths January 2, 2018

When you get a food allergy diagnosis, there is so much to learn… including what foods ARE and ARE NOT safe to eat. Let’s clear up some of the confusion surrounding different allergens and which food groups they belong in.  As always, speak with your allergist before adding any new food into your diet.

 

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COCONUT:  Coconuts are actually a member of the palm fruit family.  And, although they have “nut” in the name, they are not officially a nut.  That said, the FDA classifies them as a nut so you will see “TREE NUTS” listed on many U.S. product labels when coconut is an ingredient.

Verdict: While some people are allergic to coconut, most patients with a tree nut allergy can safely eat it.  Speak with your doctor before trying.

 

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NUTMEG:  Nutmeg is a spice that comes from seeds, not nuts.  Again, although “nut” is in the name, it’s technically NOT a tree nut.

Verdict:  According to the American Academy of Allergy, Asthma and Immunology (AAAAI), it can safely be consumed by those with tree nut allergies.

 

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PINE NUTS:  You may have heard the rumor that pine nuts are actually seeds.  And, that’s true.  BUT, there is some evidence of cross-reaction between pine nuts and peanut and almond allergies.  Doctors and researchers cannot isolate whether reactions to pine nuts are due to cross-reaction or to a separate pine nut allergy.  The FDA labels it as a tree nut.

Verdict:  Those allergic to tree nuts should AVOID eating pine nuts.

 

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WATER CHESTNUTS:  Another case of mislabeling.  Water Chestnuts are an aquatic vegetable.  They are named for their shape that resembles a chestnut.  Like any food, occasionally people find themselves allergic to water chestnuts.  But they are not tree nuts.

Verdict:  Those with tree nut allergies do NOT need to avoid water chestnuts.

 

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SHEA NUT:  Shea nut butter and shea nut oil can be found in many skin and beauty products.  Both shea nut butter and shea nut oil are derived from the seed of the shea tree’s fruit.  The shea nut is a distant relative of the Brazil nut and, as such, FDA considers shea nut a tree nut and will label it as such on ingredient lists.  Per Dr. Sicherer (via Allergic Living, read more here), studies have shown that only trace amounts of protein reside in shea nut butter or oil and no reports of topical immediate reaction or ingestion have been reported.

Verdict: Although allergy to shea nut appears to be unlikely because shea nut butter and oil lacks protein, please discuss with your allergist to get individualized guidance.

 

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ARGAN OIL:  Argan oil comes from the nut of a tree commonly found in the Moroccan desert.  Because the oil is cold-pressed, it is likely to contain protein. Argan oil is becoming an increasingly common ingredient in hair products such as styling oil, shampoo, conditioner as well as other beauty products.  You should check out how they’re made; it’s surprising!

Verdict:  If you’re allergic to tree nuts, it’s probably best to avoid Argan oil until you discuss with your allergist.

 

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BUTTERNUT SQUASH:  Again, it’s a misnomer:  there is “nut” in the name, but not in the product.  As you guessed, butternut squash is a vegetable.

Verdict:  Butternut squash is not only safe for those with tree nuts to consume, it’s also delicious!

 

THE BOTTOM LINE:  Most of the above products are safe for those with food allergies (woohoo!), but you should always discuss your particular allergies with your doctor before adding any food you are unsure of to your diet.

 

For your reference, here is the US Food and Drug Administration’s list of Tree Nuts:

  • Almond
  • Beech Nut
  • Brazil Nut
  • Butternut
  • Cashew
  • Chestnut
  • Chinquapin
  • Coconut
  • Filbert/Hazelnut
  • Ginko Nut
  • Hickory Nut
  • Lichee Nut
  • Macadamia Nut/Bush Nut
  • Pecan
  • Pine Nut/Pinon Nut
  • Pili Nut
  • Pistachio
  • Sheanut
  • Walnut/Heartnut/Butternut

Tree Nut or Not_

 

Important Story: FDA Warning to Mylan, Maker of the EpiPen, on Device Defects and Review November 6, 2017

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Earlier this fall, the FDA issued a warning to Mylan, the makers of EpiPens.  In a scathing letter, the FDA highlighted manufacturing defects as well as Mylan’s failure to conduct adequate internal reviews after receiving many complaints about the life-saving device, EpiPen’s malfunctions.  To date, there have been 7 deaths, 35 hospitalizations and 228 complaints about EpiPen and EpiPen Jr. devices this year.  [See F.D.A Accuses EpiPen Maker of Failing to Investigate Malfunctions, New York Times, Sept. 7, 2017]

 

Following an FDA inspection of the manufacturing plant, FDA’s letter to Mylan describes EpiPens that were leaking epinephrine and others that malfunctioned.  In March of this year, Mylan issued a recall of a small batch of EpiPen and EpiPen Jr devices.

 

While it is difficult to connect these defects to the deaths reported, as anaphylaxis itself can be deadly even with properly receiving epinephrine, these reports are not encouraging.

 

In February of this year, we had a frightening experience. [Please read the full story,  The Fire Drill- 5 Key Lessons from an Intensely Scary Night.]  Not long after eating at a restaurant, my 12 year old, food allergic son was rushed home, wheezing severely and coughing.  He was so weak and nauseous that he could barely stumble to the bathroom.  As I asked him questions, trying to evaluate the situation, it was becoming increasingly impossible for him to speak at all.  I wheeled around to grab my EpiPens just steps from where my son sat.  When I turned back around, he was blue.

 

This is every parent’s worst nightmare.  It was certainly mine.  Amidst the chaos of an increasingly critical and deteriorating situation, my only saving grace was that I held in my hand an EpiPen that would contain the correct amount of the life-saving drug, epinephrine and deliver it safely.

 

I can’t imagine being in that same moment now, knowing that the EpiPen in my hand may or may not save my son’s life.  That it may or may not have the right dose of medicine.  That the needle may or may not misfire.  Would the knowledge of EpiPen defects cause you to hesitate?  Would you instead call an ambulance that would take even more time to arrive?  When minutes matter, these short hesitations in action, improper delivery of medication, and any other complications that arise during anaphylaxis could be costly…. even deadly.

 

Bear in mind, Mylan has also increased the cost of EpiPen from $50 in 2008 to over $600 currently.  And, while the high cost of EpiPens are prohibitive, parents are still buying them, and they’re paying for one thing:  reassurance.  They pay for the firm knowledge that this product administers the correct amount of medicine properly every time.  If that can’t be demonstrated, there are plenty of other auto-injectors on the market with a proven track record of reliability to consider.

 

Despite these less-than-comforting reports, please continue to carry and use your EpiPens and other auto-injectors.  According to the FDA in a recent Bloomberg article, “We are not aware of defective EpiPens currently on the market and recommend that consumers use their prescribed epinephrine auto injector. We have seen circumstances in which adverse events reports increase once a safety issue is publicized, like a recall. We continue to monitor and investigate the adverse event reports we receive.”

 

I plan to keep you all informed as we continue to follow this story.

 

To read more on this story, please see EpiPen Failures Cited in Seven Deaths This Year, FDA Files Show posted on Bloomberg, Nov. 2, 2017.

 

Food Allergy Help for Hurricane Harvey Families August 30, 2017

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Families just like ours need help.  They find themselves in the path of Hurricane Harvey and many are without resources.  Not only are many thousands of people evacuated from their homes, but those who remain will likely not have access to supermarkets or deliveries as roads and commercial buildings will be effected for days or weeks.

 

The folks at the San Antonio Food Allergy Support Team posted an update today about how to donate food allergy-friendly food to those in southeast Texas.  Monetary donations are the best way to make an immediate impact.  And, food allergy-friendly donations, particularly those that make feeding children easier, are greatly appreciated.

 

Here is Allergy Shmallergy’s link to Emergency Food Allergy Donations on Amazon.  I will continue to update this list throughout the upcoming days.  This is just to get us all started and is, by no means, an exhaustive list of needs.  Feel free to send your families’ favorite allergy-friendly foods, but remember that it should be shelf-stable and not require refrigeration.

Emergency Food Allergy Donations
Link: http://a.co/129iX7e

 

Please read below for details.  And, remember: there are MANY excellent organizations that need assistance now.

 

Thank you in advance: Your help is appreciated beyond words!

 


From the San Antonio Food Allergy Support Team:

[Post updated Wed. 8/30 at NOON CST]

Texas was hit very hard by Hurricane Harvey.

Many of the people who have been evacuated from the Corpus Christi area are already here in San Antonio. We have some evacuees from Houston, but are expecting thousands more.

If you’d like to help food allergy families, here’s how…

The San Antonio Food Bank is coordinating food efforts to help ALL of Texas hurricane victims right now. San Antonio is clear and sunny and having no issues with roads closures or mail delays (unlike Houston).

San Antonio Food Bank
FOOD ALLERGY FRIENDLY
5200 Enrique M. Barrera Pkwy
San Antonio, TX 78227-2209

(210) 337-3663
Info@safoodbank.org
Mon-Fri 8am-5pm
https://safoodbank.org/

The information on the “Hurricane Harvey Emergency Response” pops up on their main page…scroll down to see all options.

•Folks can donate “MONETARY DONATIONS” and put in the NOTES section (at the bottom) that they want their donation to go to “FOOD ALLERGY FRIENDLY FOODS” – this may make the most immediate impact.

•Food allergy companies or donors can send “MATERIAL DONATIONS” food allergy products directly to the San Antonio Food Bank (address above) and clearly mark them as FOOD ALLERGY FRIENDLY – If possible, include a clear message that it’s food allergy friendly on the outside of the box, in the second address line, and on the inside of the box.

•Shipments direct from AMAZON: If you are sending allergy-friendly items directly from Amazon.com, you can enter “FOOD ALLERGY FRIENDLY ” in the “Address line 2” field for the address and include it in a “gift message” which would be inside the box, to help with package sorting.

*San Antonio Residents – You can donate food allergy friendly items to the SA Food Bank or the City Council Offices listed. Please clearly mark them as “FOOD ALLERGY FRIENDLY” inside and outside and if possible pack them in a sturdy box. You can sign up to volunteer at the SA Food Bank (you must sign up ahead of time).

FYI FARE and KFA/AAFA have blog posts with additional details. Enjoy Life and Sunbutter companies are already planning to send donations. AAFA is working with someone from the EoE community. If you happen to have a personal corporate connection looking to donate, please have them contact Chad Chittenden, Director of Food Industry Partnerships at cchittenden@safoodbank.org (210) 431-8313, but I’m sure he’s swamped and other organizations are already reaching out to companies.

–Susan & Selena — San Antonio Food Allergy Support Team (volunteer leaders & FA moms)

P.S. There are many other organizations that need general help (including the Red Cross and Blood Bank). Thanks to any of you who are helping in whatever way works for you. 

 

 

Food Allergy Retrospective: How Far Have We Come? May 17, 2017

When the term “food allergies” was first mentioned in our lives in 2005, my son was only a few months old.  Already suffering from severe, body-encompassing eczema and a family history of food allergies, my pediatrician mentioned that we’d have to approach first foods very carefully with him.  I thought she was being WAY overcautious.  Like a ridiculous amount.  I was told to avoid feeding him anything with peanuts, tree nuts, milk, egg, wheat, soy, shellfish, fish, strawberries, pork, and corn in it.  I remember thinking, who had ever heard of anyone allergic to corn?!  And, so much for Cheerios as a finger food!

 

Now twelve years later, I think about what a genius that same pediatrician was and what a long way we’ve come since that first discussion about food allergies.

 

In 2005, there were approximately 11 million Americans living with food allergies.  Today, there are 15 million. And that number is growing.  Back in 2005 there may have been 1 child with food allergies per class; now there are at least 2 in every classroom.

 

In 2005, there were no food allergen labeling laws.  Manufacturers could “disguise” ingredients under a variety of names.  If you were allergic to dairy, for example, you had to memorize over 45 different names of ingredients that contained milk protein (whey, cream, casein, lactose, curd, rennet, ghee, flavoring… read the complete list here).  There were no suggestions to include voluntary “may contain” statements.  And, manufacturers were not well informed about how to respond to customer service questions about the safety of their products.

 

In 2005, consumers had less choice of emergency medication but it was far more affordable.  A pair of EpiPens cost only about $50. Other epinephrine auto-injectors were hard to come by and Auvi-Q wasn’t even invented yet.

 

In 2005, I felt alone with my son’s condition.  I started writing about food allergies, in part, to reach out to other like-minded parents experiencing the same daily struggles and triumphs that I was.  There was no research about the psychological impact of growing up with food allergies.  I was figuring out how to parent a confident, competent kid AND how to safely navigate the world with food allergies all at once.

 

I am so thankful to you all today for being part of the Allergy Shmallergy community – for giving me feedback, reminding me that we’re not alone running into and overcoming food allergy-obstacles, and for supporting each other, helping to make each other’s lives simpler and happier.

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6 Tips for Traveling with Food Allergies March 7, 2017

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Spring break is on the horizon!  Can you smell the fresh air already?  Are you mentally packing your bags? (I am!)

 

Here are a few tips when traveling with food allergies:

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  1.  Call your airline and inquire about their food allergy policy in advance.  Ask specifically about early boarding and in-flight announcements.
  2. Most airlines will allow passengers to board the plane early in order to wipe down surfaces (this includes seat backs, seat belts, tray tables and knobs, armrests). Be sure to bring enough baby wipes or antibacterial wipes (such as Wet Ones) to cover all the legs of your travel.  Again, ask about pre-boarding at the gate.
  3. Carry your epinephrine auto-injectors and antihistamines ON BOARD.  Do not pack these away in your luggage.  [*ALLERGY SHMALLERGY TIP*: Zyrtec makes dissolvable tablets which eliminate the worry over bringing liquids through security as well as anything spilling in your bags.]
  4. If you’re traveling to a warm weather destination, you’ll need to remember to keep your epinephrine auto-injectors at room temperature – even while enjoying the beach or pool.  Pack a cool pack (like this one) and an insulated bag (like this cute lunch bag).  Store the cool packs in your hotel’s mini-fridge (who needs a $15 bag of M&Ms anyway!?) or plan on ordering a to-go cup of ice to keep the medicine cool poolside.
  5. A hotel or resort’s food services manager can usually help you navigate menus.  On our last vacation, the food services manager had food allergies himself and was invaluable in hunting down ingredients and safe alternatives for our family.  Befriend this fantastic person!
  6. If you’re planning on visiting an amusement park, taking a hike or being similarly active, consider packing a backpack into your luggage (or use one as your carry-on!).  You’ll need to bring your epinephrine auto-injectors wherever you go – especially on vacation when you’re away from home cooking, familiar restaurants and local knowledge of hospitals and doctors.  Backpacks can make carrying it easier depending on the activity – simply slip the insulated bag into your backpack and go!

 

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Two more notes:

  • Airline travelers should bring their own snacks/meals on board flights to ensure their safety.
  • Refrain from using airplane blankets and pillows as allergen residue may reside there.
  • Bring a baby or antibacterial wipe to the bathroom to wipe down door  and knob handles.

 

 

 

The Fire Drill – 5 Key Lessons from an Intensely Scary Night February 22, 2017

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I had been home from the restaurant only ten minutes with my preschooler almost tucked into bed when I got the call.

 

“Miles isn’t feeling well. He’s nauseous and is having terrible asthma. We’re heading home early,“ my husband informed me calmly. My husband and two sons left our regular sushi dinner to attend a tennis lesson, still chewing as they walked out the door.

 

My oldest son has suffered from asthma since he was 10 months old, but this just didn’t sound like the typical onset of asthma for him. Something about Eric’s voice suggested something “other.” “Do you think it could be a food allergy reaction?” I asked.

 

“I don’t know; but we’re getting home as quickly as possible.”

 

Completely abandoning my daughter in her bed, I walked to our emergency medication and unsheathed the freshest EpiPen. I was reviewing our emergency action plan as headlights tore into the driveway.

 

Calm but focused, I greeted my son at the door. He was red and hot and choking out words as I tried to check in with him about his symptoms. He could barely speak. He felt nauseous and clutched his stomach as he made his way into the bathroom, afraid he would throw up. His description of his symptoms came out in – sometimes inaudible – spurts. He was fighting for breath. He felt and looked worse than I had ever seen him.

 

While my hand calmly rubbed his back and my eyes scanned his face assessing the situation, a million thoughts raced through me in a nanosecond. Was it something he ate? Was he possibly reacting to a new allergen? Was this anaphylaxis or pure asthma…or both? The flu and other upper respiratory viruses were spreading so rampantly that nearly a third of my son’s class was out that week. And, he had mentioned having a headache and feeling a little nauseous after school – something that had seemingly subsided by dinner.

 

No matter how I weighed my options, a few small words reverberated in my brain: two systems. Most emergency action plans state that if two or more essential systems (gut/stomach, lungs, skin, heart) are affected in an allergic reaction, epinephrine should be administered immediately. I held up the auto-injectors behind my son’s back, signaling to my husband that we might need to use them. Neither of us have had to use an auto-injector on my son before (knock on everything wooden). We knew it was probably the right call now. We were both looking for the other to validate that decision.

 

As with all things, I wanted the use of the auto-injector to be the absolute right decision. I called my father-in-law, a doctor of more than 40 years, for one last vote on how to proceed. It was a brief conversation. “Get him breathing! Give him albuterol, I’m coming right over.”

 

Having caught sight of me waving the EpiPen in the air to my husband, my son had now begun to sweat with panic – making everything much worse. I sat him on the couch and tried to cool him off for just a moment – considering the facts again. Asthma. Nausea. No throat, mouth, or tongue swelling. No hives. No clear relationship between this reaction and food – but always a real possibility.

 

I looked at my sweet boy once again, suffering for breath, and noticed his pallor wasn’t quite as red any longer; it was now tingeing blue. I grabbed the epinephrine and pulled off the safety cap. At that very moment, my brother-in-law (another doctor) and father-in-law walked through the door. With stethoscope in hand and exuding a calm and caring in doses that make me tear up in appreciation even now, they examined my son and set him up on a nebulizer – a machine that delivers asthma and other respiratory medications as a penetrating, breathable mist.

 

We monitored Miles’ pulse (which was steady) and his breathing (which was labored and difficult). It took a lot of medication and effort, but Miles began processing air more efficiently. I didn’t realize until the second hour of treatment that I had been clutching his auto-injector the entire time.

 

As Miles’ color returned and the dust began to settle, he began to recall details about his day – clues that might have been helpful earlier. Like, the fact that he experienced asthma during recess at school. As he continued to improve, we noted that he was simultaneously experiencing a migraine, which can bring about nausea. Together, we determined that this was likely an acute asthma attack and not a result of his food allergies.

 

All four adults watched Miles for another several hours (well into the night) before anyone was willing to even entertain sleep. And, by then, sleep didn’t come so easily. I awoke in a gasping sweat several times that night and slipped into my son’s room to check on him. At around 5:45 am, I placed my hand on his back and he broke the quiet of the pre-dawn, humorously stating, “Mommy. Your hand is like a furnace!” Smiling and with great relief, I knew the sun would come up that morning and all would be well.

When I relayed these events to my own father, he captured it perfectly. “You had a fire drill last night.” We certainly did. And, as with any good training exercise (intentional or not), we learned some valuable lessons that night.

 

  1. Trust your instincts. I knew we needed to use epinephrine. Had there not been two doctors in the family within arms’ distance from me, I would have absolutely used it. And, so would my husband. Even though it was not anaphylaxis and everything turned out well, I STILL regret not having used the auto-injector sooner. I had my doubts about a food allergy reaction for a number of reasons. The afternoon nausea as well as the absence of hives and swelling gave me pause – which is why I called my father-in-law. But, did being right about his diagnosis make me feel better about my hesitation? No. Severe food allergic reactions can present themselves with a number of symptoms and they can escalate very quickly.

 

  1. Always, ALWAYS carry your epinephrine auto-injector with you. EVERY TIME. And, make sure that your friends, family and/or whoever is caring for your child knows how to use it (procedures are slightly different for Auvi-Q, the Adrenaclick and the EpiPen, so I recommend reviewing often). In our case, we accidentally forgot to transfer the auto-injectors from my purse to my husband’s bag, taking for granted that he’d no longer be around food; out only for an hour to play tennis. Thankfully, we live two minutes from the tennis courts. But had they been further, my husband would ABSOLUTELY have needed those auto-injectors.

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  1. As if you needed an extra reason to carry your auto-injectors: Those who have asthma are more likely to suffer from severe food allergic reactions– particularly if that asthma is not well-controlled. Asthma can complicate food allergies. Asthma occurs when there is narrowing of the airways, making it difficult for an individual to take in the proper amount of air. In my son’s case, his lungs were taking in so little air that initially my father-in-law couldn’t hear any movement with his stethoscope. No wonder he was turning blue. In an emergency situation, epinephrine can be used to treat a severe asthma attack. We were milliseconds from using it.

 

  1. If you use an epinephrine auto-injector you must go the nearest emergency room immediately. This is not because you gave the injection. Rather, those having severe food allergic reactions need additional medication and treatment. Furthermore, patients can suffer something call a bi-phasic reaction – that is, a second, delayed bout of anaphylaxis. It is estimated that up to 20% of patients suffer such a reaction.

 

  1. Once Miles went to sleep, we recapped the night with my father-in-law, who’s served in some fast-paced emergency rooms. I’ve been repeating something he said that night to everyone who will listen:

“We used to tell surgical residents,” he began, “‘If you’re considering performing a tracheotomy, then you need to do a tracheotomy.’”  The same holds true for anaphylaxis. If you think you might need to use an auto-injector, then you DO need to use one. If you’re considering it, then the time is now.

 

I’m beyond grateful that our story ends happily.  I pray you all never have to experience the intensity of a severe reaction (whether that be from food allergies or acute asthma).  But I hope that by sharing our experience and the lessons we learned, your story will end happily, too.

 


 

Essential Resource:

I can’t recommend enough this informative piece on when to give what medication during a severe allergic reaction. The information contained in this article echoed in my head during the above incident.

 

From the Food Allergy Treatment Talk blog:

Putting the Fire by Dr. Brian Schroer