Food allergies require vigilance

For 7-year-old Ben Paner, lunchtime at Pemberton Elementary School in Henrico County is partly about staying safe … from peanuts.

The second-grader brings his lunch, which often includes a sandwich made with a peanut-butter alternative. He always takes an end seat at the table he shares with other students. And the classmates seated closest to him are always those who have purchased lunch from the cafeteria — which doesn't serve any foods with peanuts or use peanut products.

"The EpiPen shadows my son wherever he goes in school. We have that written in his health plan," said Amy Paner, Ben's mother.

"The school staff is all trained," said Paner, also co-leader of the Richmond Food Allergy Support Group. "That's one of our biggest goals — to educate parents and to educate school staff of how best to keep a child safe in their environment."

That vigilance is needed, say parents of children with food allergies, aware that the slightest slip-up could mean a trip to the emergency room, or worse.

Amarria Johnson, a 7-year-old Chesterfield County girl, died Jan. 2 after having an allergic reaction when a schoolmate gave her a peanut while on the playground at Hopkins Road Elementary School, police said.

"Our group has been just devastated by this tragedy, and our heartfelt condolences go out to the family. It hits really close to home for us," Amy Paner said.

Amarria's death is one of an estimated 100 to 200 that occur in the United States annually from food allergies.

For unknown reasons, the prevalence of food allergies is increasing.

"In one study, which was a phone survey, over a period of about seven years it appears to have doubled from 0.5 percent to about 1 percent of children being allergic to peanuts specifically," said Anne-Marie Irani, a physician and chair of pediatric allergy and immunology at the Children's Hospital of Richmond at VCU.

Food allergies in general affect about 5 percent of children and 4 percent of adults, according to federal statistics.

"It's not just food allergies that's going up," Irani said. "It's asthma, hay fever, eczema, atopic dermatitis — a general increase in allergic diseases."

Experts are not sure what's behind the increase, but say it's probably a combination of genetic and environmental factors. Irani believes a theory called the hygiene hypothesis holds some weight, though not a full explanation.

"Potentially what's been happening in developed industrialized countries is that the increased use of antibiotics, antiseptics, better food and water supply, which are all good things, but we end up with our children having less infections in the early stages of development," Irani said.

For some reason, the immune system then overacts to these more common exposures.

"There is clearly no one theory that will come close to explaining all of this," said Robert Wood, a physician and chief of pediatric allergy and immunology at Johns Hopkins Children's Center in Baltimore. "It's probably multiple factors. Every theory that has some evidence to support it has got lots of holes to say it can't be the biggest reason."

Some of those other theories focus on low vitamin D levels, cesarean births, increased surveillance, the way food is processed, the modern diet's relative lack of fresh fruits, vegetable and fish, and how solid foods are introduced to infants.

"Each might explain a little part of why," said Brian Vickery, a physician and assistant professor of pediatrics at Duke University in Durham, N.C. "I don't think there is a silver-bullet answer."

Even though they don't know why, that's not stopping Wood, Vickery and other researchers across the country from trying to find better treatments. Much of the cutting-edge research is focused on desensitization therapies.

"The desensitization idea is the same idea as allergy shots where you are gradually exposing someone to what they are allergic to to try to teach their immune system to build up tolerance to that substance," Wood, at Johns Hopkins, explained. "There are lots of different approaches that we are studying. The one that looks the most promising is referred to as oral immunotherapy.

"In oral immunotherapy you are actually eating the food you are allergic to, starting with really, really incredibly small amounts, then working up over a period of months to a pretty substantial amount that you stay on for the next one or two years to try to build up progressively more tolerance."

The initial dose is less that 1/1,000th of a peanut and is given as dried peanut or peanut flour.

"By the time you work your dose up in the most recent study that we're doing, the final dose you get up to is equal to about seven peanuts."

Wood said the studies are still in the early stages, with any practical application at least five to six years away. Parents should not try this at home.

In addition to oral immunotherapy, studies are also having patients take a tiny drop of peanut extract under the tongue or through a skin patch.

Wood said in the early data, about one-fourth of subjects seemed to be cured, while the rest may have built up tolerance but then lose it when they stop eating the food on a regular basis. Those people would have to continue eating a handful of peanuts weekly, for instance, for life.

"We worry a lot about somebody who might think they are OK and then not eat it for a few weeks and then be in danger again," Wood said.

The researchers said there haven't been any deaths in the studies, which are carried out under very strict medical supervision.

Johns Hopkins has four peanut allergy studies, two milk allergy studies and one egg allergy study under way. They have completed one egg and two milk allergy studies, Wood said.

"All this has gone on in the last four to five years. This is something that just five years ago we really weren't sure would be possible at all," Wood said.

Dr. Wesley Burks, recently appointed chief of pediatrics at the University of North Carolina, Chapel Hill, led the immunotherapy research at Duke. His studies will continue, but move to UNC with him.

"We have over 150 subjects in studies right now. We are getting ready to start a series of new studies that will enroll from (age) 12 months on up," Burks said.

Parents are really motivated, Burks said, and some of that is fear.

He tries to remind parents that in most cases when there are severe allergic reactions, it's when kids have ingested a food. "Not by being in the same room or school," Burks said. "That's an important message."

Much of the research is funded by the National Institutes of Health, which in 2005 formed the Consortium of Food Allergy Research, supporting research at Johns Hopkins, Duke University, Mount Sinai Medical Center in New York and other key institutions. Consortium funding was renewed in 2010 for five years with a $29.9 million grant.

"We are also doing a big study in England to see if we can prevent development of peanut allergy," said Marshall Plaut, a physician at the NIH's National Institute of Allergy and Infectious Diseases.

In that study, children 4 to 9 months old deemed at risk of peanut allergies because they have eczema or allergies to egg, or both, will be fed a peanut protein snack called Bamba, a popular snack in some countries where peanut allergies are very low. The snack is given to babies when they are being weaned.

The study will divide an estimated 600 participants into two groups. One group will be told to avoid peanuts. The other will get a peanut snack.

"You have to get people before they are allergic," Plaut said.

Amy Paner said her son Ben had a pretty severe reaction at just 10 months old. It wasn't to peanuts, but to eggs in a pancake. He broke out in hives, she said.

That reaction eventually led to him being diagnosed with allergies to peanuts, tree nuts and eggs.

"He is my third child. It definitely causes some changes in our home. It really affects all aspects of your life," she said.

The researchers want to offer families such as the Paners something more. Enrollment in the research studies in North Carolina are full with a waiting list, Vickery said.

"This is a condition without a treatment that puts children at risk of life-threatening events," Vickery said, "and we need to be able to do better than tell them to keep away from it and here is your EpiPen."