Just the scent was all it took before 18-month-old Anthony’s body revolted. Only minutes before, his mother Mary remembers her older son Charles coming home from preschool and asking for peanut butter. Just like any other five-year-old, Charles liked his peanut butter. Mary watched Charles go into the pantry, open the jar of peanut butter and scoop out a big spoonful. Anthony, curious about what his big brother was up to, followed him into the pantry. “Anthony went right up to him, took the jar in his hands, and took a nice big whiff,” Mary says. “Maybe some of it even touched his face or got on his fingers—we’re not really sure.”

The reaction was immediate. “The first thing he did was kind of shudder—like he had a real aversion to it,” recalls Mary. Within a minute, Anthony was salivating uncontrollably, which his parents later found out meant that his throat was closing up. Then diarrhea hit, and then he started to vomit.

Mary took Anthony to the pediatrician, who immediately recognized the reaction as a peanut allergy. The doctor told her how deadly this particular food allergy could be and advised her to keep Benadryl (diphenhydramine) within arm’s reach at all times in case of future reactions. He also gave her an Epipen, a small penlike device that contains epinephrine (also known as adrenalin), which helps control the symptoms of allergic reactions, such as swelling.

Anthony, now 10, is one of around 1% of American children who suffer from a peanut allergy. About 3 million Americans—children and adults—suffer from peanut allergies. Of the approximately 150 children who die every year from food allergy reactions, 100 of those are attributed to peanuts. That’s twice the number that die from bee stings every year, but it’s still a tiny portion of the American population. For children like Anthony, however, a peanut allergy is a deadly condition. He could easily be one of the 100 who die every year from something that is considered a staple in the American diet.

To make matters worse, there is only a 20–25% chance that children outgrow peanut allergies, says Robert A. Wood, associate professor of pediatrics at Johns Hopkins University in Baltimore, who has done extensive research on peanut allergies and children. “There’s nothing to say that in those who keep the allergy that it has a tendency to lessen. If you don’t outgrow your allergy, then you have the dangerous, life-threatening form of that allergy,” he says.

Where peanuts hide • Be wary of artificially flavored nuts. They might have been deflavored and then reflavored with another kind of nut, such as a pecan or walnut. Also beware of mandelonas—these are peanuts soaked in almond flavoring. • Arachis oil is another name for peanut oil. • Many ethnic dishes (African, Chinese, Indonesian, Mexican, Thai, and Vietnamese) often contain peanuts or peanut oil, or may become contaminated with peanuts during preparation. • Foods and baked goods sold in bakeries and ice cream shops often come into contact with peanuts during preparation. • Many brands of sunflower seeds are produced on the same equipment used to make peanut-containing foods. Source: The Food Allergy and Anaphylaxis Network; www.foodallergy.org.

Blame the proteins
Peanuts and their variations, such as peanut butter, have traditionally been seen as food that even the fussiest children will eat. But what is it about a peanut that can make it so deadly? Experts do not really know, says Wood, but the blame lies somewhere in the proteins. “There are some theories, and those have to do with how the particular proteins in the peanut that cause the allergy are constructed,” says Wood. “It turns out that those things that make one protein more allergenic than another are all combined in the peanut proteins. They have all the right properties to make the protein very allergenic.”

When someone like Anthony eats a peanut, his body’s immune system mistakenly detects a hazardous substance, even though it is really harmless. This activates the body’s protection system against this substance—the IgE antibodies. Peanut particles attach themselves to these antibodies, which in turn attach themselves to cells known as mast cells. The mast cells burst and release massive amounts of histamines and other chemicals that set off an avalanche of allergic symptoms. These symptoms can affect four systems in the body: the integument (hives, itching, swelling of the skin); respiratory system (swelling of the throat, tightening of the chest, wheezing, shortness of breath); gastrointestinal system (vomiting, diarrhea); and cardiovascular system (drop in blood pressure). Anaphylactic shock occurs when the blood pressure falls sharply, but Wood says that you can die without going into shock. In fact, respiratory reactions are the most common cause of death. “You can have death from food allergies without anaphylactic shock because you don’t always have a fall in your blood pressure when your throat is being closed off,” he says. “So you can actually suffocate from the allergy and die that way.”

Once a reaction begins, it is important to administer the Epipen as soon as possible, says Wood. The Epipen is plunged into the fat part of the thigh and held there for at least 10 seconds while it releases the epinephrine. Wood explains that in many cases people die because the epinephrine is used too late—the reaction has already taken hold. In addition, Benadryl, an antihistamine, needs to get in the body quickly so it can fight the overflow of histamines that trigger the reaction.

Anthony’s allergy is so severe that when he has reactions, it hits two out of the four systems: He gets diarrhea, he vomits, and his throat closes. He also has terrible headaches, which means that his brain tissue is swelling, according to his doctors.

Two tests, a prick skin and a blood or radioallergosorbent test, are used to gauge the severity of an allergy. For the skin test, results are ranked from 1 to 4; for the blood test, results are ranked from 1 to 6. The higher the number, the more severe a person’s allergic response will be. When Anthony was first tested, he scored a 4++ on the skin test and a 6+ on the blood test. Mary says that his allergist will not do another skin test on him for fear that it might cause an allergic reaction.

Living with it
It is not surprising that living with such a severe condition takes a psychological toll on parents and children. “It’s very common to have significant psychological issues,” says Wood. “It affects parents in a psychological way as well, so that there are many parents out there whose lives have been completely turned upside down by their child’s peanut allergy and their day-to-day fear that they are going to lose their child because of an allergic reaction. And those fears are not necessarily realistic. The odds of dying of your peanut allergy are very, very small, especially if you’re equipped to deal with your reaction. But it still gets the best of some people and creates a tremendous amount of anxiety,” he says. Wood adds that the most anxious children tend to have the most anxious parents, and he has seen children who are terrified of going to school for fear they might come in contact with a peanut.

Anthony cannot take food from anyone at school or eat treats at birthday parties unless Mary knows what they are and how they have been made. “Food is such an offering between friends, and Anthony cannot accept that at face value,” says Mary. “Even if the mother has made a boxed brownie mix, I have to ask her if she served peanut butter in the kitchen that day or if there is any other possibility of cross-contamination. It’s the inadvertent contaminations that are going to hurt him.”

Cross- and inadvertent contaminations are especially important when eating in restaurants. Mary says that they have to ask a lot of questions to make sure Anthony does not mistakenly eat something containing peanuts. If they feel at all uncomfortable or unsatisfied with the answers, they leave immediately. Something like a family outing to an ice cream parlor is too risky—because there is a good chance that the scoop being used to serve the vanilla ice cream could have just been in the rocky road an hour ago. Maybe the scoop was rinsed off, but that is not enough to ensure there is no peanut residue left on it.

Grocery shopping also requires intense investigation, and food manufacturers have recently come under fire for their labeling. Between September 1999 and March 2000, the FDA inspected 85 candy, ice cream, and baked good plants in Minnesota and Wisconsin. After sampling 118 products, one in four items was found to contain peanut fragments not disclosed on the label. Food companies have also revealed that peanut flour is often used as a thickener in chili, gravy, and even spaghetti sauce.

Mary relies on the Food Allergy and Anaphylaxis Network (FAAN, www.foodallergy.org), as a resource for safety alerts and research information. Founded in 1991, FAAN works to increase public awareness of food allergies and anaphylaxis and to support research in these areas. The organization sends e-mail and postal safety alerts to members about foods that are mislabeled and might be a source of inadvertent contamination, in addition to information on cross-contamination during manufacture and production.

“Our child has a dangerous threat. If we sit down and think about it, it’s so overwhelming,” says Mary. “There are things that could happen that we could not protect him against. And it could kill him.”

Note: The family described in this article requested that their real names not be used.

Suggested reading

• National Institute of Allergy and Infectious Diseases; www.niaid.nih.gov.
• American Academy of Allergy, Asthma, and Immunology; www.aaaai.org.
• Center for Science in the Public Interest; www.cspinet.org.

Julie McDowell is an assistant editor of Modern Drug Discovery. Send your comments or questions regarding this article to mdd@acs.org or the Editorial Office by fax at 202-776-8166 or by post at 1155 16th Street, NW; Washington, DC 20036.