Our children have been allergic to peanuts since they were babies, breaking out in hives when there were even trace amounts in any food they ate. So we’ve listed their allergy in all the forms we fill out each year for the school, and avoided bringing peanuts into our home.
Then one child brought home a form that asked us to provide the school with an EpiPen, or get documentation from a doctor that showed he did not need it.
It turns out that in 2013 Congress passed the federal School Access to Emergency Epinephrine Act to help protect students at risk of anaphylactic reactions caused by food or insect sting allergies, or other triggers. The law encourages states to require schools to keep a supply of epinephrine auto-injectors, like EpiPen on hand and train school nurses and other staff members in their use. A number of states have complied with the recommendation, and schools routinely request that parents provide an auto-injector if their child has known allergies.
EpiPen has had its share of issues in recent years. In March 2020 EpiPen came under scrutiny by the Food and Drug Administration (FDA) when Pfizer, EpiPen’s manufacturer, notified the agency that people were having problems using the device. Some of the problems were from user error and some were a result of EpiPen malfunction. The FDA did not order a recall, but urged people to be aware of potential problems with the device.
In 2017 there were reports of EpiPen failures that led to hospitalizations and several deaths. In a strongly worded warning letter to Pfizer, the FDA cited a number of manufacturing violations and demanded that they be corrected. The warning was followed by a voluntary recall of the device from a number of markets, and a shortage of the drug in some areas. In the meantime, a number of other epinephrine auto-injectors, as well as a generic EpiPen. In a study comparing usability of EpiPen Jr (half-dose version for children) to a brand called Auvi-Q, participants showed a preference for Auvi-Q and were more likely to use it correctly than EpiPen Jr.
But children can outgrow food allergies — even severe ones. For younger children, allergists recommend testing once a year, since reactions can change rapidly. For older children who show high levels of reaction in tests, they recommend testing every two to three years.
It’s better to get children retested, rather than assume they are still allergic and keep refilling expensive prescriptions and have them live in fear of a food. Aside from hives, our children had no life-threatening reaction to peanuts, thankfully, so we had never needed to get a prescription for an EpiPen. When the school sent the request home, that’s when we went to an allergist.
After a skin prick test, a blood test to double-check results, and an oral sample of peanut butter that was given while in the clinic, we found out both children had outgrown their peanut allergy and would not need any medication.
This was an eye-opener for us. Children do commonly outgrow dairy and egg allergies, but statistics show it’s possible to outgrow other food allergies too.
“Eighty percent of kids will outgrow egg, soy, milk and wheat allergies, about 20% will outgrow peanuts, and 15% to 20% of those with fish and shellfish allergies will outgrow it,” says Stephanie Leonard, MD, director of the food allergy center at Rady Children’s Hospital in San Diego.
This is why it’s important to get children tested. Allergists recommend retesting, every year or every other year, depending on the severity of the allergy, before filling prescriptions for allergy medicines and restricting food habits.
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Why Test? Impact on Quality of Life and Nutrition
But on checking with many friends and acquaintances whose children have food allergies, we found that very few actually went in for retesting. On the soccer field, at school events and at birthday parties, parents routinely caution kids to not eat specific foods, and alert the organizers.
“I’m often surprised when someone is told they have an allergy seven to eight years ago, especially with milk and egg, and they haven’t had it tested since then,” says Andrew MacGinnitie, MD, PhD, an allergist-immunologist with Boston Children’s Hospital. “If [cakes or cookies are] very well baked with egg and milk in it, about two-thirds of kids with those allergies can eat them… but parents don’t know that. It’s no fun to not be able to eat egg when it’s in cakes and cookies.”
Indeed, our friend’s son, who is allergic to egg but has never been tested, has to forgo cake and ice cream at birthday parties, while all his friends dig in.
Leonard concurs, pointing out studies showing that having food allergies decreases quality of life, and it’s something you have to think about every time your children have food in public. Avoiding the food is safest, but it’s worth retesting to see if they still need to carry the emergency medication. Plus, needlessly avoiding certain foods for an allergy a child may not even have any more can rob them of essential nutrition.
Lack of Guidelines for Testing
Part of the reason many parents don’t realize they should periodically retest is because of misinformation — many assume severe allergies cannot be outgrown.
“There is an emotional and psychological cost, not just economic cost, to allergies. Sometimes there’s a lack of knowledge or experience about getting tested. It used to be easier for people to say, why don’t you just avoid it? But that attitude is changing rapidly,” explains Brian Schroer, MD, director of allergy and immunology at Akron Children’s Hospital in Ohio.
It’s not just the public that’s misinformed. Parents might check with pediatricians who may not be aware of the need to retest more often, and advise them to wait a few years.
“Many primary care doctors, pediatricians, and even some allergists were trained 10, 15, or 20 years ago, when these allergies were not so common,” Schroer says.
And as he points out, allergy tests themselves are not 100% conclusive, which is why allergists sometimes go a step further after the routine skin prick test and order a blood test. As a final step, they administer a small oral sample of the allergic food, such as egg, peanut butter or soy, and have the patient wait in their office to observe their reaction. If there is no reaction, they give a larger amount and repeat the cycle, until they know for sure.
A study in the Annals of Allergy, Asthma & Immunology showed that for every year that patients did not retest, and parents delayed introducing certain foods, the costs for medication like the EpiPen and other costs associated with avoiding allergenic foods added up to about $4,000 per year, per patient.
While there is more awareness about food allergies, thanks to all the marketing literature in the public domain, there’s not enough awareness about what constitutes a severe allergy, what’s not severe, and how to deal with it, MacGinnitie explains.
“There aren’t any published guidelines saying you should retest peanut allergies every two years or for wheat… so you need an allergist to sort it out, and often it takes some time for that to happen,” says Kimberly Leek, MD, a pediatrician and assistant clinical professor of pediatrics at the UC San Diego School of Medicine. “I think allergists need to guide pediatricians on when to suggest testing and retesting.”
Why Are Food Allergies on the Rise?
More and more people seem to be allergic to one food type or another, although the causes are not clear.
“One wrinkle I would add to that is that some patients were never even allergic in the first place,” says Schroer. “I won’t blame the parents, but when kids had skin rashes like eczema, doctors may have attributed it to food when it may have been a skin disease.”
Allergies can be based on fuzzy knowledge, Leek agrees. “They could be allergies that never existed and allergies that were misdiagnosed. You have a parent with a baby who has a cow’s milk allergy, which could be outgrown in nine to 12 months, but parents interpret a sensitivity as an intolerance, such as diarrhea after eating nectarines.”
When a parent tells Leek that their child has an allergy, she immediately asks them how they know, how it was diagnosed, who told them the child had an allergy, has the child been seen by an allergist, what kind of testing was done and what allergy plan they have in place.
Another cause for rising food allergies is delaying the introduction of certain foods. One mistake the medical community made in the past, MacGinnitie says, was in telling parents to delay introducing common allergens such as dairy, soy, egg and nuts to children. Research shows that introducing peanut foods early can actually help avoid allergies to them. Based on the strength of those findings, the National Institute of Allergy and Infectious Diseases (NIAID) developed practice guidelines, recommending that parents introduce peanut-containing foods to high-risk infants as young as four months old to avoid peanut allergy.
The bottom line is even if your children have been tested in the past for food allergies and found to have them, it’s a good idea to get them tested again to see if they have outgrown them. If they have, not only will they be happy to eat foods again they have long avoided, you won’t have to worry about carrying around an EpiPen. And now that they’ve been cleared of food allergies, our boys are enjoying an all-American treat that they never could before: peanut butter and jelly sandwiches.
