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Allergists discuss screening siblings of children with peanut allergies
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Screening younger siblings of peanut allergic children with allergy testing before peanut introduction was considered controversial in a paper written by Elissa M. Abrams, MD, of the department of pediatrics at the University of Manitoba in Canada and colleagues.
“Although certain guidelines note some value in screening this population, it is not a direct indication in the recent National Institute of Allergy and Infectious Diseases guideline,” they added in an article published in The Journal of Allergy and Clinical Immunology: In Practice.
The prevalence of food allergy in children has increased sharply in the past generation, with CDC data showing that between 1997 and 2008, the prevalence of peanut or tree nut allergy seems to have more than tripled in U.S. children.
Such data may lead parents of children with allergies to insist on screening the impacted child’s siblings, according to Richard L. Wasserman, MD, PhD, FAAAAI, of Allergy Partners of North Texas.
“Parents weren’t expecting their older child to have peanut allergy and still don’t know (in most cases) why it occurred. Their rationale is that if this could happen to one of my children, it could happen to another and I want to know. They may or may not be aware of the inconsistent data on the increased prevalence of peanut allergy in siblings of peanut allergic patients or of the data suggesting that first reactions in infants are seldom serious.”
The most significant argument against testing siblings of patients with food allergies, particularly peanuts, is the potential of a false positive, Wasserman said, and this should be discussed with parents considering screening a sibling.
He shared how he discusses various peanut allergy test results with the patient’s parents.
“If the test is negative, peanuts can be introduced at home or under supervision if you are still uncomfortable. If the test is equivocal or positive, I will refer your child to an allergist who will do a graded food challenge to peanut eliminating the false positives. If your child passes the challenge, you will be encouraged to give a peanut product at least three times a week according to the current guidelines. If the child reacts and fails the challenge, you can discuss oral immunotherapy during which a peanut product is eaten every day,” Wasserman said.
There are other important considerations for PCPs with patients who are parents of children with peanut allergies, according to Michael Pistiner MD, MMSc, director of food allergy advocacy, education, and prevention, Massachusetts General Hospital for Children and Harvard Medical School.
“If a PCP sent every single family with an older sibling that had a peanut allergy for screening, that would increase the needs for referral and further stress access issues to allergists who feel comfortable with this young population. It would further encourage sending tests that could cause false positives that could further slow down the introduction of these foods and could have impact that would increase the chance that these kids may actually develop allergy. And you don't want to do anything that is going to slow that food introduction down,” he said in an interview, adding that some parents will not feel comfortable introducing peanut unless there was some form of screening first and that screening may improve the chance that peanut would be introduced without delay.
Parents’ concerns should not be brushed aside, Pistiner noted.
“Cross contact in the sibling with peanut allergies is something that concerns families, so PCPs coming up with reasonable strategies to ensure that it does not happen takes thought, but it's completely doable,” he said.
Food Allergy Research and Education provides some ways to avoid cross contact that PCPs can share with patients:
- Use utensils, cutting boards and pans that have been thoroughly washed with soap and water. Consider using separate utensils and dishes for making and serving safe foods.
- Cook allergy-safe foods first.
- Keep safe foods covered and away from other foods that may splatter.
- Wash hands with soap and water before touching anything else if a food allergen has been handled. Soap and water or commercial wipes will remove a food allergen. Sanitizing gels or water alone will not remove an allergen.
- Scrub down counters and tables with soap and water after making meals.
- Do not share food, drinks or utensils. Teach children not to share these items.
Abrams and colleagues suggested that an end to the controversy is not likely in the near future.
“Further studies are required to accurately determine the relative risk of genetics versus environment in young siblings of peanut-allergic children. In addition, a registry of severe reactions with peanut introduction would provide information about unexpected or particularly severe reactions,” they wrote.
Until such data are available, Abrams and colleagues added their own recommendation for handling such situations.
“Families [with peanut allergic children] should be encouraged to introduce younger siblings to peanut at around 6 months of age at home if they are comfortable doing so through proper education, bearing in mind that some pre-emptive evaluation will likely still be required for those who are hesitant despite education.” - by Janel Miller
References:
Abrams EM, et al. J Allergy Clin Immunol Pract. 2018;doi: 10.1016/j.jaip.2018.01.002.
Foodallergy.org. Facts and Statistics. https://www.foodallergy.org/life-with-food-allergies/food-allergy-101/facts-and-statistics. Accessed Aug. 17, 2018.
Foodallergy.org. Accessed Aug.17, 2018. How to avoid cross-contact. https://www.foodallergy.org/sites/default/files/migrated-files/file/avoid-cross-contact.pdf. Accessed Aug. 17, 2018.
Disclosures: Pistiner reports being co-founder and content creator of Allergy Home and Allergy Certified Training and a consultant for DBV Technologies and Kaleo. Wasserman reports no relevant financial disclosures.