Questions arise about children and food allergies

by Erica Shaffer
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Food allergies are con-sidered a significant public health issue and precautionary labels on food and beverage products are mandated to protect consumers. A large proportion of childhood food allergies are outgrown, but there is no cure and avoidance is the only option for parents trying to help their children manage a food allergy. That’s why clear and accurate labels on food products are considered to be so important.

But a question is being asked: Are allergy-warning labels always necessary? Professionals in the food industry say a growing body of research shows many food products flagged as an allergy risk may contain only miniscule amounts of allergens that may not trigger a reaction in people with food allergies. They say establishing a threshold for labeling would limit confusion and improve the quality of life for allergy-sufferers.

“It’s still relatively new, it’s still in the research area,” said Marianne Smith-Edge, senior vice-president of nutrition and food safety for the International Food Information Council. “The studies are showing positively that they would be able to establish a threshold where there would be a negligible risk or reasonable certainty of no harm to the food allergic person.”

The concept of thresholds is in its infancy, but IFIC and others in the food industry are broaching the subject now in an effort to educate stakeholders about thresholds and labeling. Ms. Smith-Edge said the food industry must have a dialogue with all stakeholders that are involved — pediatricians, allergists, and registered dietitians to name a few.

“If there’s a comfort level with those that are trying to help them manage their food allergies, then there’s acceptance in that regard,” she said. “All along the way, it has to be about education, being very transparent and getting people to understand what does (threshold) mean. Whether or not it will be accepted is really through the eyes of each individual parent because it’s going to be depending on the severity of the allergen.”

She said having a discussion about thresholds would provide more scientific knowledge and perhaps make precautionary labels on food more meaningful.

But medical professionals caution that no two people are alike when it comes to the amount of an allergen that will trigger a reaction.

Actually, it’s not always easy to accurately diagnose food allergies, doctors say. A wrong diagnosis may mean a lifetime of limited food choices, a trip to the emergency room or worse. Therefore, diagnosing and managing a food allergy is of particular concern for parents.

An estimated 7.5 million people have at least one food allergy, according to findings from a large food allergy study conducted by Johns Hopkins Children’s Center, the National Institutes of Health and other institutions. The study also found that allergies were most common in children 5 years old or younger, with 4.2% testing highly positive for one food allergy, followed by children ages 6-19 at 3.8%. Children under age 5 were more than twice as likely as those older than 20 to have a food allergy. African-American boys were more than four times as likely as white women over 20 to have a food allergy.

The study used blood levels of antibodies as an indicator of actual disease. Only people with blood levels high enough to suggest clinical disease were classified as food allergic. But even using blood tests presents challenges in diagnosing a food allergy.

“The problem with looking at the blood is that there’s a possibility that it will overestimate food allergy, because there are lots of people who have positive tests that are not truly allergic to that food,” said Robert Wood, chief of pediatric allergy and immunology at Johns Hopkins Children’s Center and a principal investigator in the Johns Hopkins-N.I.H. study. “So, even if they test positive, they’re fine eating that food.”

Dr. Wood said re-searchers tried to use cutoffs where at least 90% if not 95% of people who had a blood test score above a certain level were truly allergic. However, the test did not predict how much of the food would cause a reaction, he said.

Any guidelines for food labeling should protect the food allergic public, Dr. Wood said.

“My position as a physician taking care of highly allergic patients, those more allergic patients do need to be protected,” he said. “That’s sort of the big debate, whether the threshold you determine should protect 99% or 99.9% or 99.99%, and for that person, the one-in-a-thousand who’s going to react, then having a guideline that doesn’t protect them is wrong.”

Another study found that 8%, or one of 13, children in the United States suffer from a food allergy. The Food Allergy Initiative funded the study and it was published in the July issue of Pediatrics. The study also found that children 14-17 were most likely to have a severe food allergy. But the F.A.I. study also had limitations that may point to difficulties in reaching an accurate diagnosis.

“Any time you self-report a diagnosis, there’s obviously some questions about it,” said Stanley Fineman, president-elect of the American College of Allergy, Asthma and Immunology and an allergist at the Atlanta Allergy and Asthma Clinic. “We don’t know from this study how many of those people had a doctor-confirmed appropriately diagnosed problem.

“Unfortunately, food al-lergy frequently is difficult to diagnose. There are some specific protocols and specific test procedures that you should go through to diagnose and confirm a food allergy before you label somebody as food allergic and start restricting their diet,” he said.

Dr. Fineman added that over diagnosis and under diagnosis of a food allergy is common.

“This is a concern, particularly in a growing child,” he said. “You don’t want to be limiting potentially beneficial foods — protein-containing foods and things like that which are frequently staples in kids’ diets.”

Dr. Fineman said that if a person has allergy sensitivity to a food protein, there is certainly a threshold phenomenon in which a certain amount of the allergen is eaten and it triggers a reaction. But it varies among people.

“In some people that threshold is lower than in others, and a trace amount might trigger a reaction in others,” Dr. Fineman said. “So, I usually advise patients who are allergic to a food protein not to eat any food that may be processed in a plant that might contain that food.”

As for food labels, Dr. Fineman said the public has been very fortunate to have good labeling.

“It used to be it was hard because the labeling wasn’t very good. Now the labeling is very good,” he said. “I think people are much better off now than they were a few years ago.

Ms. Smith-Edge said estab-lishing thresholds for labeling may provide consistency in labels, and it may reduce or eliminate some of the precautionary labeling. The prevalence of information labels on food has contributed to many consumers ignoring labels altogether, she added.

“In the IFIC food and health survey, when we ask people what do they look at on the label, allergens are not at the top of the list, but we see that rising,” she said. “Those who are affected are definitely going to look on the label. But I do think sometimes especially labels are ignored because they’re on everything.”

Tony Flood, director of Food Safety Communications for IFIC, said regulatory agencies such as the Food and Drug Administration are examining the issue, which has allowed the research to grow.

“It’s an opportunity to bring the research together and understand how the F.D.A. views it in terms of developing effective risk assessment tools for allergy sufferers,” Mr. Flood said. “Food allergies are a true public health issue and the severity for individuals might vary. There are a lot of people who won’t react at certain levels, so it’s an opportunity to understand what their level of sensitivity might be and help increase their quality of life so that there are choices available to them and other food allergic populations.”

Ms. Smith-Edge, who worked with food allergic patients as a registered dietitian, emphasized the importance of clearly communicating the science behind the threshold concept. But she acknowledged children’s food allergies are an emotional issue for parents, who must weigh the risks versus the benefits.

“It’s very personal depending on the complexity and the reactions that the food allergic patient has,” she said.

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