Nuts! When even a tiny bite spells frightening consequences

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DianaHaddad2More than once in her life, 14-year-old Diana Haddad has felt the panic: Her tongue and throat itch, she wheezes and gasps for breath knowing she is seconds away from her throat closing off.

Diana is severely allergic to nuts and several other foods.

Since she was 3 years old and first learned the horrible consequences of eating even a tiny portion of certain nuts, she has carried the requisite EpiPen – the epinephrine injector that delivers immediate life-saving medication to her bloodstream to counter the allergic reaction. And she declines the offer of food when she cannot be sure of its origin or ingredients.

This Suffolk girl and her parents, Mary and Louis Haddad, have learned everything they can about food allergies and do all they can to make sure she won't have an allergic reaction that sends her into anaphylactic shock. She often brings her own food from home when dining out with her family.

Still, one day this past spring, Mary brought Diana to the allergy clinic at CHKD to eat the forbidden nuts under the careful supervision of pediatric allergy specialist Angela Hogan.

With a clinical food challenge, the Haddads would learn if Diana could tolerate certain nuts regularly found in prepared foods. A double-blind test, such as the one she had that day, can also assess whether psychological factors play a role in a patient's reaction.

For Diana, the test was a dreaded step, though she knew it could help her toward a life with less intensive vigilance over what she eats. She hoped to learn that walnuts and other nuts – even those hidden in foods – could no longer threaten her life.

For the staff in the allergy clinic at CHKD, it was one of some 300 such challenges performed over the past few years since CHKD became one of only three health centers in the state where children can undergo food challenges in protected, responsive environments only for children.

"We have everything needed here to treat an allergic reaction, and we are comfortable doing that if need be," Dr. Hogan said.

Unfortunately, just minutes into Diana's challenge, she began to react. She had been given a small amount of walnut, ground-up and hidden in applesauce – a food she readily tolerates.

Diana immediately complained of an itchy throat. She had difficulty swallowing and vomited. She became very anxious that her throat was beginning to close and her blood pressure dropped.

Dr. Hogan and her staff reacted quickly with a dose of epinephrine, the essential medication for severe food reactions.

Diana's doctor says her case is somewhat different from most patients with food allergies. "She doesn't get hives at first like most patients. She goes directly into anaphylactic shock, which means she skips the usual oral antihistamine dose and goes directly to a shot from her EpiPen." The EpiPen that patients with severe allergies carry at all times delivers an emergency dose of adrenalin by injection.

DianaHaddad1As hard as it was for Mary Haddad to see her daughter's reaction, she was immediately reassured. "That's why we are here and not in an adult clinic," she said. "We believe firmly that pediatric specialists are best equipped to handle this type of test."

Opening breathing passages with epinephrine and establishing normal blood pressure are the immediate goals when a reaction occurs. "For that reason, we do food challenges only here in the clinic at the hospital," Dr. Hogan said.

While many children with milk, egg and soy allergy outgrow their allergies, the potential of a severe reaction makes it dangerous to test these foods at home, Dr. Hogan said. "In other settings, children may have been told that they were allergic to many different foods, leading to a very restricted diet. Although blood or skin tests may suggest that a child may or may not react to a food, such tests are not an exact measure of clinical sensitivity."

In the controlled setting of the hospital clinic, food challenges help determine which foods can be re-introduced safely into the diet and which ones need to be avoided, Dr. Hogan said. "Most of these 6-to-8-hour tests are not as dramatic as Diana's, but when a reaction happens, we are prepared." Diana spent that night in the watchful care of pediatric nurses on CHKD's monitored-bed unit.

"I was very sure we had to have the full force of the hospital behind us if we were going to subject Diana to this challenge," Mary said. "And now we know for sure that walnuts are as dangerous as ever for her, so we'll continue our vigilance."

Mary still recalls vividly the first time her daughter reacted to nuts, even though it was several years ago. "She began choking at a family gathering in Maryland. I believe she had eaten a chocolate-covered macadamia nut.

"Her dad and I put her in the car and raced to the nearest ER, running red lights all the way," she said. "We fortunately landed in a pediatric ER, and we believe to this day that she is still with us because we were in the hands of people who knew exactly what to do for children."

The Haddads have since learned of other nuts to which Diana is allergic, including coconuts. So her daily routine always includes carrying her own food and snacks to school at Nansemond-Suffolk Academy and avoiding any food she is not sure is safe.

"It's a life-long challenge," Mary said.

It's one which Diana basically takes in stride. "There are plenty of good things to eat that don't have nuts in them. I like fruits, vegetables, pizza and macaroni and cheese," Diana said.

But recently, as the family was watching a television show in which a genie was granting three wishes, Diana spoke up wistfully, "I know what I would wish for: A buffet where everything on it was good and was safe for me to eat!"

Dr. Hogan practices with Children's Specialty Group PLLC at CHKD.

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