Warning: This post will be controversial.
I have seen too many instances of terrified parents falsely believing that being in the same room as a peanut is going to kill their child. I have heard too much about 10 year old children being kept home from birthday parties, families being kicked off planes for requesting that peanuts not be served to anyone on board, of people demanding that high schools be peanut-free. I feel that something needs to be said.
The bottom line is this: there comes a time when we need to sit down and come to terms with the actual risk posed by inhalant exposure of peanut allergen vs. the perceived risk.
I do not need a double-blind placebo-controlled trial to tell me that the perceived risk of anaphylaxis to inhaled peanut protein far, and I mean FAR, outweighs the actual risk.
The majority of parents whose children have experienced food-related anaphylaxis are understandably traumatized by the event, and would go to the ends of the earth to prevent a repeat reaction. I get this. I personally know the nightmare of being doubled over in pain, covered in hives, and feeling my inside of my throat swell to the point that I had difficulty speaking. I am the mother of two allergic children myself, and was pleased when my son's daycare informed me they were peanut-free. To my mind, makes sense to exclude peanuts from a facility full of little kids with poor impulse control.
But I am saddened by the number of parents who wrongly have been made to feel as though the world is not safe for their children. Anaphylaxis sucks. But the vast majority of children with food allergy, even those who experience anaphylaxis with ingestion, are able to live safely in close proximity to their food triggers. Peanut protein is undetectable in the air after study subjects have consumed peanut butter. A study by Dr. Scott Sicherer (a highly esteemed clinician-researcher in the field of food allergy) evaluated 30 highly peanut-allergic children by having them sniff peanut butter for 10 minutes- none of the children reacted. This might be different with peanut flour, which could potentially trigger symptoms at points of contact: eyes, nose, lungs. However, this would be with close proximity, and is exceedingly unlikely to trigger the cardiovascular collapse associated with full-blown anaphylaxis.
So, why are so many parents telling teachers, school administrators, restauranteurs & airlines the following: "Don't you get it? My child could DIE!"
The answer is simple. Because they believe it.
At some point, a medical professional did an allergy test, gave the parents a lecture on the dangers of hidden peanut exposure, advised strict peanut avoidance, and trained the family in the proper use of autoinjectable epinephrine. None of these these are necessarily wrong.
The bad part is what's missing from the conversation. Where is the discussion about the actual risks of having peanut products in the home or school, the utility of peanut-free tables, of going out to a restaurant, of flying on a plane? What about the risk of eating those pesky "processed in a facility that also processes peanuts/tree nuts" items? This is where we, as a medical community, have let food-allergic children and their families down.
All too often, it seems easier and safer for the doctor to say- "Avoid peanuts at all costs. Here's an EpiPen- keep it close, and don't hesitate to call 911." Why unnecessarily risk a severe reaction, right? Seems logical enough. But it doesn't make things easier. It makes things harder. It FREAKS parents out.
The above statement, translated into parentese, is this: "Remember how your kid looked after eating that peanut butter cookie- all red and swollen and puking? If you're not careful- it'll happen again- might even be worse! Better be ready!" You think you're being cautious- but at what cost to your patient's quality of life? No wonder the parents are losing hair and gaining wrinkles over sleep-overs and school lunches and class trips to the state capitol! No wonder we have a new generation of children so ardently protected from any chance peanut encounter, however minute, that they've come to see the outside world as a danger zone!
This is counter to what we should be trying to accomplish as medical professionals. What is needed is a more nuanced, individualized discussion of risk, tailored to each peanut-allergic child. Parents need to know what to protect their children from, to be sure. They need excellent training in the indications and use of emergency medicine. But they also need to know which situations are relatively safe, even if it goes counter to the popularly held conceptions. This is where counseling from an allergist can be especially helpful.
It breaks my heart when I see parents who have not been adequately educated about the real risk involved with non-ingested peanut exposure, and have therefore been worried about scenarios that pose little to no risk to their children. As physicians, the onus is on us to do better by these families. All it takes it a little time, thoughtfulness, and a willingness to break free from a cookie-cutter approach to treating food allergy.