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Ask the Expert - Handling Peanut Allergy Exposure Issues
 
Q: I have a 12-year old patient with peanut allergy who was diagnosed when he developed a rash after eating peanut butter at 2 years of age. The mother belongs to a food allergy support group that has convinced her that her son’s peanut allergy is so bad that the school needs to ban all peanut products. She has also demanded that all children wipe their hands when they arrive at school and that the classroom furniture be wiped down daily and that a log be kept of this. Children in the patient’s class have been asked to not eat any peanut products at home in case they might bring it in on their clothes or have it on their breath. She has threatened legal action if this isn’t done. The school district is not convinced, so they have asked me to write a letter explaining what needs to be done.
 
A: Peanut allergy clearly is a significant issue for patients who have anaphylactic sensitivity to it. As you know, severe reactions almost always occur with ingestion. The documented cases of airborne peanut allergen causing anaphylaxis are very limited and are questionable. Even so, this mother is unlikely to be convinced by anything you can say. She also is unlikely to agree to an oral peanut challenge, which the patient might actually react to anyway so it wouldn’t answer the question.

What you need to offer is a peanut proximity challenge. This involves getting several jars of “butters” including peanut, soy, sunflower, almond and cashew butter. The jars can be covered and labeled A through E. The patient can then come into the clinic for a series of challenges with these jars. The mother and nurse doing the exposures should be blinded to the identity of the jars.

The patient can undergo 5 different challenges:
  1. Open the lid of each jar one at a time at 5 minute intervals and have the patient breathe them.
  2. Have the patient write with 5 different pens, each smeared with one of the 5 butters.
  3. Smear a small amount of each butter on the patient’s arm one at a time and leave it for 5 minutes each.
  4. Crush peanuts in shells in the room with the patient observing. If there is no reaction, the patient can hold the shells in his/her hands.
  5. Dip a tongue blade into each jar and place them in the patient’s mouth one at a time for 5 minutes (a very small oral challenge with each). At the end of the challenge, the patient will either be able to identify which jar has the peanut or the test will be declared negative. Unblind the jars and debrief the family.
There are various responses that might occur after completion of this challenge (which depend on the results of the challenge). If no reaction, the family might accept that their child is not that sensitive and the school can go back to normal. On the other hand, the family might refuse to accept the results. Either way, you can write a letter to the school outlining exactly how sensitive this patient is and what precautions, if any, are needed.
 
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