Results. Isolated PN allergy was reported by 3482 reg- is a voluntary, self-reported, or parental reported registry istrants (68%), isolated TN allergy was reported by 464 of individuals who are allergic to peanuts and/or tree nuts. individuals (9%), and allergy to both by 1203 individuals This group of individuals from the database had experi- (23%). Other self-reported food allergies included egg enced peanut and/or tree nut allergic reactions in a school (29%), cow’s milk (22%), soy (11%), wheat (6%), fish (4%), or day care setting. and shellfish (2%). Atopic disorders included atopic der- Methods. One hundred subjects were randomly se- matitis (50%), asthma (46%), and allergic rhinitis (27%). lected from the PAR database and telephone interviews Participants were more likely to have been born in Octo- were performed to characterize the number of allergic ber, November, or December (P Ͻ .0001). Eighty-two per- reactions, causative food, initial symptoms, severity of fi- cent (n ϭ 3877) had been breastfed for a median of 7 nal reactions, method of food contact, and the treatment months. The median age at first known exposure to PN rendered/school response. ϭ was age 12 months (mean 18.5 months), while the first Results. Of 4586 total database registrants, 750 (16%) ϭ known reaction was at a median age of 14 months (mean reported allergic reactions to peanuts and/or tree nuts 29.5 months). Seventy-four percent report that the first while in school or day care. One hundred subjects or reaction to PN occurred with the first exposure, and inges- parental surrogates described 115 reactions to peanuts and tion was reported as the most common route of exposure 9 reactions to tree nuts. For 25% of these subjects, a school (91%). The first reactions occurred primarily in the home, reaction was the first indication of peanut or tree nut beginning a median of 3 minutes after exposure, 76% re- allergy. A total of 32% had 1 prior reaction, 37% had 2, 11% quiring medications. The median age at first known expo- had 3 and 20% had Ͼ3 prior reactions. A total of 64% ϭ sure to TN was 24 months (mean 48 months), while the occurred in preschool with the remainder in elementary ϭ median age at first reaction to TN was 36 months (mean school or higher. Mode of contact included 60% occurring 77 months). Sixty-eight percent reported that the first re- from ingestion, 24% from skin contact/possible ingestion, action occurred with the first exposure, and the majority of and 16% from inhalation/possible skin contact or inges- first TN reactions (61%) occurred in the home. Ingestion tion. Peanut butter craft projects accounted for the most was the most common route of exposure to TN (88%). Half common ingestion. Treatment was given in 90% of reac- Ͼ of all the reactions involved 1 organ system. A second tions. Antihistamines were given in 84% and epinephrine reaction to PN was described by 2226 registrants (48%), in 28%. Epinephrine was administered by teachers, nurses, and 1072 (23%) reported a third reaction. A second reaction parents, and others. A nurse was on location for only 23% to TN was reported by 564 people (34%) and 240 (14%) of reactions. Treatment delays were secondary to delayed described a third. Subsequent PN and TN reactions attrib- recognition of reactions, calling parents, not following utable to accidental ingestion were more severe, more com- emergency plans, and, in 1 case, inability to administer mon outside the home and more likely to require treatment self-injectable epinephrine. with epinephrine, when compared with initial reactions. Conclusions. Peanut and tree nut allergic reactions are Ninety percent of the participants reported having epi- common in school and day care environments. Both acci- nephrine available at all times. Of the 10% who did not, dental exposures and new onset reactions can occur. 45% had not been given a prescription. School personnel need to be educated to recognize and Conclusions. This registry is the largest collection of treat food-allergic reactions. patients with food allergies and emphasizes important and Reviewers’ Comments. There are 2 weakness from this novel features of PN and TN reactions. Reactions are often article that stem from the reliance on self-reported infor- severe, often occur on the first exposure, and require some mation. First, this could represent an overestimation of type of medication or medical intervention. Subsequent severity of school peanut and tree nut reactions as de- reactions to PN and TN reportedly worsened in most scribed in the article. Second, when nonmedically trained patients. The majority of patients reported having epineph- Ͼ personnel report such events, reliability and historical re- rine on hand, but it is worrisome that 500 patients did not call need to be taken into account. However, in the school have epinephrine readily available, and almost half of and day care environment, nonmedically trained person- these patients had not ever been given a prescription. nel will be the first to recognize signs and symptoms of Reviewers’ Comments. This study provides valuable in- allergic reactions and therefore need to be educated re- sight into a very important aspect of food allergy. Because garding food allergies. Successful management includes 89% of the registrants are children, this data is very valu- prevention, prompt recognition, availability of medica- able for pediatricians, as it provides new insights into the tions, written emergency plans, and early administration features of these PN and TN allergies, reaffirms previous of epinephrine by teachers, nurses, parents, cafeteria work- observations, and provides a valuable source of informa- ers, and other school and day care personnel. tion for health care providers. Candace F. Remer, MD Amy M. Scurlock, MD Michael Kaplan, MD Stacie M. Jones, MD Los Angeles, CA Little Rock, AR SCHOOL READINESS FOR CHILDREN WITH FOOD ALLERGIES THE US PEANUT AND TREE NUT ALLERGY REGISTRY: CHARACTERISTICS OF REACTIONS IN Rhim GS, McMorris MS. Ann Allergy Asthma Immunol. SCHOOLS AND DAY CARE 2001;86:172–176 Purpose of the Study. The purpose of this study was to Sicherer SH, Furlong TJ, DeSimone J, Sampson HA. J Pe- identify and characterize the level of knowledge about diatr. 2000;138:560–565 food allergy and the prevention and treatment policies for Purpose of the Study. To describe clinical features of food-allergic children in elementary schools. allergic reactions to peanuts and tree nuts occurring in Study Population. A total of 273 public elementary school or day care environments. schools were randomly selected from the 2082 public ele- Study Population. Participants were from the US Na- mentary schools listed by the Michigan State Education tional Peanut and Tree Nut Allergy Registry (PAR), which Directory.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 SUPPLEMENT 435 Methods. A 21-item questionnaire, which assessed food mechanistically linked to eosinophilic allergic responses in allergy awareness, avoidance measures, and treatment the lung. strategies, was mailed to the 273 schools. Multiple-choice Study Population. Eight- to 10-week-old BALB/c mice, questions were derived from suggested school guidelines interleukin (IL)-5 gene-targeted mice, and eotaxin-deficient for anaphylaxis. inbred mice were maintained with age- and sex-matched Results. A total of 104 responses were received repre- controls. senting 109 schools (40% response rate). A total of 39% Methods. Using previously published protocols, mice characterized their school district as urban, 37% as rural, were exposed to repeated inoculations of Aspergillus fu- and 28% as suburban. Based on a school-reported estimate migatus antigens by oral, intragastric, and intranasal of 66 598 children, there was a 1.7% self-reported preva- routes. Eosinophils levels in the esophagus were analyzed lence rate of food allergies. A total of 95 schools reported by anti-major basic protein immunostaining. The tissue having at least 1 food-allergic student and 55% of those distribution of eosinophils after intranasal allergen was reported 10 or more food-allergic children. The most com- examined in the blood, bronchoalveolar lavage fluid, stom- mon food allergies were milk (81%), peanut (62%), tree ach, and small intestine. Pathologic changes were defined nuts (32%), shellfish (28%), egg (23%), wheat (22%), and using histologic examination of the esophagi and electron soy (7%). A total of 31 schools reported “other” food aller- microscope analysis of tissue eosinophil morphology. Ex- gens including fruit, chocolate, red dye, tomato, fish, or- perimental eosinophilic esophagitis was induced in ange juice, spices, and cheese. Food-allergic children were eotaxin gene-targeted mice and in IL-5 gene-targeted mice. identified primarily through official school records, and Results. Allergen-challenged mice developed marked only 16% of school had written individual emergency levels of esophageal eosinophils, free eosinophil granules, plans. For education on food allergies, schools relied and epithelial cell hyperplasia, which mimic pathophysio- mainly on parents (52%) and in-services (47%) conducted logic changes observed in humans with eosinophilic in- most commonly by school nurses or principals. Avoidance flammation of the esophagus. Of note, eosinophil levels in measures to aid in preventing accidental ingestions in- the stomach and small intestine did not significantly in- cluded food substitution and special meal requests, non- crease after allergen challenge. As opposed to the intrana- sharing food policies, and instruction for food handlers on sal route, exposure of mice to oral or intragastric allergen techniques to prevent cross-contamination. However, only does not promote eosinophilic esophagitis, indicating that 21% of schools reported instructions on reading food labels hypersensitivity in the esophagus occurs with simulta- for hidden allergens. In the event of a serious allergic neous development of pulmonary inflammation. In the reaction or on administration of epinephrine, 94% of the absence of eotaxin, eosinophil recruitment is attenuated, schools reported that they would transport the student to and furthermore, in the absence of IL-5, eosinophil accu- medical facilities. The most common site for storage of mulation and epithelial hyperplasia were ablated. epinephrine was the main office or the nurse’s office. Prin- Conclusions. These results establish a pathophysiologic cipals, nurses, and teachers were most often trained to connection between allergic hypersensitivity responses in administer epinephrine. No training of staff was reported the lung and esophagus and demonstrate an etiologic role by 10% of the schools. for inhaled allergens and eosinophils in gastrointestinal Conclusions. Schools need to formally educate their inflammation. Moreover, these investigations dissect the personnel on a school-wide basis. Important prevention cellular and molecular mechanisms involved in eosinophil measures such as reading labels, written treatment plans, homing into the esophagus. Aeroallergens may be contrib- immediate accessibility to epinephrine, and staff training uting to the pathogenesis of esophageal inflammation in a on administration of epinephrine are areas that need to be subset of patients with primary eosinophilic esophagitis emphasized. and gastroesophageal reflux disorders. Reviewer’s Comments. This study demonstrates that Reviewer’s Comments. Just when you thought you had most schools have at least 1, if not several, food-allergic heard of the last potential trigger for gastroesophageal children. It also revealed a large number of deficiencies in reflux disorders, this very provocative investigative model school policies regarding food-allergic children, such as of experimental eosinophilic esophagitis was published. lack of school-wide staff education, lack of avoidance mea- These data suggest that eosinophilic esophagitis can be sures (instructions on food labeling for cafeteria workers as mediated by extrinsic allergens and establish a causal link well as knowledge on who has food allergies), lack of between the development of allergic hypersensitivity in written emergency plans, lack of accessibility to epineph- the respiratory tract and in the esophagus. This model not rine, and lack of personnel who can administer epineph- only implicates a role for aeroallergens in the pathogenesis rine. Previous studies have shown that even those who are of esophagitis, but also provides a novel system to evaluate responsible for administering self-injectable epinephrine the treatment of eosinophilic esophageal disorders, which often are not familiar with the correct technique for admin- include gastroesophageal reflux, allergic eosinophilic istration. Schools need help from physicians on proper esophagitis, eosinophilic gastroenteritis, primary eosino- policies and programs to keep food-allergic children safe philic esophagitis, and drug reactions. from harm. John M. James, MD Helen Skolnick, MD Fort Collins, CO Princeton, NJ

ANAPHYLAXIS AN ETIOLOGICAL ROLE FOR AEROALLERGENS AND EOSINOPHILS IN EXPERIMENTAL CAN EPINEPHRINE INHALATIONS BE ESOPHAGITIS SUBSTITUTED FOR EPINEPHRINE INJECTION IN CHILDREN AT RISK FOR SYSTEMIC Mishra A, Hogan SP, Brandt EB, Rothenberg ME. J Clin ANAPHYLAXIS? Invest. 2001;107:83–90. Purpose of Study. An experimental model was estab- Simons FER, Gu X, Johnston LM, Simons KJ. Pediatrics. lished to test the hypothesis that eosinophilic esophagitis is 2001;106:1040–1044

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