2-year-old daughter's possible nut allergy

[Online Knight]

Hello all!

My wife and I have 4-year-old & 2-year-old daughters and an 8-month-old son.  Up to this point, our two oldest have "enjoyed" any foods they have consumed without any indication of food allergies.  This includes peanuts, peanut butter, walnuts, almonds, pecans and various seafood (the usual suspects).

On Friday night, I gave the girls their first pistachio... not even thinking of potential problems.  Within seconds, my 2-year-old began coughing, pointing in her mouth, and struggling to breathe.  We rushed her to the hospital, and fortunately, she is okay.  They gave her the epinephrin and other "allergy" meds.  Soon, she threw up, and all of the symptoms disappeared.  The doctor thought it could be an allergy or a reaction to the nut being stuck in her throat.

In a couple of days, she has an appointment with the allergist.  We are being told they cannot do an accurate test for 6 weeks.  How do we proceed in the meantime?  Should we banish all nuts and nut "products" from the house?  I don't think a pistachio allergy would be difficult to manage, but is it really possible that her reaction to that nut (if it wasn't a choking incident) could trigger an allergy to the peanuts and peanut butter that she has always enjoyed?  I SO want to take a jar of peanut butter in to the doctor with us and say, "let's find out for sure right now."  Am I crazy?

Most importantly, my little girl is alive and well... I thank God for that.  Now, we need to figure out what is next for the family.

I look forward to thoughts from those with experience.  This is new to our families.

Thanks!

[CMdeux]

Welcome!

My daughter has a pistachio allergy as well.  (She has a lot of other allergies, too, though.)
My husband has just a single tree nut allergy, though.


Just out of curiosity, when the ER administered epinephrine, did it seem to help almost like turning off a light switch?  If so, then that is a pretty strong indication that this incident was definitely anaphylaxis and not a choking incident.  Epinephrine won't shut off a choking incident, but it sure works well on anaphylaxis and airway narrowing from inflammation.  If the epinephrine and other meds DID NOT seem to help... then that points to a possibility that this was a mechanical airway obstruction instead.  I'm assuming that the physician wasn't able to see anything, or you'd know for sure?


Certainly follow through with testing at your allergy appointment (call a couple of weeks ahead and find out if you need to avoid any medications and for how long beforehand), but realize that it may not tell you much that you don't already know.   A positive test result doesn't mean much without a reaction history-- and it sounds as though that history isn't as clear as you'd hope.

Do you have a prescription for an EpiPen?  If not, GET ONE.  TODAY.  That device will need to go everywhere that your child goes.

  The only nut that I would caution you about in addition to pistachios are cashews.  They are quite closely related and seem to cross-react in a pretty high number of individuals.  This probably means that mixed nuts should be put away until after you know more.  But peanut butter should be fine, if she's been eating it regularly.  Unless you have additional problems, I'd continue to do things more or less as you always have.  I wouldn't go through your house and dispose of everything with a peanut warning just yet, in other words.   

As you observed, a pistachio allergy-- in and of itself-- isn't that difficult a thing to manage.  That's the good news!!

One helpful thing is that they are pretty much ONLY grown in one region of the US and in the eatern Mediterranean, which limits their ubiquity in both cuisine (restaurants) and in food processing.


Places where we have found that pistachios tend to show up:

shells can appear on beaches, in parks, people may munch them as "on-the-go snacks" (leaving the shells wherever they please.. in shopping carts, on store shelves, etc.  GRRRR) and they are common in Middle Eastern cuisine.   The shells very definitely can have enough residual protein to trigger a reaction, by the way.



Good luck!!  I'm very glad that you recognized what an emergency this was and were close to a hospital.  My daughter's first reaction, we were also very fortunate to live just a few blocks away.

[AllergyMum]

Hi.  Sorry to hear that your child may have a tree nut allergy.  Lots of great people & information here on this board. 

I find it strange that they say that they can not test for another 6 weeks.  After my son's first allergic reaction, he was tested later that same week, as was the case to each of his other allergies when they developed.  I have never heard of anyone having to wait for 6 weeks for the testing to be "accurate test".  (Perhaps there someone else may have information on this)

Personally I would avoid all tree nuts and peoples untill you have your appointment with the allergist to confirm.  Also please know that tree nuts and peanuts can be cross contaminated with each other.  And the tree nuts are found in all sort of things including soaps & shampoos, not just food.

[AllergyMum]

Also, these are 2 posts that you may be interested in....


Topic: Name list of peanut/nut words 
Name list of peanut/nut words

Topic: Nuts and their botanical names 

Nuts and their botanical names

[CMdeux]

One possible reason for the delay is that after having recieved both epinephrine and a steroid medication, a skin prick response won't necessarily return to normal for several weeks.

RAST values can be quite elevated in the wake of a reaction, too-- so even things that are NOT allergens might show up as class 1-3 in the immediate wake of anaphylaxis.  BTDT, by the way.  Can't say that I much recommend avoiding a laundry list of things that are actually not allergens.  That is pretty much the definition of "sucks," and it makes the real need for avoidance of a life-threatening allergen that much harder to get across to family/friends if you're also avoiding a half dozen things that they've SEEN your child gobble in quantity.  KWIM?

[Online Knight]

Thank you for the awesome information... VERY helpful!

To fill in some more information, the epinephrin did not trigger a "light switch" change.  In fact, the doctor began to suspect a choking incident  because of that.  My little girl was not cooperative in opening up her mouth, so they didn't see anything stuck.  They also did a quick x-ray that didn't show anything... but they said it usually wouldn't.  Even after the epinephrin, she kept drooling (which is not usual for her at all)... so the doctor started to question if it was an allergic reaction.  It was her vomiting that ended up being the "light switch" moment.  After that, she acted normal and her breathing and skin went right back to normal.

Further "muddying" the diagnosis is the fact that she is very repiratory "sensitive".  She has a history of every cold settling in her lungs and giving her pretty dramatic breathing problems (to the point of needing a nebulizer).  Her labored breathing after eating the nut was similar to those episodes in that her breaths were shallow and wheezy.

We do have an epi 2-pack now.  I know things could be worse, but I dread dragging those things around.  I used to carry them for a bee allergy (that ended up being a false positive).  I remember the difficulty of keeping them in the acceptable temperature range.

Thanks again for your help and insight!

[CMdeux]

OH, boy-- that really DOES sound like a very ambiguous set of circumstances.  I can definitely see why you wonder!

It probably doesn't help much, but the complete absense of any skin symptoms at all (hives, flushing, swelling) in a child that age is a really unusual presentation of anaphylaxis.  It's certainly possible, just unusual; even more-so in a child with sensitive or pale skin.

Does extended family have a lot of atopic conditions? (asthma, eczema, allergies)  If not, that is another factor arguing against anaphylaxis.  Again; it's certainly possible, just not as likely. 

I hope that you get a consult with a terrific pediatric allergist who can help you sort it and leave your family with a feeling of confidence in a diagnosis.    

Right now, I'd write down EXACTLY what you saw, and the time line on which things happened during the incident.  Do it now, before you forget details-- and include everything you can remember, no matter how trivial or unrelated it seems!  Start with the hour or so just BEFORE she ate the nut.  A great allergist may be able to put things together on that basis and see clues where parents and other physicians wouldn't.

[Online Knight]

Didn't mean to leave it out, but there were "skin" symptoms.  She was flushed, but then, a choking victim would be too.  She had blueing puffy lips.  She broke out in hives just before vomitting (about 25 minutes after injesting the pistachio).  After vomitting, everything went straight to normal.

[twinturbo]

It's possible both happened. Physical obstruction in a swollen airpath that was also an allergen. It's not my place to say but if you can get yourself to an allergist from Mount Sinai, Duke, National Jewish, Arkansas, Johns Hopkins, Brigham Women's, or luck out on the local level to get a really good food anaphylaxis and probably asthma allergist you may have a better foothold down the road.

If you don't know what the lung/breathing issue is exactly I'd be keen on getting that ID'd as well. Asthma, allergies and atopy (skin stuff) are interrelated.

On the peanut issue... holy moly, if she can eat it never, ever avoid anything you don't have to without a history of reaction. Which is why we're saying get a good allergist.

I know carrying epis are a pain in the rear. I have to carry 5 at all times. Two each for two kids plus mine but it is what it is.

Good luck.

[krasota]

I hope you get answers soon. 

My son reacts to cashews & mangoes and also tests positive for pistachios.  Given the food family issues there, we avoid pistachios.

You could certainly have bloodwork done without waiting 6w. 

[mommabridget]

Wow, how scary! Pistachios and cashews are in the same "family". 

I certainly understand the wanting to know, NOW!  Food allergies are bad, but not knowing is even worse.

Sorry you had to find us, but really glad you did as we do have some very knowledgeable members. Welcome. 

[maeve]

shells can appear on beaches,

Boy do they.  DD has a pistachio allergy (actually the tree nut she tests most highly positive too).  We went to the beach this summer (for the first time in years) and I helped DD search for shells.  Well, it seems that a few of the shells we gathered were pistachio shells.  They were the most enormous ones I'd ever seen.  It was DH who discovered the bounty of pistachio shells right near our blanket.  Thankfully DD did not have a reaction. 

[maeve]

shells can appear on beaches,

Boy do they.  DD has a pistachio allergy (actually the tree nut she tests most highly positive too).  We went to the beach this summer (for the first time in years) and I helped DD search for shells.  Well, it seems that a few of the shells we gathered were pistachio shells.  They were the most enormous ones I'd ever seen.  It was DH who discovered the bounty of pistachio shells right near our blanket.  Thankfully DD did not have a reaction. 

To the original poster, be careful of Mediterranean and Middle Eastern cuisines, which use pistachio quite a bit. 

[Online Knight]

Had the skin test today with our allergist.  Very-obvious reaction to pistachios.  We were told to avoid tree nuts... but should be okay with peanuts and peanut butter provided there is no cross-production.

[CMdeux]

Well, now you know, huh?
  I'm sorry.


FWIW, until she's a LOT older, you may want to avoid cashews as if you knew she was also allergic to those.  Cross-reactivity between the two nuts is very high.  Apparently the proteins are extremely similar.  Cashew is also a super-potent allergen; that is, vanishingly small amounts are often sufficient to trigger VERY severe reactions in allergic people.

(As you can see from my thread yesterday about our allergy appointment, just a skin test for cashews resulted in systemic symptoms in my daughter-- who has NEVER had any contact with cashews, at least none that we are aware of.)  These particular nuts definitely need to be given the same respect (?) as peanut for people allergic to them.


Be sure to take a close look at the anaphylaxis grading chart.  I have found it helpful to print a copy of it with 'actionable' symptoms in bold or even in red print.  That way it is VERY clear when epinephrine should be used.

Avoid:

bakery products (just in general)

Restaurants that serve: traditional E. Mediterranean cuisine, 'fusion' cuisine, pestos, and anything "crusted," as these are common places to run into pistachios.

Indian and SE Asian cuisine is FILLED with cashews, and they are frequently disguised in purees and sauces.

ANY food products from Turkey or neighboring countries should be viewed with suspicion, as cross-contamination potential will be quite high.

Mixed nuts should be seen as just as dangerous as pistachios themselves-- the reason is that they contain cashews in large numbers, and therefore ANY mixed nuts are effectively loaded with cashew protein, to which your DD is very likely equally allergic to.


Begin teaching your child these survival skills while she is young:

a) ASK mom and dad before eating-- anything.

b) DO NOT pick things up off the ground without checking with mom and dad first

c) keep your hands AWAY FROM YOUR MOUTH and

d) WASH your hands whenever you have been out and about-- and also before you eat.


Consider a medic-alert bracelet.  It's easiest to get them wearing them young, and kids who do seldom give you any trouble about wearing them through adolescence.  There are lots of medical jewelry options.  We prefer MedicAlert for the simple reason that first responders treat it with a certain amount of recognition and respect.  It also helps to convince other care providers that you mean business and that this isn't just a dietary WHIM of some sort.

(Sadly, that is an all-too-common response from people who don't know any better.)