On The Cover
Elizabeth Briand
As anyone who has ever witnessed or undergone a severe reaction to a food allergy knows, it can be a terrifying and too often life-threatening experience. Over the past 30 years, the prevalence of food allergies in the United States has climbed dramatically in both adults and children, rising 50% between 1997 and 2011 and again by another 50% from 2007 through 2021.
Today, an estimated 33 million Americans are living with at least one food allergy—that amounts to approximately 8% of children and 11% of adults. To put faces to those numbers, that 8% of children is the equivalent of two youngsters for each classroom in the United States.
That is an extraordinary number of people of all ages and backgrounds living with a condition that can cause everything from hives and runny noses to full-blown anaphylaxis, which can lead to swelling, lowered BP, shock, and potentially death within minutes. The condition can cause such significant issues and impediments to daily life that it can be covered under the Americans with Disabilities Act.
More than 3 million Americans each year experience a food allergy reaction so severe that it warrants a trip to the emergency department. In addition, approximately 40% of children with allergies have experienced a severe allergic reaction, including anaphylaxis.
Food allergies fall into three categories: IgE-mediated, which is the most common type and involves the immunoglobulin E antibody; non-IgE-mediated, where symptoms occur without the involvement of IgE antibodies; and finally, mixed, which—as the name suggests—is a combination of both IgE-mediated and nonmediated allergies. When an allergen binds to an IgE antibody, mast cells and basophils are activated, releasing histamines that then cause a range of reactions.
The most common IgE-mediated food allergens are milk, eggs, wheat, soybeans, tree nuts, peanuts, fish, shellfish, and sesame. Approximately 90% of all food allergies are caused by these nine culprits.
For young children, cow’s milk is the most common allergy, present in approximately half of infants who have food allergies. For children between the ages of 6 and 10 years old, peanuts are the most common allergen. While allergies to milk, eggs, wheat, and soy often disappear in children as they grow older, other allergies, such as those to peanuts, tree nuts, fish, and shellfish, can last a lifetime.
For adults, nearly half of those with food allergies have reported developing at least one of those allergies during adulthood, with the majority experiencing a shellfish allergy. Allergic reactions to alcoholic beverages also have been observed in teenagers and adults.
Allergies on the rise
There are a number of theories regarding the origins of today’s skyrocketing food allergy rates. They may be tied to the rising rates of other allergic diseases such as asthma. Children with food allergies, for example, are more than twice as likely to have asthma as children without food allergies, and they are more than three times as likely to have eczema. Those estimates are supported by research showing approximately 10% of children born and raised in urban centers whose families had histories of hay fever, eczema, or asthma were allergic to eggs, milk, and peanuts.
This concurrence is explained in part by the dual allergen hypothesis, said Malika Gupta, MD, associate professor at UT Southwestern Medical Center. “Kids with eczema are typically more prone to food allergies because their skin barrier is broken down and they’re exposed to foods through their skin.”
The second theory centers on improved hygiene and the idea that children are experiencing “fewer infections, less exposure to infectious burden through smaller families, and more sanitary living conditions [and] this has resulted in some immune dysregulation.”
Another theory surrounds the ongoing changes in modern American dietary habits and patterns. “Our diets have high levels of polyunsaturated fatty acids and omega-6 fatty acids, and these are considered pro-inflammatory diets,” said Gupta. “They are risk factors for most chronic or allergic diseases.”
There are some food allergies that fall outside of these theories and categories. Philip S. Mensah, PharmD, clinical assistant professor, Department of Pharmacy Practice at Mercer University College of Pharmacy in Atlanta, noted that “there are other foods that can elicit food allergies, including beef, pork, lamb, and venison.” These reactions are caused by α-gal syndrome or AGS. Although still relatively rare, CDC estimated it may affect close to 450,000 people in the United States with even more cases potentially going undiagnosed.
AGS is caused by the bite of the Lone Star tick, which is found predominantly in the southeast United States. The bite causes an allergic reaction to a sugar called α-gal, which is present in the meat of all mammals except humans and primates.
As a result, people with α-gal can experience allergic reactions to common meats, with symptoms ranging from hives and nausea to anaphylaxis, all occurring anywhere from 2 to 6 hours after eating.
Preventing and treating food allergies
Even beyond the significant medical and physical challenges, food allergies can affect children, adults, and families in other profound ways, impacting all aspects of daily life. Studies have shown, for example, that one in three children with food allergies are bullied at school due to their conditions and are twice as likely to be bullied compared with children who do not experience allergies. Growing up, these same children may miss out on common rites of passage such as sleepovers and camp stays, all for fear of being exposed to dangerous allergens.
For parents, many may worry about taking their young children to restaurants for fear of food exposures or letting them go to friends’ houses for playdates. Mothers of young children with allergies report greater levels of psychosocial stress than mothers of children without any allergy concerns.
No one is born with a food allergy, and there is no way to predict who will develop one. The majority of food allergies, however, will emerge in children ages 5 or younger. “Over time you develop reactions,” said Gupta. “It can be the first or second time you ingest a food that you will then have an allergic reaction, and that’s typically in the first year or second year of life.”
Food allergies can be difficult to determine in infants, toddlers, and preschoolers with adults not knowing whether an upset stomach or runny nose may actually be signs of the condition. “A young child may not be able to describe their symptoms or articulate how they came into contact with an allergen,” said Mensah. “It is important for parents and caregivers to know the symptoms of a food allergy.”
To help prevent the development of food allergies, guidelines issued by the National Institute of Allergy and Infectious Diseases encourage parents to introduce allergenic foods to infants. The idea is to “introduce lower-risk foods first in a child’s diet and after that, higher-risk foods such as peanuts or eggs, to prevent the development of a peanut or egg allergy,” said Gupta. “Infants should be introduced to all foods, one at a time, in an age-appropriate manner every 3 to 5 days, starting at 6 months and no earlier than 4 months.”
Karen Berger, PharmD, independent pharmacist and medical writer/reviewer agreed with the guideline but said “it’s a good idea to consult with [the child’s] pediatrician on the best way to introduce new foods.” And parents should be ready to seek emergency medical help if the infant shows symptoms such as hives, swelling, or difficulty breathing.
When it comes to treating food allergies, the standard of care is to avoid the food that triggers the reactions. Beyond that, though, there are treatments now available that can help mitigate the effects of food allergies.
Of course, for anaphylaxis, the most severe allergic reaction, the treatment is an immediate injection of epinephrine and an immediate call to emergency services. For less severe food allergy cases, though, there is a growing range of treatments that can help mitigate allergic responses.
Omalizumab, also called Xolair, is a medication previously approved for the treatment of moderate to severe allergic asthma. In 2024, it was approved by FDA for use in the reduction of allergic reactions for IgE-mediated food allergies in adults and children ages 1 year or older. The medication can reduce the risk of anaphylaxis that may occur with accidental exposure to one or more foods. “It’s not taking your allergy away, but as long as you are on the shot, if you accidentally ate a peanut, more likely than not, you would not have a reaction,” said Gupta.
Desensitization or oral immunotherapy is another potential option for patients. Palforzia, for example, is peanut oral allergen powder that is given in incrementally larger doses, first at the allergist’s office and then at home over time.
“It is desensitizing your body so if you accidentally ingest peanut somewhere, you’re not going to have a reaction, or if you do, it’s a mild reaction,” said Gupta. “It does not mean you are not peanut allergic anymore. You are just desensitized to it, as long as your body is exposed to it in some amount.” If the patient stops taking it, however, the efficacy will go away. It only lasts for as long as the individual is taking the powder.
Currently, oral immunotherapy is only FDA-approved for peanuts. “It can be done by allergists off-label for other foods, and it’s routinely done in clinical practice now,” said Gupta. “It’s called microdosing, given under the allergist’s supervision to build up tolerance.”
Researchers are also working on patches that could be placed on the skin to achieve this same type of desensitization. Called epicutaneous immunotherapy, this treatment is being developed for peanut, milk, and egg allergies.
When it comes to treating mild allergic responses, Gupta noted that allergists are no longer recommending popular medications such as Benedryl. “We are only utilizing second-generation antihistamines like cetirizine now,” she said.
In recent years, the emergence of alternatives to diphenhydramine have exposed some of its flaws. Second-generation antihistamines such as cetirizine can last up to 24 hours versus diphenhydramine’s 4 to 6 hours of effectiveness. The second-generation medications also do not cause the same types of adverse effects, such as drowsiness and dry mouth.
For children and adults with food allergies, the future is looking brighter when it comes to addressing their clinical needs. “It’s a very exciting time for the food allergy community because there are prevention strategies, more diagnostic testing, and there are also more treatment options,” said Gupta.
Pharmacists as educators and advocates
Whether in a hospital or behind the counter in a community pharmacy, pharmacists can play a significant role in helping their patients with food allergies stay safe.
Education can be one of the most valuable services they can provide. “As pharmacists, information is key,” said Mensah. “You can never provide patients with too much information. We can give parents information on common reactions, make them aware of foods that cause reactions and what to do if reactions occur.”
Perhaps one of the biggest ways pharmacists can help is by ensuring that everyone who needs an epinephrine autoinjector, or EpiPen, knows how to use one properly.
“Pharmacists need to be well-versed in how to use the EpiPen,” said Mensah. “Typically, EpiPen boxes come with two pens and a trainer. It’s good practice when the pen is about to be dispensed to open the box and flip open the caps to make sure the autoinjectors slide out easily. If it doesn’t slide out easily, then they should be replaced.”
Berger added, “It’s important for pharmacists to remind patients and their family members or caregivers to always have two pens on hand, make sure to check expiration dates and replace them with some time remaining before they expire, to account for any delays such as refill requests.”
Getting parents and caregivers comfortable with EpiPens can make a big difference when it comes to using them. “Fear of using an epinephrine autoinjector sometimes prevents people from using it in an acute emergency situation,” said Gupta. “Encouraging them to use it, to not be scared of it, and educating them that it’s a very safe medication with minimal to no side effects, generally speaking, is very helpful.”
Berger suggested pharmacists may also familiarize themselves with neffy, the nasal form of epinephrine, which was approved by FDA in August 2024. “neffy might be a suitable option for kids and their caregivers who are afraid of injections,” she said.
In addition, “while patients will have a Food Allergy and Anaphylaxis Emergency Care Plan developed by their health care provider, pharmacists can help by ensuring patients have all the necessary medications outlined in the plan, such as age-appropriate antihistamines for mild reactions, a rescue inhaler if needed, and, of course, epinephrine in the form of an injector or nasal spray,” Berger said.
Pharmacists also can protect their patients by double-checking the inactive ingredients in the medications and vaccines they are dispensing and ensuring that patients know what is in each formula. That can extend to supplements as well, such as glucosamine, which can be derived from the exoskeletons of crabs, lobsters, and shrimp.
Certain forms of progesterone and some topical steroids also may contain peanut oil excipients. And some formulations of valproic acid may contain peanut oil as a solubilizer.
Behind the counter, pharmacists can take other seemingly small but important steps to ensure patient well-being by making sure that no allergens are present within the pharmacy setting itself. “It’s important for pharmacy staff members to avoid eating while working the bench to prevent transmitting any allergens to patients,” said Berger. Pharmacists should always wash their hands after eating and before handling prescriptions. “It also gives [pharmacy team members] a legitimate reason to take a few minutes to step away and eat.”
Pharmacists also can remind individuals and families affected by allergies to “always, always check ingredients, no matter how redundant it seems and no matter how many times they always buy the same product,” said Berger, who noted an incident in which a child died after accidentally eating a certain brand of cookies that contained peanut butter. The cookies appeared in packaging that was the same as the peanut-free product. “Something like this could easily happen to anyone, and that is a scary thought,” Berger said.
When it comes to managing allergies, sharing information and asking questions can be two of the most effective ways to keep both children and adults safe. Pharmacists can be at the forefront of that approach. “A great majority of the population lives within five miles of a pharmacy, and we can play an important role in improving health literacy,” said Mensah. “And we can empower patients to deal with their food allergies.”
That kind of support can go a long way in helping children, teens, and adults whose lives are affected each day by their food allergies. Certainly for a condition that affects so many millions of people, it takes the cooperation and compassion of whole communities—whether schoolteachers and friends watching out for unintentional food exposures or physicians and pharmacists providing their clinical support and expertise—to keep people safe, healthy, and nourished. ■