Posts Tagged ‘latex allergy’

Allergens and irritants at work
Some workplaces have very high concentrations of allergens in the air, especially if proper safety procedures are not being followed. Occupational allergies can begin with symptoms in the nose, such as sneezing, blockage or constant streaming (allergic rhinitis). You may also suffer with itchy or watery eyes (conjunctivitis), a cough, sweating and a feverish feeling. Alternatively, direct contact with the allergen can produce a skin rash (dermatitis) or itchiness and swelling (contact urticaria/nettle rash and angioedema).
If you work somewhere with an allergy risk (see pp. 133-4), be vigilant for such symptoms and see your doctor immediately. These symptoms can be the forerunners of occupational asthma, which is a serious and potentially irreversible problem. Some allergens, such as latex, can even produce anaphylactic shock (a life-threatening allergic collapse).
Skin-prick tests (see p. 91) can show if you have an allergy to a substance encountered at work.
Acting promptly gives you the best possible chance of recovery and is vital if you have occupational asthma. Only if exposure to the allergen stops promptly do you have a good chance of shaking off the asthma. See your doctor as soon as possible and ask for a referral to a chest specialist, so that a definite diagnosis can be made. This is essential if you are going to make a claim for compensation.
Far too many people with occupational asthma are just sent off with an inhaler when they first see their doctor. By delaying the moment when work is identified as the source of the problem, and the exposure to the allergen is stopped, drug treatment can turn occupational asthma into a disabling lifelong problem. Although drugs can be helpful in speeding your recovery once exposure to the allergen
Latex allergy
Sensitisation to latex usually occurs at work (see pp. 133-4), or as a result of having many surgical operations. But latex allergy sometimes occurs in allergy-prone people even though they don’t work in a high-risk job and haven’t had many operations. Some doctors think that if a child with severe allergies needs surgery, this should be done in latex-free conditions, even though the child has no allergy to latex, because of the risk that the operation will sensitise.
Latex can cause either contact dermatitis (see p. 55) or a Type I allergy, whose symptoms can include urticaria, asthma and anaphylaxis. Latex allergy often goes undiagnosed. Once sensitised, you may react to balloons, elastic bands, condoms and household gloves. Latex in the air,
due to powdered latex gloves being used, can be a hazard for someone who is highly sensitive, as can latex traces in food (see box on p. 175). Medical treatment may be problematic (see p. 98 and box on p. 249). Cross-reactions to certain foods can occur (see p. 15 and p. 51).
For those avoiding latex, there are non-latex gloves (see p. 57), and non-latex condoms. Immunotherapy (see pp. 164-9) may be useful in severe cases: it can reduce sensitivity and eliminate cross-reactions to foods.
Other hazards
This article (pp. 132-5) deals mainly with allergens at work, that is, substances which provoke classical allergies (Type I reactions). In addition, there are skin irritants and antigens in workplaces which can provoke contact dermatitis (see p. 56) or contact urticaria (see p.50).
Some of the most dangerous workplace substances are those that bring on asthma but are not allergens. These are usually called low-molecular-weight asthmagens. The most notorious of these are platinum salts, isocyanates (used in cement, in the manufacture of foam, plastics and varnishes, and for spray-painting cars, aeroplanes and boats), colophony (used as a solder in electronics), glutaraldehyde (used in hospitals for sterilisation procedures), and persulphate (used in hairdressing). Powerful respiratory equipment, supplying air from outside the area (see p. 135) is needed if you work with some of these substances, e.g. isocyanates for spray-painting cars.
has ended, they should not be seen as a way of allowing you to go on working with the offending allergen or asthmagen.
If it seems plausible that your allergies or your asthma are related to your work, your doctor should be able to give you a sickness certificate, so that you can have some time away from the workplace, to see if you recover. The medical service at your workplace may be better at diagnosing occupational asthma than your own doctor, but be cautious. In some workplaces they do operate as they should and offer genuinely confidential treatment. But there have also been cases of information being passed to the management, and workers with the early signs of occupational allergies and/or asthma being dismissed on a pretext, or made redundant, to avoid a possible compensation claim. Most occupational health services claim to be independent, but they actually have to earn the trust of the workforce. Before you make any move, ask your colleagues for their views, especially those who have worked there for many years.
Choosing a job
If you have any tendency to allergies, or come from an allergy-prone family, you should be very choosy about where you work. Try to avoid workplaces where there is heavy exposure to allergens, especially airborne allergens which can provoke asthma:
• Bakeries and flour mills, where the allergens concerned may be wheat proteins in the flour, or enzymes added to the flour mix. These allergies can take years to begin.
• Other food-processing works, particularly those dealing with tea, soyabeans, other beans (e.g. gram flour), shellfish and fish (especially if automated gutting machines are used without adequate ventilation). Food preparation and sandwich-making can cause contact urticaria, if there is prolonged contact with a particular foodstuff (e.g. tomatoes).
• Farms, docks and cotton mills – or any other workplace generating dust from plant products. On farms, it is the dust from grain and hay that is often responsible, although mould spores (see p. 121) can also be the culprit. Allergies to mites (found in hay, grain and flour) sometimes occur and eczema is the most common symptom – often called simply ‘grain itch’.
• Saw mills and joineries, because of the wood dust, especially that from hardwoods and from red cedar (Thuja plicata).
• Paper recycling plants, if there is a lot of paper dust in the air.
• Detergent and pharmaceutical factories handling enzymes – these are added to ‘biological’ washing powders and are potential allergens. The risks are less these days, as the enzymes are in granule form rather than powder.
• Factories processing natural products such as psyllium or ispaghula, which are used as laxatives. Anyone who has been sensitised should avoid taking medicines containing the offending substance in the future, because these can sometimes provoke a dangerous anaphylactic reaction.
• Hospitals, clinics and dental surgeries, mainly due to latex rubber, used in gloves and equipment. Although nursing staff and surgeons are most susceptible, other staff including hospital administrative workers can occasionally be affected. Fears about the spread of the HIV virus has led to a huge increase in the use of latex gloves in medicine and dentistry, and a consequent epidemic of latex allergy. The main problem is with powdered latex gloves, which release 15,000 times as much allergen into the air as unpowdered gloves. Unpowdered, low-allergen gloves greatly reduce the risk of latex allergy developing, and non-latex gloves are even better. There are moves to ban the import of powdered latex gloves into Britain. They are already being phased out in hospitals and other medical facilities, but progress is slow in some areas.
• Other workplaces where powdered latex gloves are used, including
Making the workplace safe for everyone
Note that these choices about employment are for the individual employees to make for their own protection - an employer cannot refuse to take anyone on because they have allergies or come from an atopic (allergy-prone) family.
The reasoning behind this is that the workplace should be safe for everyone, as far as possible. As many as one in three of the population may be susceptible to allergies, and it is clearly wrong to bar all such people from major industries. Current thinking, in most countries, is that the focus should be on getting allergens and asthmagens out of the air, not keeping the more vulnerable workers out of the workplace.
hairdressers, dental surgeries, pathology laboratories and police stations. Construction workers wearing rubber gloves are also at risk. Someone who has been sensitised by powdered latex gloves may then react to other items (see box on p.132). Those severely affected can have great problems in daily life and with medical treatment, so anyone with a strong tendency to allergy should strenuously avoid becoming sensitised.
• Factories making or using rubber items may also expose workers to the risk of latex allergy. Anything made by the ‘dipping method’ (e.g. balloons, condoms, elastic bands and gloves) is highly allergenic. Moulded rubber items, such as tyres, are much less of a problem. Neoprene and other synthetic rubber items are not allergenic.
• Chiropody and podiatry clinics, where there is a risk of allergic reactions to the fungus that causes athlete’s foot. It is inhaled on skin flakes from the patients’ feet.
• Laboratories and other workplaces where animals are kept. In the case of mice, rats and other rodents, the allergen is found in the animals’ urine, and becomes airborne as the urine dries. Insects and spiders (e.g, those reared for biological pest control), are also allergenic due to small airborne particles from their bodies. Those working closely with bees (either honeybees or bumblebees, now reared for pollinating glasshouse crops) are liable to be stung frequently, and this can lead to sting allergy (see pp. 60-61).
• Hairdressing salons, where many different items are used that are potentially allergenic, including latex gloves (see above), permanent-wave solutions and henna. The risks of contact dermatitis are also high (see p. 55).
• Greenhouses, where the enclosed conditions can lead to high levels of allergens from plants, moulds and insect pests. There may also be exposure to pesticide sprays or their residues, which can greatly aggravate any underlying tendency to allergies.
If you have ever suffered from atopic eczema, work situations that can bring on contact dermatitis should also be avoided (see p. 55).
Taking a risky job
If circumstances force you to take a job with an allergy risk, observe all the safety procedures that are in place, and where you have the option of turning on extractor fans, wearing protective gear, or simply opening doors and windows, always do so. If the safety procedures seem inadequate, talk to your trade union Safety Representative, or the local Health and Safety Executive which can run a check on safety procedures in your workplace. This will be presented to the employer as a routine check, so they need never know that a member of the workforce has contacted the HSE.
Whatever you do, if you are in a risky job, don’t smoke. At a salmon processing plant in Scotland, 40% of the smokers developed allergies (resulting in asthma) to the fish allergens in the spray from the fish-gutting machine. Non-smokers - who formed the overwhelming majority of the workers - were not affected at all. In United States cotton mills, smokers are affected by levels of cotton dust in the air that are legally defined as ’safe’, while nonsmokers remain unaffected.
Passive smoking at work is also an important issue. A recent US study showed that non-smokers were more likely to develop asthma if they worked alongside a smoker. Your employer has a duty to provide you with clean air. This includes ensuring that other employees do not impose their cigarette smoke on you.
Respiratory equipment
Where respiratory equipment is needed, your employer must provide this, and it must be the right equipment for the job. It should be inspected, tested, cleaned and repaired after each use, and filters should be replaced regularly. All this is your employer’s responsibility, but check that it is being done, and always look the mask over before you put it on.
Two different types of respiratory equipment are currently in use:
• Those that give you a supply of air from outside the work area, either from a compressed-air cylinder, or via an air-hose (airline) supplied with fresh air. In Britain these are called breathing apparatus.
• Those that use the surrounding air but filter it to remove allergens and asthmagens. In Britain these are called respirators. (In some countries this term describes any kind of respiratory equipment.) Ordinary respirators may pose problems for some asthmatics because they cannot breathe in strongly enough to draw sufficient air through the filter. Powered respirators can be the answer: they have a battery-powered unit to help with pulling in the air.
There are government regulations concerning the type of equipment required for each type of allergen and asthmagen. Large companies generally follow these regulations, but small businesses, such as local sawmills, joineries and car-repainting workshops, may not even know about them.
Any respiratory equipment that has a face mask must form a tight seal with your face. Facial hair will prevent this, and so will stubble, so shave carefully. Faces vary enormously in shape, and if your face mask does not fit, ask for a different type of mask or a different type of respiratory equipment. Persist until you get one that’s right for you.
Carry out a ‘fit check’ each and every time you wear the mask. For example, with respirators, you can check the fit by covering the air intake completely with your hand and breathing in sharply: if the mask fits properly, it should collapse onto your face, and remain stuck to your face for several seconds. Look at the manufacturer’s instruction booklet as there may be a specific fit check recommended for the equipment you are using.
If there is any difficulty in breathing through the respiratory equipment, the replaceable filter cartridge or the equipment itself should be replaced. You should also take action immediately if you can smell the substance being handled – but never rely on this as a danger sign, because an extremely small amount, way beyond the detection capacity of the human nose, may be very damaging indeed to your health.
Keep your mask on throughout the work period. If you find this impossible, talk to your employer or
line manager about getting a different kind of respiratory equipment – a powered device, for example, that assists the inflow of air.
No form of respiratory equipment provides complete protection against allergens and asthmagens: there is always the chance of some small amount getting through. This is why respiratory equipment should not be used by those who have already developed occupational asthma but want to stay in their job.
Those who really cannot change jobs (e.g, farmers) are sometimes able to use a powered respirator helmet, which allows them to go on working despite the allergen. But this is not an ideal solution from a purely health point of view. Farmers can also improve matters, where moulds are the source of allergens, by keeping all harvested crops dry and thoroughly ventilated.
A lasting problem
As long as you catch the problem early, and are no longer anywhere near the allergen, your symptoms should disappear completely, but remember that you may still be highly sensitive to the allergen, even years afterwards. For a year or two at least, avoid contact with it again, even in tiny amounts. If someone else in your family works at the same place, they may bring home traces of the allergen on their clothes and hair: ask them to leave their workclothes outside the house and shower on arriving home.
With occupational allergies to airborne food particles, it is possible that the affected individual will later react to the same food when eaten. Experiment very cautiously, especially if the allergen is fish or shellfish.
The allergy may persist long after the job has ended. In one case, doctors found that a woman who had developed ‘baker’s asthma’, while working briefly in a bakery when young, was still allergic to the enzyme additive in bread 20 years later. She suffered an asthma attack whenever she ate bread.

Allergy: Selecting the Right Food

An avoidance diet is for people who already know what food or foods affect them, and simply need to

avoid those foods. A diagnostic diet is for those whose symptoms suggest that they might be suffering

from food sensitivity of some kind, and who cannot be diagnosed by indirect methods such as skin tests,

because true food allergy is not involved. A diagnostic diet is intended primarily to show whether or

not food is causing the symptoms.
The diagnostic diets themselves fall into two basic categories. Firstly, there are diets that, by a

process of elimination, identify a particular food (or foods) as a cause of symptoms. Called

elimination diets, these are used to diagnose idiopathic food intolerance (see p. 74) and certain other

kinds of sensitivity reactions to particular foods. An elimination diet is purely diagnostic - simply a

means to establish which foods are at fault. To this end, all commonly eaten foods are avoided at the

outset, and each food is then tested individually. Once an elimination diet is complete, the

information gathered is used to establish a suitable avoidance diet. For example, if milk, wheat and

oranges caused symptoms during the testing phase of the elimination diet, those foods are all avoided

in future.
Secondly, there are specific diagnostic diets, which are a great deal simpler to carry out than

elimination diets. A specific diagnostic diet aims to reduce the intake of a particular substance that

is found in certain foods. The substances concerned -histamine or nickel, for example - are known to

cause particular symptoms in susceptible people.
A specific diagnostic diet simply cuts out all the foods that contain large amounts of the substance
under suspicion. If this diet alleviates the symptoms, and does so consistently, it is plausible that

the substance concerned is indeed the culprit. However, the diet should be stopped and then started

again, preferably several times, to check the response. Once the sensitivity is confirmed in this way,

the avoidance diet which follows is basically the same as the diet used for diagnosis.
Note that there is no agreed terminology for these different kinds of diet, and the definitions given

above will not necessarily be followed in other publications. You may even come across ‘elimination

diet’ being used to mean ‘avoidance diet’, which is particularly confusing. If you are consulting other

sources of information, check the context carefully to see what meaning is intended.
There is one odd man out in this chapter - the diet to protect against asthma, described on pp. 206-7.

It is neither an avoidance diet nor a diagnostic diet, but a health-promoting diet of the kind commonly

advocated to combat other widespread conditions, such as cancer and heart disease. In fact, it has a

remarkable number of similarities to diets that reduce the risk of these other diseases.
The anti-asthma diet is immensely healthy, whereas many avoidance diets carry a risk of malnourishment.

An allergic individual following any kind of restrictive diet - especially a child - should be

medically assessed for the possible risks. That is why it is important to talk to your doctor before

starting any dietary treatment or investigation. A referral to a dietician or nutritionist may be

necessary, and your doctor can arrange this.
When malnutrition does occur as a result of self-treatment, there are often very complex factors at

work. One potential hazard with dietary treatment is that psychological problems can easily become
entwined with obsessions about food. Eating can be a potent form of self-expression, or a way of

exerting control over oneself and others. Many doctors have seen patients who are mistakenly convinced

that food sensitivity is at the root of their health problems, or those of their children. In some

cases, no amount of objective evidence to the contrary will deflect people from such beliefs.
A few people with mistaken beliefs of this kind impose very restrictive diets on themselves - or

sometimes on the whole family. The food rules that they establish may be a way of limiting contact with

the outside world, avoiding other problems and issues by making diet the central focus, or simply

making demands on other people’s time and attention.
The current fad for identifying ‘food allergy’ using very dubious diagnostic tests (see p. 93) will

probably send many more psychologically vulnerable people down this route.
Another unhelpful trend in the dietary field is the wholesale (and usually ineffective) use of

vitamins, minerals and other supplements for a great variety of diseases, including allergy and other

forms of sensitivity. It is important to realise that none of the sensitivity diseases described in

this book has nutritional deficiency as its primary cause, so supplements are not a major part of

treatment in most cases. For the majority of people with some kind of sensitivity disease, a supplement

will make only a small difference, if any. However, it is true that, with some sensitivity problems,

certain supplements may be helpful to certain individuals. The use of Vitamin C in asthma (see p. 207)

is one example of this, and there are some other instances mentioned in Chapter 2.
Generally speaking, it is better to get the vitamins, minerals and other nutrients you need (such as
antioxidants) from food, not from tablets. Studies of adult-onset asthma have shown that only natural

Vitamin E protects against the disease: supplements have no effect.
Many vitamins and minerals, along with various plant and animal extracts, are now referred to as

nutriceuticals - in other words, substances that are classed as nutritional supplements for legal

purposes, but are being marketed as if they were medicinal drugs (pharmaceuticals). Many doctors are

concerned about this, if only because of the duplicity involved. These substances can be sold freely to

the public only because they are, in theory, nutritional supplements, yet they are actively promoted to

the public as if they were drugs.
The marketing is usually indirect, to avoid falling foul of the law, but very effective nonetheless.

Advertisements for the product avoid making any medicinal claims, since these would be unlawful, and

just speak vaguely of ‘health-giving properties’. The specific medicinal claims are made in magazine

articles (which often appear right beside the advertisement), penned by journalists who have been

supplied with a great many ‘facts’ - actually unsubstantiated claims -by the manufacturer of the

supplement. These claims are reproduced uncritically, so the journalists are simply acting as

mouthpieces for the manufacturer. There is no law preventing this.
This is a ruse that circumvents important laws intended to protect consumers from misleading

advertising. Few of these products are likely to be damaging - although there are concerns about some,

especially beta-carotene supplements (see p. 207). What matters here are the large amounts of money

being made from products that frequently have few benefits for those who take them.

What exactly is in ready-made food? People with food sensitivity, especially those with severe food

allergy or coeliac disease, need a simple answer to this question, but frequently they don’t get one.

Research among food-allergy sufferers has found that, in the course of a year, half of them

inadvertently eat the food they are trying to avoid, owing to a lack of information about ingredients.

Restaurants and canteens are responsible for many of these accidents, and most of the fatalities (see

p. 111), but packaged food also plays a part.
Unfortunately, many food ingredients that are potentially allergenic, such as milk and eggs, appear in

packaged food without this being stated on the label in everyday language. The information is usually

there somewhere, however – you just need to know what words to look for.
Decoding food labels
The problems with food labels fall into two general categories:
•    some of the ingredients are described using technical terms. These are usually specific

constituents of the original foodstuff e.g. lactalbumin, one of the proteins found in milk.
•    some manufactured ingredients can be made from different starting materials. So an item such as

‘edible starch’ could be made from either wheat or maize (corn), while ‘hydrolysed protein’ could be

made from soya, maize or yeast, sometimes with wheat added.
One day, no doubt, manufacturers will realise what a burden this type of obscure labelling imposes on

their allergic customers and will start using plain language. In the meantime, food-allergy sufferers

just have to learn all the terms that may be used for their culprit food or foods.
Labels used in health-food shops and delicatessens are another matter altogether. Here the problem is

with exotic-sounding items, such as kamut, which is actually an allergenic food (wheat).
Maize (Corn)
Items always made from maize: cornflour, cornmeal, cornstarch, dextrose, polenta
Items sometimes made from maize: baking powder, cereal starch, edible starch, food starch, glucose

syrup, hydrolysed protein, hydrolysed vegetable protein, malt, malt flavouring, modified starch,

modified food starch, starch, textured vegetable protein, vegetable gum, vegetable protein, vegetable

starch
Note that the gum on envelopes and stamps is sometimes made from maize, and that many medicines contain

cornstarch.
Eggs
Items always made from eggs: ovalbumin
Items sometimes made from eggs: lecithin (In fact this is rare in foods – lecithin is usually derived

from soya. Only in pharmaceuticals is lecithin likely to be derived from egg.)
Terms used for egg on cosmetics and toiletries: Ovum
Fish
Be very cautious when travelling. The use of fish meal as an ingredient of spicy sauces is common in

Southeast Asia, and in some parts of Africa. The strength of the spices may make the flavour of the

fish undetectable.
Milk
Items always made from milk: casein, casemate, lactalbumin, whey
Terms used for milk on cosmetics and toiletries: Lac
If you see the term ‘dairy-free’ on standard packaged foods, you can safely assume that the contents

are free from goat’s and sheep’s milk, as well as cow’s milk. But be more wary with homemade or locally

produced foods labelled ‘dairy-free’ - some
people think that ‘dairy’ refers only to cow’s milk.
Parev or pareve is a term used for kosher (Jewish) food that contains neither milk nor meat. However,

there can be contamination with traces of milk.
Lactose is a sugar produced from milk, and while it is not allergenic itself, it may contain a trace of

allergenic milk proteins. The amounts involved are tiny, and will only affect the most sensitive

individuals.
The label ‘non-milk fat’ sometimes misleads people if they just glance quickly at labels. The fact that

a product contains non-milk fat does not, of course, mean that it is entirely milk-free -remember to

look for all the synonyms of milk (see above).
Nuts
Items always made from nuts: frangipane, marzipan, praline
Standard packaged food will almost always include the nuts by name, but if you are buying other food

(e.g. from a stall selling home-made food) watch out for the above names.
Be very cautious about unrefined nut oils (see p. 110). Almond essence may be produced chemically, in

which case it is safe, but some is made from real almonds and could be allergenic.
Terms used for nuts on cosmetics and toiletries: Prunus, Juglans, Bertholletia, Corylus
Peanuts
Items always made from peanuts: arachis oil, groundnut oil satay sauce
Unrefined peanut oil should be avoided. This is not much used, and unlikely to be encountered except in

Indian and Oriental cooking. Most groundnut oil sold in Britain and Europe, or used in packaged foods,

is refined and considered safe (see p. 110).
Alternative names: arachide, beer nuts, cacahuete, earth nuts, goobernuts, groundnuts, monkey nuts
You are only likely to encounter these names on imported food, or when travelling. Always be very

careful with Indian or Southeast Asian food, where the use of peanuts is very common and often not at

all obvious. Avoid chocolate from Poland, which often contains peanuts that are not declared on the

label.
Items sometimes made from peanuts: hydrolysed vegetable protein. (The usual source is soya or wheat,

but some is derived from peanuts.)
Terms used for peanut on cosmetics and toiletries: Arachis hypogea, Arachis oil
Sesame
Items always made from sesame or containing some sesame: gomashio, halva, hummus (houmus), tahini, the

drink Aqua Libra
Alternative names: ajonjoli, berme, gingelly, teel, til, simsim
Check carefully for sesame in any food from a health-food shop or a stall selling home-made food, and

in foods from the Middle East, or Chinese packaged food (e.g. stir-fry oils). Sesame oil is always

unrefined and therefore allergenic (see p. 110). Watch out for contamination by traces of sesame in

bakeries and delicatessens where goods are sold unwrapped.
Term used for sesame on cosmetics and toiletries: Sesamum indicum
Shellfish
Items sometimes containing shellfish: curry paste, fish sauce and other sauces/pastes used in Southeast

Asian cooking
Standard packaged food should mention shellfish specifically, but you may need to read the label

carefully. Be cautious about bottles of imported sauce, and home-made or takeaway food.
Soya
Items always or usually made from soya: miso, soy sauce, textured vegetable protein, tofu, vegetable

protein
Items sometimes made from soya: hydrolysed protein, hydrolysed vegetable protein, lecithin, vegetable

gum, vegetable starch Changes in ingredients
Unfortunately, the ingredients of a product can change without any obvious warning on the label, or any

change in the packaging. You should always check the label in detail, every time - even on foods that

you have eaten before without any trouble.
Wheat
Items always made from wheat: bran, flour, graham flour, hard flour, strong flour, wholemeal flour

(there are non-wheat brans and flours, of course, but the words ‘bran’ or ‘flour’, without any

qualification, usually mean wheat)
Regional names for particular types of wheat: bulgur or bulgar wheat, Chilton, couscous, dinkel, durum,

einkorn, farro, fu, kamut, semolina, spelt, triticum, triticale (a hybrid of wheat and rye)
Items sometimes made from wheat: baking powder, cereal binder, cereal filler, cereal protein, cereal

starch, edible starch, food starch, hydrolysed protein, hydrolysed vegetable protein, modified food

starch, modified starch, starch, textured vegetable protein, vegetable protein, vegetable starch.
Assume that bread, crispbread, pastry, pasta and noodles are made from wheat, unless definitely

labelled otherwise (and read the label in detail too, because a little wheat is often added to items

such as rye bread and rye crackers).
Note that buckwheat is not wheat at all - it is not even a cereal. Nor does it commonly affect

coeliacs, as is sometimes claimed, though a few coeliacs may develop an intolerance reaction to it,

through eating it very regularly.
For more information on avoiding gluten, see p. 177.
Yeast
Items usually made from yeast: leavening
Items sometimes made from yeast: hydrolysed protein, hydrolysed vegetable protein
Labelling loopholes
Manufacturers do not have to include on the label:
•    Any ingredients used in an earlier manufacturing process e.g. yeast used to make bread for

breadcrumbs, wheat flour added to spices or mustard powder during the grinding process, or bread used

to innoculate blue cheeses with mould -this can leave minute traces of gluten in the cheese.
•    Residues left by substances used during processing, such as wheat flour used to dust processing

lines or prevent dried fruits from sticking together. Manufacturers do not need to declare these

residues on the label because the substance serves no function in the final product and is present in

amounts that are considered insignificant. The vast majority of those with coeliac disease or food

allergy will tolerate such microscopic traces, but the most sensitive individuals may not. Some

coeliacs are even affected by food additives manufactured from cereals (see p. 177).
•    The individual constituents of a composite ingredient (such as salami on a pizza), if that

composite ingredient makes up less than 25% of the finished product. This is called the 25% rule. As

from November 2005, this is all set to change, thanks to the European Parliament. The contents of a

composite ingredient like salami will be listed in full. A few composite ingredients with officially

defined contents (such as jam, or chocolate) can be listed just as ‘jam’ or ‘chocolate’ if they make up

less than 2% of the product. Likewise herb mix or spice mix, if less than 2%. But there are certain

items that must always be listed if they are anywhere in the product, and however small the amount.

They are: milk, eggs, tree nuts, peanuts, sesame, mustard, celery/celeriac, fish, crustacean shellfish

(shrimps, prawns, crab etc), soya, wheat and all other cereals that contain gluten. Sulphur dioxide and

sulphites must be listed if more than 1 Oppm. This list will be reviewed from time to time.
`May contain’ labels
Labels reading ‘May contain nut traces’ are springing up like weeds on packaged food. Similar labels

relating to sesame, milk and eggs are also starting to appear.
Allergy sufferers, suddenly unable to eat foods that they formerly enjoyed, feel very frustrated about

this development. Many suspect that these labels are often just a defensive tactic - warning off

consumers with food sensitivity when the chance of the food containing the allergen is actually very

small. The danger is that some allergy sufferers may stop taking the labels seriously. Teenagers, in

particular, are increasingly dismissive of ‘May contain’ labels, and this is a huge worry for parents.
Could the need for ‘May contain’ labels be eliminated altogether with more careful factory procedures?

The problem here is that, with nuts, perfect cleaning of production machinery is extremely difficult.

Most machines have nooks and crannies in which a nut from one production process can become lodged,

only to free itself later during the making of a non-nut product. It is quite possible that someone

could encounter a whole nut, or substantial pieces of nut, in a non-nut product. That is why no one

with nut allergy, even if it is relatively mild, should disregard ‘May contain nut traces’ labels.
Some makers of confectionery and biscuits have now set up dedicated nut-free production lines, with

stringent precautions to avoid any possibility of contamination. This allows them to market products

that are guaranteed nut-free. If you cannot purchase these locally, you may be able to order them by

mail or over the Internet (see p. 255).
Note that packaged foods that have been produced on nut-free production lines in the past can be

switched to different production lines, that necessitate a ‘May contain nut traces’ label.
In some cases, a product is manufactured in two separate places, one of which is nut-free, while the

other is not. Consequently, the same product may sometimes be sold with a ‘May contain’ label and

sometimes without. Don’t disregard these labels, however illogical they might seem.
Packaging errors
As most people with food allergy are now aware, ready-made foods sometimes go out in the wrong

packaging. Alarming cases that have occurred in recent years include hazelnut yoghurts labelled Toffee

Yoghurt, and Vegetable Bake (containing nuts) sold in packets intended for Vegetable Lasagne (no nuts).
Manufacturers are increasingly aware of the hazards and when mistakes are discovered, allergy

information websites and organisations such as the Anaphylaxis Campaign are quickly informed, so that

they can alert allergy sufferers.
Belonging to such an organisation (see p. 255), and/or checking websites regularly, is definitely

recommended for anyone with food allergy. However, you should bear in mind that no information service

can protect you completely from this hazard. The odds against it are high, but one day you might just

be the unlucky person who first discovers a packaging error by suffering an allergic reaction. To

protect yourself as far as possible:
When is a nut not a nut?
Those with nut allergies often worry about eating nutmeg and coconut. In fact, allergic reactions to

these are rare. People with nut allergy are no more likely to react to nutmeg or coconut than anyone

else.
Tiger nuts or chufa nuts are not nuts at all, but the roots of a sedge plant – they are most unlikely

to cross-react with true nuts.
Peanuts, botanically speaking, are not true nuts at all. They are legumes (pulses). There can be

cross-reactions with soya and/or lupin (proceed very carefully with this novel food ingredient) but

reactions with other pulses are rare. Cross-reactions with tree nuts such as almonds and Brazils are

quite common however (see p. 15). Many people with peanut allergy can in fact eat tree nuts, but they

should be aware that a cross-reaction could develop at some stage.
Because cross-reactions between tree nuts are so common, doctors tend to speak simply of ‘nut allergy’.

However, it is possible to be allergic to one type of tree nut, without being allergic to others.
•    always check that the food in the packet looks like the photograph on the packet
•    double-check, when you serve the food, by noting the conspicuous ingredients of the meal

(carrots, for example), and ensuring that they are indeed on the list of ingredients – any discrepancy

should make you suspicious
•    note the smell and appearance of any ready-made food, before you taste it. Do this even for

very simple things such as flavoured yoghurts
•    only have a very tiny mouthful at first, and if you have any tingling of the lips or other

symptoms, however mild, stop eating immediately (this is helpful for true food allergy only, not for

coeliac disease)
•    be especially cautious about vegetarian food if you are allergic to nuts or soya.
Latex in food
Those with latex allergy may react to very small traces of it in food. This sometimes occurs with

packaged food or restaurant food that has been prepared by workers wearing latex gloves. On one

occasion a highly allergic individual reacted to a water glass that had been handled by someone wearing

latex gloves. The amounts of latex involved are minuscule, and only affect those with severe latex

allergy. However, there is a strong case for workers handling food to wear non-latex gloves, especially

with the rise in cases of latex allergy.
There are also reports of people with latex allergy reacting (usually very mildly) to cold-seal

adhesives in food
wrappers, such as those used for ice cream. The reaction only occurs if the wrapper actually touches

the lips or mouth.

Let’s hope it never happens - but if it does, knowing what to do could make the difference between surviving and not surviving. The sensible thing is to read these pages - or whichever parts are relevant to you or your child - before you encounter an emergency. It is often helpful to rehearse the procedure in your mind and actually imagine yourself going through the actions described here.
Find out in advance what the local ambulance service is like, and ask your GP for advice about who to contact in an emergency. (If you have latex allergy, check in advance that all local ambulances carry a latex-free kit.) These are the options:
• Call your GP.If the doctor is nearby and the hospital or ambulance station a long way off, this may be the best decision. Doctors in rural areas may have supplies of adrenaline for emergency treatment, and oxygen for those suffering a severe asthma attack.
• Call an ambulance. Where the local ambulance service is dependable, this is always the best option. The ambulance crew will have adrenaline and oxygen.
• Go by car or taxi to the nearest hospital
emergency department. This is not usually a
good plan, because your condition may quick-
ly get worse, and you have no emergency
treatment available. But there may be situa-
tions where it is a sensible decision. Emergencies can occur when you are away on holiday or business. Never stay anywhere without a phone – check that it is working as soon as you arrive. Make sure you have the number of a local doctor and know where the nearest hospital is. A remote holiday cottage can be a dangerous place to suffer an asthma attack or anaphylactic shock.
Anaphylactic shock
This is an extremely serious emergency, requiring immediate medical help. The signs of anaphylactic shock are listed on p.58. In the case of food allergy, there are additional signs in the mouth, lips and throat (see p. 62). Use adrenaline (epinephrine) straight away if you have it – but get emergency medical help as well. With injectable adrenaline (an EpiPen or Anapen – see p. 150), remove the cap and jab firmly into the outer thigh, going straight through any clothing. Never inject into any other part of the body – this can be dangerous.
If you have an adrenaline inhaler (see pp. 155-6) you can use this first to treat symptoms in the mouth, throat and airways, and then use the injector if you still have symptoms. (Improvise a spacer – see p. 100 – if there is difficulty in inhaling the adrenaline.) Anyone whose reactions tend to be severe should use the injector first and follow up with the inhaler if necessary. Overdosing with adrenaline is possible, and can be fatal, but using the inhaler as well as the injector is safe as long as you don’t have a heart condition (see pp. 155-6).
If you do not improve after using the injector, a second one can be used, 10-15 minutes later.
In situations where medical help is not yet available and the symptoms are not abating, another shot of adrenaline can be given every 15-20 minutes. But the maximum number of shots recommended by your doctor should never be exceeded. Keep count of how many you’ve had, and tell medical staff.
An asthmatic who does not have an adrenaline inhaler can use a beta-2 reliever inhaler such as Ventolin (see p. 152) as well as the adrenaline injection, although it probably won’t help very much.
Suppose you know for sure that you have encountered your allergen, but you don’t have any symptoms yet? In Britain, the usual advice is to wait for symptoms, but doctors in the United States say go ahead and use the adrenaline injector if you have reacted very badly in the past. In general, for people with no other health problems, it is better to give an adrenaline injection which isn’t needed than to delay giving one that is needed. Delaying the use of the injector may mean that the reaction gets out of control. Some people put off using the injector because they think it should be saved for when they ‘really need it’. In fact the adrenaline works just as well if you have used it on previous occasions.
Following anaphylactic shock, you should be kept in hospital for 6-12 hours even when everything seems fine. Attacks have recurred as much as eight hours later. Corticosteroids reduce the chance of this happening – ask if these have been given. If you are discharged early and it is a long journey home, consider waiting in the hospital, or nearby, until eight hours after the original reaction.
First aid for anaphylactic shock
A badly swollen tongue or throat can cause suffocation. If there is visible swelling and the person is unconscious or turning blue, try to keep the top of the trachea (the main airway leading from the throat) open. Use the handle of a spoon – one that has very smooth edges. Slide it carefully over the top of the tongue and into the throat. Press down gently but firmly to open the airway.
Someone who is feeling faint or dizzy, or losing consciousness, or (in the case of a child) becoming very pale and floppy, may be suffering from a dangerous drop in blood pressure. He or she is more at risk of a fatal collapse if in an upright position, because not enough blood is reaching the heart. The worst thing is to stand up suddenly, or to move (or be moved) quickly from a lying to a sitting position –death can follow within seconds. The best thing is to lie down, preferably with the legs resting on cushions or a stool so that they are above the torso, and with the arms raised above the chest. Adrenaline can be given while in this position. A stretcher should be used to get the patient to an ambulance.
Latex allergy and emergency treatment
If you have anaphylaxis due to latex allergy, going to hospital can be alarming, as you may suffer further reactions to latex gloves or equipment. Some patients with latex allergy have had such bad experiences in ambulances and hospitals that they become fearful of using their adrenaline injector, since this means they must go to the hospital afterwards. They delay using the injector, which makes the situation worse. Some doctors are now giving such patients all the medicines and training they need to manage their anaphylactic shock themselves, so that they don’t need to attend hospital.
A person who has lost consciousness should be lying down on their side in case they are sick (this reduces the chance of them inhaling their vomit). The same goes for anyone who feels nauseous.
On the other hand, if the major problem at the outset is difficulty in breathing (as it generally is in children) a sitting position is better.
It is unusual for both faintness and severe breathing problems to be present at once. If this occurs, the patient should lie down, and if there is swelling in the throat, a spoon should be used (see left) to keep the airways open.
Insect-sting allergy
If you don’t have an adrenaline injector, get medical help immediately.
If you’ve had a cutaneous systemic reaction (see p. 60) in the past, use the adrenaline injector if there is any difficulty in breathing, hoarseness, stomach cramps, diarrhoea, nausea, faintness, dizziness or confusion. If you are unsure, remember that, unless you have a heart condition, it is usually better to overreact (i.e. use the adrenaline unnecessarily) than under-react.
If you’ve had a severe systemic reaction (i.e. anaphylactic shock) in the past, use an adrenaline injector at the first sign of any reaction other than immediately around the sting.
If there is a honeybee stinger left in the skin, scrape or flick it out sideways using a fingernail, knife blade or credit card – the venom sac is attached and will go on injecting venom for up to 10 minutes if you leave it there.
Don’t try to pull the stinger out – this squeezes the venom sac and pumps more venom into the skin.
Get emergency medical help, and follow the other measures for dealing with anaphylactic shock (see left).
Don’t go alone
If you suffer vomiting or diarrhoea during anaphylaxis, and have to go to the toilet, tell someone to call an ambulance and take someone else with youto the toilet. Do not go in alone and lock the door, in case you collapse.
Asthma attacks
Even those with mild asthma, who have never had a serious attack before, can quite suddenly get into difficulties and require emergency treatment. Don’t be over-anxious about this, because it is unlikely to happen – but do be prepared. Not having your reliever inhaler with you when a severe attack starts is a recipe for disaster – always take it, wherever you go.
Deal with an attack promptly. The sooner you act, the fewer drugs you’ll need in the long run to control the attack. Most asthmatics wait too long and then under-treat their asthma.
The important thing is recognising an asthma attack, and knowing when it is getting out of control. Not all attacks are the same – some come on fast, some come on slowly.
Rapid asthma attacks come on in a matter of hours. You may have been fine all day, but then start to feel very breathless and wheezy, or begin coughing badly. Less than an hour later, despite using the reliever, the breathlessness is worse and it is a struggle to speak or walk across the room. This is a severe attack: don’t delay in getting medical help.
Slow asthma attacks come on over a period of days. At first you are more breathless and wheezy than usual, and your reliever inhaler is not helping much. Asthma wakes you up at night, and you are far more breathless than usual in the morning. This could be the beginning of a severe attack, so don’t delay in getting medical help. If you get to the point where your asthma is disturbing your sleep every night, and in the morning you have difficulty in speaking or walking about, this is a very serious situation – you must see your doctor or go to the hospital now.
A few asthmatics have great difficulty recognising when they are increasingly breathless, and for them, using a peak-flow meter (see p. 97) every day is essential. Indeed, most asthmatics find
Recognising an asthma attack in a very young child
With a young child, these signs indicate a severe asthma attack:
• the nostrils are flared
• the shoulders are unusually high
• the child can say only one or two words between breaths
• the ribs are pushed out, and the spaces between the ribs, and below the chest cage, are sucked in during breathing
• you can hear wheezing (a whistling noise)
• the lips, tongue or fingernails are blue.
If wheezing stops, without any other apparent improvement, this is a very bad sign — it may mean that the airways are now so narrow that no air is passing through them. This is called a ’silent chest’, and indicates an urgent need for medical attention.
that monitoring peak flow is a valuable way of spotting attacks in advance. However, if your peak flow seems normal, and yet you feel breathless and have a tight feeling in your chest, pay attention to your symptoms and get medical help.
Your response to your reliever inhaler is another helpful sign assessing asthma attacks. Things are serious if:
• the reliever inhaler does not seem to be working at all within 10 minutes of taking a puff
• it does not work as well as usual
• it works, but the effect wears off in less than three hours. If you have an asthmatic child, give everyone who normally takes care of the child detailed written instructions for recognising and dealing with an asthma attack. People forget verbal instructions especially in an emergency. A child who is exhausted or upset c. an attack should always be given medical care.
Taking action
If your reliever inhaler is not working well (see above), take another puff to open up your airways – and then take further action. as described below.
If you seem to be in the early stages of a slow asthma attack check your management plan, and if your peak flow has fallen below the recommended level, double the dose of inhaled steroids (twice as many puffs each time) now. Add any other medicines (e.g. steroid tablets) as recommended by the management plan.
Those who don’t have a peak-flow meter or management plan should double the dose of inhaled steroids and make an urgent appointment to see the doctor.
If you are suffering a rapid attack, or a slow attack that has got out of control, you need emergency medical help. Ring for an ambulance, ring your doctor, or go to the hospital – the ideal course of action will vary, depending on where you live (see p. 98).
Use your reliever inhaler until medical help arrives. You can take a puff every 5-10 minutes if needed, but keep a count of how many puffs you’ve had and stop after 30. Some doctors suggest taking up to 30 puffs all at once. (If you have a heart condition, this dose might be dangerous: follow your doctor’s advice.)
If it is difficult to inhale, use a spacer – this can make all the difference, especially for children.
You can improvise a spacer from a plastic cup, a plastic bottle, or a paper bag. Make a hole in the bottom of the cup or bottle, or in one corner of the paper bag, and insert the mouthpiece of the inhaler here. The open end of the cup, bottle or bag goes in or over the mouth – with the bag, you have to bunch it up and hold it around the mouth. Squirt the inhaler repeatedly into the improvised spacer, while breathing steadily in and out.
The six golden rules for asthma attacks
• Breathe as slowly as possible and concentrate on breathing out, not on breathing in. Exhale as fully as you can and your in-breath will follow automatically.
• Never panic – if you do, you may start hyperventilating, and this makes matters much worse (see p. 226). Panicky parents are the worst possible thing for an asthmatic child during an attack.
• Adopt a position that makes breathing as easy as possible. Propping your arms up at about shoulder height can help – for example, sit back-to-front on a dining chair, with your arms folded and resting on the back. Or put pillows on a table, sit in an upright chair, and rest your head and arms on the pillows. Don’t lie down, as this makes matters worse. Open a window, as long as the air outside is not cold, polluted or loaded with pollen.
• Avoid factors that can make an asthma attack worse, for example, vigorous activity, cold air, irritants and allergens.
• Drink plenty of water, fruit juice or other liquids as a lot of water is lost through the surface of the airways during an asthma attack, and you can become dehydrated.
• Don’t take anything to help you sleep, even herbal pills. If your asthma gets worse during the night, you need to wake up so that you can get more air.
After an attack
Asthmatics who have suffered a severe attack are occasionally sent home from hospital before they are completely better. A few people have died as a result of being discharged too soon. So if you feel breathless or otherwise unwell after you leave hospital, don’t hesitate to go back – or seek other medical help.
See your GP or specialist within a few days of any emergency treatment. Don’t be over-confident just after a severe attack – this can be a very vulnerable time. Take more rest than usual and drink plenty of fluids, as you may be dehydrated. Keep taking your preventer inhaler at the increased dose – reducing the dose now could lead to another severe, possibly fatal, attack. Keep taking steroid tablets if you have been given them.
If you produced a lot of mucus during the attack, try to clear it, but without violent coughing. Mucus can sometimes form solid plugs which block small airways. Treatment by a physiotherapist would help, and expectorants – drugs which help loosen mucus –can also be useful (ask your pharmacist about these). Don’t take ordinary cough medicine (see box on p. 163). There are also some breathing exercises which can help to clear mucus (see p. 231).
An asthma attack represents a chance to learn more about preventing asthma – so think about what went wrong. Had you forgotten to take your preventer inhaler regularly? How long is it since you had your medicines reviewed by the doctor or asthma clinic? Have you been using your peak-flow meter daily? Were you exposed to a high dose of allergen or an irritant?
A reaction to aspirin-like drugs
Aspirin sensitivity can begin quite suddenly in someone who has previously taken aspirin without trouble. If you have unexplained chronic urticaria, or polyps in the nose, plus asthma and/or rhinitis, the development of aspirin sensitivity at some time in the future is a distinct possibility (see p. 151).
A sensitivity reaction to aspirin or aspirin-like drugs usually begins between 30 minutes and two hours after the drug is taken. You will have some or all of these symptoms:
• a runny or badly blocked nose, and red eyes
• a feeling of warmth, flushing and sweating
• a general rash
• a sensation of tightness in the chest, a dry cough, increasing breathlessness
• malaise and exhaustion
• vomiting or diarrhoea
• swelling (angioedema) and/or nettle rash (urticaria). If you have such symptoms get emergency medical help immediately because the reaction can quickly develop into severe asthma, shock, collapse and unconsciousness.
If you have asthma, use your reliever inhaler as much as required (up to 30 puffs) until medical help arrives. Anyone who has an adrenaline (epinephrine) auto-injector, or an adrenaline inhaler, can use this as well – up to 30 puffs of the inhaler, or whatever maximum dose is given in the instructions. Tell the ambulance crew and doctors exactly what you have taken.