Q:

7/28/2012  
Does the Academy have a position on advice to patients with peanut and tree nut allergy traveling on commercial airlines?

Do we have a position on how the airlines should handle these patients?

Is there hard data on in-flight reactions from airborne nut/peanut?

A:

Thank you for your inquiry.

The Academy does not have a position paper on this particular topic. However, literature is available for patients, and there are studies investigating the occurrence of food allergy reactions during airline flight.

Below you will find the abstracts of these two articles, one from the Annals of Allergy, Asthma, and Immunology and the other from the Journal of Allergy and Clinical Immunology, dealing with the issue of allergic reactions to foods during an airline flight. In addition, there are two published commentaries on these articles. The references for these commentaries are:

Weiss C. Letter to the Editor. Commercial airlines and food allergy. Annals of Allergy, Asthma, and Immunology 2008 (November); 101(5):556-557.

James JM. Airline snack foods: tension in the peanut gallery. Journal of Allergy and Clinical Immunology 1999 (July); 104(1):25-27.

In addition, there is a general statement on air travel and children's health issues that has a section on allergic reactions during airline flight. This appeared in Pediatric Child Health. This article is available to you free of charge online. I have have provided a link to the article for your convenience.

Air travel and children’s health issues: Pediatric Child Health. 2007 January; 12(1): 45–50

Finally, there is excellent information available through the Food Allergy and Anaphylaxis Network (FAAN). Their website has an article entitled "Ten Tips for travelers with Allergy" and an article entitled "Flying with Food Allergy". The links to both of these articles is copied for you below:

FAAN WEBSITE: Ten tips for travelers with allergy

FAAN WEBSITE: Flying with food allergy

Since a significant portion of these reactions occur by inhalation, I have also copied below an abstract on food hypersensitivity by inhalation (Ramirez) which was written for physicians and puts the issue of such reactions into perspective.

Thank you again for your inquiry and we hope this response is helpful to you.

Ann Allergy Asthma Immunol. 2008 Jul;101(1):51-6.
Allergic reactions to peanuts, tree nuts, and seeds aboard commercial airliners.
Comstock SS, DeMera R, Vega LC, Boren EJ, Deane S, Haapanen LA, Teuber SS.
Source
Division of Rheumatology, Allergy, and Clinical Immunology, Department of Internal Medicine, University of California, Davis, School of Medicine, Davis, California, USA.
Abstract
Background: Minimal data exist on the prevalence and characteristics of in-flight reactions to foods.
Objectives: To characterize reactions to foods experienced by passengers aboard commercial airplanes and to examine information about flying with a food allergy available from airlines.
Methods: Telephone questionnaires were administered to individuals in a peanut, tree nut, and seed allergy database who self-reported reactions aboard aircraft. Airlines were contacted to obtain information on food allergy policies.
Results: Forty-one of 471 individuals reported allergic reactions to food while on airplanes, including 4 reporting more than 1 reaction. Peanuts accounted for most of the reactions. Twenty-one individuals (51%) treated their reactions during flight. Only 12 individuals (29%) reported the reaction to a flight attendant. Six individuals went to an emergency department after landing, including 1 after a flight diversion. Airline personnel were notified of only 3 of these severe reactions. Comparison of information given to 3 different investigators by airline customer service representatives showed that inconsistencies regarding important information occurred, such as whether the airline regularly serves peanuts.
Conclusions: In this group of mainly adults with severe nut/seed allergy, approximately 9% reported experiencing an allergic reaction to food while on board an airplane. Some reactions were serious and potentially life-threatening. Individuals commonly did not inform airline personnel about their experiences. In addition, the quality of information about flying with food allergies available from customer service departments is highly variable and, in some cases, incomplete or inaccurate.

J Allergy Clin Immunol. 1999 Jul;104(1):186-9.
Self-reported allergic reactions to peanut on commercial airliners.
Sicherer SH, Furlong TJ, DeSimone J, Sampson HA.
Source
Division of Pediatric Allergy/Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, USA.
Abstract
Background: Allergic reactions to food occurring on commercial airlines have not been systematically characterized.
Objective: We sought to describe the clinical characteristics of allergic reactions to peanuts on airplanes.
Methods: Participants in the National Registry of Peanut and Tree Nut Allergy who indicated an allergic reaction while on a commercial airliner were interviewed by telephone.
Results: Sixty-two of 3704 National Registry of Peanut and Tree Nut Allergy participants indicated a reaction on an airplane; 42 of 48 patients or parental surrogates contacted confirmed the reaction began on the airplane (median age of affected subject, 2 years; range, 6 months to 50 years). Of these, 35 reacted to peanuts (4 were uncertain of exposure) and 7 to tree nuts, although 3 of these 7 reacted to substances that may have also contained peanut. Exposures occurred by ingestion (20 subjects), skin contact (8 subjects), and inhalation (14 subjects). Reactions generally occurred within 10 minutes of exposure (32 of 42 subjects), and reaction severity correlated with exposure route (ingestion > inhalation > skin). The causal food was generally served by the airline (37 of 42 subjects). Medications were given in flight to 19 patients (epinephrine to 5) and to an additional 14 at landing/gate return (including epinephrine to 1 and intravenous medication to 2), totaling 79% treated. Flight crews were notified in 33% of reactions. During inhalation reactions as a result of peanut allergy, greater than 25 passengers were estimated to be eating peanuts at the time of the reaction. Initial symptoms generally involved the upper airway, with progression to the skin or further lower respiratory reactions (no gastrointestinal symptoms).
Conclusions: Allergic reactions to peanuts and tree nuts caused by accidental ingestion, skin contact, or inhalation occur during commercial flights, but airline personnel are usually not notified. Reactions can be severe, requiring medications, including epinephrine.

Clin Mol Allergy. 2009 Feb 20;7:4.
Food hypersensitivity by inhalation.
Ramirez DA Jr, Bahna SL.
Source
Allergy & Immunology Section, Louisiana State University Health Science Center in Shreveport, 1501 Kings Highway, Shreveport, LA, USA.
Abstract
Though not widely recognized, food hypersensitivity by inhalation can cause major morbidity in affected individuals. The exposure is usually more obvious and often substantial in occupational environments but frequently occurs in non-occupational settings, such as homes, schools, restaurants, grocery stores, and commercial flights. The exposure can be trivial, as in mere smelling or being in the vicinity of the food. The clinical manifestations can vary from a benign respiratory or cutaneous reaction to a systemic one that can be life-threatening. In addition to strict avoidance, such highly-sensitive subjects should carry self-injectable epinephrine and wear MedicAlert(R) identification. Asthma is a strong predisposing factor and should be well-controlled. It is of great significance that food inhalation can cause de novo sensitization.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology