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New international study led by University of Michigan identified behaviors that could reduce anxiety, chances of allergic reactions

Few situations can provoke more anxiety for people with peanut or tree-nut allergies than having an allergic reaction while flying on an airplane and being unable to get help.

But in a new study, published in the Journal of Allergy and Clinical Immunology-In Practice, researchers found passengers who engaged in eight mitigating factors were less likely to report an allergic reaction.

This is the first study to show that in-flight peanut and tree nut allergy is an international problem, says lead author and pediatrician Matthew Greenhawt, M.D., M.B.A., M.Sc., of the University of Michigan’s Food Allergy Center and C.S. Mott Children’s Hospital. Past research has focused on the U.S. and only on those who had reactions, instead of including those who did not.

Greenhawt, and his co-authors from Allergy & Anaphylaxis Australia and the International Food Allergy & Anaphylaxis Alliance, asked passengers to answer an online survey about their in-flight experiences.  More than 3,200 people from 11 countries completed the survey. Of those, 349 reported having an allergic reaction during an airline flight.

Passengers with peanut/tree nut allergies who reported taking these actions had significantly lower odds of reporting a reaction:

(1) requesting any accommodation

(2) requesting a peanut/tree nut-free meal

(3) wiping their tray table with a commercial wipe

(4) avoiding use of airline pillows

(5) avoiding use of airline blankets

(6) requesting a peanut/tree nut-free buffer zone

(7) requesting other passengers not consume peanut/tree nut-containing products

(8) not consuming airline-provided food

“Flying with a peanut/tree nut allergy is equal parts frustrating and frightening for allergic passengers.  These eight passenger-initiated risk-mitigating behaviors may help clinicians wishing to advise concerned patients planning to fly commercially,” says Greenhawt, of U-M’s Food Allergy Center.

Greenhawt says most airlines still serve peanuts and tree nuts or snacks and meals with peanuts or tree nuts included. Canada is the only country with any formal policy in place, which requires a 3-row buffer zone with advance notification only on Air Canada flights, he says.

“So these behaviors are simple, practical measures which may offer some protection and reduce anxiety until formal policies are implemented.”

The study also found that epinephrine, a common and effective treatment, was drastically underused in-flight. Only 13.3 percent of passengers reporting a reaction received epinephrine as treatment.  Flight crews were notified regarding 50.1 percent of reactions.  In a similar study of US passengers five years ago, Greenhawt noted a similarly low rate of epinephrine use.

“Despite that 98 percent of passengers had a personal source of epinephrine available, epinephrine was underused to treat a reaction. Flight crews were not always readily alerted to reactions when they occurred, but interestingly, when they were notified, it was associated with a higher odds that epinephrine was used to treat the reaction,” Greenhawt says.

Interestingly, nationality was not a significant factor influencing the use of epinephrine as treatment.

“We still think the risk of an in-flight reaction is small, but it’s hard to imagine a more helpless situation than having a reaction while you’re at 35,000 feet in an airplane,” Greenhawt says. “But this study identifies some things passengers can do to reduce their anxiety. We want them to fly. It can help improve their quality of life.”

“But more importantly, these findings provide a starting point for airlines to consider in terms of their own policies, where they could work with passengers to mitigate risk.  I think that consideration for training crew to identify anaphylaxis is another important potential measure to consider given that crew involvement significantly increased the odds of reported epinephrine use.  Poor crew notification of events has been noted in the earlier airline studies, so perhaps the solution is to train crew to be more proactive,” Greenhawt says.

Greenhawt adds that future study is necessary to further validate the effectiveness of these passenger-initiated risk-mitigating behaviors and create better educational efforts around the use of epinephrine.

Additional authors: Of Allergy & Anaphylaxis Australia in Sydney, New South Wales, Australia: Fiona MacGillivray, Geraldine Batty and Maria Said. Of The Global Food Protection Institute in Battle Creek, Mich.: Christopher Weiss, PhD

Funding: Supported in part by the National Center for Research Resources and the University of Michigan Food Allergy Center


About C.S. Mott Children’s Hospital in the University of Michigan Health System:

Since 1903, the University of Michigan has led the way in providing comprehensive, specialized health care for children. From leading-edge heart surgery that's performed in the womb to complete emergency care that's there when you need it, families from all over come to the University of Michigan C.S. Mott Children's Hospital for our pediatric expertise. In 2013, C.S. Mott Children’s Hospital was ranked eighth in the nation in Parents Magazine’s 10 Best Children’s Hospitals ranking. To learn more, go to

C.S. Mott Children’s Hospital operates a food allergy clinic, specifically designed to care for patients with food allergies and eosinophilic gastrointestinal disorders.

matt-greenhawtMatthew Greenhawt, MD, MBA, MSc, is assistant professor, Department of Internal Medicine, Division of Allergy & Clinical Immunology and the University of Michigan Food Allergy Center, University of Michigan Medical School and University of Michigan Health System Ann Arbor, Michigan.  He is a member of KFA’s Medical Advisory Team.


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Comments (11)

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I would recommend wiping down the whole seating area, not just the tray table.  


I would also bring all my own food.  I think it is great if airlines are offering peanut or nut-free flights but I think there 35,000 feet isn't where I would want to find they made any type of mistake.


I think researching which airlines will and will not make announcements, grant buffer zones, do or do not serve peanuts, nuts, etc is also a good idea.  Some airlines are accommodating and some are not and which is which changes with time.


Hi Francine,


A good approach would be for you to discuss this with your child's allergist in advance of the plane trip and see if your child's emergency care plan needs to be updated for the flight and the trip away from home.  You might need to carry more epinephrine autoinjectors, for instance, based upon what your allergist will recommend.

Kids With Food Allergies

Hi Francine. 


In our case, our allergist told us always carry 2 Epipens at all times - every day. When we fly, we are supposed to carry 3 Epipens, Benadryl, and liquid Prednisone (steroids). In the event of an in-air anaphylaxis we were directed to give our son his Epipen and wait a few minutes. If he was recovering, we were to give him his first dose of steroids (since that is what he'd do if we came to the ER after giving the Epipen). In the event the first Epipen didn't resolve the anaphylaxis, we were to give the second Epipen. Again, wait to see... and then give steroids.  We also have a signed letter from our allergist that explains my son's allergies and lists all the meds that we are required to travel with. (Just in case airport security gets fussy with us....)


I don't know if you are familiar with this article, but I wanted to share. It's Dr. Wood's info on airborne peanut allergies:


Also, here is a great article that sums up policies and flying with a nut allergy. It speaks to the fact that while some airlines can provide a "nut free" flight, it doesn't stop passengers from bringing their own. And yes, even in 2013 people still bring their own nuts on the plane.


Of course, if a person is very peanut allergic they should speak to their allergist about the safety of flying, and perhaps making alternative travel arrangements.  


Southwest allows early boarding for airborne peanut allergies- enough time for you to go and wipe down the seats and trays before everyone else gets on.  They also avoid actually serving peanuts on the flight- they gave cookies and crackers instead. 


In addition to taking common-sense precautions and increasing communication with flight crew during reactions, the study also seems to reinforce another critical need: to educate allergic individuals and their families/caregivers more effectively around how and when to use the EpiPen. Underutilization of EpiPen is not only a problem in the air, but also on the ground. Education can reduce anxiety (i.e. by shifting some of the focus from the problem onto a "solution") and lead to more competence and confidence using this life-saving medication.


I just wanted to add that I just booked a flight from the USA to Europe with KLM (Dutch Airline) operated by Delta. After purchasing our tickets I called up Delta to notify them about my 3 years old son's peanut/tree nut and dog allergies and I asked what their policy was to accomodate us. Just like on Air Canada, they ensured me they will create a 3-row buffer zone in front and behind us. They will not serve any nuts to these passengers. Good to know!

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