Day: February 1, 2016

What Are Risk Factors for Latex Allergy?

Patient Presentation
A 4-year-old male came to clinic for his health supervision visit. He had a history of lumbar meningomyelocoele not requiring a ventriculoperitoneal shunt. He had a wheelchair for mobility but otherwise was developmentally appropriate and was verbally a precocious child. The past medical history was significant for repair of the meningomyelocoele after birth. He had a history of several urinary tract infections but generally had no problems with his clean intermittent bladder catheterization. The family history was non-contributory. As the physician was preparing to examine the child the mother asked to see the box of gloves. “I know that these are probably latex-free, but better to always check. He’s not latex allergic now and I want to keep it that way,” she said as she double-checked the box confirming they were latex-free.

The pertinent physical exam showed a happy boy sitting in his wheelchair. Vital signs were normal with weight and head circumference trending at the 25%.
His examination was notable for a well-healed scar on his lumbo-sacral area. He had small legs without muscle tone or sensation. The diagnosis of a healthy 4 year old with meningomyelocoele was made. He was current with his immunizations except for seasonal influenza. The physician also confirmed that the live attenuated vaccine did not contain latex.

Discussion
Latex comes from the Hevea brasiliensis plants. There are multiple potentially allergenic polypeptides within the plant’s fluid called Heb b 1-13. True sensitizers are Heb b 1, 5 and 6. Heb b 8 and 12 are cross-reacting proteins.

The type of the latex product and how it is prepared makes a difference in exposure to the latex allergens. Certain extruded latex products such as catheters and rubber stoppers have higher concentrations of true sensitizer allergens. Products made from molds such as gloves have higher concentrations of potential allergens than latex made in sheets such as such as dental dams. Use of powder substances in gloves also increases latex allergen exposure. Cross reactivity with certain foods is called latex-fruit syndrome and includes apples, avocado, chestnuts, banana, kiwi, tomato, bell pepper and carrot. Ficus trees also have some cross-reactivity.

Diagnosis of latex sensitivity and true allergy in the US is usually made by skin prick test conducted in a clinical setting by an allergist. Treatment can include various immunotherapies with the assistance of an allergist. Indications for allergy testing can be found here.

Avoidance of latex products is the best option but it’s difficult to do as latex products are all around us in our environment including clothing (undergarments, socks, bathing suits), sports equipment (balls, grips, masks), condoms, rubber bands or erasers, carpet backing, etc.. In the medical areas, latex in gloves is the one most people think about but other products include the rubber used in stethoscope tubing, rubber hammers, multiple-use vials, syringes, bulb syringes, tourniquets, catheters, bandages, electrodes, heat/cold wraps, impermeable bedding, anesthesia circuits, CPR supplies such as masks and mannequins, surgical clothing, etc. In dentistry, dental dams and orthodontic elastic bands commonly come to mind, but also filling and impression materials may contain it. A list of consumer products that potentially contain latex and some alternatives can be found here.

Questions useful in eliciting a history of latex sensitization or allergy include asking about reactions when exposed to latex balloons or dental dams for dental procedures.

Learning Point
Latex hypersensitivity is about 0.3-4% of the pediatric population. Subpopulations though can be as high as 71%. The highest risk is for patients with spina bifida.

Risk factors for latex allergy and sensitization include:

  • Occupation
    • Food preparation workers
    • Housekeeping personnel
    • Gardener
    • Hairdressers
    • Healthcare workers – surgeon, nursing, laboratory worker, technician, etc. Latex positivity is up to 12% of healthcare workers
    • Others with exposure to frequent gloving
  • Patients who are frequently instrumented or have multiple (N > 5) surgeries
    • Spina bifida – these patients appear to have more sensitization than other similarly exposed patients
    • Urological abnormalities
    • Congenital heart disease
    • Hydrocephaleus
    • Tracheoesophageal fistula
    • Other congenital malformations
  • Having atopy – 1% of atopic children have latex allergy

Questions for Further Discussion
1. What are the 4 types of allergic hypersensitivity?
2. What steps should be taken if a child with latex allergy comes to the clinic or is admitted to the hospital?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Latex Allergy

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Latex Allergy Association. Consumer Products. Available from the Internet at http://latexallergyresources.org/consumer-products (cited 210/26/15).

Sampathi V, Lerman J. Case scenario: perioperative latex allergy in children. Anesthesiology. 2011 Mar;114(3):673-80.

Lucas JS, du Toit G, Lloyd K, Sinnott L, Forster D, Austin M, Clark C, Tuthill D, Brathwaite N, Warner J; Science and Research Department, Royal College of Paediatrics and Child Health. The RCPCH care pathway for children with latex allergies: an evidence- and consensus-based national approach. Arch Dis Child. 2011 Nov;96 Suppl 2:i30-3.

Nettis E, Delle Donne P, Di Leo E, Fantini P, Passalacqua G, Bernardini R, Canonica GW, Ferrannini A, Vacca A. Latex immunotherapy: state of the art. Ann Allergy Asthma Immunol. 2012 Sep;109(3):160-5.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital