“Real Housewives of New York” cast member and Skinnygirl brand founder Bethenny Frankel made some much-needed social media impact recently—not for a new business venture, but for her food allergy experience in flight.

After a lifetime enduring “shame, (unwanted) attention and eye-rolling” when she alerted others about her fin fish allergy, Frankel recently survived a stay in the intensive care unit after unknowingly eating fish in a bowl of soup.

On the heels of that traumatic experience, and wary of further exposures, she notified the airline about her allergy in advance of an upcoming trip and asked that fish not be served.

Once in flight, however, Frankel reports she noticed the smell of fish wafting through the cabin. At 35,000 feet, with limited air circulation, a potential risk of allergic reaction by inhalation spurred Frankel into action, as she asked the crew to refrain from serving the fish.

Allergenic protein could be present in the steam generated as the fish baked in the galley. Recently, a child in New York had a fatal reaction to fish, just by inhaling the aromas from his grandmother’s home cooking that included fish.

 Few allergens pose such airborne risks, but Frankel’s experience casts a spotlight on allergy safety concerns while traveling. While it is clear that eating an allergen is the most common way food allergies are triggered, other possible routes of exposure are skin or mucosal contact (rubbing eyes, for example), or heating, cooking or inhaling particles.

There is no way to predict the severity of a food allergy reaction, and past reactions aren’t good indicators of what might happen in the future.

According to the American College of Asthma, Allergy and Immunology, food allergies can develop at any age. A widespread misconception is that food allergies primarily affect only children, but many adults can be first diagnosed in adulthood.

Northwestern University researchers recently estimated the prevalence of food allergies in the United States is 7.6 percent in children and 10.8 percent in adults, impacting roughly 6 million children and 26 million adults.

Food allergy prevalence seems to be increasing, and the surge of food allergic children of the last two decades are now in college and careers. Coping with the unique set of problems that confront allergic people has only recently started to affect the average flyer.

As a nurse and member of a family of young adults with food allergies, I find that packing for a trip requires much more than not forgetting the toothbrush or sunscreen. Safe foods, cleaning wipes, epinephrine auto-injectors (more than one dose may be needed) and other medications, such as antihistamines and inhalers, are stockpiled and stashed in carry-on luggage, stored nearby for easy access.  

Photos posted on social media of pistachios wedged between plane seat cushions, peanut shells crushed on the floor, and food crusted on tray tables keep allergic travelers and their caregivers on high alert, so planning also comprises preemptive precautionary actions.

The early boarding move allows us to inspect and wipe down seats and tray tables to eradicate any visible crumbs or spills and other traces of allergenic protein. Some place a protective cover over the seat and tray to avoid contact reactions.

The buffer zone move creates adjacent allergy-free rows and requires passenger cooperation, requesting that seatmates eat those peanuts or tree nuts after landing. The announcement alerting fellow travelers that an allergic passenger is on board and asking them to avoid consuming allergens requires a team approach with the crew.

Although these are simple measures, they make allergic travelers feel safer and more in control, but airline policies regarding these practices vary widely. That is odd considering that chances are, on every airline flight, there are several passengers with food allergies.

While consideration of the allergic customer’s safety needs and comfort level is far from universal, some policies are changing. Recently Southwest Airlines stopped serving peanuts, and American Airlines instituted an early boarding option.

Allergic travelers may not request these actions, hoping to avoid embarrassment, resentment or derision. Other travelers make their requests known, in hopes of voluntary accommodation. But the stakes here are high, and it shouldn’t be necessary to rely on the kindness of strangers.

Foods containing common allergens continue to be served by many airlines. Reports of roasted nuts causing anaphylaxis and peanuts contributing to reactions are common knowledge in the allergy social media community.

Still, extreme examples abound, such as nut-allergic travelers being told to sit in the bathroom while snacks were served. Airline staff admonished passenger Dua Lipa on a recent flight that her sister might need epinephrine because the airline is not nut-free. In another instance, passengers booed when told nuts would not be served. 

What would a food allergy reaction look like in flight? Symptoms of allergic reactions run the gamut, from mild to severe and life-threatening. Hives, itching, gastrointestinal upset, runny noses, itchy eyes, anxiety, feelings of impending doom, throat tightening, shortness of breath or exacerbations of asthma are some of the symptoms that can occur.

Emergency treatment is recommended when two or more body systems are involved. Anaphylaxis is a severe and potentially life-threatening multisystem allergic reaction that can progress to breathing difficulties and shock.

A recent insurance claims data analysis revealed food allergy anaphylaxis health insurance claims had risen 377 percent, and also suggested that adults sought care for about one third of these claims. These findings collectively imply that not only are food allergies prevalent in adults, they also require significant health care resources—resources that may not be available on a plane.

Statistics indicate that nearly 2 percent of in-flight medical emergencies, and 4.5 percent of flight diversions are allergy-related. These reports of allergic reactions requiring onboard treatment or flight diversion underscore the need for vigilance and commonsense measures to keep people safe.

Lianne Mandelbaum, an allergy mom and the founder of The No Nut Traveler blog, asserts that a “standard international airline anaphylaxis action plan” is needed.  Crews can be trained, she writes, to recognize anaphylaxis and administer epinephrine auto-injectors.  

Just as flight crews are prepared to use an automated external defibrillator and to administer CPR, so too should they be ready to help in the event of an allergic reaction.

Though medical flight kits contain vials of epinephrine, medical expertise is required to draw up the correct dose and administer this life-saving medication, so this is a barrier to its use. Easy to use auto-injectors, which can be self-administered by children, facilitate this treatment but are stocked only at the discretion of the airline, with Alaska Airlines, British Airway, Jet Blue and United recently listed as airlines carrying them

Although Good Samaritans often randomly come to the rescue, all airline personnel should be trained to assist. An anaphylactic passenger could require multiple doses of epinephrine or could be unable to self-administer, and, if traveling alone, unable to explain where their emergency medications were located. 

In some cases, anaphylaxis can lead to a loss of consciousness, as it did in Frankel’s case, so the preparedness of staff—with both knowledge of the potential allergy and appropriate medications and resources—might be the factor that ensures quick resolution or survival.

To be sure, allergic individuals should carry safe food and necessary medications with them on their travels. Given the prevalence of food allergies in both children and adults, and considering the unique circumstances of air travel, where medical treatment is limited and not easily accessed, airlines in good conscience must create a safer air travel environment where all passengers can feel at ease.

While airlines can never eliminate all allergens from air travel, standardized policies and procedures can make flying safer. The industry has a long way to go to make the skies friendlier.