Aluminum sulfate calcium acetate

U.S. BRAND NAMES — Domeboro® [OTC]; Gordon Boro-Packs [OTC]; Pedi-Boro® [OTC]

PHARMACOLOGIC CATEGORY
Topical Skin Product

DOSING: ADULTS — Dermal inflammation, dermatitis: Topical: Soak affected area in the solution 2-4 times/day for 15-30 minutes or apply wet dressing soaked in the solution for more extended periods; rewet dressing with solution 2-4 times/day every 15-30 minutes

DOSING: ELDERLY — Refer to adult dosing.

DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Powder, for topical solution:
Domeboro®: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)
Gordon Boro-Packs: Aluminum sulfate 49% and calcium acetate 51% per packet (100s)
Pedi-Boro®: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)

DOSAGE FORMS: CONCISE
Powder, for topical solution:
Domeboro® [OTC]: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)
Gordon Boro-Packs: Aluminum sulfate 49% and calcium acetate 51% per packet (100s)
Pedi-Boro® [OTC]: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)

GENERIC EQUIVALENT AVAILABLE — No

ADMINISTRATION — For external use only. Do not occlude dressing to prevent evaporation.

USE — Astringent wet dressing for relief of inflammatory conditions of the skin; reduce weeping that may occur in dermatitis

WARNINGS / PRECAUTIONS
Other warnings/precautions: Appropriate use: For external use only; avoid contact with eyes. Discontinue use if irritation occurs. OTC duration of therapy: Not for OTC use >7 days.

DRUG INTERACTIONS
Bisphosphonate Derivatives: Calcium Salts may decrease the absorption of Bisphosphonate Derivatives. Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification

Calcium Channel Blockers: Calcium Salts may diminish the therapeutic effect of Calcium Channel Blockers. Risk C: Monitor therapy

CefTRIAXone: Calcium Salts (Intravenous) may enhance the adverse/toxic effect of CefTRIAXone. Ceftriaxone binds to calcium forming an insoluble precipitate. Management: Use of ceftriaxone with calcium-containing solutions within 48 hours of one another is contraindicated in neonates (28 days of age or younger). In older patients, flush lines with compatible fluid between administration. Risk D: Consider therapy modification

DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Risk C: Monitor therapy

Eltrombopag: Calcium Salts may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., calcium-containing products) by at least 4 hours. Risk D: Consider therapy modification

Estramustine: Calcium Salts may decrease the absorption of Estramustine. Risk D: Consider therapy modification

Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements. Risk D: Consider therapy modification

Quinolone Antibiotics: Calcium Salts may decrease the absorption of Quinolone Antibiotics. Of concern only with oral administration of both agents. Exceptions: Moxifloxacin. Risk D: Consider therapy modification

Thiazide Diuretics: May decrease the excretion of Calcium Salts. Continued concomitant use can also result in metabolic alkalosis. Risk C: Monitor therapy

Thyroid Products: Calcium Salts may diminish the therapeutic effect of Thyroid Products. Management: Separate the doses of the thyroid product and the oral calcium supplement by at least 4 hours. Risk D: Consider therapy modification

Trientine: Calcium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum concentration of Calcium Salts. Risk D: Consider therapy modification

Aluminum sulfate calcium acetate

U.S. BRAND NAMES — Domeboro® [OTC]; Gordon Boro-Packs [OTC]; Pedi-Boro® [OTC]

PHARMACOLOGIC CATEGORY
Topical Skin Product

DOSING: ADULTS — Dermal inflammation, dermatitis: Topical: Soak affected area in the solution 2-4 times/day for 15-30 minutes or apply wet dressing soaked in the solution for more extended periods; rewet dressing with solution 2-4 times/day every 15-30 minutes

DOSING: ELDERLY — Refer to adult dosing.

DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Powder, for topical solution:
Domeboro®: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)
Gordon Boro-Packs: Aluminum sulfate 49% and calcium acetate 51% per packet (100s)
Pedi-Boro®: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)

DOSAGE FORMS: CONCISE
Powder, for topical solution:
Domeboro® [OTC]: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)
Gordon Boro-Packs: Aluminum sulfate 49% and calcium acetate 51% per packet (100s)
Pedi-Boro® [OTC]: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet (12s, 100s)

GENERIC EQUIVALENT AVAILABLE — No

ADMINISTRATION — For external use only. Do not occlude dressing to prevent evaporation.

USE — Astringent wet dressing for relief of inflammatory conditions of the skin; reduce weeping that may occur in dermatitis

WARNINGS / PRECAUTIONS
Other warnings/precautions: Appropriate use: For external use only; avoid contact with eyes. Discontinue use if irritation occurs. OTC duration of therapy: Not for OTC use >7 days.

DRUG INTERACTIONS
Bisphosphonate Derivatives: Calcium Salts may decrease the absorption of Bisphosphonate Derivatives. Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification

Calcium Channel Blockers: Calcium Salts may diminish the therapeutic effect of Calcium Channel Blockers. Risk C: Monitor therapy

CefTRIAXone: Calcium Salts (Intravenous) may enhance the adverse/toxic effect of CefTRIAXone. Ceftriaxone binds to calcium forming an insoluble precipitate. Management: Use of ceftriaxone with calcium-containing solutions within 48 hours of one another is contraindicated in neonates (28 days of age or younger). In older patients, flush lines with compatible fluid between administration. Risk D: Consider therapy modification

DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Risk C: Monitor therapy

Eltrombopag: Calcium Salts may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., calcium-containing products) by at least 4 hours. Risk D: Consider therapy modification

Estramustine: Calcium Salts may decrease the absorption of Estramustine. Risk D: Consider therapy modification

Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements. Risk D: Consider therapy modification

Quinolone Antibiotics: Calcium Salts may decrease the absorption of Quinolone Antibiotics. Of concern only with oral administration of both agents. Exceptions: Moxifloxacin. Risk D: Consider therapy modification

Thiazide Diuretics: May decrease the excretion of Calcium Salts. Continued concomitant use can also result in metabolic alkalosis. Risk C: Monitor therapy

Thyroid Products: Calcium Salts may diminish the therapeutic effect of Thyroid Products. Management: Separate the doses of the thyroid product and the oral calcium supplement by at least 4 hours. Risk D: Consider therapy modification

Trientine: Calcium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum concentration of Calcium Salts. Risk D: Consider therapy modification

Patient information: Anaphylaxis symptoms and diagnosis

ANAPHYLAXIS OVERVIEW — Anaphylaxis is a potentially deadly allergic reaction that is rapid in onset. It is most often triggered by foods, medications, and insect stings. There are many other possible triggers.

Anaphylaxis is an unpredictable condition. Many people who experience it have a known allergy and some have had one or more milder allergic reactions previously. Others, who are not even aware that they have an allergy, can suddenly experience severe anaphylaxis. Even the first episode of anaphylaxis can be fatal.

The severity of anaphylactic reactions can be minimized by recognizing the symptoms early, having proper medication available for self-treatment, and seeking emergency medical care promptly. This topic reviews the symptoms and diagnosis of anaphylaxis. Treatment and prevention of anaphylaxis are discussed separately. A separate topic discusses how to use an epinephrine autoinjector. (See "Patient information: Anaphylaxis treatment and prevention" and see "Patient information: Use of an epinephrine autoinjector").

ANAPHYLAXIS SYMPTOMS — Symptoms of anaphylaxis generally begin within minutes to an hour of exposure to a trigger. Less commonly, symptoms do not develop for several hours.

The most common symptoms of anaphylaxis are hives (urticaria) and swelling of the skin (angioedema), which occur in 80 to 90 percent of reactions. Respiratory symptoms occur in about 50 percent of reactions, and are especially common in people who also have asthma or another chronic respiratory disease. Extremely low blood pressure, causing lightheadedness, dizziness, blurred vision, or loss of consciousness (passing out) occurs in about 30 percent of reactions.

Anaphylaxis can cause symptoms throughout the body: Skin: Itching, flushing, hives (urticaria), or swelling (angioedema) Eyes: Itching, tearing, redness, or swelling of the skin around the eyes Nose and mouth: Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste Lungs and throat: Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking Heart and circulation: Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure Digestive system: Nausea, vomiting, abdominal cramps, or diarrhea Nervous system: Anxiety, confusion, or a sense of impending doom

A severe form of anaphylaxis causes sudden collapse without other obvious symptoms, such as hives or flushing. This form of anaphylaxis occurs most commonly after a person is given a medication into a vein or is stung by an insect.

Up to 20 percent of people with anaphylaxis have biphasic (two-phase) or protracted (prolonged) anaphylaxis. A person with biphasic anaphylaxis has a reaction that resolves and then recurs hours later without further exposure to the trigger. The late phase reaction usually occurs within eight hours, but may occur up to 72 hours after the initial symptoms. A person with protracted anaphylaxis has signs and symptoms that persist for hours or even days despite treatment, although this is rare.

ANAPHYLAXIS TRIGGERS — The trigger for a person's anaphylaxis may be obvious or it may be difficult to identify.

Common anaphylaxis triggers can include: Foods: In children, hen's eggs, cow's milk, peanuts, tree nuts, fish, wheat, and soy are the most common food triggers.

In teens and adults, peanuts, tree nuts, fish, and crustaceans (shellfish such as shrimp) are the most common triggers.

Any food, including fruits and vegetables, and some spices and food additives, can cause anaphylaxis. Medications, especially certain antibiotics (such as penicillin or amoxicillin), medications for pain and fever (such as aspirin or ibuprofen), some x-ray dyes (also called radiocontrast media), and others Venom from insects, including bees, hornets, wasps, and fire ants Latex from natural rubber, found in some latex gloves, balloons, condoms, sports equipment, and medical products Allergen immunotherapy ("allergy shots"), such as those given for the treatment of allergic rhinitis (hay fever) Exercise, either by itself, or after eating certain foods (eg, wheat, celery, seafood), medications (eg, aspirin), or exposure to cold air/water Less common triggers include exposure to airborne allergens (such as horse dander), human seminal fluid, and cold temperatures.

Sometimes a specific trigger cannot be identified, even after a thorough evaluation. This condition is called idiopathic anaphylaxis. (See "Patient information: Anaphylaxis treatment and prevention").

IgE mediated anaphylaxis — In most people, anaphylaxis is caused by the presence of proteins called immunoglobulin E (IgE) antibodies. IgE antibodies are normally produced in the body for the purpose of fighting certain infections. In people with allergies, however, IgE is made in response to non-infectious substances, such as foods, medications, or insect venoms. This IgE then sticks to the outside of mast cells and basophils, a type of white blood cell.

If a person with IgE antibodies to a specific allergen is exposed to that allergen again, the cells may suddenly become activated. The activated cells release large amounts of inflammation-causing chemicals (including histamine) into the blood stream, causing anaphylaxis.

The chemicals released from the cells cause the signs and symptoms typical of anaphylaxis. (See "Anaphylaxis symptoms" above). The allergic reaction can be so strong that it becomes life-threatening; for example, sudden severe swelling in the throat can lead to suffocation.

In some people with anaphylaxis, the reaction is caused by a process that does not involve allergens and IgE. However, the symptoms and treatment are the same.

ANAPHYLAXIS RISK FACTORS — Some people are more likely than others to experience anaphylaxis or to develop severe symptoms during anaphylaxis, for example, those who have one or more of the following: Previous sudden severe allergic reaction involving the whole body — People who have had allergic reactions to a particular substance in the past are at increased risk of anaphylaxis. However, the severity of past allergic reactions does not reliably predict the severity of future reactions; people with mild reactions in the past may experience severe anaphylactic reactions in the future. Asthma — People with asthma are more likely to have more severe respiratory problems during anaphylaxis. The combination of food allergy (especially to peanuts and tree nuts) and asthma seems to put people at risk for life-threatening episodes of anaphylaxis. Other diseases — People with chronic lung disease, especially older adults with chronic obstructive pulmonary disease (COPD) or emphysema, are at increased risk of complications during an anaphylactic reaction. People with coronary artery disease and other heart diseases are also at greater risk of developing complications during an anaphylactic reaction.

ANAPHYLAXIS DIAGNOSIS — The diagnosis of anaphylaxis is based upon symptoms that occur suddenly after being exposed to a potential trigger, such as a food, medication, or insect sting.

Is it anaphylaxis or another problem? — A number of other heath problems can cause symptoms that are similar to those of anaphylaxis. These include a severe asthma attack, a heart attack, a panic attack, or even food poisoning. Evaluation by a specialist can help to clarify the diagnosis.

Tryptase is a protein that is released into the blood during an anaphylactic reaction. An increased amount of tryptase can sometimes be measured in a blood sample collected during the first three hours after anaphylaxis symptoms have begun. Unfortunately, tryptase levels are normal in many people with anaphylactic reactions. For example, it is seldom elevated in food-induced anaphylaxis

Patient information: Anaphylaxis symptoms and diagnosis

ANAPHYLAXIS OVERVIEW — Anaphylaxis is a potentially deadly allergic reaction that is rapid in onset. It is most often triggered by foods, medications, and insect stings. There are many other possible triggers.

Anaphylaxis is an unpredictable condition. Many people who experience it have a known allergy and some have had one or more milder allergic reactions previously. Others, who are not even aware that they have an allergy, can suddenly experience severe anaphylaxis. Even the first episode of anaphylaxis can be fatal.

The severity of anaphylactic reactions can be minimized by recognizing the symptoms early, having proper medication available for self-treatment, and seeking emergency medical care promptly. This topic reviews the symptoms and diagnosis of anaphylaxis. Treatment and prevention of anaphylaxis are discussed separately. A separate topic discusses how to use an epinephrine autoinjector. (See "Patient information: Anaphylaxis treatment and prevention" and see "Patient information: Use of an epinephrine autoinjector").

ANAPHYLAXIS SYMPTOMS — Symptoms of anaphylaxis generally begin within minutes to an hour of exposure to a trigger. Less commonly, symptoms do not develop for several hours.

The most common symptoms of anaphylaxis are hives (urticaria) and swelling of the skin (angioedema), which occur in 80 to 90 percent of reactions. Respiratory symptoms occur in about 50 percent of reactions, and are especially common in people who also have asthma or another chronic respiratory disease. Extremely low blood pressure, causing lightheadedness, dizziness, blurred vision, or loss of consciousness (passing out) occurs in about 30 percent of reactions.

Anaphylaxis can cause symptoms throughout the body: Skin: Itching, flushing, hives (urticaria), or swelling (angioedema) Eyes: Itching, tearing, redness, or swelling of the skin around the eyes Nose and mouth: Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste Lungs and throat: Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking Heart and circulation: Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure Digestive system: Nausea, vomiting, abdominal cramps, or diarrhea Nervous system: Anxiety, confusion, or a sense of impending doom

A severe form of anaphylaxis causes sudden collapse without other obvious symptoms, such as hives or flushing. This form of anaphylaxis occurs most commonly after a person is given a medication into a vein or is stung by an insect.

Up to 20 percent of people with anaphylaxis have biphasic (two-phase) or protracted (prolonged) anaphylaxis. A person with biphasic anaphylaxis has a reaction that resolves and then recurs hours later without further exposure to the trigger. The late phase reaction usually occurs within eight hours, but may occur up to 72 hours after the initial symptoms. A person with protracted anaphylaxis has signs and symptoms that persist for hours or even days despite treatment, although this is rare.

ANAPHYLAXIS TRIGGERS — The trigger for a person's anaphylaxis may be obvious or it may be difficult to identify.

Common anaphylaxis triggers can include: Foods: In children, hen's eggs, cow's milk, peanuts, tree nuts, fish, wheat, and soy are the most common food triggers.

In teens and adults, peanuts, tree nuts, fish, and crustaceans (shellfish such as shrimp) are the most common triggers.

Any food, including fruits and vegetables, and some spices and food additives, can cause anaphylaxis. Medications, especially certain antibiotics (such as penicillin or amoxicillin), medications for pain and fever (such as aspirin or ibuprofen), some x-ray dyes (also called radiocontrast media), and others Venom from insects, including bees, hornets, wasps, and fire ants Latex from natural rubber, found in some latex gloves, balloons, condoms, sports equipment, and medical products Allergen immunotherapy ("allergy shots"), such as those given for the treatment of allergic rhinitis (hay fever) Exercise, either by itself, or after eating certain foods (eg, wheat, celery, seafood), medications (eg, aspirin), or exposure to cold air/water Less common triggers include exposure to airborne allergens (such as horse dander), human seminal fluid, and cold temperatures.

Sometimes a specific trigger cannot be identified, even after a thorough evaluation. This condition is called idiopathic anaphylaxis. (See "Patient information: Anaphylaxis treatment and prevention").

IgE mediated anaphylaxis — In most people, anaphylaxis is caused by the presence of proteins called immunoglobulin E (IgE) antibodies. IgE antibodies are normally produced in the body for the purpose of fighting certain infections. In people with allergies, however, IgE is made in response to non-infectious substances, such as foods, medications, or insect venoms. This IgE then sticks to the outside of mast cells and basophils, a type of white blood cell.

If a person with IgE antibodies to a specific allergen is exposed to that allergen again, the cells may suddenly become activated. The activated cells release large amounts of inflammation-causing chemicals (including histamine) into the blood stream, causing anaphylaxis.

The chemicals released from the cells cause the signs and symptoms typical of anaphylaxis. (See "Anaphylaxis symptoms" above). The allergic reaction can be so strong that it becomes life-threatening; for example, sudden severe swelling in the throat can lead to suffocation.

In some people with anaphylaxis, the reaction is caused by a process that does not involve allergens and IgE. However, the symptoms and treatment are the same.

ANAPHYLAXIS RISK FACTORS — Some people are more likely than others to experience anaphylaxis or to develop severe symptoms during anaphylaxis, for example, those who have one or more of the following: Previous sudden severe allergic reaction involving the whole body — People who have had allergic reactions to a particular substance in the past are at increased risk of anaphylaxis. However, the severity of past allergic reactions does not reliably predict the severity of future reactions; people with mild reactions in the past may experience severe anaphylactic reactions in the future. Asthma — People with asthma are more likely to have more severe respiratory problems during anaphylaxis. The combination of food allergy (especially to peanuts and tree nuts) and asthma seems to put people at risk for life-threatening episodes of anaphylaxis. Other diseases — People with chronic lung disease, especially older adults with chronic obstructive pulmonary disease (COPD) or emphysema, are at increased risk of complications during an anaphylactic reaction. People with coronary artery disease and other heart diseases are also at greater risk of developing complications during an anaphylactic reaction.

ANAPHYLAXIS DIAGNOSIS — The diagnosis of anaphylaxis is based upon symptoms that occur suddenly after being exposed to a potential trigger, such as a food, medication, or insect sting.

Is it anaphylaxis or another problem? — A number of other heath problems can cause symptoms that are similar to those of anaphylaxis. These include a severe asthma attack, a heart attack, a panic attack, or even food poisoning. Evaluation by a specialist can help to clarify the diagnosis.

Tryptase is a protein that is released into the blood during an anaphylactic reaction. An increased amount of tryptase can sometimes be measured in a blood sample collected during the first three hours after anaphylaxis symptoms have begun. Unfortunately, tryptase levels are normal in many people with anaphylactic reactions. For example, it is seldom elevated in food-induced anaphylaxis

Patient information: Allergy to penicillin and related antibiotics

PENICILLIN ALLERGY OVERVIEW — Serious allergies to penicillin are common, with about 10 percent of people reporting an allergy. However, about 90 percent of people who believe they are allergic can take penicillin without a problem, either because they were never truly allergic or because their allergy to penicillin diminished and resolved over time.

People who have a remote history of allergic reaction to a medication may become less allergic as time passes. Only about 20 percent of people will be allergic to penicillin 10 years after their initial allergic reaction if they are not exposed to it again during this time period.

WHAT IS PENICILLIN? — Penicillin is one of the most commonly prescribed antibiotics. It is part of a family of antibiotics known as beta lactams. Penicillins can be classified into the following categories: Penicillin G (also known as benzylpenicillin) Anti-staphylococcal penicillins (nafcillin, oxacillin, cloxacillin and dicloxacillin) Broad spectrum penicillins

- Second generation (ampicillin, amoxicillin and related agents)
- Third generation (carbenicillin and ticarcillin)
- Fourth generation (piperacillin)


Anyone who is allergic to one of the penicillins is allergic to all penicillins. One of the major differences among the penicillins is the range of bacteria against which they are active. Penicillin G and the anti-staphylococcal penicillins treat a small number of specific bacteria. On the other hand, the second, third, and fourth generation penicillins are capable of treating a wide range of bacteria, and are therefore called "broad spectrum".

REACTIONS TO PENICILLIN — A variety of unexpected reactions can occur after taking penicillin.

Adverse reactions — "Adverse reaction" is the medical term for any undesirable reaction caused by a medication. Allergic adverse reactions are less common than non-allergic adverse reactions. Stomach upset and diarrhea are examples of non-allergic adverse reactions.

It is important to distinguish non-allergic adverse reactions from true allergic reactions. Some people report that they are allergic to penicillin when actually they have had a non-allergic side effect. As a result, the person may be treated for a particular infection with a less-effective or more toxic antibiotic. This can lead to antibiotic failure or resistance, which can be costly and prolong illness.

When reporting past problems with antibiotics, it is important to provide as much detail as possible about the reaction. Anyone who is uncertain if a past allergic reaction was truly caused by allergy should avoid the antibiotic until they have discussed the situation with their healthcare provider.

Rashes — Several different types of rashes can appear while people are taking penicillin. Rashes that involve hives (raised, intensely itchy spots that come and go over hours, show picture 1) suggest a true allergy.

However, some people, especially young children, can develop flat, blotchy rashes that spread over days but do not change by the hour (show picture 2). These rashes typically start after several days of treatment. This type of rash is less likely to indicate a dangerous allergy, although it can be difficult to distinguish between different types of rashes that occurred in the past. Taking a photograph of a rash is always helpful.

Allergic reactions — An allergic reaction occurs when the immune system begins to recognize a drug as something "foreign". Several different symptoms can indicate that a person is allergic to penicillin. These include hives (raised, intensely itchy spots that come and go over hours) (show picture 1), angioedema (swelling of the tissue under the skin, commonly around the face), wheezing and coughing from asthma-like reactions (narrowing of the airways into the lungs).

A past history of these types of reactions is important because the person might develop a more severe reaction, such as anaphylaxis, if they were to take the antibiotic again. Mild to moderate allergic reactions to penicillins are common, occurring in 1 to 5 percent of people.

Anaphylaxis — Anaphylaxis is a sudden, potentially life-threatening allergic reaction. Symptoms include those of an allergic reaction, as well as very low blood pressure, difficulty breathing, abdominal pain, swelling of the throat or tongue, and/or diarrhea or vomiting. Fortunately, anaphylaxis is uncommon. (See "Patient information: Anaphylaxis symptoms and diagnosis").

PENICILLIN ALLERGY TESTING — In some situations, it is necessary to determine with certainty if a person is allergic to penicillin. Testing for allergy is recommended in the following situations: People who have a suspected penicillin (or closely related antibiotic) allergy and require penicillin to treat a life-threatening condition for which no alternate antibiotic is appropriate. People who have frequent infections but have suspected allergies to many antibiotics, leaving few options for treatment. Penicillin skin testing is suggested for anyone with a history of penicillin allergy (when penicillin skin test solutions become commercially available again). Because 90 percent of people will test negative, this type of evaluation can decrease medical costs and reduce the use of unnecessarily strong (ie, broad-spectrum) antibiotics.

Penicillin skin testing does not provide any information about certain types of reactions. This includes anyone who has experienced a severe reaction with extensive blistering and peeling of the skin (Stevens-Johnson syndrome or toxic epidermal necrolysis), a widespread sunburn-like reaction that later peeled (erythroderma), or a rash composed of small bulls-eyes or target-like spots (erythema multiforme),
People with these types of reactions should never again be given the medication that caused the reaction. This applies to all situations since a second exposure could cause a severe progressive reaction and even death.

Skin testing — Skin testing is the most reliable method to determine the risk of a serious, sudden onset allergic reaction in a person with a history of allergy to penicillin.

Several different types of penicillin preparations are required for skin testing. These preparations can be manufactured commercially but are not currently available in the United States. Thus, the most reliable type of skin testing for penicillin allergy cannot be performed in the United States at this time. It is expected that the preparations will be available again within the next 12 to 24 months.

Until skin tests are available, options for people who may be allergic to penicillin include: Take an different antibiotic Undergo a challenge test (See "Challenge testing" below) Undergo desensitization (See "Penicillin desensitization" below)

Skin testing procedure — Skin testing should be done by an allergist in an office or hospital setting. Testing usually takes less than one hour to complete. The skin is pricked with weak solutions of the various preparations of penicillin and observed for a reaction. This may cause discomfort due to itching, but it is not painful. If there is no skin reaction, slightly stronger solutions are then used.

A positive skin reaction is an itchy, red bump that lasts about half an hour and then resolves. The testing is stopped if a skin reaction occurs since this indicates that the person is truly allergic.

If the patient completes the skin testing without a positive reaction, a single oral dose of full strength penicillin is commonly given. This confirms that the patient does not have an allergy to the medication. The oral dose is given since there is a very small risk of false negative results (when the skin test is negative although the person is actually allergic).

Interpreting results — Medical tests, including skin testing, are rarely 100 percent accurate. Most people with a positive penicillin skin test will experience an allergic reaction if given penicillin or a related antibiotic (as would be expected). However, 3 percent or less of people with a history of penicillin allergy and a negative skin test will experience an allergic reaction. These reactions are always mild, and anaphylaxis in this situation is rare.

If a person has a negative skin test and has no reaction to an oral dose of the antibiotic, no future precautions are necessary.

Challenge testing — Because skin testing is not currently available in many places, a healthcare provider may recommend a challenge test. However, this is only recommended if the person requires penicillin, no other antibiotic is available, and the chances of a true allergy are small (eg, last reaction was at least 10 years ago or allergic reaction symptoms not likely caused by true allergy). If the chances of a true allergy are high, desensitization is generally recommended.

Challenge testing is usually done in an office setting, starting with a very small dose of the antibiotic given by mouth. If the person tolerates the smallest dose, a larger dose is given every 30 to 60 minutes until he/she has signs of an allergic reaction or the full dose is given. If the person tolerates the full dose, he or she is not allergic to the antibiotic.

PENICILLIN DESENSITIZATION — Desensitization can be done for people who are truly allergic to penicillin but require treatment with it or a closely related antibiotic. Desensitization refers to a process of giving a medication in a controlled and gradual manner, which allows the person to tolerate it temporarily without an allergic reaction.

Technique — Desensitization can be performed with oral or intravenous medications, but should always be performed by an allergy specialist. There are different techniques for desensitization. Some patients undergo desensitization in an outpatient clinic under supervision while others are treated in an intensive care unit.

Limitations — While usually successful, desensitization has two important limitations. Desensitization does not work and must never be attempted for certain types of reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis, erythroderma, and erythema multiforme). Desensitization also does not work for other types of immunologic reactions to antibiotics, such as serum sickness, drug fever, or hemolytic anemia. Desensitization is temporary. A person is unlikely to have an allergic reaction to the medication during treatment, after undergoing desensitization, as long as the antibiotic is taken regularly. However, once the antibiotic is stopped for more than 24 hours (times differ slightly for different medications), the person is again at risk for a sudden allergic reaction. Repeat desensitization is required if the same medication is needed again.

OTHER ANTIBIOTIC ALLERGIES — Reliable skin tests are not commercially available for some antibiotics. Thus, determining if a person has an allergy to these antibiotics is more difficult, and is mostly based on the history of the reaction. Skin testing with other antibiotics is sometimes performed, but the results are much less certain than those of penicillin testing.

Cephalosporins — Cephalosporins are a class of antibiotics closely related to penicillin. There are a number of cephalosporin medications available, a few of which include cephalexin (Keflex®), cefaclor (Ceclor®), cefuroxime (Ceftin®), cefadroxil (Duricef®) , cephradine (Velocef®). cefprozil (Cefzil®), loracarbef (Lorabid®), ceftibuten (Cedax®), cefdinir (Omnicef®), cefditoren (Spectracef®), cefpodoxime (Vantin®) and cefixime (Suprax®).

People with a history of penicillin allergy have a small risk of having an allergic reaction to cephalosporins. If possible, penicillin skin testing should be performed in these individuals. Since testing will be negative in about 90 percent of these people, a negative test will allow them to take cephalosporins safely. People with a positive skin test to penicillin have a small risk of an allergic reaction to cephalosporins and may require more caution in terms of how the cephalosporin is administered.

Allergic reactions to cephalosporins are less common than reactions to penicillin. In addition, skin testing to evaluate cephalosporin allergy is not as accurate as penicillin skin testing. If a cephalosporin is required, then there are several options: Take an different antibiotic Undergo a challenge test (See "Challenge testing" above) Undergo desensitization (See "Penicillin desensitization" above)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient information: Allergy to penicillin and related antibiotics

PENICILLIN ALLERGY OVERVIEW — Serious allergies to penicillin are common, with about 10 percent of people reporting an allergy. However, about 90 percent of people who believe they are allergic can take penicillin without a problem, either because they were never truly allergic or because their allergy to penicillin diminished and resolved over time.

People who have a remote history of allergic reaction to a medication may become less allergic as time passes. Only about 20 percent of people will be allergic to penicillin 10 years after their initial allergic reaction if they are not exposed to it again during this time period.

WHAT IS PENICILLIN? — Penicillin is one of the most commonly prescribed antibiotics. It is part of a family of antibiotics known as beta lactams. Penicillins can be classified into the following categories: Penicillin G (also known as benzylpenicillin) Anti-staphylococcal penicillins (nafcillin, oxacillin, cloxacillin and dicloxacillin) Broad spectrum penicillins

- Second generation (ampicillin, amoxicillin and related agents)
- Third generation (carbenicillin and ticarcillin)
- Fourth generation (piperacillin)


Anyone who is allergic to one of the penicillins is allergic to all penicillins. One of the major differences among the penicillins is the range of bacteria against which they are active. Penicillin G and the anti-staphylococcal penicillins treat a small number of specific bacteria. On the other hand, the second, third, and fourth generation penicillins are capable of treating a wide range of bacteria, and are therefore called "broad spectrum".

REACTIONS TO PENICILLIN — A variety of unexpected reactions can occur after taking penicillin.

Adverse reactions — "Adverse reaction" is the medical term for any undesirable reaction caused by a medication. Allergic adverse reactions are less common than non-allergic adverse reactions. Stomach upset and diarrhea are examples of non-allergic adverse reactions.

It is important to distinguish non-allergic adverse reactions from true allergic reactions. Some people report that they are allergic to penicillin when actually they have had a non-allergic side effect. As a result, the person may be treated for a particular infection with a less-effective or more toxic antibiotic. This can lead to antibiotic failure or resistance, which can be costly and prolong illness.

When reporting past problems with antibiotics, it is important to provide as much detail as possible about the reaction. Anyone who is uncertain if a past allergic reaction was truly caused by allergy should avoid the antibiotic until they have discussed the situation with their healthcare provider.

Rashes — Several different types of rashes can appear while people are taking penicillin. Rashes that involve hives (raised, intensely itchy spots that come and go over hours, show picture 1) suggest a true allergy.

However, some people, especially young children, can develop flat, blotchy rashes that spread over days but do not change by the hour (show picture 2). These rashes typically start after several days of treatment. This type of rash is less likely to indicate a dangerous allergy, although it can be difficult to distinguish between different types of rashes that occurred in the past. Taking a photograph of a rash is always helpful.

Allergic reactions — An allergic reaction occurs when the immune system begins to recognize a drug as something "foreign". Several different symptoms can indicate that a person is allergic to penicillin. These include hives (raised, intensely itchy spots that come and go over hours) (show picture 1), angioedema (swelling of the tissue under the skin, commonly around the face), wheezing and coughing from asthma-like reactions (narrowing of the airways into the lungs).

A past history of these types of reactions is important because the person might develop a more severe reaction, such as anaphylaxis, if they were to take the antibiotic again. Mild to moderate allergic reactions to penicillins are common, occurring in 1 to 5 percent of people.

Anaphylaxis — Anaphylaxis is a sudden, potentially life-threatening allergic reaction. Symptoms include those of an allergic reaction, as well as very low blood pressure, difficulty breathing, abdominal pain, swelling of the throat or tongue, and/or diarrhea or vomiting. Fortunately, anaphylaxis is uncommon. (See "Patient information: Anaphylaxis symptoms and diagnosis").

PENICILLIN ALLERGY TESTING — In some situations, it is necessary to determine with certainty if a person is allergic to penicillin. Testing for allergy is recommended in the following situations: People who have a suspected penicillin (or closely related antibiotic) allergy and require penicillin to treat a life-threatening condition for which no alternate antibiotic is appropriate. People who have frequent infections but have suspected allergies to many antibiotics, leaving few options for treatment. Penicillin skin testing is suggested for anyone with a history of penicillin allergy (when penicillin skin test solutions become commercially available again). Because 90 percent of people will test negative, this type of evaluation can decrease medical costs and reduce the use of unnecessarily strong (ie, broad-spectrum) antibiotics.

Penicillin skin testing does not provide any information about certain types of reactions. This includes anyone who has experienced a severe reaction with extensive blistering and peeling of the skin (Stevens-Johnson syndrome or toxic epidermal necrolysis), a widespread sunburn-like reaction that later peeled (erythroderma), or a rash composed of small bulls-eyes or target-like spots (erythema multiforme),
People with these types of reactions should never again be given the medication that caused the reaction. This applies to all situations since a second exposure could cause a severe progressive reaction and even death.

Skin testing — Skin testing is the most reliable method to determine the risk of a serious, sudden onset allergic reaction in a person with a history of allergy to penicillin.

Several different types of penicillin preparations are required for skin testing. These preparations can be manufactured commercially but are not currently available in the United States. Thus, the most reliable type of skin testing for penicillin allergy cannot be performed in the United States at this time. It is expected that the preparations will be available again within the next 12 to 24 months.

Until skin tests are available, options for people who may be allergic to penicillin include: Take an different antibiotic Undergo a challenge test (See "Challenge testing" below) Undergo desensitization (See "Penicillin desensitization" below)

Skin testing procedure — Skin testing should be done by an allergist in an office or hospital setting. Testing usually takes less than one hour to complete. The skin is pricked with weak solutions of the various preparations of penicillin and observed for a reaction. This may cause discomfort due to itching, but it is not painful. If there is no skin reaction, slightly stronger solutions are then used.

A positive skin reaction is an itchy, red bump that lasts about half an hour and then resolves. The testing is stopped if a skin reaction occurs since this indicates that the person is truly allergic.

If the patient completes the skin testing without a positive reaction, a single oral dose of full strength penicillin is commonly given. This confirms that the patient does not have an allergy to the medication. The oral dose is given since there is a very small risk of false negative results (when the skin test is negative although the person is actually allergic).

Interpreting results — Medical tests, including skin testing, are rarely 100 percent accurate. Most people with a positive penicillin skin test will experience an allergic reaction if given penicillin or a related antibiotic (as would be expected). However, 3 percent or less of people with a history of penicillin allergy and a negative skin test will experience an allergic reaction. These reactions are always mild, and anaphylaxis in this situation is rare.

If a person has a negative skin test and has no reaction to an oral dose of the antibiotic, no future precautions are necessary.

Challenge testing — Because skin testing is not currently available in many places, a healthcare provider may recommend a challenge test. However, this is only recommended if the person requires penicillin, no other antibiotic is available, and the chances of a true allergy are small (eg, last reaction was at least 10 years ago or allergic reaction symptoms not likely caused by true allergy). If the chances of a true allergy are high, desensitization is generally recommended.

Challenge testing is usually done in an office setting, starting with a very small dose of the antibiotic given by mouth. If the person tolerates the smallest dose, a larger dose is given every 30 to 60 minutes until he/she has signs of an allergic reaction or the full dose is given. If the person tolerates the full dose, he or she is not allergic to the antibiotic.

PENICILLIN DESENSITIZATION — Desensitization can be done for people who are truly allergic to penicillin but require treatment with it or a closely related antibiotic. Desensitization refers to a process of giving a medication in a controlled and gradual manner, which allows the person to tolerate it temporarily without an allergic reaction.

Technique — Desensitization can be performed with oral or intravenous medications, but should always be performed by an allergy specialist. There are different techniques for desensitization. Some patients undergo desensitization in an outpatient clinic under supervision while others are treated in an intensive care unit.

Limitations — While usually successful, desensitization has two important limitations. Desensitization does not work and must never be attempted for certain types of reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis, erythroderma, and erythema multiforme). Desensitization also does not work for other types of immunologic reactions to antibiotics, such as serum sickness, drug fever, or hemolytic anemia. Desensitization is temporary. A person is unlikely to have an allergic reaction to the medication during treatment, after undergoing desensitization, as long as the antibiotic is taken regularly. However, once the antibiotic is stopped for more than 24 hours (times differ slightly for different medications), the person is again at risk for a sudden allergic reaction. Repeat desensitization is required if the same medication is needed again.

OTHER ANTIBIOTIC ALLERGIES — Reliable skin tests are not commercially available for some antibiotics. Thus, determining if a person has an allergy to these antibiotics is more difficult, and is mostly based on the history of the reaction. Skin testing with other antibiotics is sometimes performed, but the results are much less certain than those of penicillin testing.

Cephalosporins — Cephalosporins are a class of antibiotics closely related to penicillin. There are a number of cephalosporin medications available, a few of which include cephalexin (Keflex®), cefaclor (Ceclor®), cefuroxime (Ceftin®), cefadroxil (Duricef®) , cephradine (Velocef®). cefprozil (Cefzil®), loracarbef (Lorabid®), ceftibuten (Cedax®), cefdinir (Omnicef®), cefditoren (Spectracef®), cefpodoxime (Vantin®) and cefixime (Suprax®).

People with a history of penicillin allergy have a small risk of having an allergic reaction to cephalosporins. If possible, penicillin skin testing should be performed in these individuals. Since testing will be negative in about 90 percent of these people, a negative test will allow them to take cephalosporins safely. People with a positive skin test to penicillin have a small risk of an allergic reaction to cephalosporins and may require more caution in terms of how the cephalosporin is administered.

Allergic reactions to cephalosporins are less common than reactions to penicillin. In addition, skin testing to evaluate cephalosporin allergy is not as accurate as penicillin skin testing. If a cephalosporin is required, then there are several options: Take an different antibiotic Undergo a challenge test (See "Challenge testing" above) Undergo desensitization (See "Penicillin desensitization" above)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Barbados Cherry

The Barbados cherry, a member of the Malpighiaceae, is an interesting example of a fruit that rose, like Cinderella, from relative obscurity about 40 years ago. It was at that time the subject of much taxonomic confusion, having been described and discussed previously under the binomial Malpighia glabra L., which properly belongs to a wild relative inhabiting the West Indies, tropical America and the lowlands of Mexico to southern Texas, and having smaller, pointed leaves, smaller flowers in peduncled umbels, styles nearly equal, and smaller fruits. M. Punicifolia L. (M. glabra Millsp. NOT Linn.) has been generally approved as the correct botanical name for the Barbados cherry, which is also called West Indian cherry, native cherry, garden cherry, French cherry; in Spanish, acerola, cereza, cereza colorada, cereza de la sabana, or grosella; in French, cerisier, cerise de St. Domingue; in Portuguese, cerejeira. The name in Venezuela is semeruco, or cemeruco; in the Netherlands Antilles, shimarucu; in the Philippines, malpi (an abbreviation of the generic name).

Plate XXV: BARBADOS CHERRY, Malpighia punicifolia

Description

The Barbados cherry is a large, bushy shrub or small tree attaining up to 20 ft (6 m) in height and an equal breadth; with more or less erect or spreading and drooping, minutely hairy branches, and a short trunk to 4 in (10 cm) in diameter. Its evergreen leaves are elliptic, oblong, obovate, or narrowly oblanceolate, somewhat wavy, 3/4 to 2 3/4 in (2-7 cm) long, 3/8 to 1 5/8 in (9.5-40 mm) wide, obtuse or rounded at the apex, acute or cuneate at the base; bearing white, silky, irritating hairs when very young; hairless, dark green, and glossy when mature. The flowers, in sessile or short-peduncled cymes, have 5 pink or lavender, spoon-shaped, fringed petals. The fruits, borne singly or in 2's or 3's in the leaf axils, are oblate to round, cherry-like but more or less obviously 3-lobed; 1/2 to 1 in (1.25-2.5 cm) wide; bright-red, with thin, glossy skin and orange-colored, very juicy, acid to subacid, pulp. The 3 small, rounded seeds each have 2 large and 1 small fluted wings, thus forming what are generally conceived to be 3 triangular, yellowish, leathery-coated, corrugated inedible "stones".

Origin and Distribution

The Barbados cherry is native to the Lesser Antilles from St. Croix to Trinidad, also Curacao and Margarita and neighboring northern South America as far south as Brazil. It has become naturalized in Cuba, Jamaica and Puerto Rico after cultivation, and is commonly grown in dooryards in the Bahamas and Bermuda, and to some extent in Central and South America.

The plant is thought to have been first brought to Florida from Cuba by Pliny Reasoner because it appeared in the catalog of the Royal Palm Nursery for 1887-1888. It was carried abroad rather early for it is known to have borne fruit for the first time in the Philippines in 1916. In 1917, H.M. Curran brought seeds from Curacao to the United States Department of Agriculture. (S.P.I. #44458). The plant was casually grown in southern and central Florida until after World War II when it became more commonly planted. In Puerto Rico, just prior to that war, the Federal Soil Conservation Department planted Barbados cherry trees to control erosion on terraces at the Rio Piedras Experiment Station. During the war, 312 seedlings from the trees with the largest and most agreeably-flavored fruits were distributed to families to raise in their Victory Gardens. Later, several thousand trees were provided for planting in school yards to increase the vitamin intake of children, who are naturally partial to the fruits.

An explosion of interest occurred as a result of some food analyses being conducted at the School of Medicine, University of Puerto Rico, in Rio Piedras in 1945. The emblic (Emblica officinalis L.) was found to be extremely high in ascorbic acid. This inspired one of the laboratory assistants to bring in some Barbados cherries which the local people were accustomed to eating when they had colds. These fruits were found to contain far more ascorbic acid than the emblic, and, because of their attractiveness and superior eating quality, interest quickly switched from the emblic to the Barbados cherry. Much publicity ensued, featuring the fruit under the Puerto Rican name of acerola. A plantation of 400 trees was established at Rio Piedras in 1947 and, from 1951 to 1953, 238 trees were set out at the Isabela Substation. By 1954, there were 30,000 trees in commercial groves on the island. Several plantings had been made in Florida and a 2,000-acre (833-ha) plantation in Hawaii. There was a great flurry of activity. Horticulturists were busy making selections of high-ascorbic-acid clones and improving methods of vegetative propagation, and agronomists were studying the effects of cultural practices. Smaller plantings were being developed in Jamaica, Venezuela, Guatemala, Ghana, India, the Philippines and Queensland, Australia, and even in Israel. Many so-called "natural food" outlets promoted various "vitamin C" products from the fruits–powder, tablets, capsules, juice, sirup.

At length, enthusiasm subsided when it was realized that a fruit could not become a superstar because of its ascorbic acid content alone; that ascorbic acid from a natural source could not economically compete with the much cheaper synthetic product, inasmuch as research proved that the ascorbic acid of the Barbados cherry is metabolized in a manner identical to the assimilation of crystalline ascorbic acid.

The large plantation of the Hawaiian Acerola Company (a subsidiary of Nutrilite Products Company) was abandoned for this reason, and low fruit yields; and, so it is said, the low ascorbic acid content because of the high copper levels in the soil. Puerto Rican production was directed thereafter mainly to the use of the fruit in specialty baby foods.

Frozen fruits are shipped to the United States for processing.

Varieties

In 1956, workers at the University of Florida's Agricultural Research and Education Center in Homestead, after making preliminary evaluations and selections, chose as superior and named the 'Florida Sweet', a clone that was observed to have an upright habit of growth, large fruits, thick skin, apple-like, semi-sweet flavor, and high yield.

The first promising selections in Puerto Rico, on the bases of fruit size, yield and vitamin content, were identified as 'A-l' and 'B-17', but these were later found to be inferior to 'B-15' in ascorbic acid level and productivity. Yields of 10 clones ('A-l', 'A-2', 'A-4', 'A-10', 'A-21', 'B-2', 'B-9', 'B-15', 'B-17', and 'K-7') were compared over a 2-year period (1955-56) in Puerto Rico and 'B-15' far exceeded the others in both years.

A horticultural variety in St. Croix, formerly known as M. thompsonii Britton & Small, has displayed unusually large leaves and fruits and more abundant flowers than the common strain of Barbados cherry.

Climate

The Barbados cherry can be classed as tropical and subtropical, for mature trees can survive brief exposure to 28º F (-2.22º C). Young plants are killed by any drop below 30º F (-1.11º C). It is naturally adapted to both medium- and low-rainfall regions; can tolerate long periods of drought, though it may not fruit until the coming of rain.

Soil

The tree does well on limestone, marl and clay, as long as they are well drained. The pH should be at least 5.5. Elevation to 6.5 significantly improves root development. Acid soils require the addition of lime to avoid calcium deficiency and increase yield. The lime should be worked into the soil to a depth of 8 in (20 cm) or more.

Propagation

If seeds are used for planting, they should be selected from desirable clones not exposed to cross-pollination by inferior types. They should be cleaned, dried, and dusted with a fungicide. It should also be realized that the seeds in an individual fruit develop unevenly and only those that are fully developed when the fruit is ripe will germinate satisfactorily. Germination rates may be only 50% or as low as 5%. Seedlings should be transferred from flats to containers when 2 to 3 in (5-7.5 cm) high.

Air-layering (in summer) and side-veneer, cleft, or modified crown grafting are feasible but not popular because it is so much easier to raise the tree from cuttings. Cuttings of branches 1/4 to 1/2 in (6-12.5 mm) thick and 8 to 10 in (20-25 cm) long, with 2 or 3 leaves attached, hormone-treated and set in sand or other suitable media under constant or intermittent mist, will root in 60 days. They are then transplanted to nursery rows or containers and held in shade for 6 months or a year before being set out in the field. Some fruits will be borne a year after planting but a good crop cannot be expected until the 3rd or 4th year. The tree will continue bearing well for about 15 years. There is a lapse of only 22 days between flowering and complete fruit maturity.

Grafting is generally practiced only when cuttings of a desired clone are scarce or if a nematode-resistant rootstock is available on which to graft a preferred cultivar; or when top-working a tree that bears fruits of low quality.

Culture

The Barbados cherry tree will grow and fruit fairly well with little care. For best performance, Puerto Rican agronomists have recommended a fertilizer formula of 8-8-13 twice annually for the first 4 years at the rate of 1/2 to 1 lb (0.22-0.45 kg). Older trees should have 3 to 5 lbs (1.35-2.25 kg) per tree. In addition, organic material should be worked into the planting hole and also supplied in amounts of 10 to 20 lbs (4.5-9 kg) per tree. Under Florida conditions, a 10-10-10 formula is given in February, 1 lb (0.22 kg) for each year of growth. In May, July and September, a 4-7-5-3 formula is recommended, 1 lb (0.22 kg) for each year of age up to the 10th year. Thereafter, a 6-4-6-3 mixture is given–5 lbs (2.25 kg) per tree in late winter and 10 lbs (4.5 kg) per tree for each of the summer feedings. On limestone soils, sprays of minor elements–copper, zinc, and sometimes manganese–will enhance growth and productivity. Young trees need regular irrigation until well established; older trees require watering only during droughts. Mature plants will bear better if thinned out by judicious pruning after the late crop and then fertilized once more.

Pollination and Fruit Set

In Florida, bees visit Barbados cherry flowers in great numbers and are the principal pollinators. Maintenance of hives near Barbados cherry trees substantially improves fruit set. In Hawaii, there was found to be very little transport of pollen by wind, and insect pollination is inadequate. Consequently, fruits are often seedless. Investigations have shown that growth regulators (IBA at 100 ppm; PCA at 50 ppm) induce much higher fruit set but these chemicals may be too costly to buy and apply.

Season

In Florida, the Bahamas, Puerto Rico and Hawaii the fruiting season varies with the weather. There may be a spring crop ripening in May and then successive small crops off and on until December, but sometimes, if spring rains are lacking, there may be no fruits at all until December and then a heavy crop. In Zanzibar, the bearing season is said to be just the months of December and January.

Harvesting

For home use, as dessert, the fruits are picked when fully ripe. For processing or preserving, they can be harvested when slightly immature, when they are turning from yellow to red. As there is continuous fruiting over long periods, picking is done every day, every other day, or every 3 days to avoid loss by falling.

The fruits are usually picked manually in the cool of the early morning, and must be handled with care. For immediate processing, some growers shake the tree and allow the ripe fruits to fall onto sheets spread on the ground. Harvested fruits should be kept in the shade until transferred from the field, which ought to be done within 3 hours, and collecting lugs are best covered with heavy canvas to retard loss of ascorbic acid.

Yield

There is great variation in productivity. Individual trees may yield 30 to 62 lbs (13.5-28 kg) in Puerto Rico. In Jamaica, maximum yield in the 6th year is about 80 lbs (36 kg) per tree; 24,000 lbs/acre (24,000 kg/ha). Venezuelan growers have reported 10 to 15 tons/ha; the average in Puerto Rico is 25 tons/ha/yr. 'Florida Sweet' in Florida has yielded 65 tons/ha. A plot of 300 trees of 'Florida Sweet' has borne crops of 6,300 to 51,300 lbs (2,858-23,270 kg) of fruit from March to November, in Homestead, Florida.

In Puerto Rico, a planting of 200 trees may be expected to produce 3,600 to 5,400 lbs (1,636-2,455 kg) of juice. From the juice there can be extracted at least 120 lbs (54.5 kg) of vitamin C expressed as dehydroascorbic and ascorbic acid, providing the content is determined to be 2%. In Puerto Rico, it is calculated that 10 tons of fruit should yield 435 lbs (197 kg) ascorbic acid. In a commercial operation using ion-exchange resins, the yield of ascorbic acid from Barbados cherry juice is expected to be about 88%.

Keeping Quality

Ripe Barbados cherries bruise easily and are highly perishable. Processors store them for no more than 3 days at 45º F (7.22º C). Half-ripe fruits can be maintained for a few more days. If longer storage is necessary, the fruits must be frozen and kept at 10º F (-12.22º C) and later thawed for use. At one time it was believed that the fruits could be transported to processing plants in water tanks (as is done with true cherries) but it was discovered that they lose their color and ascorbic acid content in water.

At room temperature–85º F (29.44º C) in Puerto Rico–canned Barbados cherries and also the juice lose color and fresh flavor and 53% to 80% of their ascorbic acid content in one month, and metal cans swell because of the development of CO₂. Refrigeration at 44.6º F (7º C) considerably reduces such deterioration. Juice in the home refrigerator will lose 20% of its ascorbic acid in 18 days. Therefore, the juice and the puree should be kept no longer than one week.

Pests and Diseases

One of the major obstacles to successful cultivation of the Barbados cherry is the tree's susceptibility to the root-knot nematode, Meloidogyne incognita var. acrita, especially in sandy acid soils. Soil fumigation, mulching and regular irrigation will help to keep this problem under control. The burrowing nematode, Radopholus similis, is also a cause of decline in otherwise healthy trees.

In Florida, the foliage is attacked by wax scale, Florida mango scale, and other scale insects, whiteflies, a leaf roller, and aphids. In Guatemala, the aphid, Aphis spiraecola, attacks the leaves and young, tender branches. This pest and the Hesperid caterpillar, Ephyriades arcas, require chemical control. In Puerto Rico, the tree is often damaged by the blue chrysomelid of acerola, Leucocera laevicollis. Some fruits may be malformed but not otherwise affected by the sting of stinkbugs. None of these predators is of any great importance.

The major pest in Florida is the Caribbean fruit fly, Anastrepha suspensa, which seems to attack all but very sour fruits and the larvae are commonly found inside. In Guatemala, a fruit worm, Anthonomus florus, deposits its eggs in the floral ovary and also in the fruits; the larvae feed in the fruits causing deformity and total ruin. Drastic control measures have been employed against this predator, including the incineration of all fallen, infested fruits and the elimination of all related species that serve as hosts.

Few diseases have been reported. However, in Florida, there are cases of anthracnose caused by Colletotrichum gloeosporioides, and leafspotting by the fungus, Cercospora bunchosiae, is a serious malady in Florida, Puerto Rico and Hawaii. Green scurf, identified with the alga, Cephaleuros virescens, occurs in Puerto Rico.

Food Uses

Barbados cherries are eaten out-of-hand, mainly by children. For dessert use, they are delicious merely stewed with whatever amount of sugar is desired to modify the acidity of the particular type available. The seeds must be separated from the pulp in the mouth and returned by spoon to the dish. Many may feel that the nuisance is compensated for by the pleasure of enjoying the flavorful pulp and juice. Other-wise, the cooked fruits must be strained to remove the seeds and the resulting sauce or puree can be utilized as a topping on cake, pudding, ice cream or sliced bananas, or used in other culinary products. Commercially prepared puree may be dried or frozen for future use. The fresh juice will prevent darkening of bananas sliced for fruit cups or salads. It can be used for gelatin desserts, punch or sherbet, and has been added as an ascorbic acid supplement to other fruit juices. The juice was dried and powdered commercially in Puerto Rico for a decade until the cost of production caused the factory to be closed down.

The fruits may be made into sirup or, with added pectin, excellent jelly, jam, and other preserves. Cooking causes the bright-red color to change to brownish-red. The pasteurization process in the canning of the juice changes the color to orange-red or yellow, and packing in tin cans brings on further color deterioration. Enamel-lined cans preserve the color better.

Wine made from Barbados cherries in Hawaii was found to retain 60% of the ascorbic acid.

Food Value Per 100 g of Edible Portion*
Calories	59
Moisture	81.9-91.10 g
Protein	0.68-1.8 g
Ether Extract	0.19-0.09 g
Fiber	0.60-1.2 g
Fat	0.18-0.1 g
Carbohydrates	6.98-14.0 g
Ash	0.77-0.82 g
Calcium	8.2-34.6 mg
Phosphorus	16.2-37.5 mg
Iron	0.17-1.11 mg
Carotene	0.003-0.408 mg
(Vitamin A)	408-1000 I.U.
Thiamine	0.024-0.040 mg
Riboflavin	0.038-0.079 mg
Niacin	0.34-0.526 mg
Ascorbic Acid**

*According to analyses made in Hawaii, Guatemala, and elsewhere.

**According to analyses at the Massachusetts Institute of Technology of fruits grown in Barbados: 4,500 mg (green), 3,300 mg (medium-ripe), 2,000 mg (very ripe). The ascorbic acid level of unripe fruits can range up to 4,676 mg and such ratings are exceeded only by the fruits (rose hips) of Rosa rugosa Thunb., which may have as much as 6,977 mg/100 g. This constituent varies as much as 25% with the clone, the locale, cultural methods and degree of exposure to sunlight during developmental stages and after harvesting. At INCAP (Instituto de Nutricion de Central America and Panama), in Guatemala assays in 1950-1955 showed distressingly low levels–an average of 17 mg/100 g, whereas fruits sent to INCAP by air and in dry ice from Florida were analyzed and contained 1,420 mg/100 g. In field experiments, treatment of young fruits on the tree with 200 ppm gibberellic acid has brought about a marked increase in the ascorbic acid content of the mature fruits.

The ascorbic acid is not totally destroyed by heat, for the jelly may contain 499-1,900 mg/100 g. Of the total ascorbic acid in Barbados cherry juice, 0.18% is in the bound form. Other constituents include dextrose, levulose, and a little sucrose.

Harmful Effects

Physicians in Curacao report that children often require treatment for intestinal inflammation and obstruction caused by eating quantities of the entire fruits, including seeds, from the wild Barbados cherries which abound on the island.

People who pick Barbados cherries without gloves and long sleeves may suffer skin irritation from contact with the minute stinging hairs on the leaves and petioles.

Other Uses

Bark: The bark of the tree contains 20-25% tannin and has been utilized in the leather industry.

Wood: The wood is surprisingly hard and heavy. Trials have demonstrated that it refuses to ignite even when treated with flammable fluid unless perfectly dry.

Medicinal Uses: The fruits are considered beneficial to patients with liver ailments, diarrhea and dysentery, as well as those with coughs or colds. The juice may be gargled to relieve sore throat.

Barbados Cherry

The Barbados cherry, a member of the Malpighiaceae, is an interesting example of a fruit that rose, like Cinderella, from relative obscurity about 40 years ago. It was at that time the subject of much taxonomic confusion, having been described and discussed previously under the binomial Malpighia glabra L., which properly belongs to a wild relative inhabiting the West Indies, tropical America and the lowlands of Mexico to southern Texas, and having smaller, pointed leaves, smaller flowers in peduncled umbels, styles nearly equal, and smaller fruits. M. Punicifolia L. (M. glabra Millsp. NOT Linn.) has been generally approved as the correct botanical name for the Barbados cherry, which is also called West Indian cherry, native cherry, garden cherry, French cherry; in Spanish, acerola, cereza, cereza colorada, cereza de la sabana, or grosella; in French, cerisier, cerise de St. Domingue; in Portuguese, cerejeira. The name in Venezuela is semeruco, or cemeruco; in the Netherlands Antilles, shimarucu; in the Philippines, malpi (an abbreviation of the generic name).

Plate XXV: BARBADOS CHERRY, Malpighia punicifolia

Description

The Barbados cherry is a large, bushy shrub or small tree attaining up to 20 ft (6 m) in height and an equal breadth; with more or less erect or spreading and drooping, minutely hairy branches, and a short trunk to 4 in (10 cm) in diameter. Its evergreen leaves are elliptic, oblong, obovate, or narrowly oblanceolate, somewhat wavy, 3/4 to 2 3/4 in (2-7 cm) long, 3/8 to 1 5/8 in (9.5-40 mm) wide, obtuse or rounded at the apex, acute or cuneate at the base; bearing white, silky, irritating hairs when very young; hairless, dark green, and glossy when mature. The flowers, in sessile or short-peduncled cymes, have 5 pink or lavender, spoon-shaped, fringed petals. The fruits, borne singly or in 2's or 3's in the leaf axils, are oblate to round, cherry-like but more or less obviously 3-lobed; 1/2 to 1 in (1.25-2.5 cm) wide; bright-red, with thin, glossy skin and orange-colored, very juicy, acid to subacid, pulp. The 3 small, rounded seeds each have 2 large and 1 small fluted wings, thus forming what are generally conceived to be 3 triangular, yellowish, leathery-coated, corrugated inedible "stones".

Origin and Distribution

The Barbados cherry is native to the Lesser Antilles from St. Croix to Trinidad, also Curacao and Margarita and neighboring northern South America as far south as Brazil. It has become naturalized in Cuba, Jamaica and Puerto Rico after cultivation, and is commonly grown in dooryards in the Bahamas and Bermuda, and to some extent in Central and South America.

The plant is thought to have been first brought to Florida from Cuba by Pliny Reasoner because it appeared in the catalog of the Royal Palm Nursery for 1887-1888. It was carried abroad rather early for it is known to have borne fruit for the first time in the Philippines in 1916. In 1917, H.M. Curran brought seeds from Curacao to the United States Department of Agriculture. (S.P.I. #44458). The plant was casually grown in southern and central Florida until after World War II when it became more commonly planted. In Puerto Rico, just prior to that war, the Federal Soil Conservation Department planted Barbados cherry trees to control erosion on terraces at the Rio Piedras Experiment Station. During the war, 312 seedlings from the trees with the largest and most agreeably-flavored fruits were distributed to families to raise in their Victory Gardens. Later, several thousand trees were provided for planting in school yards to increase the vitamin intake of children, who are naturally partial to the fruits.

An explosion of interest occurred as a result of some food analyses being conducted at the School of Medicine, University of Puerto Rico, in Rio Piedras in 1945. The emblic (Emblica officinalis L.) was found to be extremely high in ascorbic acid. This inspired one of the laboratory assistants to bring in some Barbados cherries which the local people were accustomed to eating when they had colds. These fruits were found to contain far more ascorbic acid than the emblic, and, because of their attractiveness and superior eating quality, interest quickly switched from the emblic to the Barbados cherry. Much publicity ensued, featuring the fruit under the Puerto Rican name of acerola. A plantation of 400 trees was established at Rio Piedras in 1947 and, from 1951 to 1953, 238 trees were set out at the Isabela Substation. By 1954, there were 30,000 trees in commercial groves on the island. Several plantings had been made in Florida and a 2,000-acre (833-ha) plantation in Hawaii. There was a great flurry of activity. Horticulturists were busy making selections of high-ascorbic-acid clones and improving methods of vegetative propagation, and agronomists were studying the effects of cultural practices. Smaller plantings were being developed in Jamaica, Venezuela, Guatemala, Ghana, India, the Philippines and Queensland, Australia, and even in Israel. Many so-called "natural food" outlets promoted various "vitamin C" products from the fruits–powder, tablets, capsules, juice, sirup.

At length, enthusiasm subsided when it was realized that a fruit could not become a superstar because of its ascorbic acid content alone; that ascorbic acid from a natural source could not economically compete with the much cheaper synthetic product, inasmuch as research proved that the ascorbic acid of the Barbados cherry is metabolized in a manner identical to the assimilation of crystalline ascorbic acid.

The large plantation of the Hawaiian Acerola Company (a subsidiary of Nutrilite Products Company) was abandoned for this reason, and low fruit yields; and, so it is said, the low ascorbic acid content because of the high copper levels in the soil. Puerto Rican production was directed thereafter mainly to the use of the fruit in specialty baby foods.

Frozen fruits are shipped to the United States for processing.

Varieties

In 1956, workers at the University of Florida's Agricultural Research and Education Center in Homestead, after making preliminary evaluations and selections, chose as superior and named the 'Florida Sweet', a clone that was observed to have an upright habit of growth, large fruits, thick skin, apple-like, semi-sweet flavor, and high yield.

The first promising selections in Puerto Rico, on the bases of fruit size, yield and vitamin content, were identified as 'A-l' and 'B-17', but these were later found to be inferior to 'B-15' in ascorbic acid level and productivity. Yields of 10 clones ('A-l', 'A-2', 'A-4', 'A-10', 'A-21', 'B-2', 'B-9', 'B-15', 'B-17', and 'K-7') were compared over a 2-year period (1955-56) in Puerto Rico and 'B-15' far exceeded the others in both years.

A horticultural variety in St. Croix, formerly known as M. thompsonii Britton & Small, has displayed unusually large leaves and fruits and more abundant flowers than the common strain of Barbados cherry.

Climate

The Barbados cherry can be classed as tropical and subtropical, for mature trees can survive brief exposure to 28º F (-2.22º C). Young plants are killed by any drop below 30º F (-1.11º C). It is naturally adapted to both medium- and low-rainfall regions; can tolerate long periods of drought, though it may not fruit until the coming of rain.

Soil

The tree does well on limestone, marl and clay, as long as they are well drained. The pH should be at least 5.5. Elevation to 6.5 significantly improves root development. Acid soils require the addition of lime to avoid calcium deficiency and increase yield. The lime should be worked into the soil to a depth of 8 in (20 cm) or more.

Propagation

If seeds are used for planting, they should be selected from desirable clones not exposed to cross-pollination by inferior types. They should be cleaned, dried, and dusted with a fungicide. It should also be realized that the seeds in an individual fruit develop unevenly and only those that are fully developed when the fruit is ripe will germinate satisfactorily. Germination rates may be only 50% or as low as 5%. Seedlings should be transferred from flats to containers when 2 to 3 in (5-7.5 cm) high.

Air-layering (in summer) and side-veneer, cleft, or modified crown grafting are feasible but not popular because it is so much easier to raise the tree from cuttings. Cuttings of branches 1/4 to 1/2 in (6-12.5 mm) thick and 8 to 10 in (20-25 cm) long, with 2 or 3 leaves attached, hormone-treated and set in sand or other suitable media under constant or intermittent mist, will root in 60 days. They are then transplanted to nursery rows or containers and held in shade for 6 months or a year before being set out in the field. Some fruits will be borne a year after planting but a good crop cannot be expected until the 3rd or 4th year. The tree will continue bearing well for about 15 years. There is a lapse of only 22 days between flowering and complete fruit maturity.

Grafting is generally practiced only when cuttings of a desired clone are scarce or if a nematode-resistant rootstock is available on which to graft a preferred cultivar; or when top-working a tree that bears fruits of low quality.

Culture

The Barbados cherry tree will grow and fruit fairly well with little care. For best performance, Puerto Rican agronomists have recommended a fertilizer formula of 8-8-13 twice annually for the first 4 years at the rate of 1/2 to 1 lb (0.22-0.45 kg). Older trees should have 3 to 5 lbs (1.35-2.25 kg) per tree. In addition, organic material should be worked into the planting hole and also supplied in amounts of 10 to 20 lbs (4.5-9 kg) per tree. Under Florida conditions, a 10-10-10 formula is given in February, 1 lb (0.22 kg) for each year of growth. In May, July and September, a 4-7-5-3 formula is recommended, 1 lb (0.22 kg) for each year of age up to the 10th year. Thereafter, a 6-4-6-3 mixture is given–5 lbs (2.25 kg) per tree in late winter and 10 lbs (4.5 kg) per tree for each of the summer feedings. On limestone soils, sprays of minor elements–copper, zinc, and sometimes manganese–will enhance growth and productivity. Young trees need regular irrigation until well established; older trees require watering only during droughts. Mature plants will bear better if thinned out by judicious pruning after the late crop and then fertilized once more.

Pollination and Fruit Set

In Florida, bees visit Barbados cherry flowers in great numbers and are the principal pollinators. Maintenance of hives near Barbados cherry trees substantially improves fruit set. In Hawaii, there was found to be very little transport of pollen by wind, and insect pollination is inadequate. Consequently, fruits are often seedless. Investigations have shown that growth regulators (IBA at 100 ppm; PCA at 50 ppm) induce much higher fruit set but these chemicals may be too costly to buy and apply.

Season

In Florida, the Bahamas, Puerto Rico and Hawaii the fruiting season varies with the weather. There may be a spring crop ripening in May and then successive small crops off and on until December, but sometimes, if spring rains are lacking, there may be no fruits at all until December and then a heavy crop. In Zanzibar, the bearing season is said to be just the months of December and January.

Harvesting

For home use, as dessert, the fruits are picked when fully ripe. For processing or preserving, they can be harvested when slightly immature, when they are turning from yellow to red. As there is continuous fruiting over long periods, picking is done every day, every other day, or every 3 days to avoid loss by falling.

The fruits are usually picked manually in the cool of the early morning, and must be handled with care. For immediate processing, some growers shake the tree and allow the ripe fruits to fall onto sheets spread on the ground. Harvested fruits should be kept in the shade until transferred from the field, which ought to be done within 3 hours, and collecting lugs are best covered with heavy canvas to retard loss of ascorbic acid.

Yield

There is great variation in productivity. Individual trees may yield 30 to 62 lbs (13.5-28 kg) in Puerto Rico. In Jamaica, maximum yield in the 6th year is about 80 lbs (36 kg) per tree; 24,000 lbs/acre (24,000 kg/ha). Venezuelan growers have reported 10 to 15 tons/ha; the average in Puerto Rico is 25 tons/ha/yr. 'Florida Sweet' in Florida has yielded 65 tons/ha. A plot of 300 trees of 'Florida Sweet' has borne crops of 6,300 to 51,300 lbs (2,858-23,270 kg) of fruit from March to November, in Homestead, Florida.

In Puerto Rico, a planting of 200 trees may be expected to produce 3,600 to 5,400 lbs (1,636-2,455 kg) of juice. From the juice there can be extracted at least 120 lbs (54.5 kg) of vitamin C expressed as dehydroascorbic and ascorbic acid, providing the content is determined to be 2%. In Puerto Rico, it is calculated that 10 tons of fruit should yield 435 lbs (197 kg) ascorbic acid. In a commercial operation using ion-exchange resins, the yield of ascorbic acid from Barbados cherry juice is expected to be about 88%.

Keeping Quality

Ripe Barbados cherries bruise easily and are highly perishable. Processors store them for no more than 3 days at 45º F (7.22º C). Half-ripe fruits can be maintained for a few more days. If longer storage is necessary, the fruits must be frozen and kept at 10º F (-12.22º C) and later thawed for use. At one time it was believed that the fruits could be transported to processing plants in water tanks (as is done with true cherries) but it was discovered that they lose their color and ascorbic acid content in water.

At room temperature–85º F (29.44º C) in Puerto Rico–canned Barbados cherries and also the juice lose color and fresh flavor and 53% to 80% of their ascorbic acid content in one month, and metal cans swell because of the development of CO₂. Refrigeration at 44.6º F (7º C) considerably reduces such deterioration. Juice in the home refrigerator will lose 20% of its ascorbic acid in 18 days. Therefore, the juice and the puree should be kept no longer than one week.

Pests and Diseases

One of the major obstacles to successful cultivation of the Barbados cherry is the tree's susceptibility to the root-knot nematode, Meloidogyne incognita var. acrita, especially in sandy acid soils. Soil fumigation, mulching and regular irrigation will help to keep this problem under control. The burrowing nematode, Radopholus similis, is also a cause of decline in otherwise healthy trees.

In Florida, the foliage is attacked by wax scale, Florida mango scale, and other scale insects, whiteflies, a leaf roller, and aphids. In Guatemala, the aphid, Aphis spiraecola, attacks the leaves and young, tender branches. This pest and the Hesperid caterpillar, Ephyriades arcas, require chemical control. In Puerto Rico, the tree is often damaged by the blue chrysomelid of acerola, Leucocera laevicollis. Some fruits may be malformed but not otherwise affected by the sting of stinkbugs. None of these predators is of any great importance.

The major pest in Florida is the Caribbean fruit fly, Anastrepha suspensa, which seems to attack all but very sour fruits and the larvae are commonly found inside. In Guatemala, a fruit worm, Anthonomus florus, deposits its eggs in the floral ovary and also in the fruits; the larvae feed in the fruits causing deformity and total ruin. Drastic control measures have been employed against this predator, including the incineration of all fallen, infested fruits and the elimination of all related species that serve as hosts.

Few diseases have been reported. However, in Florida, there are cases of anthracnose caused by Colletotrichum gloeosporioides, and leafspotting by the fungus, Cercospora bunchosiae, is a serious malady in Florida, Puerto Rico and Hawaii. Green scurf, identified with the alga, Cephaleuros virescens, occurs in Puerto Rico.

Food Uses

Barbados cherries are eaten out-of-hand, mainly by children. For dessert use, they are delicious merely stewed with whatever amount of sugar is desired to modify the acidity of the particular type available. The seeds must be separated from the pulp in the mouth and returned by spoon to the dish. Many may feel that the nuisance is compensated for by the pleasure of enjoying the flavorful pulp and juice. Other-wise, the cooked fruits must be strained to remove the seeds and the resulting sauce or puree can be utilized as a topping on cake, pudding, ice cream or sliced bananas, or used in other culinary products. Commercially prepared puree may be dried or frozen for future use. The fresh juice will prevent darkening of bananas sliced for fruit cups or salads. It can be used for gelatin desserts, punch or sherbet, and has been added as an ascorbic acid supplement to other fruit juices. The juice was dried and powdered commercially in Puerto Rico for a decade until the cost of production caused the factory to be closed down.

The fruits may be made into sirup or, with added pectin, excellent jelly, jam, and other preserves. Cooking causes the bright-red color to change to brownish-red. The pasteurization process in the canning of the juice changes the color to orange-red or yellow, and packing in tin cans brings on further color deterioration. Enamel-lined cans preserve the color better.

Wine made from Barbados cherries in Hawaii was found to retain 60% of the ascorbic acid.

Food Value Per 100 g of Edible Portion*
Calories	59
Moisture	81.9-91.10 g
Protein	0.68-1.8 g
Ether Extract	0.19-0.09 g
Fiber	0.60-1.2 g
Fat	0.18-0.1 g
Carbohydrates	6.98-14.0 g
Ash	0.77-0.82 g
Calcium	8.2-34.6 mg
Phosphorus	16.2-37.5 mg
Iron	0.17-1.11 mg
Carotene	0.003-0.408 mg
(Vitamin A)	408-1000 I.U.
Thiamine	0.024-0.040 mg
Riboflavin	0.038-0.079 mg
Niacin	0.34-0.526 mg
Ascorbic Acid**

*According to analyses made in Hawaii, Guatemala, and elsewhere.

**According to analyses at the Massachusetts Institute of Technology of fruits grown in Barbados: 4,500 mg (green), 3,300 mg (medium-ripe), 2,000 mg (very ripe). The ascorbic acid level of unripe fruits can range up to 4,676 mg and such ratings are exceeded only by the fruits (rose hips) of Rosa rugosa Thunb., which may have as much as 6,977 mg/100 g. This constituent varies as much as 25% with the clone, the locale, cultural methods and degree of exposure to sunlight during developmental stages and after harvesting. At INCAP (Instituto de Nutricion de Central America and Panama), in Guatemala assays in 1950-1955 showed distressingly low levels–an average of 17 mg/100 g, whereas fruits sent to INCAP by air and in dry ice from Florida were analyzed and contained 1,420 mg/100 g. In field experiments, treatment of young fruits on the tree with 200 ppm gibberellic acid has brought about a marked increase in the ascorbic acid content of the mature fruits.

The ascorbic acid is not totally destroyed by heat, for the jelly may contain 499-1,900 mg/100 g. Of the total ascorbic acid in Barbados cherry juice, 0.18% is in the bound form. Other constituents include dextrose, levulose, and a little sucrose.

Harmful Effects

Physicians in Curacao report that children often require treatment for intestinal inflammation and obstruction caused by eating quantities of the entire fruits, including seeds, from the wild Barbados cherries which abound on the island.

People who pick Barbados cherries without gloves and long sleeves may suffer skin irritation from contact with the minute stinging hairs on the leaves and petioles.

Other Uses

Bark: The bark of the tree contains 20-25% tannin and has been utilized in the leather industry.

Wood: The wood is surprisingly hard and heavy. Trials have demonstrated that it refuses to ignite even when treated with flammable fluid unless perfectly dry.

Medicinal Uses: The fruits are considered beneficial to patients with liver ailments, diarrhea and dysentery, as well as those with coughs or colds. The juice may be gargled to relieve sore throat.

Black sugar maple

Hard maple

A. nigrum Michx. f.

Source: Magness et al. 1971

Maple sugar and syrup are obtained from the sap of these two species and are solely products of the United States and Canada. The Indians were making crude syrups and sugar from maple sap before the coming of white men. The preparation of maple sugar and syrup is strictly a farm industry, occurring from Kentucky northwest to Iowa, northeast to Maine and north into Canada. Native stands of these maple species are tapped to obtain the dilute juice or sap. The trees are not a cultivated crop, although competing useless trees may be removed and maple stands may be thinned to promote better growth and sugar yield. Only a small proportion of the available trees of these species are actually tapped. It is estimated that more than 200 million such trees are growing in the United States, and less than 6 million are tapped.

The tapping is done by boring a small hole (under 0.5-inch diameter) horizontally into the tree so as to penetrate through the outer or sap wood. On large trees up to four such taps may be made at one time. Tapered spouts (hollow tubes) are driven into the holes to fit tightly, and the sap flows through this tube and is collected in sap buckets. it is important to protect the buckets and contents from rain water. Tapping is done in late winter, before bud break. During periods when temperatures are above freezing at this season sap flow is quite abundant, A tap hole usuallv produces 5 to 15 gallons of sap, though much more than that is sometimes obtained. Sugar content of the sap also varies widelv, from l0 to 30°Brix or higher.

Portable tanks of various types are used to collect the sap, which is poured into the tank through strainers. An alternative method is to use pipc lines to carry the sap to the evaporation equipment.

Originally a single open kettle over a fire was used to evaporate the excess water in the sap to produce syrup. Now multiple evaporators are mainly used, the syrup being transferred as it becomes more dense. Usually 2 or 3 transfers are made. Modem evaporating pans have flues in them through which the heat from the fuel passes to speed the process and codserve fuel. For standard-density syrup, concentration is to 65.5°Brix, which is about 86 percent solids by weight. If the sap tests 2.4°Brix, 34 gallons would be required to produce one gallon of syrup.

Slow evaporation--or longer heating time--in the final stages of concentration result in a darker colored syrup. More rapid evaporation at this stage gives a lighter colored, higher grade syrup. Sensitive thermometers are used to determine when the syrup is concentrated to the standard of 65.5 Brix. The completed syrup contains solid granules, mainly calcium malate, termed sugar sand. For toable syrup these must be removed. On the farm they may be allowed to settle out or are removed by filtering. Centrifuging is efficient if available.

To produce various types of maple sugar, the syrup is further heated and additional water driven off. If heated to a boiling point of 230°F. and cooled rapidly without stirring a solid cake is formed. Stirring during cooling results in crystal formation. For fine crystals the highly supersaturated solution is seeded with fine crystals and stirred rapidly, which results in rapid formation of great numbers of fine crystals.

Numerous products, as maple cream, or butters, soft-sugar candies, maple spread, and candies utilize maple syrup or sugar. Total maple syrup production in the United States averaged approximately 1,400,000 gallons, 1961-66, inclusive. This includes that made into sugar. In addition about 800,000 gallons of syrup and 5,145,000 pounds of sugar were imported annually from Canada during those years.