Adventures of an Allergist Mommy

December 6, 2010 — The first food allergy guidelines were issued today by the National Institutes of Health's National Institute of Allergy and Infectious Diseases (NIAID). These guidelines have been a long time coming... the emphasis is on: 1. Appropriate diagnosis based on correlation with the clinical history and not simply a positive blood or skin test- food allergy is often overcalled on the basis of testing without proper interpretation 2. Not summarily restricting vaccines such as MMR and influenza in egg-allergic patients 3. Not unnecessarily restricting the maternal diet in an attempt to prevent food allergies in the fetus and infant 4. Prompt use of intramuscular epinephrine in the event of anaphylaxis The full report (58 pages): http://download.journals.elsevierhealth.com/pdfs/journals/0091-6749/PIIS0091674910015666.pdf The summary report (44 pages): http://www.niaid.nih.gov/topics/foodAllergy/clinical/Documents/FAGuidelinesExecSummary.pdf A synopsis of the ...

It's here- cold season. All over town, boogery kids are wiping snot on their sleeves, their hands, and us.  One of the most important things you can teach your child is how to properly blow his/her nose.  It's one of the "skills" I check for whenever a young child comes to my office with symptoms of an upper respiratory infection.  I'm always amused by the number of kids blowing air out of their mouth! Here are my tips for getting the "highest yield", so to speak, from a nose blow. 1. Get some saline nasal spray.  If you're doing this in the morning, we have crust to loosen before we get this party started. (If you have a pressurized can of saline with a gentle spray nozzle, all the better.  There are multiple brands- they all work pretty well.)  Instill the saline into each nostril- enough so that it starts dripping out. 2. Dab the drips with a tissue. 3. Have your child take a deep breath. 4. With your finger on the tissue, apply enough...

The setting- breakfast table on Saturday morning The cast of characters- the Allergistmommy and Son #1 Me: I have a surprise for you! We're going somewhere special today! Son #1 (eyes lighting up): Are we going to Hawaii!?!!? Me: Umm... no.  We're going to the pumpkin patch. Son #1: Oh, okay. (He loved it anyway, even if it wasn't paradise on earth.)

One of the most exciting recent developments in the treatment of food allergy is the development of Food Allergy Herbal Formula 2 (FAHF-2), a combination of nine herbs from traditional Chinese medicine.  The therapy is based on a traditional formula called Wu Mei Wan (used for gastrointestinal parasitosis), but has since been modified to remove some ingredients and add others, in an effort to improve the safety profile and increase effectiveness for food allergy. Wu Mei Wan is one of the classic herbal formulas taught to students of traditional Chinese medicine.  Over time, it has become apparent that the active ingredients may have utility beyond the original application. Previous animal studies have demonstrated that FAHF-2 not only protects severely peanut-allergic mice from reactions during peanut challenge, but also that the beneficial effects may last for up to 6 months after discontinuing treatment.  Phase 1 human trials in the United States have shown promise t...

Son #2 woke up this morning looking like a streetfighter! Dramatic swelling of the eye(s) such as this can occur for a variety of reasons: 1. Allergic reaction to ingested food or drug (generally affects both eyes) 2. Direct contact with environmental allergen or food allergen (can affect one or both eyes) 3. Hereditary or acquired angioedema (can affect one or both eyes) 4. Injury (usually affects one eye) 5. Low protein levels (generally affects both eyes) 6. Infection (generally affects one eye) 7. Insect bite (can affect one or both eyes) In this case, my little one endured a mosquito bite at the outer corner of his left eye yesterday afternoon.  It was mildly swollen at the time, and became progressively worse as the night wore on. Does this mean he has a mosquito allergy? Actually, no more than anyone else.  Certain areas of skin, such as around the eyes and on the lips, are more loosely attached to underlying tissues and muscles than skin elsewhere on the b...

In case anyone has ever wondered why comprehensive asthma education is important, please watch the following clip.  Hilarious! http://www.4shared.com/file/136718954/bedbbcbe/dr_house_best.html

Excellent Article from the American College of Allergy, Asthma & Immunology- reposted with permission. Summer Means Barbecues, Picnics – and Food Allergies Ants, bees and rain aren’t the only things that can put a damper on a picnic or barbecue. For more than 12 million Americans food allergies can ruin the fun too, by causing problems ranging from the mild (itchy bumps and stomach aches) to the severe and life-threatening (swelling of the throat and difficulty breathing). Be food allergy savvy at your next picnic, whether you are planning the event or have food allergies yourself. The American College of Allergy, Asthma and Immunology offers the following tips for keeping food allergies off the menu: Consider condiment packs – Instead of large containers of condiments, use individual-sized packets of ketchup, mustard, relish and mayonnaise. These condiment packs will prevent cross contamination that can occur when sharing large containers. Pack foods se...

Thanks to the Mothers of Children Having Allergies (MOCHA) group for the following update! Illinois State Board of Education (ISBE), in conjunction with the Illinois Department of Public Health (IDPH), has released the Guidelines for Managing Life-Threatening Food Allergies in Illinois Schools. According to State Law, each local school board is required to have a policy based on these guidelines in place by Januray 2011- a sample policy based on these guidelines will be made available to all school districts in August. With any luck, the school boards will simply adopt the recommended sample policy- this is the expectation. The guidelines and associated forms are available online at: http://www.isbe.net/nutrition/htmls/food_allergy_guidelines.htm The sample policy will be available to member school districts and to any non-member school district that requests a copy. Even if you don't live in Illinois, this can be an excellent starting point as your food-allergic child p...

Macrolide antibiotics (such as azithromycin) are popular choices when treating acute ear infections in children due to a short (5 day) course of treatment, once-daily dosing, and low incidence of gastrointestinal side effects. However, macrolide antibiotics, while generally effective against the most common pathogens in acute ear infections in children (streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis), are quickly losing effectiveness as resistant strains of bacteria increase. A 2007 study by the CDC demonstrated a 22.7% rate of macrolide resistance among strep. pneumoniae isolates (the most common cause of ear infections). 2004 recommendations from the American Academy of Pediatrics and the American Academy of Family Physicians advised against the use of macrolides for acute ear infections unless a patient has an immediate-type allergic reaction to penicillin. However, the rate of macrolide prescription continues to dwarf the documented rate of immediate-...

Hallelujah! Angels sang this morning, as my husband and I awoke to find that for the first time in almost 5 years, there was no pint-sized human barrier separating us. Son #2 slept through the night! In his own crib, without waking even once! There is no credit to take for this miracle, only thanks to give... and fingers to cross hoping that this new development sticks!

Thanks to the American Academy of Allergy, Asthma & Immunology, and the American College of Allergy, Asthma & Immunology for the following update. It has come to our attention that there is a generic epinephrine autoinjector (without a specific name) that is being distributed by Greenstone (a generic division of Pfizer). According to Greenstone's website, this injector is identical to a product named Adrenaclick , distributed by Shionogi Pharma. Apparently Shionogi has authorized Greenstone to distribute the same device as an unbranded or "generic" item. We call your attention to this because it may result in substitution by the pharmacy of the generic for a brand name prescription, or vice versa. The issue which merits comment is that the instructions for the administration of EpiPen , a product distributed by Mylan Pharmaceuticals, is different than the instructions for the administration of either the Adrenaclick or the "generic" auto...

Went to a Greek restaurant with the family yesterday for a combined Graduation and Mother's Day celebration. The boys loved the saginaki! Son #2 kept yelling, "Fire, fire!" (oh, dear.) Son #1 asked: "Daddy, why do you keep shouting 'Oprah!'?"

Have an expired epinephrine autoinjector and don't know how to dispose of it properly? Here's an opportunity to donate your expired medication to a good cause! AllergySense is collecting expired epinephrine autoinjectors for use as training devices at hospitals and clinics in the U.S. and Canada. As a thank you - for each autoinjector you donate, you'll be entered in a drawing for some nice prizes! Here's the link: http://www.allergysense.com/promo_epi.php

Anyone who hails from Chicago knows that we have two seasons: winter and construction. Now that construction season is upon us, it is often difficult to stay in a good mood while commuting. When construction delays forced me to take a circuitous route home last week, bypassing the highway and winding through all sorts of local roads we had never seen before, I was starting to get frustrated. I mean, how is it that every highway needs to be upgraded every spring? I just want to get on the highway and fly home, you know? Kids are in the car, we're hungry and tired, and I could feel my blood starting to boil as we hit yet another red light. We finally pulled into the garage, and my 5 year old says, "Mommy, I really liked the new way you took us home today- it was very creative !" God bless preschool teachers. God bless 'em.

Especially important during this active allergy season- Please see the following link for a list of lot numbers affected in the McNeil recall (affecting Tylenol, Motrin, Zyrtec & Benadryl). http://www.mcneilproductrecall.com/page.jhtml?id=/include/new_recall.inc

A parent of 2 food-allergic kiddo's shared an interesting tidbit with me the other day, of which I was not previously aware. If your child has a history of anaphylaxis to a food allergen, he/she may be a candidate for a 504 plan, which creates a specific plan outlining the accommodations that may be needed in the school setting to ensure that the student with a disability (in this case, severe food allergy) is not excluded from the full educational resources available to other children due to his/her disability. From the Department of Education website: Section 504 is a federal law designed to protect the rights of individuals with disabilities in programs and activities that receive Federal financial assistance from the U.S. Department of Education (ED). Section 504 provides: "No otherwise qualified individual with a disability in the United States . . . shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be s...

One of my nurses snapped the following photo today... funny and sad at the same time.

Eyjafjallajokull (ay-yah-FYAH-lah-yer-kuhl). Say that five times fast! No matter how you pronounce it, this volcano has been in the news and in water-cooler conversations around the world. It has affected travelers, governments, and reportedly, even a rhinoceros who got stuck en route! On Friday, the World Health Organization issued a warning for patients in Europe with asthma and other respiratory problems, claiming that the ash cloud released by the volcano could be "very dangerous" for them due to the abrasive and corrosive nature of volcanic dust particles. However, they have since toned down this warning. The tiny particles of volcanic ash which are most likely to cause these issues are still very high up in the atmosphere- too high to cause significant problems for individuals on the ground (except in the immediate vicinity of the volcano). A low-pressure weather system expected over Iceland later this week may push the ash cloud towards the Arctic and prompt rain w...

The dangers of environmental tobacco smoke (ETS) have been well-documented. Environmental tobacco smoke has been associated with increased risk for not only asthma and ear infections, but also with meningitis and sudden infant death syndrome. Young children are particularly susceptible to these ill-effects. The risk is not limited to second-hand smoke, however. Third-hand smoking occurs when an individual is exposed to an environment in which someone has been, but is not currently, smoking. Quoting from the Pediatrics article "Beliefs About the Health Effects of 'Thirdhand' Smoke and Home Smoking Bans" by Jonathan P. Winickoff, MD, MPH et al: " Research has documented the association between smoking in the home and persistently high levels of tobacco toxins well beyond the period of active smoking. These toxins take the form of particulate matter deposited in a layer onto every surface within the home; in loose household dust; and as volatile toxic comp...

With the awareness of food allergies increasing, there is expanded interest in the various methods of diagnosing food allergy. Of course, the skin test vs. blood test debate is ongoing. (I have more trust in the skin test, in case you're wondering.) There are also plenty of proponents of what I call "weird science". These are unproven methods that might make someone feel like they're getting an answer (and are certainly enriching the practitioner), but do very little to diagnose actual food hypersensitivity and, more often than not, lead to unnecessarily restrictive diets. However, there's decidedly less discussion about what is considered the most definitive way to diagnose food allergy- the oral food challenge. A food challenge is a test that involves giving a patient incrementally larger doses of a specific food by mouth over a period of time, all the while monitoring the patient for signs and symptoms of an allergic reaction. Because the risk of an acute ...

Just went a local restaurant to pick up lunch. As I exited my car, I was shocked to see a mother shielding her ~4 year old son with the car door while he urinated in the parking lot- in the spot directly in front of the restaurant entrance! I'm sorry, but this is inexcusable. You're not camping in the woods, you standing in front of at least fifty people behind glass walls. In a restaurant that has a bathroom, for goodness sakes! If your child cannot control his bladder, I understand- all children toilet train at their own pace. Sometimes, especially while you're learning, "I gotta go" means, "I gotta go NOW". But parental actions dramatically impact what our children learn to accept as appropriate behavior. People knock country music sometimes. but there are some lessons to be learned... I was listening to a Dixie Chicks album in the car yesterday, and was struck by the following lyrics: "Our children are watching us, they put their trust in u...

Those who know my children personally know that Son #1 is cautious and thoughtful, and Son #2 is impulsive and and fearless. So, the following conversation seems especially intuitive. Son #1: Mommy, I'm going on a trip to Mexico. Me: Ooh... mommy wants to come! Son #1: No, you can't come. It's a kids trip! Me: Will you be taking your brother along? Son #1: No- he can't come either. He's just going to run around all over Mexico and cause problems.

Warning: This post will be controversial. I have seen too many instances of terrified parents falsely believing that being in the same room as a peanut is going to kill their child. I have heard too much about 10 year old children being kept home from birthday parties, families being kicked off planes for requesting that peanuts not be served to anyone on board, of people demanding that high schools be peanut-free. I feel that something needs to be said. The bottom line is this: there comes a time when we need to sit down and come to terms with the actual risk posed by inhalant exposure of peanut allergen vs. the perceived risk. I do not need a double-blind placebo-controlled trial to tell me that the perceived risk of anaphylaxis to inhaled peanut protein far, and I mean FAR, outweighs the actual risk. The majority of parents whose children have experienced food-related anaphylaxis are understandably traumatized by the event, and would go to the ends of the earth to prevent a repea...

A Japanese study published in the European Journal of Allergy and Clinical Immunology (link: http://www3.interscience.wiley.com/journal/123251237/abstract?CRETRY=1&SRETRY=0 ) shows what many of us in the allergy world have suspected for a long time- mom's prenatal diet does have an impact of the risk of atopic manifestations in offspring at 16-24 months of age. The study evaulated over 700 Japanese mother-child pairs. A diet-history questionnaire evaluated maternal consumption of fruits, vegetables, and antioxidants during pregnancy (at week 17). Atopic symptoms were evaluated based on criteria from the International Study of Asthma and Allergies in Childhood (at aged 16-24 months). The study found that higher maternal intake of green and yellow vegetables, citrus fruit, and β-carotene during pregnancy was significantly associated with a reduced risk of eczema, but not wheeze, in the offspring. Maternal vitamin E consumption during pregnancy was significantly inversely relat...

Physicians, like many other professionals, have continuing education requirements. We are exposed to the newest research and advances while in training, but after we pass our board exams and enter practice, the onus is on us to maintain our knowledge to current standards. Without regular reading and attendance at medical conferences, you can easily get left behind as medicine advances. I am currently attending the Annual Meeting of the American Academy of Allergy, Asthma & Immunology in New Orleans. It is always a wonderful meeting, full of new information to bring home to my patients. I will be periodically tweeting medical information that I believe may be of interest to my readers: http://twitter.com/allergistmommy Other colleagues will be doing the same- Matthew Bowdish, M.D. is an allergist who has shared information from past allergy conferences, and will be tweeting at http://twitter.com/matthewbowdish (His tweets from the Western Allergy Society meeting were great, and...

Confession #1: I am still co-sleeping with Son #2. Why is an 18 month old in charge of my bed? I blame absence of any set routine. Because I parent my kids with the help of their grandmothers during the week while DH is out-of-town for work, the boys have 3 households, and 3 separate beds each. While this has fostered a great deal of flexibility and adaptability in my sons, it has also made it difficult to establish bedtime consistency. Hence, Son #2 wedges himself quite comfortably between DH and me in the middle of the night (even on weekends, when he easily could be in his crib). This is also why the odds of a Child #3 coming along any time soon are remarkably slim. Confession #2: I no longer enjoy nursing, and am desperately trying to wean. I feel guilty admitting this, because I am such an ardent proponent of breastfeeding. However, partly due to Confession #1, and partly due to my own inability to suffer my child's noctural complaints, I have enabled Son #2 in hi...

The Health Organization Committee that determines the composition of the yearly influenza vaccine met last week, and has decided to include H1N1 in the 2010-11 vaccine. It is recommended that the following viruses be used for influenza vaccines in the 2010- 2011 influenza season (northern hemisphere): – an A/California/7/2009 (H1N1)-like virus; – an A/Perth/16/2009 (H3N2)-like virus;# – a B/Brisbane/60/2008-like virus. For the full report, please go to: http://www.who.int/csr/disease/influenza/201002_Recommendation.pdf This was anticipated, but there was a chance that the H1N1 would still be separated into an additional injection, so I am pleased that my patients will only need a single dose of vaccine to get coverage for both seasonal and H1N1 influenza this coming year. Interestingly, the strain of H1N1 is the same as in the 2009-10 H1N1 vaccine- so it may actually serve as a booster dose for patients who received the vaccine this past season.

At the end of every patient visit, I let my patients know when I would like to see them again. For some patients, the visits are infrequent- once a year for a well-controlled patient with nasal allergies. However, for asthmatics, I recommend more frequent visits. Lately, I've begun noticing that my chronic asthma patients occasionally look at me sideways when I tell them that I expect to follow-up with them every 3-4 months to document asthma control and adjust medications. There have been a few disgruntled phone calls after a patient learns that only 3 months worth of refills have been submitted to the pharmacy, instead of the standard 6-12 month supply. It has occurred to me that my patients are not alone in their confusion as to why their physician can not bear to be apart from them for more than 12 weeks at a time, so let me explain myself: 1. I am not secretly in love with you. 2. I am not trying to get paid for shooting the breeze with you quarterly. 3. I am not in cahoot...

Son #1 woke up three times overnight and ended up in Grandma's bed after he decided that me marching him back to his own room was no longer acceptable. (Grandma's are softies.) Son #2 was actually sleeping soundly for the first time in weeks, until the earthquake woke us up. Earthquake? Yes, earthquake. (Thank goodness our cities are built on a thick layer of bedrock, and that our municipalities enforce building codes.) I woke up to a foot of snow covering my car, and my windshield wipers were frozen to my windshield. Yipee. So, the thought of trudging to work on a day when the majority of patients will choose to stay home was less than enticing. However, as I was driving along, the wheels of all the cars in front of me on the highway aerosolized the slush on the road. It's a strikingly clear and sunny day, and when the sunlight hit the airborne slush droplets, it had the magical effect of creating small rainbows between me and my fellow commuters. From slushy mess t...

Time flies- it's been a whole year since the first Allergist Mommy blog post! In that time, I've enjoyed sharing my perspective on the latest developments in pediatric allergy. It's nice to have an audience other than my husband for my musings. I haven't asked, but I think he also appreciates that I have redirected my educational efforts away from him. :) In the past year, you've learned how (against the odds) Son #1 outgrew his peanut allergy. You've read about Son #2's eczema and developing asthma. You've seen how underneath the cool exterior, physicians are parents too. We worry about our kids the same way our patient's parents do. And we make the same mistakes that everyone does. That said, I hope I've also shed some light on the fact that while we certainly don't have all the answers, physicians can help shed some light on the mystery that is modern medicine, and be valuable guides to help parents and children navigate the challen...

It's that time of year- the heat is on indoors, and the humidity in our homes takes a nosedive. Kids (especially those with a history of eczema) start getting itchy, scaly, cracked skin. Ouch! We all want to minimize the amount of medication we apply to our children's bodies, so try these these quick tips first: 1. lukewarm baths/showers, no greater than 10 minutes 2. pat (don't rub) dry with a towel that is free of fabric softener 3. immediately apply an emollient - a ceramide-containing cream all over the body in the AM (Cera/ve, Mimyx, Atopiclair are all good choices), and don't skimp on the petroleum jelly at bedtime (who cares of they're a little slippery?) 4. keep the ambient humidity in your home between 40-50% 5. turn down the heat! For most cases of dry winter skin, the above is enough to keep a bad eczema flare at bay. However, if your child's skin does flare up, don't be afraid to use the topical anti-inflammatory ointments (they work better t...

I was so proud of myself. I had a little extra time on my hands (don't ask me where it came from, because I can't imagine I'll ever find it again), so I decided I would take a trip to the store and buy all the supplies I needed to make cute peanut/treenut-free Valentine's Day goodie bags for Son #1's preschool class. I dutifully purchased stickers, little plastic baggies, pencils, and individually wrapped/labelled candies for distribution to the little cuties. I sat and patiently assembled all the bags for him and his 13 classmates, and even made an extra couple of bags, just in case. Last night, I read the newsletter from his classroom: "If your child will be bringing Valentines in for our party on the 12th, please make sure to bring for everyone, so we don't have any hurt feelings." Excellent point- I couldn't agree more. (hence the extra few bags!) The newsletter continued: "We have 22 students." WHAT??!?! 22?! Ahem- where did the...

A recent article in the Wall Street Journal ( Is Your Kid Truly Allergic? Tests Add to Food Confusion) recently highlighted the inherent problems with over-calling food allergy in children on the basis of serum IgE testing. I was impressed with the article, and encourage parents of allergic children to read it: http://tinyurl.com/yb5fw5s This is an issue that most allergists run into on a fairly frequent basis- a parent walks into the office with bloodwork ordered by another physician. Tests returned as "positive" for multiple foods, so for the past 3 months, parents have restricted all these foods (generally there's always something that's a pain in the butt to eliminate, like soy or wheat). Now we have a child who is still as symptomatic as ever, and cranky to boot. When I tell the parents that their child in all likelihood is not allergic to all of the eliminated foods, the reactions are a mixture of relief and annoyance: "That's great news, but why di...

Short little post to get me back into blogging after a small hiatus: I've been thinking a lot about the legacy that we leave for our children. For some, the legacy they leave is material in nature: a substantial inheritance to start them on their way, a business to provide them a livelihood, a home in which to raise their own families... For others, it is memories of wonderful times together: family vacations, heartfelt conversations, carefully preserved photographs and videos... I hope to leave both of these for my sons, but the more I think about it, the more I want my legacy to be a way of thinking about themselves and the world around them. Anyone who knows me knows that my children don't really resemble me- they are miniatures of their father (I was simply the vessel). So, since the only thing they seem to have inherited from me is a predisposition for allergies and asthma, I'm hoping to instill in them my life philosophy. So, I decided to sum up into a single statem...