We all want to be realllllly healthy and it makes sense that what we eat is a place to start. Right? Well not so fast. Jenny (isn’t her real name to protect the innocent) went to her health club to lose some weight and get into shape. Jenny had always struggled with being overweight and was even laughed at in grade school because she was plump. (not funny if you’re one of those kids) Continue reading The Problem with Foods–foods that make me want to throw up
Food allergy is a constant source of anxiety to parents of children who could in fact die or suffer a severe reaction to foods. Believe it or not, the government has done a nice job with information pertaining to public safety, in this case, food allergy in schools. In case you think I’m kidding about the severity of food allergy, the YouTube link below should change your mind. The second link from the CDC is the “official word” on food allergy in schools.
Food allergy is a very common and even popular disease to have. This results in some predictable patient behavior such as:
1. I have allergy based on a blood test only, and I tolerate this food all the time. This may not be allergy at all, but simply a condition called “asymptomatic hypersensitivity”. Relax, some foods you can eat without allergy symptoms even though a blood or skin test is positive.
2. It is fashionable nowadays to have gluten sensitivity. Many patients will perform gluten challenges at home to see if bread or starches make abdominal cramping, skin rashes, or even concentration problems improve or worsen with the offending food. This practice becomes a problem if you are concerned with anaphylaxis (difficulty breathing, low blood pressure) to foods such as peanut, milk, or eggs to name a few. It’s one thing to experience more abdominal bloating after a gluten challenge and a much more dangerous situation to lose consciousness after ingesting peanut.
3. I’m grateful to be a member of the American Academy of Allergy, Asthma, and Immunology (AAAAI) in part because they help me as an allergist to stay current of all the thousands of recommendations published every year on my specialty. One such service is “Ask the Expert” forum and I’d like to share a recent post with you about food challenges.
Here’s the take-home message and the full answer is available if you click on the link below:
1. Food anaphylaxis can be related to the total amount of food ingested. In other words, don’t assume that tolerating a very small amount of peanut will guarantee that you can tolerate peanuts ad lib! Food challenges are performed under close supervision in order to determine HOW sensitive you are.
2. Oral desensitization to foods is still in the research stage and the experts on treating food allergy do not recommend this procedure be performed outside of a research protocol. It only takes one bad outcome to taint any progress made with treatment of food anaphylaxis.
Anyway, it’s lunchtime, and talking about food does make me hungry!
Pork-cat syndrome a rare (but real!) allergy
Allergic to cats? Then beware of pigs — or at least, the meat that comes from these sty-dwelling swine. A small number of people who are sensitive to felines may also get allergic reactions to eating pork. Continue reading Pork-Cat connection
I always enjoy National Medical Meetings….good food, meeting old friends, and yes, even learning something! The College of Allergy annual meeting was held in California just one week ago……and what are the hot topics this year?
Here’s an article and interview from Medscape about this year’s meeting. Why am I interested? Dr. Portnoy was my mentor (professor) during my fellowship training in allergy. Way to go Jay!
Here’s what he had to say–This international food allergy conference features the latest on eosinophilic esophagitis, unusual and “off the beaten track” food allergies, spice allergies, and developments in food immunotherapy.
“Food allergy is always something that people are interested in,” Jay Portnoy, MD, professor of pediatrics at the University of Missouri, Kansas City, and Mercy Children’s Hospital, told Medscape Medical News.
Dr. Portnoy, who chaired this year’s abstract committee, highlighted a few of the presentations on food allergy that he considers particularly noteworthy.
“Researchers at Northwestern University in Chicago have found that kids with egg and milk allergy are more likely to outgrow those allergies than if they have tree nut or shellfish allergy. So when the doctor says your child will probably outgrow their egg or milk allergy, they’re not too far off,” he said.
Another study examines how people who are allergic to hen eggs might be able to tolerate them when they are baked. “It turns out that baking the egg actually denatures or neutralizes the allergen, more so than if you just partially cook it. If you introduce cakes and cookies into your diet, you will be able to most likely broaden your diet and improve the quality of your life,” he said.
One presentation of definite note is on a newly identified and possibly life-threatening allergic reaction to mammalian meat. Researchers have determined that the lone star tick is the primary reason for meat-induced alpha-gal allergic reactions.
“This new food allergy, alpha-gal, is more common than we thought. There is a high prevalence in some areas of the country, particularly in the central and southern regions of the United States,” Dr. Portnoy explained.
Alpha-gal is a sugar found in red meats such as beef, pork, and lamb. In the study to be presented, positive alpha-gal rates were 32% higher in areas with a lone star tick population than in other areas of the United States.
Symptoms of alpha-gal allergic reactions range from mild hives to potentially life-threatening anaphylaxis.
“The reaction is delayed. A lot of people have experienced this, and now we know what it is. This is why it is so important to come to the annual meeting and learn about these unusual allergic reactions,” he said.
The topic of spice allergies is also on the meeting agenda.
According to a statement issued by the ACAAI, spices are one of the most widely used products, and are found in foods, cosmetics, and dental products. The US Food and Drug Administration does not regulate spices, which means that they are often not noted on food labels.
As a result, they are one of the most difficult allergens to identify and avoid.
“While spice allergy seems to be rare, with the constantly increasing use of spices in the American diet and a variety of cosmetics, we anticipate that more and more Americans will develop this allergy,” said Sami Bahna, MD, DrPH, from the Louisiana State University Health Sciences Center in Shreveport.
“Food allergy is a very important topic for allergists because we need to understand the most current research; recently, the field has seen a lot of changes,” ACAAI President Stanley Fineman, MD, from the Atlanta Allergy and Asthma Clinic in Georgia, told Medscape Medical News.
“There is a lot of new understanding about food allergies, new diagnostic tools, and some potential treatments,” he said. “This is the place to find out the latest information; when you go back to your practice, you [will] be on the cutting edge.”
Back by popular demand is the annual literature review course, where experts present what they feel are the key articles of the year on topics such as immunology, allergic rhinitis, ocular allergies, and immunology. “We have almost 500 people already registered for this program. Some people look forward to this program all year long to catch up on the literature. It’s a very popular feature of the meeting,” Dr. Fineman said.
The slogan for this year’s meeting is “Over the Horizon: Expanding Expertise,” which captures the essence of what the conference is about, he noted.
“The program committee selected this theme to help us see what is going on in the future, to expand our expertise, to make sure that we are able to keep current, and to hone our skills so we can adapt to any changes in healthcare and any new research involved with treating our patients,” Dr. Fineman explained.
“Most allergists go to the meeting to find out what’s new in allergy, to keep their skills up, to interact with colleagues, and to validate what they do. Because, like most allergists and most physicians, if you are in practice and you don’t interact with other physicians, you can start to develop quirky styles of practice that may not be the best practices. It’s really a good idea to touch base with colleagues, interact, and hone your skills,” Dr. Portnoy added.
“At this meeting, allergists will hear about an unusual case and then remember a patient who had the same thing. That’s how advances in our field are made,” he said.
I could say it better. With all the controversy swirling around health care reform, it’s refreshing to learn about what really matters for taking care of patients….that’s why I keep going to work every day!
Schools are quite paranoid about giving any medication on their watch. The liability for giving sunscreen when you don’t need it? Zero. This is very similar to the use of epinephrine in a school aged child with food allergy. You certainly don’t want to withhold epi and risk anaphylaxis or death, when the risk of giving the EpiPen is negligible even if you don’t need the drug. Maybe our policies in schools will change after a large malpractice case gets media attention for NOT giving epinephrine at the appropriate time for peanut allergy.
Ok, another study about the dangers of food allergy (yesterday in USA Today). You would think the occurrence of food allergy to KNOWN allergens (peanut & milk) would decrease given all the attention given to accidental ingestion. Evidently, this is not the case. Explanations? Maybe we’re afraid of giving epinephrine. In my personal experience, giving epinephrine is analogous to “waving the white flag.” It doesn’t have to be nor should it be when treating children with suspected food allergy. As I tell my nurses, “give the epi, then call the doctor!”
Milk allergy may cause life-threatening anaphylaxis in children & adults. Wouldn’t it be nice if milk allergy could be “cured?”
The adverse immune reactions to cow’s milk proteins can range from immediate, potentially life-threatening reactions to chronic disorders. Cow’s milk allergy (CMA) is the most common food allergy in infants and young children, affecting 2–3% of general population. That’s a lot of kids! Most studies have shown the prognosis for developing tolerance to cow’s milk to be good, with the majority outgrowing their allergy by age 3 years.
Because no treatments are available to cure or provide long-term remission from food allergy, allergen-specific treatments and strategies that attempt to alter the allergic response to specific food allergens are expected. The approach that attracts a significant interest in the scientific community, as well as the public and media, is oral immunotherapy (OIT).
To begin treatment for food allergy, your doctor should do the following:
- IgE must be demonstrated to the food in question. That means skin testing or blood tests.
- Who wants to be cured? That’s what desensitization accomplishes. If you gradually increase the amount of offending food (milk powder for instance), sensitive patients will no longer react to an accidental ingestion. Pretty cool…but wait, that’s not all!
- Permanent tolerance, as illustrated, means are you protected from ingestion of milk when you haven’t had exposure for say 2 months? Because it’s not known how to predict whether patients develop tolerance, this procedure of OIT is not recommended for clinical use at this time.
Almost all children receiving oral desensitization (OIT) experienced allergic symptoms during the protocol that primarily involved urticaria and angioedema. That’s mild and treatable.
Table 1. Oral food desensitization for IgE-mediated cow’s milk allergy
|Study||Patients (N)||Success rate||Comments|
|Staden et al. , CM and egg||CM 14; egg 11; control group 20; age 0.6–12.9 years||9/35 (36%) permanent tolerance; 3/25 (12%) tolerance with regular intake (desensitization); 4/25 (16%) achieved partial tolerance||The first randomized clinical trial of OIT. The rate of spontaneous food allergy resolution in the control group (7/29, 35%) was similar to the treatment group.|
|Longo et al. , CM||CM 60; 30 active group; 30 control group; age 5–17 years||11/30 (37%) tolerated 150 ml f CM; 13/30 (53%) tolerated 5–150 ml||The first study including children with previous anaphylaxis to cow’s milk; 3 children 10% discontinued the study because of severe systemic reaction. 17/30 children of active group reported side-effects at home.|
|Skripak et al. , CM||CM 20; active to placebo; ratio 2 : 1; age 6–21 years||12 (92%) of active group reached the dose 5140mg of CM (range 2540–8140 mg); no change in the placebo group||The first double-blinded, placebo-controlled clinical trial for OIT; the median frequency of side-effect was 35% in the active group compared with 1% of the placebo group.|
|Pajno et al. [19•], CM||CM 30; active to placebo; ratio 1 : 1; age 4–13 years||10 (76%) of active group tolerated 200 ml CM; no change in the placebo group||The first blinded trial with the weekly up-dosing regimen carried out in 18 weeks. Two children (15%) of active group discontinued the trial because of systemic reaction.|
Legend for the above table: CM, cow’s milk; OIT, oral immunotherapy.
Desensitization state can be achieved by approximately 36–92% of the children treated with specific immunotherapy; the rate of permanent tolerance is unknown.
An alternative route of allergen delivery is through an epicutaneous patch (EPIT). CMA was confirmed by an oral food challenge at baseline. Children received three 48-h applications (1mg of skimmed milk powder or 1mg of glucose as placebo) through a skin patch each week for 3 months. EPIT-treated children had a trend toward an increased threshold dose in the follow-up oral milk challenge. There was no change in the placebo group. The most common side-effects were local pruritus and eczema at the site of EPIT application.
The possibility of the appearance of adverse events or reactions during OIT is quite frequent. Side-effects have been reported by patients in all trials.
Severe systemic side-effects have been reported with either rush schedule or weekly up-dosing regimen. The frequency of serious events and the severity of reactions are greatest on the initial days and least on the days following desensitization when high doses of cow’s milk intake are reached by patients.
Mild reactions such as abdominal pain, throat pruritus, gritty eyes, watery eyes, transient erythema and sneezing usually do not require stopping desensitization. On the contrary, when rhinitis, dyspnea, asthma, generalized urticaria and hypotension occur as a single symptom or in combination, OIT should be postponed or stopped.
A life-threatening asthma reaction caused by desensitization to milk was described by Nieto et al. Adverse events are largely unpredictable, and they can occur during home dosing. Several systemic reactions have occurred at previously tolerated doses in the setting of exercise,viral illness and suboptimally controlled asthma.
Of note, these reactions had been well controlled by antihistamines, steroids or epinephrine. Because desensitization( s) place patients at risk for systemic reactions, it is not appropriate to implement OIT in clinical practice settings at this time. Therefore, OIT can be performed for research purposes or as ‘avant-garde’ and modern therapy for IgE-mediated food allergy in specialized pediatric centers.
- Patriarca G, Nucera E, Roncallo C,et al. Oral desensitizing treatment in food allergy: clinical and immunological results. Aliment Pharmacol Ther 2003; 17:459–465.
- Nieto A, Fernandez-Silveira L, Mazon A, Caballero L. Life-threatening asthma reaction caused by desensitization to milk. Allergy 2010; 65:1342–1343.
My transcriptionists are not only good at what they do, but when they hear me talk as much as I do, it’s almost family.
I am reading a book called, Don’t Kill the Birthday Girl by Sandra Beasley, and I thought of you.
- It’s a memoir about the author’s life with food allergies, what it was like growing up with allergies, etc. She has a variety of food allergies along with environmental allergies.
- It’s not very long but it seemed like a book parents who have kids with allergies or individuals suffering from allergies in general would really be able to relate to. Good advice Stephanie!
- The author is really honest about what it’s like living with allergies but she’s humorous about it at the same time.
- The one thing that shocked me is that when the author was a teenager she thought about overdosing on Benadryl because she was tired of living with allergies. Don’t kid yourself, the quality of life in patients with allergy isn’t very good….much worse than heart disease or even diabetes.
- I think this book could help people with allergies, so they don’t feel alone. I don’t feel alone but I know I’m the only one in my family with allergies and none of them get what an allergic reaction is really like so I’m really enjoying this book.
Stephanie, thanks for the suggestion and I’m sure many of our readers will also enjoy the book. You’ll have to ask her permission to “friend”, but here’s her link—>profile.php?id=1192230038&sk=photos
Here’s the link from Amazon about further information on the book: Book on Allergies from Amazon
From Medscape Allergy & Immunology by Marrecca Fiore
Ever wonder what other allergists are reading? After sorting through the long list of articles published on Medscape during the past year, it seems our member audience of allergists and clinical immunologists was most interested in:
- Food allergies
The top 10 articles list is comprised of the most-read content of 2011. If you missed any of these articles, please take a look at them now. Thanks Marrecca for your work on compiling the list.
The List–I’ll comment when appropriate!
10. Office-Based Oral Food Challenge Safely Diagnoses Food Allergy
A letter published August 11th in the Journal of Allergy and Clinical Immunology said that food challenges can be safely done in a physician’s office as long as certain precautions are taken.
- Precautions include having resuscitative equipment in office during the challenge.
- What foods do you challenge to? I’d start out with egg, milk, wheat to name a few.
- Some exciting potential for “desensitization” and oral tolerance as well.
9. Pathophysiology of Itch and New Treatments
As highlighted in this paper, the pathophysiology of itch is diverse and involves a complex network of cutaneous and neuronal cells. The article explains current treatments as well as experimental and promising therapies.
- Patients would rather have ANY symptom except itching.
- Be careful! Itching can be a result of correctable causes….like elevated bilirubin. Don’t miss this one.
Dr. Matthew Fenton from NIAID and Dr. Hugh Sampson, past president of AAAAI, review the food allergy guidelines and discuss how these principles should guide clinical practice.
- The most important guideline to follow–please avoid a food “panel” which misleads many patients to think they have a food allergy & you may just have an irrelevant positive test.
7. The Itch That Rashes
A 2-year-old presents with a persistently itchy rash. What is the most appropriate management?
6. Common Variable Immunodeficiency at the End of a Prospering Decade: Towards Novel Gene Defects and Beyond
This review highlights the most important publications of the past year, with an emphasis on novel findings in genetics and the immunophenotype of CVID.
5. Molecular Diagnosis of Peanut and Legume Allergy
Peanut- and legume-induced allergic reactions can be fatal and can significantly impair the quality of life of patients and their families. This paper reviews and discusses recent studies on the molecular diagnosis of peanut and other legume allergy.
4. I’m Struggling to Live on $160,000 a Year: MD Lament
Most people who don’t have “MD” or “DO” after their name would assume that $160,000 is a good annual income. However, many physicians find it a challenge to live on that amount. Why can some manage easily while others are struggling to pay the bills?
3. Hymenoptera Venom Immunotherapy
Hymenoptera stings can induce allergic systemic and occasionally fatal reactions. What is the best treatment?
- Bee sting shots are >90% effective & I’ve learned much about allergy shots for pollens based on research for bee stings.
2. Influenza Vaccine: Guidelines for Those With Egg Allergy
Vaccine expert Paul A. Offit, MD, explains the new influenza guidelines for individuals with egg allergy.
- The bottom line: Flu shot is probably safe even in patients with egg allergy. This was taboo only 5 years ago….the more you know, the less you know!
1. New Test for Peanut Allergy a Step Forward
Measuring antibody levels of 2 peanut protein components in patients may be a better predictor of allergic reactions than current diagnostics.
These articles did not make our Top 10, but they came close.
Can Inhaled Corticosteroids Prevent Asthma Exacerbations?
ICS therapy is the mainstay of asthma treatment, but can it also be used as a preventive measure?
Helping Families Manage Food Allergy in Schools
School can be a frightening place for food-allergic children and their parents. Are physicians providing the best information to help them?
Food allergy is an increasing problem in homes and schools. How do we determine who is at increased risk for anaphylaxis?
As always, if you have difficulty reading or obtaining any of these articles, let me know–I’ll be glad to help.