We are having a picnic at our school for new families. One parent says that there is severe latex allergy in her family and requested that no one bring balloons to the event. Is this a reasonable request?
By Dr. Paul Ehrlich
In March, I wrote about a New England Journal of Medicine article that showed a correlation between children growing up on German farms and a lower incidence of asthma than city kids. I wrote that this seemed to confirm aspects of the Hygiene Hypothesis, but that the popular press made too much of it. I also said that farming practices in different places might produce different results.
Little did I know that I would only have to wait till August to get my contrary data. An abstract just turned up on the website of the Journal of Allergy and Clinical Immunology entitled “Rising prevalence of asthma is sex-specific in a US farming population.” It recounts “population-based studies of asthma and atopy in the Hutterites of South Dakota, a communal farming population, to assess temporal trends in asthma and atopy prevalence and describe the risk factors for asthma.”
Don’t know who the Hutterites are? Neither did I, but here is some of what I found on Wikipedia:
“Hutterites (German: Hutterer) are a communal branch of Anabaptists who, like the Amish and Mennonites, trace their roots to the Radical Reformation of the 16th century. Since the death of their founder Jakob Hutter in 1536, the beliefs of the Hutterites, especially living in a community of goods and absolute pacifism, have resulted in hundreds of years of odyssey through many countries. Nearly extinct by the 18th and 19th centuries, the Hutterites found a new home in North America. Over 125 years their population grew from 400 to around 42,000…
“Hutterite colonies often own large tracts of land and, since they function as a collective unit, can afford top-of-the-line farm implements. Some also run industrial hog, dairy, turkey, chicken, and egg production operations.”
What were the study’s conclusions?
“Asthma has increased over a 10- to 13-year period among Hutterite females and atopy [allergy] has become a significant risk factor for asthma, suggesting a change in environmental exposures that are either sex limited or that elicit a sex-specific response.”
My purpose in writing this is not to say, “I told you so.” Rather, it is to underscore my original premise. Namely, that we can’t draw sweeping conclusions on the basis of a single set of data. Asthma is a complex set of symptoms, a “syndrome” not a single disease. In our book we quote a pulmonologist named Dr. Anthony Gagliardi who said, “the study of asthma is the study of one.” That is, there are so many triggers and so many symptoms involved in asthma that you have to look at each patient as an individual. The Hutterite research has produced some fascinating variables, not least of which is that women are at risk but not men. It may be that the Hutterites have readily adopted modern farming technology even as they have preserved their old ways in other respects, resulting in crucial changes to their environment. In the meantime, none of the research will result in breakthrough prevention or treatment. We are obliged to fight asthma and allergies with the tools we have.
By Dr. Paul Ehrlich
Cats in the Cabin
MSNBC’s website had a recent letter about air travel precautions if you are allergic to cats. The answer was incredibly thorough, pointing out such details that American Airlines has a peanut-free policy but will allow up to seven pets to travel in the cabin. The article recommends calling your airline, discussing their policies ahead of time, inquiring whether any pets have been booked—at a hefty fee to the owners—to ride in the cabin, and ask to be seated as far away as possible.
As we have written previously, the highly allergenic dander of cats is very sticky and a problem for, say, small school children whose coats may be hung touching those of kids who have cats at home, so the allergen will follow them home. The same thing can happen when a passenger’s coat ends up in the overhead bin of an airliner. And of course, even though dander may be sticky, some of it will circulate in recycled air of the cabin.
If you have a really bad cat allergy and one of the little beasts is scheduled to fly with you, we recommend the advance use of a medication call cromolyn sodium:
“Cromolyn sodium is … a perfect example of a niche medicine that can be used tactically for certain situations. One of the things that make it incredibly useful as a niche medicine is that it is incredibly safe and side effect–free. The other is that it works to stave off allergic reactions when taken before and even during high exposure to allergens. For example, if your child is allergic to cats and you’re going to visit Aunt Rachel with her beloved calico cat Rambo for the weekend, your child might start puffing cromolyn sodium on Friday.”
Unfortunately, this is a cumbersome way to deal with this problem, and as I have also noted before, a convenient inhalable form of cromolyn sodium is no longer on the market because it isn’t profitable enough.
Finally, what you can do is change your traveling clothes at the first available opportunity if they have come in contact with cat allergen, wrap them in plastic, and launder them quickly.
Another story that caught our eye was about a Frenchman on a flight from Paris to San Francisco who knew he was allergic to cashews but somehow thought it wouldn’t hurt to eat some almonds. Fortunately, Dr. Schuman Tam, a Bay Area allergist, responded to the call for a doctor and treated the Frenchman for the rest of the flight with epinephrine from the plane’s emergency kit.
First of all, kudos to the hero allergist (there’s a phrase you don’t hear very often). But second, what is wrong with allergy education in France that someone who’s allergic to cashews doesn’t worry about almonds? What’s the French for “tree nuts”? This gives us even more reason to promote the concept of component testing. It’s not the food you are allergic to, it’s certain proteins that might turn up in very different foods because, as I have written previously, “nature doesn’t want to reinvent the wheel either.”
By Dr. Paul Ehrlich
As our millions of followers know, Dr. Chiaramonte and I are very particular about how we use allergy tests. Physicians who rely solely on tests to diagnose an allergy without a proper history or specialized clinical experience are going to end up with a lot of false positives and treatment that is wrong and expensive. This is particularly important with food allergies because it affects diet. Avoiding too many foods can lead to malnutrition.
As we say in our book: “The science shows us that skin tests and blood tests don’t really measure the same things. The antibodies that register in a blood test have a half-life of two days. They come and go without putting your immune system on a state of red alert. The ones that react in the skin have a half-life of six to eight weeks, which means that your body is ready to strike for a protracted period.”
The new NIAID food allergy guidelines call for abandoning the old blood tests—called RAST (radioallergosorbent test) in favor of “sensitive fluorescence enzyme-labeled assays” which measure allergy at the molecular level. I use these, and they are a great step forward, but it’s still no substitute for my own clinical judgment as an allergist. Among other things, they can help tell whether a patient is dangerously allergic to, say, peanuts, or mildly so.
But that’s not why I’m writing this. When new patients bring us previous test results, we often find ourselves fighting not the last war, but the one before that. For example, one “alternative” practitioner recently came to our attention for warning about allergy to caffeine, which is not an allergen, as I have written previously. What does he use to support his allergy diagnoses? A test called ELISA. I couldn’t believe it. This test is the poster child for false positives. It may indicate reactivity by revealing IgG—the good antibody—but it doesn’t reliably show allergy.
However, my surprise was mild compared to what I felt when presented with results for something called AllerTest, which is marketed along with nutritional supplements by something called the Trump Network—yes, that Trump. Far be it from me to disparage these tests without knowing more about them, and that is the point. There is no evidence I can find how they work, or if they work at all, not even on their website, let alone the medical literature. Absent evidence, as a doctor, I can only recommend that the Trump empire stick to real estate development. As a New Yorker, that’s a hard line to write. Suffice it to say, I went back to the drawing board with this patient.
By Dr. Larry Chiaramonte
A recent study, published in the Annals of Allergy, Asthma & Immunology, followed 176 children from birth through age 7. One of the variables measured was the presence of mold in the home. What they found should surprise no one who reads this website regularly: By age 7, 18% of the children had asthma, and those who lived in a home rated as having a high level of mold during the first year of life were 2.6 times more likely to have asthma as those whose homes had low level of mold. This study focuses on a problem that allergists have recognized for ages. Dr. John Weiner, the Australian allergist who did a recent post for us, sent us a link from 2002 that included this:
“Skin prick test results from 1132 people with asthma in Australia, Europe and the US showed that those sensitized to molds were up to 3 times more likely to have severe asthma (BMJ 2002;325:411).”
We harp on the subject of mold because it is a potent allergen and because it is frequently overlooked in taking medical history. Just recently we were asked to review a questionnaire for a consumer pediatric website that when complete could be presented to doctors to help jumpstart the diagnostic process. It was very competent concerning seasonal allergens and behavior, but it was missing, among other things, any mention of water damage either at home or at school. Big omission.
The six most obnoxious words in the English language are: “As we say in our book.” But we can’t help it; it’s all there. As we say in our book:
“Molds are widespread in the environment and are common causes of severe allergies and asthma. Molds are a primitive type of plant. Their spores are similar in size to pollen grains. Some common molds are visible, such as the blue mold that grows on stale bread and cheese or the black mildew between your bathroom tiles. Molds grow inside homes wherever it is moist, such as in damp basements and around leaky plumbing. Like pollen grains, the mold spores themselves are microscopic so most molds cannot be seen.”
As we also point out, mold can afflict brand new homes as well as old ones because of poor construction. What makes this problem more vexing is that the sensory clues for mold are both visual and olfactory. You can see water damage and you can smell mold. Water damage should be repaired. Mold spores can be effectively removed by regular ventilation and washing affected areas with household bleach. Indoor humidity should be maintained at 50 percent or lower by using air conditioning and dehumidifiers. Sump pumps should be used in damp or flooded basements.
Unfortunately, as I have observed over the years, and as Dr. Ehrlich recently confirmed, immunotherapy for mold is effective only 50% of the time, compared to 80% or more for most common allergens. I believe this is because it encompasses the whole mold, not the spores that fly through the air and cause allergies. A colleague of mine developed an extract to the spores, which must be technically very challenging and expensive to make because it was not commercially viable under managed care reimbursement rates, and so it was discontinued.
By Dr. Paul Ehrlich
I am forever fascinated by how little allergen it takes to cause a reaction, and I regularly use case studies from my practice to drive home to new patients, their parents and caregivers how much care they must take.
In Asthma Allergies Children: a parent’s guide we tell an R-rated story.
A G-rated example happened last week during a sweltering day in New York City when a very peanut allergic six-year old patient greeted his father returning from work. His father loves peanut butter, and he only eats it at the office. That afternoon he had some for lunch, and by the time he arrived home after taking the “1” train to 242nd Street and walking five blocks he was sweating profusely.
His son greeted him at the door, threw his arms around Dad and kissed his sweaty face. Within minutes the boy had difficulty breathing, began wheezing and had an anaphylactic reaction.
I can only imagine how low the peanut protein concentration in Dad’s perspiration was. I invite comments.
By Anna Allanbrook
Principal, Brooklyn New School–PS 146
As principal of a public elementary school in Brooklyn, New York for fourteen years, after teaching there for several years, I can say that the dilemma presented by the epidemic of peanut allergy has been part of our administrative agenda for almost two decades. We have also faced many other allergy-related challenges in that time. For example, before we moved to our current building, we had a coal-fired furnace, which undoubtedly didn’t help our asthmatic kids. But though it may surprise some of the readers of this website, the peanut issue has grown less urgent over the years although the numbers of allergic students have grown. Why? Because the precautions we take are now so routine that it takes a backseat to the other exigencies of providing high quality education to Brooklyn children.
We have more than five hundred students in a building that also houses a grade six-to-twelve school. We have first-year admission based on a lottery to ensure a diverse student body. We have many special needs children. A significant percentage of our students qualify for free breakfast in the school. This is not a homogeneous population by any means, except for the fact that most of our families are attracted by our educational philosophy and reputation, which does, I suppose, incline our community towards consensus and trust, values that extend to things like the way food-related behavior is regulated. Peanut allergy is old news in our school and it is not a battle that has to be fought repeatedly. Attempts to opt out of vaccination are much more contentious.
When peanut allergy first popped up we improvised, creating a peanut-free table in our cafeteria where the school nurse presided each lunchtime. This may not have been much fun for the three kindergartners at that initial table, but they were safe and they were part of the action. We never had any incidents, and in time we abandoned this precaution. We know which children are at risk. The staff is universally trained in how to manage an emergency. At an initial staff meeting every year, the nurse reviews the signs of anaphylaxis and performs an EpiPen demonstration. Much of my wonderful staff has sat through this every year and know it by heart. The new recruits pay close attention and ask questions. They discuss how to advise parents about snacks and birthday fare. We also have a full complement of trips outside the schools, usually by subway and bus. Our students are not sealed from contact with the world of art, science, nature, or, and this is very important in our New York City “gorgeous mosaic” multicultural curriculum, food. But we are careful. Again, because of the spirit of community and shared values about the well-being of students, this is not a tough sell. Maybe if we had more of the fault lines in our population that have made this a problem elsewhere we would have a problem.
Quite a while back, we did have one incident in a classroom with a “cluster” teacher present—meaning a teacher who teaches a particular subject in several different classrooms. Someone had a snack that contained peanuts, and one little boy who probably knew better, just couldn’t resist. The nurse was summoned, the student was treated and rushed to the hospital.
I can’t generalize for every school in the country. As a mother, I certainly empathize with other parents’ worries. As a principal in New York, I also understand that I have the prerogative of making my school peanut free, but I think it would be an economic handicap to many of our students, and provide a misleading sense of security. For now, because of our long attention to the problem, our vigilant and well-trained staff, and because our families are united around a vision of good education, it’s just not an issue. We agree about the big things, and that has made managing peanut allergy a very small one for us.
(Elementary School Principal of the Year is awarded by the Academy of Educational Arts and Sciences)