A blogger Mom took her child for a food challenge and they got good news. See it here.
Q: A child comes in with a rash a few days after receiving AMOXICILLIN for an ear infection. It is red, blotchy, and spreads across the body. It appears to be a drug reaction rather than a viral exanthem. Does this mean the child cannot take PENICILLIN in the future? Is the child restricted from trying any other “CILLIN” – DICLOXACILLIN, etc.
— Dr. L
Dear Dr. L,
The majority of side effects observed in AMOXICILLIN clinical trials were of a mild and transient nature and less than 3% of patients discontinued therapy because of drug-related side effects. The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%).
This is an “allergic reaction” but it is NOT related to a life threatening one. I think there is little risk if the child takes PENICILLIN in the future and should not be restricted from trying any other “CILLIN”, including DICLOXACILLIN.
By Dr. Paul Ehrlich
I recently realized that I had reached a milestone in my 30 years plus of practice. I went more than a month without prescribing an oral antihistamine. This has implications for the way health care is bought and paid for in the United States.
Let’s review for a moment the old way of doing things. The first antihistamines, including diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton) started out as prescription drugs. They had a side effect: they made you sleepy, so you couldn’t drive or operate heavy machinery after using them, as the labels still warn.
Drug companies had a medical incentive as well as a financial one to develop the next generation of antihistamines, which didn’t knock you out. And so we got the wave of drugs that included loratadine (Claritin) and cetirizine (Zyrtec), which stopped the sneezing and itching without making you long for the couch. As they approached the end of their patent protection, the drug companies that made them started to add a few bells and whistles at the molecular level so they could get premium prices again.
But things have changed. Insurance companies don’t want to pay for new drugs that don’t make a big difference from the old ones and have stopped paying for them. The OTC drugs cost about the same at retail as a standard co-payment. In the meantime, members’ health dollars go for urgent things, including asthma treatment, or cost-efficient measures like immunotherapy and asthma control medications, or so we hope. Regardless, those with chronic allergies should use the OTC drugs as part of a medication strategy, not as a substitute for monitoring and treatment. It’s not that I won’t prescribe the newer medications at all, but I will do so when indicated.
I must also point out that the OTC, self-medicating approach doesn’t work for every allergy or allergy-related condition. For example, as Dr. Chiaramonte describes so movingly in his postscript to our book, many inner-city kids rely dangerously on Primatene, the OTC inhaler, to keep their asthma in check. It gives them a dangerous jolt that’s even worse than the one they would get from prescription albuterol. Both are worse for them in the long run than inhaled therapies like Advair, which with regular conscientious use keeps them from having attacks, arrests inflammation, and halts the dangerous process of airway remodeling.
Those who rely on OTC Neo-Synephrine to keep their sinuses clear would be better off with the prescription drugs like Nasonex or Omnaris (both of which I prescribe regularly) if they have allergic rhinitis. Regular use of Neo-Synephrine can make the sinuses look like hamburger. But they would also be better off with a high-concentration 2-3% saline solution sinus rinse, such as those marketed as SaltAire and Ocean, which come in convenient plastic squeeze bottles. The bargain-minded parent can make this at home: 2 or 3 heaping teaspoons of Kosher or sea salt (no additives) and one level tablespoon of baking soda, mixed in a quart of tap water. You can buy a plastic squeeze bottle or a 30-cc bulb syringe for easy administration.
In the end, the answer to your allergic symptoms will probably lie in a combination of judicious use of drugs, both high-tech and low-tech, changing your behavior, keeping an eye on the weather, perhaps watching what you eat, and generally living right. The most important body part an allergist treats is the brain.
(To read about The Hows and Whys of Allergy Medication, turn to chapter 8, Asthma Allergies Children: a parent’s guide.)
(Note: Dr. Ehrlich has worked for the Claritin Council, sponsored by Claritin. His participation is for information purposes only and he does not, nor does this website, endorse one OTC drug over another. All have characteristics that make them more or less useful than others for certain individuals at different times.)
By Dr. Larry Chiaramonte
One of the persistent discussions in treating asthma is whether to start with smaller, milder dosages of medication and “step up” if they prove ineffective, or start with heavier dosages and “step down.”
In the South Bronx, New York where I practice, and indeed with most asthmatics, patients want to get the condition under control immediately, even if it means taking more medication, as they should. After inflammation is under control, we can take the steps to ratchet down the reliance on high dosages, using peak flows, measuring exhaled nitric oxide, and other means to fine-tune our choice of medications and their dosages.
In this initial treatment, we have three primary weapons:
1.Long-acting beta agonist [LABA]to relax the spasm in the bronchial muscles;
2. Montelukast, a leukotriene-receptor antagonist (LTRA], since leukotrienes are an important cause of allergy.
3. Inhaled corticosteroids [ICS] to thin thick mucous and reduce inflammation.
We try to avoid systemic steroids such as prednisone because they affect the larger immune system instead of just the lungs. (That’s not to say they aren’t effective with asthma. In the days before inhaled steroids, bragging rights went to the doctor who used the least amount of systemic steroids. One of my teachers said at a national meeting he never used steroids to treat
asthma. This was technically true, he transferred from his care all the severe asthmatics to others on his staff, who then used steroids.)
Unfortunately, inhaled corticosteroids still have a vestige of the old stigma attached to them, although it is largely unwarranted. They are central to our NIH asthma guidelines. The NIH states that ICS are safe, necessary for reducing airway inflammation, and prevent the damage of airway remodeling. Add to the historic mistrust of corticosteroids the confusion with testosterone-derived steroids that athletes use and the result is great reluctance to use, or even on the part of primary care doctors to prescribe, these most effective asthma drugs, even after twenty years of safe usage.
While I prefer to step down from aggressive treatment, I don’t have anything against stepping up strategy, unless, as frequently happens, it means avoiding ICS unless nothing else works. Patients suffer in the meantime.
[Note: A different take on this issue “Step-up Therapy for Children with Uncontrolled Asthma” by Robert F. Lemanske, Jr., M.D. appears in the March 18, 2010 issue of the New England Journal of Medicine. There is also a related editorial by Erika von Mutius, M.D., and Jeffrey M. Drazen, M.D.
By Sally Noone–
Watching your child experience an allergic reaction can be frightening for a parent. Instinctively, you want to make your child feel better and use every trick you have to make them better.
It starts with recognizing when something is happening. Allergic reactions to foods can have different types of symptoms. Some involve the skin, with hives or an itchy rash or eczema flare. Others may begin with difficulty breathing. Whatever the symptoms, we must be ready to start treatment quickly.
You might work with your child’s doctor to personalize an emergency treatment plan for every contingency. A cool bath can soothe your child’s skin when there is a rash or itchy hives, but it provides no real treatment for the cause. You must understand the underlying physical process, and treat that. For example, hives are caused by a release of histamine during an allergic reaction, but only focusing on the hives may distract you from other symptoms such as swelling or breathing problems that are potentially very serious. Treating with an antihistamine medication that you doctor has recommended, such as Benadryl or Zyrtec, can help to block this histamine release as you carefully continue to observe for signs of a progressing allergic reaction. Often, the hives and their itchiness begin to resolve within 20 to 30 minutes but it is important to continue to watch for other symptoms.
A food allergy reaction accompanied by difficulty breathing needs to be treated promptly. It is a medical emergency. A steamy shower is an excellent treatment for croup, but breathing problems associated with a food allergic reaction require different treatment. Epinephrine, given by injection, is the medication universally prescribed to treat this type of reaction. This medication is available in auto injectors such as EpiPen, EpiPen Jr. or Twinject, which are available by prescription. Anyone who may be in a position of having to use these devices—you, your child, the babysitter, teachers, grandma and grandpa—should be trained in their use so when the time comes, they don’t panic or hesitate. Other treatments are administered by inhaler or nebulizer. These can make the child feel more comfortable and less panicky. It is best to give epinephrine first, then the inhaler or nebulizer treatment if you suspect a food allergy reaction. Stopping the life-threatening event comes first; comfort comes second. Anytime epinephrine is given, your child needs to be taken to an Emergency Department for further care and observation. Sometimes the symptoms of a reaction can appear to have resolved, and then come back later. If this does occur, it is best to be in the Emergency Department where they know what to do. Don’t be tempted to skip the Emergency Department!
In most cases, it is best to allow 911 to provide transportation to the hospital because you don’t want to drive in an anxious state. When you call, tell the 911 operator that your child has had an allergic reaction and has received epinephrine. This alerts them to send the proper level of responder to meet your child’s needs as they provide transportation to the hospital.
An emergency treatment plan can be very helpful in providing information about allergic reactions and their treatment to anyone who may be in a position of having to look after your child in an emergency. Typically, the plan includes the signs and symptoms of an allergic reaction, along with the correct dosages of medications to be used. Reviewing the plan with your child’s caregivers provides a good opportunity for you to practice with the auto injector trainers.
Is it still scary? Of course it is. This is your child we’re talking about. But knowledge and training will allow you to react like a pro when the time comes.
Sally Noone, R.N., M.S.N., C.C.R.C., conducts clinical research at the Jaffe Food Allergy Institute of the Mt. Sinai School of Medicine in New York City. She was drawn into the field by the case of a girl who was hospitalized after a milk-allergy attack at the age of 4. Read more about Sally and her work with food allergic children in chapter 13 of Asthma Allergies Children: a parent’s guide.
Q: What do you think about using a peanut-sniffing dog for a severely peanut-allergic child?
Dr. Ehrlich replies:
This is a new wrinkle in discussion of what to do when children have life-threatening food allergies, which we write about in chapter 14 of Asthma Allergies Children: a parent’s guide. To summarize what we say there:
Cases where children are sensitive to fleeting exposure, not just ingestion, are extremely rare.
These dogs are really expensive, as are their inspiration—drug- and explosive-sniffing dogs–so it’s not for everyone because of basic economics. It’s not a particularly cost-effective use of the family health-care budget.
I have heard talk of a foundation to raise money to support this approach. I’m not one to question people’s philanthropic impulses–I would certainly donate for training seeing-eye dogs. However, peanut allergy is not blindness. I can think of many areas in the field of pediatric food allergy that will produce more bang for the tax-exempt buck, primarily because the dog approach projects a fundamental misunderstanding of the problem. The seminal study of peanut fatalities by Dr. Hugh Sampson shows that they happen when people are exposed to peanuts far from their normal surroundings and are exposed accidentally, such as mountain climbers whose climbing partners carry energy bars that contain peanuts.
Anyone who expects to encounter peanuts at school or the mall can prepare for it by carrying an epinephrine injector such as Epi-pen or Twinject at far less cost, which they should do even if they have a dog. Epinephrine is safe, even with repeat injections.
A family that expects a dog to create a peanut-free bubble is in for trouble because they will create a false sense of security. It’s not a peanut-free world. I agree with the Food Allergy and Anaphylaxis Network that even schools should not be peanut free. The children should understand their condition, never eat food that mom didn’t give them including birthday cupcakes, and their teachers and nurses ought to be trained to help in the event of anaphylaxis. Their classmates should be taught to respect those who have this condition.
By Dr. Ehrlich
Nothing separates “science” from sound medical practice more than the use and misuse of allergy testing. Inappropriate testing leads doctors and their patients down blind alleys and dead ends, wasting time, money, and health. More times than I care to remember a new patient arrives in my office like the one this past week, a twenty-three year old man with eczema who recently moved from Florida to New York City. He told me that he is allergic to some twenty foods from milk to asparagus.
His history included some laboratory results of tests that were performed while he was living in West Palm Beach and he said that his physician advised him to stay away from all these foods. His diet was thus reduced to a narrow spectrum that was making his life miserable and his eczema no better.
With the patient in front of me I called the 800 number of the lab and spoke with a woman about the tests. The first thing she wanted to know was what state I was calling from. When I told her I was from New York, she told me that their lab work would not be covered by my patient’s insurance company. (My patient paid cash up front but this shows where their priorities lie.) I then asked her about the tests performed, and she told me they were IgG4 tests to the various foods. I thanked her for the information, hung up and looked at the young man.
“The tests they performed were phonies, with no redeeming clinical significance,” I said without hesitation. “They only tell me only that you have eaten these foods in the past. You’re probably not allergic to any.”
The remainder of the visit included tests related to IgE antibodies, the ones that count, to various foods as well as a few environmental allergens, and they were all negative, suggesting that he could begin all the foods he had eliminated from his diet. Needless to say, he was thrilled. It turned out his eczema came from exposure to dust mites. The history was obvious to an allergist, which his Florida doctor was not, and in fact had never bothered to take a history. Between his insurance company and his own pocket, the Florida office visit and the tests probably involved an outlay three times what it cost at an allergist (yours truly) with nothing to show it. A patient’s history is everything and the tests performed done usually to substantiate what a trained doctor usually suspects.
A final thought: this kind of misdiagnosis of food allergy is bad enough in an otherwise healthy 23-year old. It’s quite another in very small children. I regularly see very small kids whose diets are needlessly circumscribed for the same bogus reasons who are in fact being malnourished. This falls under the antiseptic but loaded heading “failure to thrive.” [For more on food allergy, see chapter 5 Asthma Allergies Children: A Parent’s Guide.]
Q: Can you provide an anaphylaxis action plan similar to the asthma action plans that are in use in schools and in homes?
–Dr. P (pediatrician)
Dear Dr. P,
You can find a link to an food allergy action plan, which includes anaphylaxis, by clicking on “Action Plans” at the top of this page. This one comes to us courtesy of the pioneering organization, Food Allergy and Anaphylaxis Network [FAAN].
Familiarity with this plan will take the guesswork out of anaphylaxis and the emergency it represents. The plan depicted at food allergy.org talks about signs of mild reaction as well as moderate and more severe ones.
It promotes the use of the epinephrine when the time is at hand. Caution dictates that if breathing becomes a problem, whether in the form of a cough or constriction, epinephrine should be used. If you as a pediatrician are in touch with the parent during an episode, you should make treatment decisions based on your knowledge of the patient and the parent according to criteria such as: are they new to the problem?; are they familiar with the different medications and what they do?; do they understand what happens to the body during anaphylaxis? (For a full discussion of anaphylaxis read chapter 5 and elsewhere in Asthma Allergies Children: a parent’s guide.)
By Dr. Larry Chiaramonte
One of the reasons I have practiced allergy medicine with such enthusiasm over the years is that the immune system, specifically as it pertains to allergies, is inherently dramatic. In our book, you will see that we resort continually to non-medical metaphors to explain the workings of the biology of allergy, and they are vivid. Police actions. Military maneuvers, both strategic and tactical. All the stuff of a good action movie. Even the two critical antibodies are part of the story. IgG is the Good antibody; IgE is the Evil one.
We explain in the book that IgE didn’t start out bad. It was there to fight parasites that are common in less hygienic societies. It is still utilized by the body for this purpose in parts of the world without good sanitation. In allergic people, however, as we explain in the book, it’s as if these antibodies had been entombed for hundreds of years, and when they come out, they’re intent on destroying something like, well, The Mummy, only the targets are proteins in otherwise harmless things like ragweed or peanuts.
IgE(vil) is the class of antibody responsible for allergic symptoms, and IgG(ood) blocks the reaction of IgE [allergic antibody] with the allergen. The objective to is to have more good stuff than bad stuff.
For me, an additional fascination is how this battle between good and evil has played out over the course of human history, and as an occasional feature of this blog, I will be sharing some of this drama with you.
For example, allergies were the mysterious reason King Menses of Egypt was killed by the sting of a wasp at some between 3640 and 3300BC. Allergy to horses caused Britannicus, the son of the Roman Emperor Claudius, to withdraw in disgrace from battle.
In 1906 a pediatrician Clemens von Pirquet, borrowed the word allergy from the Greek word meaning “altered state”. (By the way, the sci-fi thriller “Altered States” has nothing to do with allergies.) The events in an allergic reaction include the body’s recognition of a foreign material, production of specific chemical response and a greater reaction to the foreign material on a second exposure. Most of the time this doesn’t affect the individual, but with allergies a parasite-fighting system goes rogue.
In the late 1800s, Dr. Charles Blackley’s children came in from playing in the English countryside with some stalks of grass. The pollen from these stalks caused him to have an allergic attack. In addition a few grains on a starch caused swelling. Dr Blackley knew he had a clue to his springtime “hay fever” and “hay asthma.” He collected pollen, then systematically applied it to his skin, conjunctiva, nose, and airways. He surmised that something in his own physiology and not in that of non-allergic people caused his symptoms, and the positive skin test was born. Now we know that IgE was the culprit.
In 1911, English Doctors Noon and Freeman both had spring pollen allergies. They injected themselves with grass pollen extracts. They thought the pollen contained a poison like snake venom, and they could build resistance though the antibodies created by the injections. They missed the fact that while the pollen did not contain a poison, it does contain antigens that naturally cause allergic IgE antibodies in some people. They were on the road to discovery of the two types of antibodies, IgG and IgE.
Coming soon: Good vs. Evil: part deux
By Dr. Paul Ehrlich
On Doctor Radio, my host asked me why her son’s doctor is reluctant to call the boy’s “reactive airway disease” asthma. I told her, allergists joke about this phenomenon–we refer to it as “the A Word.” Reluctance to label a child with the A word is not just an exercise in beating around the bush. Parents and doctors are wary of branding children with a chronic disease that can cause trouble later on. For example, insurance companies, which we will have to contend with for the foreseeable future, will remain wary of a history of chronic disease. The child may also be limited about participation in sports and other activities. These are legitimate concerns, although not necessarily medical.
However, there are also reasons pertinent to the state of medical science. We are becoming more sophisticated in our understanding of asthma. As we explain in chapter 3 of Asthma Allergies Children: a parent’s guide, “asthma” is now frequently described as “syndrome”—that is a set of symptoms such as airway inflammation and constriction rather than a disease with one underlying cause, such as allergies. Infections and air pollution can also cause what the British call “twitchy” airways. We have to understand what’s behind the symptoms and treat that as well as the symptoms.
As Dr. Jeffrey M. Drazen and Dr. Erika von Mutius wrote in an editorial in the New England Journal of Medicine in March:
“[T]he onus lies with the treating practitioner to follow patients closely and to be sure that they improve as a result of the therap[y]. If there is no improvement, the patient should be switched to an alternative medication and again closely monitored…For the patient whose asthma is hard to control, there is simply no substitute for attentive individual follow-up. The words of Francis Weld Peabody remain true today, that ‘the secret of the care of the patient is in caring for the patient.’”