Asthma Allergies Children parent's web guide

Asthma Allergies Children | is a website devoted to ideas that are within the guidelines set by accredited medical authorities for treatment of asthma and allergies.

Parent Mailbag

White Spots Connected to Inhaled Steroid?

By

Our daughter is on Flovent. She has food and environmental allergies and Oral Allergy Syndrome. Recently, she started getting white patches on her skin. Had one on her back that cleared up with an anti-fungal cream. Now, she has one prominent one on her forehead and minor splotching on her cheek. We have an appointment with the dermatologist in a couple of weeks.

I saw that increased yeast can be a side effect of Flovent. This made me wonder if this could be causing the white patches. I hope it is not vitiligo.

Do you know of any cases or connection between oral steroid and skin conditions with fungus or other cause?

Jennifer

I would say that there is some increased risk of yeast growth for folks on Flovent, but this is generally in the mouth and not on the skin. However, many MANY people not on Flovent get yeast overgrowth on their skin, so they are not necessarily related. Sometimes kids get a condition called p. alba, that is not really caused by a yeast but can look like it:
And here is the common yeast infection of the skin:
Peter Lio, MD
Peter A. Lio, MD is an Assistant Professor of Clinical Dermatology & Pediatrics at the Northwestern University Feinberg School of Medicine, and a Diplomate of the American Board of Dermatology.

Child Afraid of Allergy Shots; What’s a Mother to Do?

By

A mother writes:
We have decided to get allergy shots for my daughter who just turned 7. She is terrified of shots. Do you know of any literature that might help her through this or have any ideas about how to get her to cooperate?
–Voice from the Corn Belt

Dear Voice,
Thank you for writing. I am glad to know that this long-validated treatment is still holding its own out in the Midwest. Every day I see the immense improvements shots can make in the lives of patients of all ages. I’m glad your daughter is above the age of 5, which, as we write in our book, is really the age when shots start to prove their value and we don’t recommend them for younger than that.

While I am not aware of any literature that might help, I have developed several techniques in my career that do seem to help get kids acclimated to regular shots:

One is that with the permission of both sets of parents, I will try to get a new shot patient to first watch a veteran child take the shot and when there is no painful reaction, the new kid will try to be as brave as the old one. This works particularly well with boys, who don’t want to appear look like wusses, and several mothers have a knack for arriving at just the right time for this, although your daughter is obviously not subject to the macho factor. Another is that I have learned a repertoire of magic tricks. Kids actually like their appointments because they get to see me do these, although after awhile they just want to get it over with, since I’m not exactly Criss Angel or Harry Houdini.

An older technique that I always clear with Mom ahead of time is to douse my hand alcohol after swabbing the target area on the kid’s arm, and administer a sharp slap–not painful but just enough to elicit a startled reaction–and then give the shot. There’s some neurological dissonance that distracts from any pain from the shot. In general distraction is the best way to defuse the apprehension that is the worst part of these injections.

And by the way, when my father, a pediatrician, would bring his bag home from the office, we always knew we were going to get shots. My younger brothers would see him get out of the car carrying his bag and hide in the woods for hours.

Dr. Ehrlich

For more on considering shots as treatment for your child, see this guest post by Dr. Harold Nelson

What do I do now?

By

A Mom writes:

I just got back results for my child’s ISAC test. If I am reading it correctly she is NOT allergic to sesame, cashew or hazelnut. She has multiple food allergies and any additions to her diet are a great help. What do I do now?

Ms. Tar Heel

Dear Ms. Tar Heel,
I certainly understand your excitement. For those who don’t know, ISAC (Immuno Solid-phase Allergen Chip) is shorthand for ThermoFisherScientific’s component test, offered under the brand ImmunoCap. Their website reads–

ImmunoCAP ISAC offers:
• Specific IgE measurement of allergen components from nearly 50 different allergen sources
• Semi-quantitative results for 112 allergen components
• Component resolved diagnostics using only purified natural or recombinant allergen components

Component testing is a big advance over older blood testing, which only measures IgE in the blood, and is not considered diagnostic of food allergy. Component testing shows sensitivity levels to different parts of food proteins that are more-or-less seriously allergenic. However, I must point out that every test is “just another test” and the real indicator is a food challenge. Mothers tell me that their kids remain reactive to certain things despite encouraging results like the ones you describe. So I instruct them in what I call the “skin-lip test” which they can do at home.

All they need is a sample of the food, a little water, and a camera. First they crush the food and mix it with water. They choose a patch of skin on the back (so that the child can’t inadvertently scratch it and get the allergen in their eyes or mouth) and draw a circle around it to make it easy to spot, then take a “before” picture. Finally they rub the allergen solution on it and wait 15 minutes, then take an “after” picture. If there is no reaction, they repeat the process—minus drawing the circle—on the patient’s lip. This time, if there is no reaction, they can ask their allergist to perform an office oral challenge.

Many parents are understandably cautious about doing the lip portion at home, so they might ask that their allergist do that part for them.

Dr. Paul Ehrlich

Local Honey

By

Sneezing in South Brooklyn wrote:
Can local honey help with springtime allergies? If so, how does it work, how should it be used, and where can I find a good variety for my location?

Dear Sneezing,
The short answer, in language you would surely understand: fuhgeddaboudit.

Seriously, I checked with one of our consulting doctors and he said there’s no evidence that it works although it’s a charming myth. I also looked it up in the Journal of Allergy and Clinical Immunology (JACI–pronounced Jackie) and found no listings for it. You can find discussion of anaphylaxis to honey related to pollens in the honey itself and also possibly some components of bee venom, which is a very dangerous allergen, on the AAAAI website. Go to AAAAI.org and search for “honey”.

I did search for a local supplier and found one who produces from “sturdy Fort Greene bees” at BrooklynBee.com, although he is out of stock. However, I don’t know if Fort Greene is local enough for you even if it did work. I can only imagine that for bees to live in Brooklyn they would have to be very tough. Good luck.
Henry Ehrlich

Cough-Variant Asthma Diagnosed After Six Months

By

A Mom writes:
My 7-year-old daughter was diagnosed this week with cough-variant asthma (allergist did lung test, allergy testing and chest x-ray). She had had the chronic cough since July 2012 but every time we went to the pediatrician she had either an ear infection or sinus infection. Does this go away with time? I have found only a little information on this type of asthma.

Her medications include: Flovent HFA 44mcg inhaler-2puffs 2 two a day, Fluticasone prop spray 50mcg–1 spray each nostril, Proair HFA 90 mcg inhaler-albuterol-as needed.

I’m wondering what we can do so that eventually she can be off medication, if that is possible and what nutritional routes we can pursue. Generally we are pretty healthy eaters. Thank you so very much.

Dear Mom,
Thanks very much for writing. Cough-variant asthma is kind of obscure, and it’s a shame your daughter had to suffer for so long before it was diagnosed. Pediatricians often struggle with patients’ asthma even when the classic symptoms are presented, but better late than never, and I’m pleased to have this chance to weigh in. This is the way we describe it in our book, which you should buy and keep at your bedside as your general reference.

“[S]ome asthmatics never wheeze during attacks but only cough. They suffer from so-called cough-variant asthma, which occurs when inflammation and bronchoconstriction are concentrated in parts of the airways, not spread generally throughout them as they would be in what might be deemed “normal” asthma. Think of them as ‘sleeper cells’ that can provoke general trouble for the whole body, as the patient is wracked with extended coughing episodes. The coughing is the body’s effort to expel these local troublemakers, as if they were actual physical entities, such as dust or particles of dirt. We must treat to control the underlying inflammation as we would with the more familiar wheezing.”

Your doctor is doing a good job from the looks of it, and certainly give it time, but if problem persists here are a couple of other ideas.

The challenge is to get the inhaled corticosteroids to all the little nooks and crannies where there are outposts of inflammation and bronchoconstriction. This is difficult in a child’s airways because the small airways are really small. Oral steroids will do the trick but for many reasons we don’t want to use it. One alternative is to use montelukast (Singulair), which blocks leukotrienes—mediators that are released from mast cells along with histamines. Another idea to discuss with your allergist is the possible use of something called QVAR, which is a small-particle inhaled corticosteroid, and might be added to the current regimen, and if there is improvement, he might experiment with taking one of them away.

While I have no special ideas on diet, some good news: As your daughter grows, so will her airways. That is why cough-variant asthma tends to diminish with time. Keep us posted.

Dr. Paul Ehrlich

Combined Action Plans for Food Allergy And Asthma?

By

I like how FAAN’s food allergy action plan stresses that for LUNG symptoms, epinephrine must be given and that inhalers/bronchodilators are not enough.

My daughter has both asthma and food allergy. She has asthma symptoms a lot so I am concerned that schools will think “asthma” not “food allergy” when she has symptoms such as coughing or wheezing. Most of the time they will be right, and I don’t want her over epi’d, but it’s so important to epi if it is a FA reaction.

Is there a way the doctors in the food allergy and asthma community can come up with a version of a standard asthma action plan that takes into account the special needs of those with asthma and FA?

For instance, I requested our pulmonologist to add into her asthma action plan that if asthma meds don’t work in 5 minutes, to consider EpiPen.
However, I think there may be a better way to communicate how schools and such should deal with isolated respiratory symptoms in a child with both asthma and one diagnosed with a potentially life-threatening food allergy.

Just to add, my daughter is entering first grade, so it may not be obvious if she touches her allergen, then puts her hands in her mouth. Plus, her food allergen—sesame–is not required to be clearly labeled on food packages so knowing when she has been exposed to her allergen may be tricky.

Thanks.
A Mom

Dear Mom,

Thank you for your question.

I am also a mother of two children who have both asthma and food allergies. I understand your concern about telling the difference between asthma and food allergy reactions. I have had to make that call sometimes with my own boys, one of whom also has a sesame allergy.

Unfortunately, there really isn’t a clear answer for your question. While asthma symptoms and food allergy symptoms may seem the same, there are some clear distinctions. Therefore, combining the two plans into a single one is not recommended. For example, in a food allergy reaction frequent coughing and feeling the need to the clear throat are obvious signs. When wheezing is present it is more difficult to differentiate. Basically this falls in the “better safe than sorry” realm. You may not be aware that up until around 1985, epi was how asthma attacks were treated {note: it was the active ingredient in Primatene, which is now off the market}. Therefore, if this were not so long ago, we would be administering the same medication, regardless of cause. No harm will come if epi is administered, and it will help either condition. The best course of action will depend on all of the available information at the time.

My advice to you is to meet with the school nurse and whoever else has contact with your child. Explain what to look for in making the distinction. You know your child best. However keep in mind that people with both asthma and food allergies are at higher risk for fatal reactions because their breathing is already compromised, so quick action is key. If there is any doubt the school nurse will use the epi, as she should.

Please feel free to contact us with any further questions.

Harriet Spitzer-Picker A-EC

Dogs and Asthma

By

Best Friend or Asthma Foe?

I am wondering if exposure to dogs when a person is already allergic increases their chances of developing asthma? This is not as random as it seems. My daughter is allergic to dogs and does react. We have been invited to a home with dogs for Thanksgiving, which the hosts say are hypoallergenic. I should be able to control symptoms with her meds, but my biggest concern is actually for the long-term risk rather than the acute risk. I usually avoid homes with dogs, but my husband thinks I am over—reacting (maybe I am) and really wants to go for Thanksgiving so I told him I would look into it.

Southwest Mom

Dear Southwest,
This is a classic case of the Mom-Dad divide on allergic issues.  Moms do tend to be more cautious than Dads.  Without knowing more particulars on your daughter’s condition, I can’t say how this visit might affect her.  However, a couple of things—there is no such thing as a hypoallergenic dog, although as we say in our book (p. 213), small, well-groomed dogs are less allergenic than big unwashed ones.

Second, and more important, in general, if your daughter is asthma prone, sooner or later you will find out; it’s not like you have a series of get-out-of-asthma-free cards that you can use up. Asthmatic symptoms are usually set off by a variety of triggers.  If it’s not dogs it will be something else.  If you are worried that a single exposure might set her off, you should think about the level of underlying inflammation, which may be subtly altering her airways as well as leaving her vulnerable in the short term.  It may be that she already has asthma, even if there is no wheezing.  Ask your allergist about measuring the level of exhaled nitric oxide (EnO), which is a marker for inflammation that I have used very successfully.  Depending on how old your daughter is, you might think about immunotherapy, which can be helpful for allergic asthma and that it works better for dogs than for cats. Have you considered it? Also, if you can get cromolyn sodium (Asthma Allergies Children: a parent’s guide, p. 148) in anticipation of visits like this you can reduce your child’s asthmatic reactivity.

Good luck.

Dr. Chiaramonte

 

Too Soon to Test?

By

Does your research show that parents are testing their children for food allergies BEFORE actually trying to feed their children the food item? Especially for peanuts?
–Arizona Mom

Dear Arizona,

Good question! The problem is that many doctors, suspecting one allergy, will test for a whole battery of allergens without any clinical indication that they are warranted. Some reactivity will lead to a suggestion that the food is dangerous, or at least, better be safe than sorry. This has its absurd manifestations, such as Orthodox Jews being tested for shrimp, lobster, and pork, all foods that they will likely never eat, and be found positive. Research shows that they can test positive to shellfish because they are cross-reactive with allergens in dust mites and cockroaches, which they have inhaled, I might add, not eaten. Normally, we think of food allergies developing only after you have actually ingested the food. However, even the Orthodox can be rebellious. There’s a touching story about this in our book. A teenage boy tested positive for lobster (having eaten it naughtily with some friends) and his father the Rabbi, asked him sternly but kindly in Yiddish, “How did it taste?”

With people who have no such dietary restrictions, an equivocal finding of allergy can lead to making life more miserable than it has to be because you may decide to limit the diet unnecessarily. As to the issue of retesting, if you are using iffy tests as the baseline for your diagnosis, the results will remain iffy. Why sit around with your fingers crossed waiting for a false positive to turn to a negative?

Allergists rely on tests to a limited extent. A thorough clinical history is more important. Once I am convinced that a food allergy is real, as time goes on, I don’t routinely check to see if children are “still” positive. I take my cues from the patient. What usually transpires is that Mom will bring the child to the office and report that he ate (whatever) and nothing happened. With something like ice cream for a child who is egg or dairy allergic, the child will usually indulge himself pretty thoroughly before getting up the courage to tell Mom and Dad. That doesn’t usually happen with things like kiwi.

I will then do a modified food challenge—the gold standard double blind placebo food challenge is pretty arduous, and this is bad enough. This should only be done by an experienced allergist. It consists of applying a sample of the food to the skin, taking before and after pictures. If the first application doesn’t react, we repeat the process on the lips without letting the patient ingest it. The final stage is full ingestion, with the doctor at the ready with epinephrine. By the time we get to this stage, we are pretty sure there will be no harm.

Interestingly, even if the results are negative, both patient and parents won’t automatically incorporate the new freedom into the diet. They remain wary; having been so disciplined about eating the food, they might avoid it out of residual fear or habit, not out of necessity.

One last word. We talked about component testing briefly in the book, but we know a lot more about it now. I was one of the early adopter allergists in this country (it is common in Europe); Phadia, (now Thermo Fisher Scientific) approached me because I am visible in the New York allergy community to try its ImmunoCap tests. The FDA has dragged its feet in approving them, so reimbursement remains a problem, although approvals are now coming through. Regardless, many parents are all too happy to pay for them out of pocket—they aren’t really that expensive. Unlike old blood tests, or even skin tests, they show whether a patient is only reactive, mildly allergic, or dangerously allergic. This could supply the missing link on the question of retesting.

Dr. Ehrlich

Breast Feeding and Food Allergies

By

In your book, you present the idea of eliminating the most allergenic foods from a breastfeeding mom’s diet. The information I have been able to find on this subject is limited and conflicting. Can you provide sources, links to studies, or other reliable information? The last thing I was told by our allergist is that there is not enough research to support restrictions without symptoms in the baby. However, even delaying, as opposed to preventing, atopic disease is worth it to me. Thanks!

Expectant Mom

Dear Expecting
Thanks for reading the book. This is why we launched the website in tandem with the book. Medicine moves faster than print. Since the book came out, the NIAID, which is part of the National Institutes of Health, published guidelines for diagnosing and treating food allergies last December, which we have written about before.

This is what it says on this topic:

5.3. Prevention of Food Allergy
5.3.1. Maternal Diet During Pregnancy and Lactation
Guideline 36: The EP does not recommend restricting maternal diet during pregnancy
or lactation as a strategy for preventing the development or clinical course of FA.
5.3.2. Breast-Feeding
Guideline 37: The EP recommends that all infants be exclusively breast-fed until
4 to 6 months of age, unless breast-feeding is contraindicated for medical reasons.

Dr. Paul Ehrlich

SiteLock
%d bloggers like this: