We talked about the findings at the meeting. We shared  experiences and concerns and we talked about a number of great ideas to help children with food allergy. One of the most thought provoking topics was looking at food allergy as a public health problem. This is definitely a public health problem. As an aside, the request for comments on the ‘ Food Allergy Mangement…’ draft began with a very effective attention getting statement-’Food allergy is an important public health problem….’ . To my dismay (that recent Masters of Public Health degree affecting my perspective again), the guidelines’ intention was to help with diagnosing and managing food allergy and not the public health issues. I applaud this work and the work of the committee that put this together. I have never made any responses to requests for comments on guideline drafts in the past. This draft of the guidelines stimulated me to offer a few comments. The acceptance of these food allergy guidelines is  important and desperately needed before we can be effective in any public health approach to food allergy. We need to critically look at what food allergy is and what is not food allergy. We need to listen to the story of what happens with exposures to food and carefully select the appropriate tools/tests to make the diagnosis. We also need to support efforts to help treat current food allergy issues and hopefully prevent the development of food allergy.

I shared with the group a review by Scott Sicherer on ‘What is New in Pediatric Allergy’. In this session Dr. Sicherer selected a few key articles that have appeared over the past year dealing with food allergy. A few of the food allergy topics included; The Natural History of Wheat Allergy (Keet, 2009), Food Protein-Induced Enterocolitis Syndrome (Mehr, 2009), Timing of Food Introduction and the Development of Atopy (Nwaru, 2010), and Dietary Advice, Dietary Adherence, and the Acquisition of Tolerance in Egg-allergic Children (Allen, 2009).

1. Wheat allergy resolved faster than egg or milk allergy.

2. FPIES- depending on the population studied, different foods are causitive and there seems to be differences in the rate of resolution. The overall prognosis is good.

3. Sensitization (having a positive allergy test, not necessarily symptomatic with exposure) was seen with the late introduction of a number of foods in this cohort of children from Finland.

4. Dietary advice is not uniformly followed, the advice given did not correlate with outgrowing egg allergy, adherence to the advice did not correlate with resolution, and accidental exposures to egg did not affect the outcome (outgrowing the allergy).

We also talked about research projects and protocols that involve food desensitization and food tolerance. Wes Burks from Duke University presented information on a number of studies. This work is ongoing at Duke, University of Arkansas, and at Mt.Sinai (New York). It is important to understand the differences between achieving a state of desensitization or tolerance.

1. Desensitization is the temporay increase of the amount of a food that would trigger an allergic reaction. This would offer protection from a life-threatening event due to an exposure.

2. Tolerance is the permanent loss of allergic reactivity due to changes in the immune system.

Desensitization and tolerance may work through similar mechanisms. Small exposures would not cause life threatening events in the desensitized child, however only the tolerant child could eat larger amounts of the culprit food without consequences.

The enthusiasm for participation in studies that may end the fear of a food reaction was intense. I was very impressed. A mother mentioned that she would donate her home if her child could participate in a program that would lead to desensitization/tolerance for peanut.

I shared the findings from an abstract of a study from the University of Michigan (abstract # 746). This was a report from a survey that represented the US population. In this survey 3-4% of those responding had a child with a life-threatening food allergy. Twenty five percent of responders knew someone with a food allergy. Of the families who had a child with a food allergy, 80% were accommodated by the school or daycare and of those, 50% of the staff had specific training in food allergy. Nearly 50% of the responders said that they were not at all inconvenienced by measures needed to protect the food allergic child, 25% were somewhat inconvenienced, and a few said it was very inconvenient for them.

We spent some time talking about this. Some of us were surprised by the findings. The charge to the group and the charge to anyone involved with children with food allergy is to advocate and to make others aware of the issues. The Southside Food Allergy Support Group offers an excellent program called
PAC- Protect Allergic Children. PAC has a detailed presentation that can be given in a number of venues.  The programs are ‘Food Allergy Safety in Schools’ and ‘Creating a Safe Home for Food Allergic Families’. Information on these programs can be obtained from the Southside Food Allergy Support Group.

One topic for a future meeting most certainly will be a summary of the final Food Allergy Guidelines.

My thanks to the Southside Food Allergy Support Group for the invitation to speak (as a disclosure, I am an advisor to the group as well). Keep the kids safe!!

Respectfully submitted,

Fred Leickly

So how has this year shaped-up?

There are 36 posts-what appears on the home page (reviews, stories, comments) and there are 11 pages. Of course the home page will grow as hot topics in the world of allergy appear. I still need to create pages dealing with more of the clinical conditions we see in the allergy clinic- look for anaphylaxis, allergic rhinitis, recurrent infection, drug allergy, and stinging insect allergy. I also want to post a page on ‘non-allergy’ .

The site has an analytical program attached that keeps tract of a visit to the site. Over the past year ‘Leickly Stories’ has had 3,500 visits from 69 countries. Two-thirds of those visits are new.

I also want to thank my 4 subscribers- apparently there are four people who receive a notice that this site has an update to share. To become a subcriber just click on that curly logo in the upper right corner of the home page. It is an RSS feed for the site.

Hopefully, I can start collecting allergy experiences from children/families that I see in my practice to share with others. The world of allergy can be scary. For those who are new to it, hearing how others have dealt with the problems helps establish a confidence and comfort level. It also lets people and children know that they are not alone in this struggle.

Fred Leickly

As with all of these courses I learned from a group of wonderful speakers and there are a few things I will add to my practice. Here are a few things to share.

First- I was under the impression that warmth would be associated with places that had the word “Mexico” associated with it. Santa Fe was colder than back home here in Indiana! There was snow as well. Surprise! Despite the weather it is a most beautiful place.

Second- the people are very warm and friendly. Here is an example-my hat has many pins from a variety of states, countries, and places that I have visited. I was with my wife and our friends having the obligatory ice cream after a dinner with a rather spicy salsa. A gentleman came up and gave me a pin that commemorates the celebration of 400 years of Santa Fe, New Mexico. He loved the hat and thought that the pin would be a welcome contribution. I offered to pay for the pin but was denied. The gentleman was the president of the Santa Fe 400 year committee and he assured me that he had a plentiful supply of those pins. I didn’t catch your name- thanks yet again.

Places and things visited- Santa Fe 400 (left lower).

Third- The speakers for this program were all top-notch.

• Dr. Veda Ackerman- Pulmonary- James Whitcomb Riley Hospital for Children, Indiana
• Dr. Meg Fisher- Infectious Diseases- Children’s Hospital at Monmouth Medical Center, New Jersey
• Dr. Ivor Hill- Gastroenterology- Wake Forest University School of Medicine, North Carolina
• Dr. Todd Mahr- Allergy & Immunology- University of Wisconsin Medical School,  LaCross, Wisconsin
• Dr. Anthony Mancini- Dermatology- Northwestern University Feinberg School of Medicine, Chicago, Illinois
• Dr. David Schonfeld- Developmental/Behavioral Pediatrics- Cincinnati Children’s Hospital Medical Center, Ohio

Fourth- Here are just a few excerpts from the program;

Pediatric Pulmonology I work with Dr. Ackerman. In fact it was at an AAP course that I first met her and she was instrumental in recruiting me to Riley Hospital. Over the years I have heard her talk on many subjects for a wide variety of audiences.

Cough suppressants have no real role in children. There are no studies to support the safety and efficacy of these agents in children. Cough suppression in children may be hazardous and contraindicated.

Infectious Disease Very few bacteria lung infections cause wheezing except for mycoplasma infections. Most of the wheezing from infection is due to respiratory viral infections.

Most viral respiratory tract infections have a gradual onset of symptoms. The exception is influenza which hits hard and fast.

Fever may be helpful- the influenza virus will not survive/replicate in a host with elevated temperature. Treating the fever may help the virus to continue to replicate which can prolong the illness and prolong the spreading of the virus. Viral shedding may be prolonged with antipyretics (acetaminophen, ibuprofen).

Gastroenterology Celiac disease is a common concern. Confirm the diagnosis before treating. Constipation is not due to a food allergy in children. In dealing with constipation, the child controls the sphincter- this makes yelling at the child quite useless as a therapy.

Allergy Air filters for house dust mite avoidance do not work due to the nature of dust mite allergens. However a HEPA filter on a vacuum cleaner helps filter the exhaust. Carpeting on concrete (finished basements) helps house dust mites grow.

Food allergens are proteins/glycoproteins they are not fats or carbohydrates (sugars).

The peanut allergy child/family needs to be aware that peanut is sometimes made to look like or substitute for tree nuts. Faux almonds in baked goods may be peanuts. READ THE LABEL AND IF YOU DON’T KNOW, THEN DON’T EAT IT.

Dermatology I could not resist asking the definition of eczema, atopic dermatitis (AD), allergic atopic dermatitis, and non-allergic dermatitis. The answer restored my faith in this area: you should work with eczema and atopic dermatitis and forget the other two terms. Thank you Dr. Mancini!

One of the shared conditions with allergy is ‘atopic dermatitis’.  The presentation debunked myths associated with this condition.

These myths were-

•             Topical steroids are unsafe and should be avoided.
•             Antihistamines don’t really help.
•             Staph Aureus is an innocent bystander
•             Food Allergy is a common culprit

The debunking

•             Topical steroids are the mainstay of treatment.
•             Antihistamines help with itch and help with sedation.
•             Treating staph infections of the skin help with healing.
•             While 30-60% have a positive test for a food, only 10-30% have worsening of the condition due to a food exposure.

The role of allergy is recognized, but it is only part of a much larger scenario. Foods seem to be part of the problem in the more moderate to severe cases. Full and strict avoidance of a food in many cases does not modify the course of the disease. All too often parents blindly eliminate foods which can lead to dietary and nutritional deprivation. Co-management of AD by dermatology and allergy is vital.

Aeroallergen issues were a concern in the teenager with AD.

Developmental/Behavioral Pediatrics The specialties of D/B and allergy rarely mix except in CME programs like this one. Behavioral issues are not secondary to allergy. Given this, we don’t have many if any consults from the specialty.

Dr. Schonfeld’s lectures were; Supporting children in times of crisis, Connecting with patients and families to conduct a behavioral/mental health interview, and How children come to understand illness and how we can learn to explain it better.

These were very interesting topics and Dr. Schonfeld did fantastic job. I am sure he is wonderful with his patients.

I have always tried to engage the child in my evaluations. After all, the child is the patient. In our practices we need to be sure the child is involved to some extent (depending on age/maturation). There should be no secrets about their condition. The child can better deal with what is going on if they understand it. Our job is to facilitate that understanding and the processing of the information. Adherence to therapy should be improved with comprehension. We should also understand that we should not try to do all this in one visit.

Dr. Schonfeld pointed out that ‘health education’ is rarely taught in medical school. In my situation, I learned about health education in my MPH curriculum. A quote that I will always keep in mind is “You don’t need to be an expert in pediatrics to explain illness to children-you need to be an expert in children.

This was a great conference and it was made great by an outstanding faculty. If you have a chance hear any of these pediatric specialists speak, do not hesitate in listening to what they have to say. If you have a chance to see them for the care of a child, then I am assured that you are in very capable hands.  

Fred Leickly

Providence, Rhode Island was the host city for this Practical Pediatrics offering. In early April Providence does not have a lot going on. The weather was wet and cold. This kept us indoors. The seafood and Italian food were great! I also recommend the IMAX 3-D movie Aliens vs. Monsters. Despite the inclement weather, I did learn a few new things and learned to appreciate many other aspect of care for our children.

Dr. Martin T. Stein, Professor of Pediatrics at the University of California, San Diego shared a few thoughts on pediatrics in general. He presented things that made me stop and wonder about the incredible job that is done by healthcare providers that look after our children. Did you know that for well child care the recommendation is for 31 visits? Back in the day (okay, 1974) only 14 well child care visits were the standard. I am sure this increase is due to the need for guidance, safety, development, and prevention. It makes our pediatricians busier. I also learned that our children benefit from a level of primary care above what is offered in other countries. The United States is the only country where board certified pediatricians provide that essential well child care. I have always held our pediatricians in high esteem. I learned a few things that have increased my respect for them and for what they do.

I learned a few more things about allergy and had a few of my standard issues emphasized by Dr. William T. Boleman, who is the Chief of Allergy at the Keesler Medical Center (USAF) in Biloxi, Mississippi.  I learned that controversies in allergy are not at all unique to Indiana. Mississippi seems to be affected by theories, practices, and therapies done under the name of allergy, but clearly without a shred of evidence that allergy accounts for the problem. Dr. Boleman talked about sugar, wheat, yeast, chemical, electromagnetic radiation, hormones, and voodoo allergy testing including IgG antibodies to foods. One of his messages was to be sure that the story matches a condition in which allergy may be a cause. History taking remains an essential part of any allergy evaluation.

I have always enjoyed listening to the dermatologists. Their lectures are replete with pictures and practical information on a wide variety of things that can affect our skin. Dr. Miriam Weinstein from Toronto Sick Children’s hospital shared her opinion on a condition that is often seen by both the allergist and the dermatologist. That condition is atopic dermatitis, a form of eczema that has associations with allergy. I was surprised and concerned after the talk on evidence-based therapy of atopic dermatitis. She had pulled references from the dermatology literature. The evidence-based review is a critical summary of good and bad studies. One of my courses in the public health program actually taught us how to critique one of these reviews. It is quite an art to go over a vast literature looking for answers to specific questions and making sure that the methods used to get that answer were without any flaws.

The things that I learned and what I thought would be very helpful for the children I see with atopic dermatitis in my allergy practice include the emphasis that it is not just one thing such as a food that will trigger a flare of itchy, dry, flaky skin. There are many different reasons for the condition to flare and sometimes it just happens. When we discover something like a food that could trigger that is great because there is one less thing to worry about.

We also need to keep the skin as moist as possible. Moisturizing the skin can be considered front or first line therapy. These children need to be so slicked-up that they just slide through your fingers.

Using the topical steroid ointments once a day may be just as effective as using them twice a day and using them a few times during the week even when the skin is clear may help keep the skin from flaring.

I now emphasize that the use of the anti-histamines is not so much for the itch component of the skin, but for sedation. A significant amount of scratching of the skin occurs during the night. Helping with sleep by taking advantage of the sedative aspects of antihistamines makes a difference. Choices here would be agents like Benadryl or preferably Atarax (Hydroxyzine).

Skin infection needs to be controlled. The scratching and breakdown of the skin leads to infection. The infected skin then causes further scratching and misery.

Also, contrary to what an allergist would like to believe, being allergic to house dust mites and consequent house dust avoidance techniques may not make any difference in controlling flares.

Food allergy may not be the cause of many of the flares. Unfortunately these children have many positive skin tests and the track record is that the positive predictive value of the food test is about 50%. So when the allergy test for food is positive, there is a 50/50 chance that it is relevant and that exposure to that food causes a flare of the skin. Of all the foods that have been associated with flaring, egg is the most common.

It is important to keep learning new things, new perspectives, and be open to changes that may be of benefit to our patients. Hopefully a few of these tidbits may help.

Fred Leickly

The meeting’s agenda covered a wide variety of clinical conditions. It would have been impossible to attend every session. I chose sessions on the allergic environment, eczema, immunotherapy, food allergy, re-certification, headaches, and asthma. There are a number of ideas that are evolving and a number of things currently done in allergy/asthma care that need to change. Each and every one of these topics is truly worthy of more extensive review. I would be happy to use this blog to delve into topics in more detail (per request).

Atopic Dermatitis (aka Eczema)

I still need to be convinced regarding what to call this condition. Dr. Jeff Travers (chief of Dermatology at the IU School of Medicine) and I go back and forth on this topic. During the meeting I heard the concept of extrinsic and intrinsic atopic dermatitis. Extrinsic means from the outside and intrinsic from the inside. These terms have also been used for years to describe two presentations of asthma: extrinsic asthma due to allergy, and intrinsic asthma when no allergy is found. The word atopic means 1) the tendency to come from families with allergy, 2) to make the antibody seen with allergy (IgE, which would be elevated) and 3) to have positive allergy tests. Thus, Intrinsic AtopicDermatitis means no allergy demonstrated (intrinsic) in a condition associated with allergic sensitization (atopic). This blending of terms leads to confusion–why not stick with the simpler term of eczema?

I learned about the use of silver impregnated clothing to decrease the amount of bacteria on the skin. Skin bacteria can cause flaring of atopic dermatitis.

A number of  genes associated with atopic dermatitis have been discovered. These discoveries should increase our understanding on how this condition starts and hopefully how we can manage it better.

There was information on allergens that contain enzymes called proteases and how these protease containing allergens aggravate the skin.

Probiotics have been used to treat allergic conditions especially conditions related to food allergy. A review of studies on probiotics have not shown them to be effective in preventing or treating atopic dermatitis.

I listened to debates about being proactive in skin care therapy vs. being reactive. Proactive would be trying to prevent and reactive being treating only when there is a problem. This idea was particularly interesting. Atopic Dermatitis Guidelines and package inserts for a variety of medications used for atopic dermatitis treatment stress short courses of use, the reactive approach. The proactive debater posed the problem of a chronic disease that will have episodic flaring. The abnormality of the skin is there all the time requiring the need for medication to be used perhaps twice a week to avoid flares (those times when the skin is more itchy, more inflamed, and more broken down). Pediatrics deals extensively with disease prevention. My pediatric perspectives are preventative- proactive. All too often we (as patients) tend to be crisis-oriented or reactive to chronic conditions. I am obviously on the proactive side of this argument.

Therapies emphasized moisture and more moisture. Keep these kids wet! This is clearly a major step that is contrary to previous approaches that recommended the avoidance of frequent soaking/bathing. The avoidance of baths is clearly one of those long established principles of atopic skin care that has fallen by the wayside in contemporary skin care.

Foods are an issue in atopic dermatitis. The protease containing allergens such as molds, pets, and mites may have a role in triggering flares.

In Boston a program that has had success includes insuring compliance with the medications (taking them as prescribed), addressing the parents concerns about medication side-effects (helps with compliance), decreasing the itch, and increasing sleep. These are all essential elements to help with control of the condition.

Of note, we need to re-think the role of a specific therapy and make adjustments. Antihistamines are frequently used in atopic dermatitis. In allergic rhinitis and in hives, these products help control itch. However, in atopic dermatitis, the antihistamines have little effect on itch. The role of the anti-histamine is to sedate. Most of the scratching happens at night. A sedating antihistamine used at night works best.

Asthma

There were a number of new ideas regarding asthma. Look for vitamin D to have a possible role in treatment.

Current recommendations from evidenced-based asthma guidelines point out a difference between adults and children and the use of the long-acting bronchodilators in the two populations. These agents are called long-acting broncho-dilators (LABAs). In children, we should increase the dose of the inhaled corticosteroid before adding a LABA. This recommendation appears in two major asthma guidelines with type A evidence used to support the recommendation. This type of evidence (A) means that there are a substantial number of studies that support this statement.

Asthma may be related to bacterial colonization at birth and to the occurrence of the common cold virus later in life. Evidence was also presented regarding the observation from large population studies that the process of airway inflammation starts well before actual symptoms. We heard about diet, viruses, stress, ozone, and endotoxin having a role in the development of asthma. The gene or genes for asthma need to be present. These genes then need to be activated or expressed for the child to show the signs and symptoms of disease. Bacterial colonization and a variety viruses may have a role in activating the genes.

Headaches

This was a great session. The audience heard from an ENT surgeon, an allergist, and a neurologist regarding their approach to headaches. The consensus was that migraine is the biggest player in these situations. The connection of allergy to headache has always been a concern. However, headache is not a manifestation of allergy. There are many studies that have looked at this. People with headaches can have positive allergy tests but does that make the allergen the cause of the headache? Think about other conditions or associations. Could there be an allergic cause for an appendicitis?

I heard of the concept of ‘allergic appendicitis’ during this presentation. It was very odd to hear about this in a headache session, but a valid point was made. This concept of the allergic appendix was compared to allergic headaches. Follow along; data from a national health survey from 1994 indicated that 50% of the population reported that they had allergy. So if someone who had problems with the appendix was allergy tested, the chances are very high that allergy would be found. This however does not make the inflammation of the appendix due to allergy. You can find a significant number of positive allergy tests, be sure of why the tests are being ordered. Think migraine more often as a reason for headache. Allergy is not a major reason for headaches.

Food Allergy

The biggest news from the meeting was the work done by Wes Burks at Duke on peanut allergy. This is exciting and long awaited for those who have peanut allergy and for the families who have someone with peanut allergy. Immunotherapy for peanut trials have allowed the equivalent of about 12 peanuts to be eaten without any problems/reactions. This would certainly take the fear from accidental exposure to peanut especially from tabletops at school cafeterias. I have to check my note again, but I had written down the treatment would be a suppository(?).

There was a very popular abstract (a quick presentation of work in progress prior to it being published in a journal) on food allergy and the over- use of panels for food allergy (pet peeve). A New York Times article a few months ago reported that food allergies were being over diagnosed. Dr. Sears at National Jewish Hospital in Denver, Colorado reported on over one hundred children seen at their center who had food allergy as determined by blood test panels. The average number of food allergies reported were six. After undergoing food challenges the number decreased to only 2 foods. 88% of the foods this group of children were told to avoid based on RA ST panels were added back into the diet. Using a food challenge, no one with meat ‘allergy’ had a positive food challenge (where meat caused a problem), 88% of the grain ‘allergic’ children were negative on challenge, and 83% of the fruit and vegetable group were also negative after a food challenge. Bottom line- the use of these panels is giving falsely positive information and leading to a misdiagnosis of food allergy.

Allergy Testing

I learned that I should no longer use the word RAST. The term is outdated and refers to a technology not used. The blood tests for allergens should no longer have a 0-6 grading scale and should only be reported in what is actually measured kU/l of serum. The test measures a concentration of a specific antibody in the blood. The relationship of that concentration to clinical activity needs to be determined by the clinician. I predict that the interpretation of the blood test results may be a huge issue.

A new in vitro or blood test for specific IgE in the blood is called an ISAC chip. This technology will help with cross-reacting proteins. We see the problem of cross-reactivity with multiple positive allergy tests to legumes (peanut, soy, beans, and peas). I think this will be a very worthwhile test in allergy.

There are three blood tests out there for detecting specific IgE. These are the Immunolite, ImmunoCap, and Hytec. Each of these measure something different. They measure a different population of IgE antibodies and may not be comparable. Caution was advised regarding the blood tests for specific IgE. The physician should know the method used, the validity of the assay, the performance of the laboratory in doing the assay, and realize that no test for allergy is infallible.

Conclusions

Each and every one of these topics could stand alone for more detail and interpretation and I would be most happy to elaborate in more detail. Let me know if you would like more information by adding a comment. If there continues to be an increase in the use of specific IgE panels (as advocated by those who market these tests) we will be doing significantly more food challenges in our office. Usually we are doing food challenges for those who may have outgrown a food allergy. We certainly can offer a food challenge for a child who has been told that food allergy exists based on blood test results. One of my tasks upon my return to the office is to look at our track record of doing food challenges. I hope to report on our successes and failures for our food challenge experience with milk, egg, soy,wheat, and of course peanut.

Respectfully submitted,

Fred Leickly