Allergy App?

There is an interesting article referenced on the front page of the Indianapolis Star Monday October 31, 2016  .
The article actually is on page 3A and continues on 14A. It has an eye-catching title, “Think you have allergy? There’s an app for that”.
I am an allergist- one could say that my perspective is slanted and self-serving. I have looked at this with a critical eye. There are a number of things to ask about this app.
The article mentions that testing at an allergist can run as much as $1,200- be careful or now total cost would be $1,499.99 when you add the cost of the ‘app’.
Now I am confused. An ‘app’ in current context is a program or software, designed to fulfill a specific purpose as downloaded to a mobile device. So for $299.99 I can download this allergy app to my Iphone and have allergy testing done and since I have the app, I can continuously use it to monitor my ‘allergies’ in the same manner that I would use Waze to navigate traffic? Or each time I ask the app for service is that another $299.99 of cost generated? Is it a one and done ‘app’?
I first thought that the app would include a lancet for my mobile device for the blood extraction and the wherewithal to make the allergy diagnosis on site without any need to wait two weeks for results.
There are a few talking points on this.
1. I did not see anywhere that this was IgE vs. IgG. IgE is the antibody responsible for type I hypersensitivity reactions. IgG is not linked to any adverse clinical condition (Choosing Wisely Campaign)
2. The specific allergens were general categories- many commonly used panels for the blood testing of allergy contain items that are not seen in Indiana (Bermuda grass). All too often Food Panels contain foods that the child has never ingested. These types of tests have high false positive levels and cannot be used to predict allergy.
3. Allergy testing has been available for many years- through the specialists and through blood tests that are frequently used by primary caretakers. This app provides a diagnostic tool in the hands of the patient, avoiding the need for primary or specialty care.
4. I agree with Dr. Holbreich and I would add that the eye is critical but so are the ears and what is between the ears-the knowledge, training, and experience with allergy. The medical history is the critical part of the evaluation- the experienced ears listen to the story of cause/effect relationships and the expertise of the allergist decides what to look for.
5. I also agree that the safety of this app and the value may lie in the non-detectable result- no detectable antibody and the app diagnoses no allergy. (Any comments on the false negative rates on this?).
Safety? In the world of food allergy there is a concept called tolerance. Observations from oral immunotherapy and from performing oral food challenges indicate that even though antibodies (IgE) are made against a food and that food is ingested without any allergic problems, then there is immunologic tolerance. If that food is avoided, due to a test result and was previously eaten without symptoms, tolerance could be lost and an allergic reaction may occur.
6. Tests like this often include extra comments – like highly or very allergic. They only indicates the presence of the antibody. Severity is not predictable by a skin test nor by a blood test (see the National Guidelines for The Diagnosis and Management of Food Allergy 2010).
7. I would wonder if this is a yes or no type of test- is antibody there yes or no. Blood tests done in our IU Health Lab return with a concentration of IgE antibody per volume (kU/L). Through the allergist’s eyes this reflects the risk of a reaction with exposure. As an example, a blood test for milk would be positive at 0.8 kU/L, but at that value, the risk of an allergic reaction to milk would be <5%.
8. Interpretation, guidance, action plans, natural history, verification, questions, and treatment are then offered – by whom, with what credentials.
Other than having the test available for the patient, this is not new. There are a number of issues to be concerned about.
An allergy app that is needed is one that can quickly tell a mom or dad who happens to be grocery shopping for their food allergic child that a product poses a risk. A bar code scanner that links known allergies of the user to the scanned information on the product.
FEL 10/31/2016

October 31, 2016 · fleickly · No Comments
Tags:  · Posted in: Allergies, Allergy Testing

Teal Pumpkin Halloween

Teal Pumpkin Project.
 
Monday is Halloween- I recall when I was a cub scout (only a few years ago) at our Halloween Pack meeting all the cubs (now being a Cleveland Indian fan I do not want to mention anything related to that team in Chicago- Go Tribe!) would come to the meeting dressed up in their Halloween costumes.
 
Each of us had to say a little quip. My mom was the den leader and she put this together for me;
‘Three hundred and sixty four days of the year, I am a cowboy or farmer, but on Halloween, my secret dream is to be a knight in armor.”
 
My usual costume involved a lot of cardboard, tin foil, and a used KFC bucket for my helmet.
 
Halloween should be fun for kids and families. It is scary and can even be more scary because of what may lurk in the ‘treat’ part of trick or treat for a food allergic child.
 
The tradition is candy- and lots of it. The problem is that candy can contain, may contain, and may be made on the same machinery with foods that cause allergic reactions. The smaller individual packages may not have a label that lists contents.
 
Word of advice- and our patients have heard me say this before- If you do not know what is in the product- DO NOT EAT IT!
 
The Teal Pumpkin project is a welcome answer for a safe Halloween for the food allergic children. The founders clearly challenged the tradition that the treat needs to be a food. I looked at the Halloween rules and I did not see a bylaw indicating that all treats must be food.
 
Those who try to forward food allergy awareness (FARE) suggest that a Teal Pumpkin be there to greet the young ghouls, goblins, Steves (minecraft-Calvin), princesses, and knights etc. who march to your door and demand a NON-FOOD TREAT FROM YOUR TEAL PUMPKIN- or you will be tricked.
 
Last year we set up our Teal Pumpkin in our Allergy Clinic. This year, FARE sent one to us as well. Always with the parent’s permission, we allow the youngster to pick a treat from our Halloween bowl.
 
I should know better- I held the bowl out for a family of kids to make choices and I think I was standing there patiently waiting for 20 minutes before all were satisfied.
 
Have a safe TEAL Pumpkin Halloween- from all of us at IU Health North Pediatric Allergy.
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October 29, 2016 · fleickly · No Comments
Tags: , ,  · Posted in: Allergies, Allergy in Children, FARE, Food Allergies, Food Allergy Community Events

Flu Vaccine and Egg Allergy Children 2016

There are two major organizations who have provided flu vaccine guidance; the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC).

Thankfully, the recommendations have been very similar.

The AAP is child-focused and has the input from the American Academy of Allergy, Asthma, and Immunology (AAAAI) as well as the American College of Allergy, Asthma, and Immunology (ACAAI). The CDC also has significant input into their recommendations and they are intended for all age groups. In our allergy clinics we abide by the AAP recommendations.

 

From the AAP

 

All children with egg allergy can receive influenza vaccine with no additional precautions from those of routine vaccinations.

 

The Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology, states that special precautions regarding medical setting and waiting periods after the administration of IIV to egg-allergic recipients beyond those recommended for any vaccine are no longer warranted. Therefore, the algorithm used beginning in the 2011–2012 influenza season to guide vaccination precautions on the basis of the severity of the allergic reaction to eggs is not necessary.

 

The CDC statements (from the MMWR) regarding egg allergy are as follows;

 

 

  • Removal of the recommendation that egg allergic recipients should be observed for 30 minutes post vaccination for signs and symptoms of an allergic reaction.  Providers should consider observing all patients for 15 minutes after vaccination to decrease the risk for injury should they experience syncope, per the ACIP General Recommendations on Immunization.
  • A recommendation that persons with a history of severe allergic reaction to egg (ie., any symptom other than hives) should be vaccinated in an inpatient or outpatient medical setting (including, but not necessarily limited to hospitals, clinics, health departments, and physician offices), under the supervision of a health care provider who is able to recognize and manage severe allergic conditions.The egg-allergic population is at no increased risk of a severe reaction to the flu vaccine due to egg content and as with all vaccine policies, flu vaccines should be given in environments that are equipped to handle severe allergic reactions.

The egg-allergic population is at no increased risk of a severe reaction to the flu vaccine due to egg content and as with all vaccine policies, flu vaccines should be given in environments that are equipped to handle severe allergic reactions.

FEL 9/14/2016

September 14, 2016 · fleickly · No Comments
Tags: ,  · Posted in: Egg Allergy, Influenza vaccine

FARE Community Engagement Charter

FARE is recruiting for their Community Engagement Council.

https://drive.google.com/file/d/0B4GJGGVIaZ9VRkJUbm5oUjJVN0k/view?usp=sharing

 

The link is for the Charter.

This link is for the application https://form.jotform.com/62144750057149

FEL 8/16/2016

August 16, 2016 · fleickly · No Comments
Posted in: Uncategorized

Perspectives on Food Allergy

Being on the other side.

As a pediatric allergist I hear the stories and share advice on how to handle situations. We need to keep the child out of harm’s way and we also want them to have the social interactions that they need and thrive on- an important part of a child’s development.

A few weeks ago Anna (my granddaughter) was invited to a ‘bounce house birthday party’. That in and of itself was a new experience for me. Her mom and dad were going out of town to a wedding so Anna and her older brother Calvin were on our watch for a good part of the weekend.

Tree nut anaphylactic Calvin was invited to the party- and our thanks to the family for doing that. A thanks for many reasons.

Upon arrival, we mentioned the tree nut allergy to the family. They were very responsive and checked the labels for us and assured us that the cake had nothing to do with tree nuts (my summary term for ‘contains, may contain, or made on the same machinery’).

So let the bouncing begin. A very active party, quite different from pin the tail on the donkey and games of that sort. My neck still hurts from watching two very active kids do the up and down thing on a host of bouncing opportunities. After the second room came the pie (pizza), the cake, and the ordeal.

All the parents were sitting watching the 10 children enjoy the lunch. I was looking for that cake.

The attendant brought it in. I spied the offering on the table and began to drift towards it, slowly. My intention was to analyze the cake (despite the father’s assurances). I did not want him to think I didn’t trust him, but I have always had families look for themselves and be wary-my usual words of advice ‘if you do not know for sure, do not let the child eat the food and never trust wait staff for guidance on ingredients’. I was experiencing the angst and the awkwardness that food allergic families have or may have. This was also an experience health care professionals should go through if they deal with children with food allergies.

I slowly crept towards that cake, a few steps at a time, watching parental eyes between moves.  I first got to the trash can- no packaging, no labels there for me to see. I had to see that cake.

A few more steps. Now I can clearly see the frosting, the sprinkles- no obvious tree nuts there. I needed to check the platter- perhaps the information that I sought was there. How do I lift a birthday cake (that belonged to someone else) high enough to discover that ingredient label? I turned my back to the crowd and looked- NOTHING- no label. Now what??

Back to my seat – about 10 feet from Calvin. Of note, if you ask him what his favorite food is, he will tell you cake. Favorite food and potential for a reaction. Of note, Calvin had a reaction to a purported tree nut free cake that may have been contaminated by tree nuts at the bakery. He was served a piece and made quick work of it. As a 5 year old will do, he ate, rolled his eyes to be silly which caused me to jump to my feet. All was good. He enjoyed the entire piece and did well.

For me this was like a laboratory practical examination- I know the literature on the problem, I have heard many stories from families, and now I was able to experience this first hand. It is a good life lesson and helps when you can share what you experienced. It does help to experience real-life situations- it makes you better prepared to guide a patient/family. I hope I can be more at ease for the next one.

FEL 7-20-2016

 

 

July 20, 2016 · fleickly · No Comments
Tags: ,  · Posted in: Allergies, Family, Food Allergies

Tonsiliths

A story to share from clinic. This is one of those stories that is very common in daily life, but not all that common in the clinic. My guess is that the referring provider may not have experienced this, had never known anyone to have this complaint, and probably never had a parent express these concerns.

The chief complaint was mucus balls in the throat. They were hard, mostly irregularly shaped-almost like a tiny cauliflower and smelled, no rather reeked, of an aroma that was reminiscent of some former living animal that decided to die under your porch.

The young lady had ‘Tonsiliths’ or ‘Tonsil Stones’.

Many of us have experienced this, it is fairly common however, it is rarely brought up in casual conversation and it rarely something shared during a clinic visit. These stones are nasty and foul smelling- they will never be part of an awareness campaign.

They are made of mucus, dead cells, food debris, and of course our oral bacteria which contribute to many odiferous compounds- hydrogen sulfide (bad eggs), methyl mercaptan (rotten cabbage), and others we need not mention. All the ingredients for the stones form in the crypts of the tonsils. Calcium is added to the mix to ossify the mass.

These stinky little stones can cause a few real problems; sore throat, halitosis (fancy word for bad breath), ear pain, and tonsillitis.

They happen to occur more frequently in those who have chronic tonsillitis. One obvious remedy is to remove the tonsils.

Clearly not an ‘allergy’. The mother struggled with this as well. What followed was interesting- being told I was the first to define this problem for her. She was so pleased that for some reason she wanted to take me home (?). I also got quite a big hug as well.

 

June 8, 2016 · fleickly · No Comments
Tags: ,  · Posted in: Allergy Clinic, Interesting Stories

Food Allergy/Asthma Connection(?)

Today at our Pediatric Pulmonary, Allergy, and Sleep section’s CME activity, I presented this talk on the connection of food allergy to asthma.

To access this, go to the Lecture page or link Food Allergy/Asthma Connection (?)

FEL 6/7/2016

June 7, 2016 · fleickly · No Comments
Tags: , ,  · Posted in: Allergies, Asthma, Food Allergies, Food Allergy and Asthma

Can We Prevent Food Allergies?

This talk was given on Tuesday May 11th, 2016 at the 51st Annual Riley Hospital for Children’s Pediatric Conference.

The link to the talk can be found on the the ‘Lectures’ page.
FEL

May 11, 2016 · fleickly · No Comments
Posted in: Uncategorized

51 Annual Riley Hospital for Children’s Pediatric Conference

Tuesday May 10th-
I have the honor of speaking at the 51st Annual Riley Hospital for Children’s Pediatric Conference
My talk for the first plenary session is ‘Preventing Food Allergy’
That is a hot topic now- actually keeping a child from developing a food allergy by the early introduction of the hyper-allergenic foods.
I am trying a few new twists for the talk- a video of a food allergic child talking to a group of children (all really very cute kids) and an opportunity to sample one of those early feeding foods.
I am borrowing from Sion Owen (friend and author of a great book- The War on Boring)- and hope that the presentation will educate, entertain, and inspire change.

FEL 5/8/2016

May 8, 2016 · fleickly · No Comments
Tags: ,  · Posted in: Allergy in Children, Food Allergies, Meeting Updates, Presentations, Preventing Allergy

Food Allergy Action Month

May is ‘Food Allergy Action’ month and the week of May 8-14 is Food Allergy Awareness Week. Of note, I have been asked to present at the 51st Riley Pediatric Conference, May 10th at the first plenary session on the hot topic of food allergy prevention.

A few weeks ago I was asked to write a piece about an aspect of food allergy. I chose a topic that is somewhat unique to what we do in our clinic- Food Challenges. I was very steadfast in the message I wanted to say. In an effort to make a long story short, the editor and I did not share the same perspectives. I withdrew the article- regretting the giving up the opportunity to post what we do with a larger audience, but I had to remain firm on the content. What follows is the article;

Important stops to consider during your journey through the world of food allergy; the role of the food challenge.

The first step has been taken, your child has had a reaction to a food. You have reached out for direction and the guidance given may have included allergy testing or a referral to an expert in food allergy. Your suspicions have been verified by an allergy test, but there are unexpectedly more items found during the evaluation. Additional tests were performed and now you have a concerning list of allergenic foods to avoid. This list may contain foods that were eaten frequently without any reactions or foods that your child has never ingested. The obvious advice you are given is full and strict avoidance. The journey becomes more precarious. You and your child are afraid of the dismal prospects for a life without fear of a reaction. The quality of life suffers and the child’s nutrition may suffer. There is also the concern about the cost that surrounds special diets, schools, and medical supplies for reactions.

There are a few questions that you need to ask;
1. Is there a chance that this food allergy will go away?
2. Is there a chance that some of these test results are falsely positive?

Is there a way to verify an allergy test result?

The answer to that is an emphatic YES! Food allergy challenges can provide the correct direction-eat or avoid.
The food allergy challenge is also an allergy test and it is the gold standard test for food allergy.
When the history is obvious and the skin test supports the suspicion, a blood test called specific IgE may help sort out the risk of a reaction. If the risk is low, then a food challenge is a consideration.
We offer food challenges in a controlled clinical environment where we have the “e’s’;
1. Experience
2. Expertise
3. Equipment
The idea behind the food challenge is the gradual introduction of the allergenic food. There are about 10 exposures, each step is twice the amount until a full serving has been given. The procedure takes about 4 hours.
When you arrive we take care of registration, vital signs, and an examination. We review the history and have you sign a consent. We take time to answer any questions. We explain the procedure to the child as to what to expect and we make it very clear that at any time there is a concern, we stop and evaluate. The decision to continue is made together with the team, the parent, and the child.
Yes, we have had reactions that have caused us to stop. We have had concerns that led to a long waiting periods prior to stopping or continuing. We have had to place barrier creams on the face to keep the child from having a rash from wearing the food. We have had long talks with the children who are scared because they have been told of dire consequences due to the food. Some of the children are so well educated about avoidance that it makes the food challenge very hard to do.
What is our food allergy experience? We have done food challenges for egg, milk, wheat, peanut, soy, fish, shellfish, sesame seed, corn, watermelon, and tree nuts. Our track record is a pass in 80%.
The food challenge has serves many purposes; it paves the way for good nutrition. It helps with quality of life issues, it ends the need for injectable epinephrine, and importantly, it helps resolve the fear of a food allergy.

FEL 5/1/2016

May 1, 2016 · fleickly · No Comments
Tags: , , ,  · Posted in: Allergies, Allergy in Children, Allergy Testing, Food Allergies, Food Challenges