There are literally hundreds of food additives including colors, flavors, spices and preservatives, that are added to the foods we eat everyday in order to enhance the flavor, change the color or texture, or to increase the shelf-life of the food product. Most individuals will come into contact with many of these additives every day as a part of a normal, balanced diet. We often don’t think about - or pay attention to - the potential allergy issues associated with these additives.
Like anything we ingest, there is always the potential for an adverse reaction, including both immunologic (allergic), and non-immunologically (non-allergic) reactions. The range of symptoms attributed to food dyes, spices, and additives is diverse, but may include classical allergy symptoms such as anaphylaxis, asthma, hives, rash, and nasal symptoms, as well as non-allergic symptoms such as headache, behavioral changes, digestive difficulties, and fatigue.
In general, dyes and additives very rarely cause a true allergic reaction. There is much circumstantial description of symptoms attributed to various additives or colorants, but controlled trials that have examined this issue have been inconclusive in establishing a cause and effect relationship. There is, however, evidence supporting the fact that some additives can provoke an antibody mediated reaction that would be considered an “allergy”.
The following is a summary of agents that have shown the most convincing evidence of true allergic reactions, and agents which cause symptoms that are not the result of an allergy, and are best characterized as an adverse reaction.
Two agents in particular have demonstrated proof that a true allergic reaction can result from their use. One of these is Carmine, a crimson/wine red/pink natural color derived from the pulverized, dried bodies of female Coccus cacti insects.
The red dye contains residual insect body protein, and this has been shown to cause a true allergy as mediated by a specific antibody. Carmine has been linked to asthma induced from inhalation of the dry powder. Interestingly, this has been reported to occur primarily in men.
Anaphylaxis, on the other hand, has been shown almost exclusively in females who presumably become sensitized to this agent through its use in makeup and cosmetics. As a result of this sensitization, ingestion of carmine containing items can subsequently result in serious allergic reactions.
The other agent which can induce an allergic reaction is Annatto. Annatto is a yellow colored powder derived from the seed of the Bixia orrellana bush. Most people have been exposed to annatto, as it is used to color dairy products, as well as confections, soda, and processed goods. This is the agent responsible for the distinctive color in cheese, and butter, and macaroni. Outside of the U.S. it is used in meats as well.
Annatto allergy has been demonstrated on standard allergy scratch tests, as well as specialized research laboratory tests, in sensitive individuals.
Other natural colorants that have shown more limited evidence of true allergic reactions include saffron (asthma, anaphylaxis), anthocyanins in grapes (anaphylaxis to grape containing products including certain wines), and paprika.
There have been several clinical trials that have looked at whether colorants can cause symptoms including allergy and behavioral changes. None of these trials have shown any evidence that such an association exists, though anecdotally, there are many parents and individuals who are convinced that one does indeed exist.
Yellow dyes were implicated in some of the earliest reports of possible colorant induced allergy. Tartrazine (FD&C Yellow #5) has been linked to reports of chronic hives, asthma, and cross-reactivity in aspirin allergic patients. Chronic hives was studied in oder to determine if chronic hives could be “unmasked” by allergy to tartrazine. Again, no evidence exists that supports such associations. In fact, in cases where the dye appeared to cause allergy symptoms, further analysis determined that the symptoms may have resulted from confounding or coincidental causes, such as withholding chronic medication.
Tartrazine has also been shown to have no clinical cross reactivity in inducing hives in aspirin/ibuprofen allergic patients, and consequently, there is no contraindication to this dye in an aspirin sensitive patient. Its role in inducing asthma also has not been supported by medical evidence. One randomized, placebo controlled trial did suggest that very high doses (>10 times that encountered in use in a medication dose) of tartrazine may induce hyperactivity in children, though this effect was not seen at low doses commonly used commercially in foods or medicines. Contact reactions to tartrazine, as well as other certified dyes, are a recognized entity.
Other certified colors questionably linked to allergy include FD&C#40 (Red 40) and FD&C yellow #27.
Since spices are derived from plants, there are some case reports of symptoms resulting from spice allergy. Many of these spices share the very same proteins to those found in certain pollens, and have theoretical ability to induce a phenomenon called the “oral allergy syndrome”, which rarely results in a serious allergic reaction. Occupational inhalation of several spices has been associated with reports of asthma attacks.
Sesame and other similar seeds such as poppy, commonly used as spices, share common allergenic proteins and are increasing in the U.S. as a cause of serious allergic reactions. Sesame and other seed allergies are very clearly antibody mediated, with reliable cutaneous as well as blood tests available to aid in the diagnosis.
Because spices often have aromatic properties, contact with the skin can induce irritation through direct tissue damage. Spices can also cause contact dermatitis similar to a Nickel allergy or poison ivy type reaction. In general, spice induced reactions are uncommon, and anaphylaxis or major allergy symptoms from spices are rare. Testing to these agents is best done with fresh specimens, but this is a non-standardized process, and the test may irritate the skin making interpretation difficult. Avoidance of spice agents is also a somewhat daunting task, given their common use in the American diet.
BHT and BHA are two popular synthetic antioxidants used in foods to help preserve texture, especially in animal fats. In 1958, they were declared generally regarded as safe for use in food. Animal toxicology studies have shown BHT may induce immunologically mediated lung damage and fibrosis, but alternatively, both BHT and BHA have been shown to be protective for certain types of malignancy, and possibly possess anti-atherosclerotic properties. These effects have not been demonstrated in humans. In case reports, both have been implicated in inducing asthma and chronic hives, but other studies have not supported this association. Otherwise, BHT/BHA is linked to contact reactions.
Monosodium Glutamate (MSG) is a very controversial additive found commonly in Chinese food, though it is certainly not limited to this type of cuisine. In 1968, a physician published a letter to the editor of The New England Journal of Medicine detailing an odd constellation of neurological symptoms experienced when eating at a Chinese restaurant, suggesting that MSG could be the causative agent. Thus, a major controversy which still exists today was sparked.
At high doses in humans, nausea can result and several case reports suggest that MSG exacerbated asthma. Others have suggested that hives may be attributed to MSG. Though difficult to perform, several challenge studies have shown no evidence of an MSG symptom complex, or even symptom development. Asthma studies showed a similar lack of evidence to support an association with MSG, as have the few studies done to explore the role of MSG in provoking chronic hives. MSG causing headache has been studied, but was not shown to have a significant association, despite widespread belief to the contrary.
In summary, MSG probably does not cause symptoms based on controlled studies, but high doses may infrequently be associated with symptom development, especially headaches.
Sulfites are widely used as a preservative. Unlike many other additives, sulfites do have a well defined role as provoking asthma, although not as commonly as originally thought. Asthma has been demonstrated after sulfite administration in several studies, and fatal reactions have been described. The association is much better established in adults than in children. It is not known exactly how sulfites trigger asthma, but positive skin tests have occurred, implying that it is an antibody mediated reaction.
Sulfites affect only about 5% of asthmatics and tends to be more common in those with more severe and persistent asthma. Most experts recommend a controlled challenge to confirm symptoms after a history of a reaction. In such individuals, avoidance of sulfite containing items is strongly encouraged. Interestingly, epinephrine devices (EpiPen® or Twinject®) do contain small amounts of sulfites, but the medication is still effective (and highly recommended) to treat a sulfite induced reaction.
Sulfite sensitive individuals with asthma do have a certain degree of tolerance to sulfites, abut certain foods are more dangerous than others, especially acidic foods. Foods with less than 10-50 ppm sulfites are far less likely to induce a reaction, but this has not been readily tested. Avoidance is highly recommended, as is confirmation of the reactivity with an oral challenge under the watchful eye of an allergist.
These items are common preservatives in wide use in food and other products. Both have been implicated in chronic urticaria, but there has been no evidence to suggest an association with asthma. Paraben use in local anesthetics has been attributed in systemic reactions, and parabens are known to cause contact dermatitis.
It is very difficult to identify the particular food additive in question as the true culprit in precipitating a reaction, especially since there are many other items that could also be responsible. of great help to an allergist evaluating such a complaint is a clear, concise history of exposure to the particular item consistently causing symptoms.
If symptoms are intermittent despit
According to published studies, between 10-15% of the general population are allergic to cats and dogs. This high incidence of animal allergy, coupled with the fact that approximately 50-70% of homes have a dog or cat living indoors, makes pet allergy a major health consideration. It has been estimated that of the two million people allergic to cats, at least 1/3 of them live with at least one cat in the home. And, to make matters worse for the allergic individual, many homes where there are no indoor pets will still contain enough allergenic pet proteins to cause allergic reactions.
Allergy to cats is twice as common as allergy to dogs. Regardless of the animal or species, it is likely that the cause of the allergic reaction is not the hair or fur at all. One highly allergenic source is the dander or old skin scales of the animal. These particles are deposited wherever the pet goes - on the bed, the couch, and in the carpet. Dander allergens are extremely small and easily become airborne, eventually depositing themselves and clinging to furniture, draperies, wall coverings, and even the walls themselves. Because of its stickiness, the allergenic dander can remain in the house for six to twelve months or longer after the animal has been removed from the house.
In cats and dogs, saliva and urine are also potential sources of allergens. They are deposited on the fur through licking and urination. When the hair or fur dries, the microscopic particles flake off, become airborne, and become readily accessible to the airway of the allergic individual.
The major cat allergen is called Fel d 1, and is formed in the sebaceous glands of the skin and is present in saliva. Fel d 1 is deposited on the fur from sebaceous gland secretions and through saliva when cats lick themselves clean. The major dog allergen has been identified as Can f1.
Some people who are allergic to animals will begin to have symptoms immediately upon entering a home or room where a pet resides. Symptoms might include the acute onset of itchy, watery eyes, itchy nose and throat, sneezing, runny nose, and nasal congestion. Even asthma symptoms, including coughing, wheezing, tightness of the chest, and difficulty breathing can be induced almost immediately upon exposure. Unfortunately, if one is sensitive enough, it does not take a lot of animal dander to cause an allergic reaction. The allergen is so small and light that it remains airborne for long periods of time, making it readily available to be breathed in and begin causing a problem.
On the other hand, many pet allergic individuals will not react acutely when exposed to an animal. Because of constant exposure, they may react, over time, by having daily, chronic symptoms such as persistent nasal congestion, runny nose, itchy eyes, nose, and palate, as well as coughing, wheezing, or shortness of breath.
Unfortunately, there are no known breeds of either cats or dogs that do not produce allergenic dander. It must be remembered that allergies can also be produced by exposure to proteins in pet hair, saliva, and urine. Therefore, every cat or dog has the potential for causing allergies. Patients often comment that “I am allergic to my neighbor’s cat or dog, but I am not allergic to my own”. This may be explained by some species differences, or possibly due to some desensitization which may have taken place with one’s own pet. Bottom line: If you are allergic to dogs or cats, it is not advisable to own one, even if it is from a species that reportedly produces less allergen.
Even if you have never had an indoor pet, it is likely that you have detectable pet allergen in your home, and maybe even enough to be causing chronic respiratory symptoms. Since dander is very small, light, and sticky, it can attach itself to your or your child’s clothes and be deposited in your house unknowingly. And if one has outdoor animals, their allergens will inevitably be carried into the home by those who have direct contact with the animal, especially children.
An important fact to remember is that many school classrooms have dog and cat allergens in high enough concentration to cause allergic reactions. It has also been reported that in some school classrooms, there is as much cat and dog allergen as in homes where cats and dogs reside!
The cornerstone of allergy treatment is to avoid or minimize exposure to known allergens to the maximum degree possible. Therefore, when an allergy specialist confirms the diagnosis of pet induced allergy, the doctor has the difficult task of making it clear that the patient will likely continue to have allergic reactions as long as the pet remains in the home.
Recommending that the pet be removed from the home can be a difficult task, as families become emotionally attached to their pets, and the pet is commonly described as “a member of the family”. Most doctors know that family pets often win out and remain in the home, so the doctor can only suggest the best ways to live with the pet.If the pet does remain in the house, it is not unreasonable for the allergist to insist that the animal never come in the bedroom of the allergic sufferer. This “compromise” can be helpful, although generally not curative. The allergic individual should endeavor to create a totally allergy free zone in his or her bedroom, the room where one spends a great percentage of their life.
The bedroom of a pet allergic individual should be cleaned frequently. All hard surfaces in the bedroom should be wiped with a moist cloth to remove the small and sticky animal dander which has likely adhered floors, carpets, walls, furniture, ceiling fans, lamp shades, and even ceilings. In addition, every part of your home, especially the bedroom, should be vacuumed with a HEPA vacuum cleaner. If you have hard surface floors, they should be mopped weekly. In addition, it may be helpful to run a HEPA air cleaner in the bedroom. Pets should be washed or treated with a dander removal product every two weeks. This removes much of the allergenic dander from the fur before it becomes airborne.
Allergy to one member of a food family can mean allergy to other members of the same botanical family because of shared or cross-reactive allergens. While many people contend that they are allergic to all seafood, fruits, starches, greasy foods, or spices, in reality they are allergic to a particular food family. For example, the following food items are not in the same food families, so an individual could be allergic to one food, but not the other.
Examples of foods that are not in the same food family:
Examples of foods that are in the same food family:
For a downloadable PDF of over 200 foods and their food family classification, click here (opens as a PDF).
For a downloadable PDF of food families and the foods that they contain, click here (opens as a PDF).
Immunotherapy, also called desensitization or hypo-sensitization, is a form of treatment wherein extracts of allergens (pollens, dust, molds, etc.) are introduced into the body to induce an immunologic response, resulting in the eventual reduction or elimination of the allergic reaction.
Not all allergic patients need immunotherapy. The decision as to who would benefit from this treatment depends on the nature of the allergy, i.e., what the allergic patient is allergic to and the severity of the allergic symptoms. Also, immunotherapy is indicated for patients allergic to substances which they cannot avoid. The appropriateness of immunotherapy will be determined only after careful consideration of all of these factors.
It should be realized, however, that immunotherapy, although very effective, is never the sole modality in the treatment of the allergic individual. Immunotherapy is just one component of a comprehensive approach which may also include environmental control, and, when necessary, the use of medicines. A carefully balanced approach will offer the patient the best chance for a resolution of the allergic problem.
To understand how immunotherapy works, a brief explanation of the allergic response is necessary. In the simplest terms, an allergy is the immune system’s overreaction to things to which it ordinarily should not react, such as dust mites and pollen.
Immunotherapy is intended to “reprogram” the immune system so that it no longer over responds when exposed to the offending allergen(s). This is accomplished by repeatedly exposing one’s immune system to the allergens over a long period of time. Like with any immunization, such as polio, tetanus, or pertussis, the actual administration of the substance causes the immune system to create antibodies against the substance administered.
Traditionally, the “gold standard” of immunotherapy has been in the form of injections of the allergen into the subcutaneous tissue of the upper arm, so called allergy shots. Allergy shots are presently the preferred form of immunotherapy by the vast majority of board certified allergists.
There has been increasing evidence in the medical literature suggesting that sublingual (under the tongue) immunotherapy may be equally as effective and safer than traditional allergy shots. Sublingual immunotherapy (SLIT) has been used in Europe for years and clinical trials are now underway in the U.S. to establish their efficacy and safety.
Immunotherapy is effective in reducing or eliminating allergic symptoms in the vast majority of patients appropriately placed on this therapy. In most patients, desensitization offers slow, steady, and significant improvements within six to 12 months after initiation of treatment. Some people report relief only after a few weeks to months, although this is unusual. If a patient fails to receive significant improvement within 18 months, then this treatment should be reassessed. Most patients complete the immunotherapy program in three to five years. Most have long-term improvement after desensitization is discontinued, lasting many years and sometimes lifelong.
Because allergy injections contain substances to which the patient is allergic, there is always a chance, although small, of an allergic reaction. The reactions to allergy shots can be divided into three categories:
It is not unusual for one to have a small local reaction at the site of the injection. This usually consists of minor swelling, redness, and itching. Reactions less than the size of a quarter are generally not significant, but should be mentioned to the allergy nurse prior to one’s next injection. Large local reactions may indicate that the allergy serum is too strong and adjustments of the dosage may need to be made at various times during the course of immunotherapy.
A systemic reaction is defined as one which occurs distant from the injection site and may involve multiple organ systems. They occur on rare occasions in highly sensitive individuals, or when individuals are receiving increased natural exposure to their allergens, such as occurs in pollen sensitive individuals during the spring and fall. These reactions may include generalized redness, itching, sneezing, runny nose, hives, coughing, wheezing and difficulty breathing. Even though very serious allergic reactions have been described in the medical literature, including a drop in blood pressure (shock) and even death, these are extremely rare.
Systemic reactions can almost always be averted by prompt recognition and treatment of symptoms. It is for these rare allergic reactions that all patients are required to wait in a physician’s office 20 to 30 minutes after an allergy injection.
Delayed reactions are usually local, but on rare occasions, can be systemic. They usually begin several hours after an allergy shot, but may be delayed as long as 24 hours. These symptoms are generally mild, but may include local itching, swelling and pain at the injection site, nasal symptoms, or wheezing.
For an individual who is experiencing an acute or ongoing allergic reaction, such as hay fever, asthma, or hives, then an additional injection of allergen may increase the risk of a reaction. If one is unsure as to whether the injection should be given, one should consult the injection nurse and a decision will be made as to whether the dose should be decreased, or whether the injection should be postponed.
An injection should not be given if the patient has had a significant fever within 24 hours. If asthmatic patients are experiencing any wheezing or respiratory distress, the injection should not be given. Injections should be postponed at least twenty four hours after receiving a flu shot, tetanus shot, or any type of immunization. One should avoid vigorous exercise one hour prior to and one hour after an allergy shot.
The answer is a simple NO. Even though the chances of an allergic reaction are very low, it is essential that the injection be given in a physician’s office where an unexpected reaction could be quickly treated. Injections should be given only by those experienced in treating allergic emergencies. Patients should never give themselves an allergy injection!
For all practical purposes, nothing. One’s overall response to desensitization is dependent upon the cumulative dose of allergen received over a long period of time, not an individual dose. Therefore, if an occasional injection is missed, the overall program will not be affected. Everyone will miss an injection once in a while due to illness, vacations, or unforeseen events, and this is to be expected. On the other hand, one should be very diligent in receiving their injections on schedule as much as possible.
Yes! As mentioned previously, allergic reactions to the injections are very rare, but they do happen. Most of these reactions will become evident within 20 to 30 minutes. Therefore, after receiving your allergy shot, you must wait in the allergist office for 20 to 30 minutes.
Some medicines used to treat high blood pressure, heart rhythm disturbances, and headaches, can make the treatment of an allergic reaction more difficult. These medicines, called beta blockers, are widely used. Some commonly prescribed beta-blockers include:
If you are taking one of these medicines, report this information to your allergist or the allergy nurse and hopefully an alternative medicine can be found so that the immunotherapy program can be continued.
Pregnancy is not a contraindication to allergy shots. However, initiation of desensitization is not recommended during pregnancy. For those who become pregnant after starting immunotherapy, studies indicate that allergy shots are safe to continue, but the dose should be held constant.
In the majority of cases, the answer is definitely yes. Allergy symptoms can vary from mild to severe and can cause chronic symptoms of the eyes, ears, nose, throat, lungs, and skin, leading to a compromised quality of life. In addition, allergies are of one of the leading causes of days missed from school and work, and overall loss of productivity. If it has been determined that desensitization can play a very important role in your or your child’s comprehensive allergy program, stick with it. You will likely be very pleased with the results.
Environmental control is the first and best step toward better allergy control.
If you have dust mite allergies, encasings for the mattress and pillows are an absolute must according to most allergists. This is because mite-proof encasings will create a complete barrier between the dust mite allergic individual and dust mites, which are found by the millions in mattresses, pillows, and comforters. Without encasings, as you move during sleep the allergenic by-products of the mites are stirred up from your bedding and are breathed directly into the nose and lungs. With encasings, this harmful process is stopped. The invisible particles are blocked by the encasing and are no longer breathed in all night.
Contrary to popular belief, so called “hypoallergenic” pillows need to be encased as well, because the phrase “hypoallergenic” only means that the materials used to construct the pillow are less likely to cause an allergic reaction. Dust mites are still found in these pillows.
In the past, people have resisted encasings because they were made of plastic or vinyl and were crinkly and hot. But softer and more durable fabric encasings are now available that eliminate these discomfort problems. Some of the newest mite-proof encasings use tightly woven, soft, comfortable fabric to protect you from this powerful allergen. In fact, these breathable encasings are so cool and comfortable that most people do not even realize they are sleeping on them.
Eliminating dust mites and their allergen from
sheets, blankets, comforters and mattress pads is really quite simple. Just wash these items every 10-14 days in hot (130 degree F) water. Washing in hot water kills the microscopic mite and effectively removes the allergen.
High quality blankets and laundry additives are available which will eliminate mites even in cold water. If washing your comforter is impractical, you can encase your comforter just like you would your mattress. By the way, it is important to know that dust mites are common to almost all households and have little to do with good or bad housekeeping. Most that are available can take 50 or more washings and still look and feel like new.
Vent filters are inexpensive filtering kits that cover incoming air conditioning and heat air vents. They are designed to minimize all kinds of airborne allergens from entering a room from other areas of the house via the ductwork. Although not as efficient as a true
HEPA air cleaners, they are a great and inexpensive start.
High Efficiency Particulate Air (HEPA) cleaners are considered to be the gold standard in room air cleaning. One powerful unit can easily reduce offending airborne allergen in a room by 90% and keep the room clean as long as it remains running.
HEPA air cleaners do not lose efficiency and require only occasional filter changes. It is important to know that dust mite allergen is removed only while airborne, i.e., for only 20 minutes or so after disturbance. The continuous air movement from the HEPA filter has a ventilation effect. It moves allergens into the air cleaner, thereby continuously reducing the reservoir of allergens in room air to help you avoid these offending particles.
HEPA air cleaners come with different power levels. Air cleaning power is very important and is measured in air changes per hour (the number of times per hour the entire volume of air in the room can be filtered). The more often the air is cleaned in the room, the fewer allergens remain.
Cleaning a room’s air ten or more times per hour is ideal. However, most experts agree HEPA air cleaners should have the capacity to clean your bedroom’s air no less than six times per hour. Beware of weak HEPA air cleaners that clean a room’s air less than five times per hour. Despite having a HEPA filter, such units simply do not have the power to pull air from more than a few feet away. The remainder of the air in the room stays unfiltered and loaded with allergens. Recent advancements in technology are producing powerful machines that are actually very quiet while running, even on the highest speed.
Sold under several labels, there are products available that denature (neutralize) dust mites and other indoor allergens in carpets and upholstered furniture. These sprays do not kill dust mites, so the mites continue to produce the allergen, making more frequent treatments necessary. Some of these sprays use a 3% tannic acid solution while others use newer technologies. There are also several types of powders designed for use on carpeting since it is a favorite place for mites to live. Another way to control allergens in your carpet is frequent vacuuming, but consider using special bags or a HEPA vacuum cleaner for best results.
Needless to say, the best treatment for pet allergy is not to have an indoor pet. If that is not possible, do not let your pet sleep in the same room with you, and ideally, the pet should never come in the bedroom.
Pets should be washed or treated with a dander removal product every two weeks. This removes much of the allergenic dander from the fur before it becomes airborne. True HEPA air cleaning and vacuuming will further reduce the presence of this allergen.
High humidity (above 45-50%) promotes dust mite and mold spore growth. Running an air conditioner or high-efficiency dehumidifier can help reduce humidity levels. Kits are available that test for the presence of molds. It is also wise to use a humidity gauge to monitor moisture levels in your home.
Mold spore allergies are common because spores grow readily in showers, bath rooms, basements, etc. The airborne spores can be avoided with good continuous air cleaning, but preventing mold spores from growing is also important. Normal cleaning with soap and water or using chlorine bleach is not a long term way of eliminating mold and mildew. Plus, the use of harsh chemicals can be bad for your health as you breathe them in during cleaning.
There are now strong, non-toxic,biodegradable cleaners that are very easy to use and take very little effort. Such measures are especially important for homes with mold problems in basements and crawl spaces. Furnace systems in those areas can actually pull in these mold spores and distribute them throughout the house via the duct system. Preventatives are inexpensive and simple to use.
There are furnace filters that are used in place of inexpensive, fiberglass, disposable filters and, they do a much better job of filtering the air in the home. Although not as efficient as true HEPA air cleaners, they do cover a larger area. Since they cannot filter unless the furnace fan runs, it is advisable to run the furnace fan often to get maximum filtration.
There are two main types available: Permanent and Pleated. The permanent types are a good long-term investment, will usually last the life of your furnace and require monthly washing. Pleated furnace filters are by far the best filters. These are not washable and have to be changed every 3 months or so depending on the brand. There are other methods for filtering the air in your entire home, but they are usually very expensive and require installation by a professional technician.
If you decide to use a furnace filter, you may still want to cover the vents in your bedroom, because the air has to travel through the ductwork where it can gather any number of allergens. A word about built-in “electronic” air cleaners: These cleaners are sold under several brand names, require separate power to operate and are installed by heating and air companies. These units lose efficiency rapidly after only 20 to 30 hours of use. Unless the dust collection plate element is washed at least weekly - instead of the “recommended” monthly or quarterly - little or no filtering will take place. Also, these units are very expensive. A much more economical solution might be having several room HEPA air cleaners and space them out in the home to get “whole-house” air cleaning that does not require weekly maintenance.
Most vacuum cleaners cannot retain particles under 10-20 microns in size. The dust collection bag is simply too porous. Because airborne allergen particles range in size from 1 to 15 microns - much smaller than most vacuums can trap - the millions of particles expelled through a vacuum cleaner bag can be dangerous for allergy sufferers.
The real problem is that this harmful, microscopic dust is never picked up and stays in the home to accumulate year after year. True HEPA vacuum cleaners are 99.97% efficient down to 0.30 microns, so they pick up allergens permanently without sending them back out into the room.
The decision to buy an allergy vacuum cleaner should be based on filtering efficiency, not the various “bells and whistles” available. Even a water-based machine can only filter down to about 10 microns which means millions of microscopic particles escape back into the room. Many companies currently make true HEPA vacuum cleaners in both canister and upright styles. Models are also available without bags but allergy sufferers must empty them carefully, without causing an allergenic dust cloud.
The first reports of stinging insect allergy came from the Middle East thousands of years ago. Even at that time, people understood that a small insect, such as a bee or a wasp, had the potential to cause serious illness or even death. Today, physicians, and in particular allergy specialists, are equipped to diagnose and protect individuals with stinging insect allergies.The most common insects to cause stinging insect allergies are wasps, hornets, yellow jackets, and honey bees. Fire ants also cause allergic reactions, but they are classified as a biting insect and not a stinging insect.
The initial stage of a stinging insect allergy reaction occurs immediately after the venom of a stinging insect is introduced through the skin, causing local tissue damage and the release of histamine and other chemicals. The resulting tissue damage is largely responsible for the pain, swelling, redness, and itching that we experience at the site of a sting. Although most local reactions are mild and cause swelling and inflammation localized around the sting site, the area of swelling and inflammation can be quite large. For example, one may be stung on the finger, yet the swelling may progress to include the entire arm. Both of these reactions, by virtue of the fact that they are contiguous with the sting site, are considered local allergic reactions.
The most severe type of insect sting allergic reaction is called a systemic or anaphylactic reaction. This reaction occurs in individuals who have had prior stings by similar insects and have become sensitized to the stinging insect venom. The sensitization stimulates the immune system to develop allergic antibodies (IgE) that circulate and bind the venom protein upon future stings. The binding of IgE to the venom protein can trigger a severe anaphylactic reaction consisting of hives, throat closing, wheezing, difficulty breathing, a drop in blood pressure (shock), and possibly death. Such reactions require emergency treatment and a delay in treatment can be catastrophic.
An allergist will likely identify the insect responsible for stinging insect allergy with specialized allergy testing. This type of testing is generally reserved for individuals who have had a previous systemic reaction. Allergists perform skin testing to common stinging insects including honey bees, wasps, hornets and yellow jackets. Imported fire ants can also cause an anaphylactic reaction and testing is also available for this insect.
Based on the test results, your allergy specialist will determine the risk for future reactions and whether immunotherapy, or desensitization therapy, is indicated. Unfortunately, many patients never have their allergic reactions evaluated by an allergist, thus placing them at risk for severe reactions with subsequent stings.
Upon being stung, one should check whether the stinger is still in the skin. Interestingly, only the honey bee leaves its stinger due to its barbed configuration. If the stinger is present, it should be removed immediately. One should avoid squeezing the venom sac as this may introduce more venom into the skin. Rather, it should be scraped off of the skin with a finger nail, a credit card, or another sharp object. Ice should then be placed on the sting site, and a rapid acting antihistamine, such as diphenhydramine (Benadryl) should be administered. Minor local reactions should resolve spontaneously, although the swelling and inflammation may persist for several days.
Systemic reactions require immediate and intensive treatment. If a patient has any signs of a systemic reaction, such as generalized hives, redness of the skin or a sense of heat, difficulty swallowing or the sensation of the throat closing, tightness in the chest, or light-headedness, then emergency medical help should be called (911) immediately. If available, self-injectable epinephrine (Epipen) should be administered without delay. The sooner the Epipen is injected, the more effective it will be in stopping the allergic reaction. If the reaction is persistent, the dose may need to be repeated. Antihistamines should also be given immediately. In addition, steroids may be needed to prevent a late or delayed reaction after the initial systemic reaction. The most important concept to remember about a systemic reaction to an insect sting is to not delay treatment. A systemic stinging insect allergic reaction is a true and serious allergic emergency and should be treated accordingly.
It is also critical that one follow up with an allergist after a systemic reaction. Your allergist will prescribe an auto-injector containing epinephrine or adrenaline (EpiPen or EpiPen Jr) which should accompany one at all times. These devices allow one to self-inject if they should be stung again and exhibit symptoms suggesting an impending systemic reaction.
Any person who has had a systemic reaction to a stinging or biting insect should be referred to an allergy specialist. Allergists have been trained to treat insect sting allergies using a desensitization procedure called venom immunotherapy. Venom immunotherapy works by introducing small amounts of the insect venom that caused the patient’s reaction in order for the immune system to develop a tolerance to future stings. It is extremely effective for most insect sting allergies such as bees, hornets, wasps or fire ants, and is highly effective in preventing future systemic reactions. The treatment is considered safe and works relatively quickly. Any individual who has had a systemic reaction should ask his or her physician for a referral to an allergist in order to determine whether venom immunotherapy is appropriate.
General precautions for insect allergic individuals include:
Food allergies can be one of the most frustrating and complex allergy issues facing physicians, patients, and families. Considering the unlimited number of foods (and food additives) that are consumed, the variable time between ingestion and the allergic reaction, and the varied and often subtle symptoms which result, it seems miraculous when the food that is causing the food allergy symptoms is actually identified.
Although an individual may have a food allergy to any food, there are eight foods that account for 90% of all food allergies. The most common food allergies are milk, eggs, peanut, tree nuts, fish, shellfish, soy, and wheat.
Approximately 4% of Americans are estimated to have food allergies. The prevalence of food allergies is highest (6-8%) in infants and young children under three years old. Fortunately, the incidence of documented food allergies decreases with age, probably due to the development of tolerance in children allergic to milk, wheat, soy, and eggs. Of the 2.5% of children allergic to milk, approximately 80% will “outgrow” their milk allergy by five years of age. Of all of the foods, peanut allergies are least likely to be outgrown. Recent studies have shown that only about 20% of children will lose their allergy to peanuts.
For purposes of simplicity, food allergies can be divided into two types: the immediate hypersensitivity reaction and the delayed hypersensitivity reaction.
The immediate allergic reaction to foods is the best understood, most easily diagnosed, but the most serious of all food allergic reactions. This reaction represents the “classic” allergic reaction. At the cellular level, an allergen (the food protein) comes in contact with an IgE antibody specific to that food, resulting in the release of histamine and a multitude of other chemical mediators. Once released into the tissues and circulation, these mediators cause an immediate allergic reaction.
This reaction, which generally occurs within minutes after ingestion of the allergenic food, can be relatively mild or severe. Symptoms of a relatively mild to moderate reaction might include a rash (urticaria, commonly referred to as hives), itching, generalized redness of the skin, heat, facial or eyelid swelling, nausea, abdominal cramping, vomiting and/or diarrhea. Such reactions are generally treated with a quick acting antihistamine and generally run their course over a few minutes to hours.
The most severe allergic reactions, or anaphylaxis, generally have a rather quick onset after the food is eaten. Symptoms might include those mentioned above, but, can rapidly progress to difficulty breathing (chest tightness due to bronchial constriction and swelling of the airways), a drop in blood pressure leading to shock, and even death. Anaphylaxis, or impending anaphylaxis, must be treated immediately. Epinephrine (adrenaline), which is available for self administration, must be given immediately, and repeated, if necessary. This represents a true medical emergency and should never be taken lightly.
Any person who has possibly experienced an immediate allergic reaction to a food should consult a board certified allergist. The allergist will likely test the patient, either through the skin or blood, in order to identify or confirm the allergenic food. Once it has been determined which food(s) caused the immediate allergic reaction, the allergist will consult with the patient and family about the elimination of the food(s) from the diet and the management of any further reactions.
A delayed food allergy reaction, while less dangerous in terms of one’s immediate health, can be much more difficult to diagnose and treat. As the name implies, there is often a delay of usually hours to days between the time of ingestion and the onset of symptoms, making the history less valuable in establishing a cause and effect relationship.
Part of the difficulty in diagnosing these reactions is that there is not yet available a reliable allergy test which can accurately diagnose or predict a delayed reaction. Allergy skin testing and RAST or ImmunoCap blood tests are not helpful, as they measure only the IgE antibody, the antibody responsible for immediate reactions. Research has not yet identified the antibody or antibodies responsible for delayed reactions, although there has been considerable interest and research in the possible role of the IgG antibody in the delayed allergic reaction. There is now a blood test available to measure this antibody, but its reliability as a predictor of delayed allergy has not yet been established.
The optimal method of determining whether one is suffering from a delayed hypersensitivity reaction, and to which food(s), is the elimination diet and subsequent challenge to that food. Elimination or reduction of symptoms after the avoidance of the offending food(s) from the diet may take weeks to become evident, therefore, one must be very patient. The most common foods likely to cause delayed reactions are milk and dairy products, and wheat and other grains.
The symptoms resulting from a delayed reaction can involve several organ systems and may be quite subtle in their presentation. In addition to more classic allergy symptoms such as nasal congestion, runny nose, rash (eczema or hives), etc, delayed reactions may present with symptoms such as frequent headaches, recurrent or chronic abdominal pain, lethargy, irritability, dark circles under the eyes, limb pain, and recurrent ear or sinus infections, to name a few.
Food allergies in babies and food allergies in infants can be especially challenging. Food allergy symptoms in the newborn and in babies may include colic (irritability), excessive spitting (even projectile vomiting), rashes including eczema or hives, nasal symptoms including congestion and/or runny nose, coughing or wheezing, diarrhea (sometimes bloody), constipation, and even poor weight gain.
If a baby under a year of age is truly allergic, it is almost always caused by a food. And, the food most likely to be responsible is cow’s milk. A small percentage of milk allergic babies are also allergic to soy.
It is also possible for babies who are exclusively breast fed to be allergic to a food protein being passed through the nursing mother’s milk. In such a case, it is likely that the baby is reacting to a food eaten by the nursing mother, such as milk and/or dairy products.
It is also important to be aware that many foods can cross react with other foods within the same food group or family. Familiarity of food groups is a must for the food allergic individual.
Food allergy treatment can be summarized in one word - avoidance. As simple as this may sound, avoidance of many foods is very difficult. Shopping can be quite challenging, especially at first, as it will require close scrutiny of the multiple ingredients included, especially in packaged and commercial foods. Eating out of one’s home, such as in restaurants, at school, or others’ homes requires extreme diligence and curiosity about the foods served. In those people allergic to multiple foods, a consultation with a dietician is sometimes very helpful in designing safe diets. Your allergist will be very helpful in recommending the multiple resources available to help with these challenging issues.
Steroid creams or ointments, also called topical steroids, are frequently used to treat all types of skin inflammation in both children and adults. The most common conditions treated with steroid creams by allergists include eczema or atopic dermatitis, and contact dermatitis.
Topical steroids are most commonly prescribed in several forms including creams, ointments, and lotions. Steroid creams are the most commonly prescribed for most skin inflammation, but ointments are substituted when the skin requires additional moisture and better penetration of the steroid into the skin. Lotions are typically thinner and are used to cover more extensive areas of the body and hairy areas.
It is important to understand a general approach to the use of topical steroids. The first principle to understand is that not all steroid creams are equal. In fact, they vary widely in their potency, but their labeling can be quite misleading. For example, Diprolene® 0.05% is much, much more potent than Hytone® 2.5%, even though one would think that a 2.5% cream would be stronger than a 0.05% cream. As can be seen by the list below, many topical steroids are available in a wide variety of different strengths and potencies. Your physician will prescribe the appropriate potency of cream or ointment based on the degree of inflammation, whether it is acute or chronic, the location on the body of the rash, and the extent of the skin area that needs to be treated.
In general, one should use the least potent steroid cream necessary to reduce and control the skin inflammation. If the area to be treated is highly inflamed, a potent steroid cream is usually prescribed initially to accelerate the healing process. High potency steroids are to be avoided on the face and genital areas where the skin is particularly thin. High potency steroid creams should be used for only a few days, maximally a week or two. Once the inflammation shows significant improvement, physicians will commonly transition to one of the weaker topical steroids which can be used for control on a more long term bases. The more high potency creams and ointments are generally applied only once or twice a day, while the weaker creams such as hydrocortisone cream 1%, which can be bought without a prescription, can be applied four times a day.
Steroid creams and ointments should be applied thinly and sparingly, but the area to be treated should be coated completely. If the lesion to be treated is highly inflamed or is oozing or weeping, then covering with a bandage may increase the penetration of the medication and augment healing.
Topical steroids are generally very safe for repeated and long-term use. But, it is important to remember that depending on the potency of the cream, the extent of skin area treated, and the duration of treatment, the steroid can be absorbed in significant amounts to cause local or systemic steroid side effects. Local effects include thinning of the skin, local changes in pigmentation, or the development of telangectasias, or tiny blood vessels visible in the skin. It is therefore critical that these medications be used under the guidance of a physician experienced in the use of these medications.
TOPICAL STEROIDS (list is not inclusive)
Betamethasone Dipropionate Gel & Ointment USP (Augmented 0.05%) - Diprolene®
Clobetasol Propionate Cream, Ointment, Solution, Emollient & Gel USP 0.05% - Temovate®
Diflorasone Diacetate Ointment USP 0.05% - Psorcon®
Halobetasol Propionate Cream/Ointment 0.05% - Ultravate®
Betamethasone Dipropionate Ointment USP 0.1% - Diprosone®
Desoximetasone Cream & Ointment USP 0.25%, Gel 0.05% - Topicort®
Amcinonide Cream and Ointment USP 0.1% - Cyclocort®
Diflorasone Diacetate Cream & Ointment USP 0.05% - Florone®
Fluocinonide Cream, Ointment, Gel & Solution USP 0.05% - Lidex®
Halcinonide Cream 0.1% - Halog®
Medium Potency III
Betamethasone Valerate Ointment USP 0.01% - Valisone®
Diflorasone Diacetate Cream USP 0.05% - Florone®, Maxiflor®
Mometasone Furoate Ointment USP 0.1% - Elocon®
Amcinonide Lotion 0.1% - Cyclocort®
Medium Potency IV
Fluocinolone Acetonide Cream USP 0.2% - Synalar® HP
Fluocinolone Acetonide Ointment USP 0.025% - Synalar®
Desoximetasone Cream USP 0.05% - Topicort® LP
Flurandrenolide Ointment USP 0.05% - Cordran®
Triamcinolone Acetonide Ointment USP 0.1% - Aristocort®, Kenalog®
Medium Potency V
Betamethasone Dipropionate Lotion USP 0.05% - Diprosone®
Flurandrenolide Cream USP 0.05% - Cordran®
Hydrocortisone Butyrate Cream USP 0.1% - Locoid®
Hydrocortisone Valerate Cream USP 0.2% - Westcort®
Betamethasone Valerate Cream USP 0.1% - Valisone®
Fluocinolone Acetonide Cream USP 0.025% - Synalar®
Prednicarbate Emollient Cream USP 0.1% - Dermatop®
Triamcinolone Acetonide Cream/Lotion USP 0.1% - Kenalog®
Low Potency VI
Alclometasone Dipropionate Cream/Ointment USP 0.05% - Aclovate®
Desonide Lotion USP 0.05% - DesOwen®
Fluocinolone Acetonide Cream & Topical Solution USP 0.01% - Synalar®
Triamcinolone Acetonide Cream USP 0.1% - Aristocort®
Desonide Cream USP 0.05% - Tridesilon®
Betamethasone Valerate Lotion USP 0.1% - Valisone®
Low Potency III
Hydrocortisone Cream, Ointment & Lotion USP 1% & 2.5% - Cortaid or Hytone®
Allergies in children are extremely common. The statistics are staggering and the incidence of childhood allergies and childhood asthma is increasing dramatically. It is estimated that over 8 million children in the U.S. have allergic rhinitis, or hay fever, and over 5 million have childhood asthma. Recent studies have also shown a dramatic increase in food allergies in children and it is now estimated that over 8% of children are allergic to one or more foods. Over 10% will have eczema or atopic dermatitis during early childhood. In a general pediatrician’s office, it has been estimated that over 20% of children seen by pediatricians on a daily basis are because of childhood allergy symptoms or childhood asthma symptoms. Most children with allergies can be managed by the pediatrician, but many require a referral to a pediatric allergist because of recurrent, chronic, or severe allergy symptoms.
In its simplest terms, an allergy is the result of the immune system recognizing a normally harmless substance (such as a food or pollen) as a potential harmful substance. As critical, necessary, and helpful the immune system is to good health, an allergy is an example one arm of the immune system misinterpreting vital information presented to it, and reacting to that information inappropriately. The allergic state is also referred to as atopy.
Regardless of age, all allergies start the same way. Allergic individuals are born with an allergic gene as part of their DNA. This gene may express itself very early in life, or it may lay dormant for many years before activation. Once activated, the potential for allergies will always exist.
The process of becoming allergic involves a series of very complicated and intricate relationships between many chemicals, called mediators or cytokines, and cells in the immune system. Once the allergic gene is “turned on”, the allergy activation process begins when one is exposed to an allergen such as peanuts, dust mites, or pollen for the first time. This exposure may have occurred in utero, or through exposure on the skin, by inhalation, or ingestion. The specific allergen is then recognized by specialized immune cells and then processed by the immune system. As a result of this initial exposure, allergy antibodies are formed to that particular allergen. Once formed, these antibodies are present in the tissues and the circulation, and are now primed and activated to react during a subsequent exposure to the allergen. Upon exposure of the antigen to the preformed antibodies, the two molecules attach like a key in a lock. This attachment is the critical step which then sets off a cascade of cellular events, leading to the release of histamine and other chemical mediators. These chemicals, once released, cause dilation the blood vessels, constriction of smooth muscles, and the activation of mucous glands. The grand finale of this process is an allergic reaction, which can vary in its intensity from mild to severe.
Childhood allergies can become evident at any age. Contrary to popular opinion, newborn allergies do exist, as do allergies in babies of all ages. As a general rule, if a newborn, infant, or toddler presents with childhood allergy symptoms, the most likely allergen responsible is one that they are exposed to repeatedly, and in this age group, the most likely allergen is a food. And, the earlier the presentation, the more likely the baby is allergic to milk. It is important to note that milk allergy can occur in nursing babies as cow milk protein ingested by the mother can be passed to the baby through the breast milk. Newborns and infants allergic to cow’s milk based formulas or cow’s milk products ingested by the mother may first manifest their allergy symptoms with gastrointestinal symptoms such as excessive spitting and even projectile vomiting after feeding. These newborns and infants are also commonly irritable and have colic as a result of abdominal discomfort. If the newborn or infant being fed a cow’s milk formula is exhibiting these symptoms, it is often necessary to try a milk free formula, such as a soy containing formula. Soy allergy or intolerance is also seen, but much less frequently that cow’s milk allergy. If the symptoms do not improve, then it is prudent to try a hydrolyzed milk formula. A hydrolyzed formula is one in which the milk protein is degraded and broken down into its amino acid components, a process which eliminates the allergy potential of the offending intact protein. For the breast fed infant having symptoms, it would necessary for the mother to eliminate milk from her diet to ascertain if the milk is causing the symptoms.
Another common infant allergy symptom is eczema. Eczema generally presents in the first few months of life as red, dry, itchy patches on the skin. It is commonly found on the cheeks and behind the ears, but as the child grows, it is most characteristically found in the bends of the arms and in the folds behind the knees. In addition to isolated eczematous patches, children with eczema commonly have generalized dry skin. In approximately half of the cases of eczema in childhood, allergies are the cause or exacerbating factors. When allergies are the cause of eczema, it is commonly referred to as atopic dermatitis, although both of these terms are used interchangeably. In the allergic variety, an allergy to a food is often responsible, although exposure of allergens to the skin, such as proteins of dust mites, can also exacerbate atopic dermatitis. High on the list of suspected foods in the child with eczema are milk, eggs, and wheat. As a general rule, eczema tends to improve over time, and most children are symptom free by the age of six. Unfortunately, some children who have atopic dermatitis go on to develop nasal allergies and/or childhood asthma, a progression described as the “atopic march”.
Children are commonly allergic to the things they breathe. As a general rule, the more frequent and chronic the exposure, the earlier the onset of allergy symptoms. For example, a child who has repeated or chronic exposure to pets, dust mites, or cockroach allergen may begin to exhibit respiratory symptoms beginning as early as a year of age because of the constancy of the exposure. On the other hand, because of episodic exposure, a child is unlikely to develop allergies to seasonal pollen until three or four years of age.
The most common manifestation of allergies in children is allergic rhinitis. Allergic rhinitis results from the inhalation of allergens into the nose and the subsequent allergic inflammation which results in the lining of the nose and sinuses. The inflammation leads to swelling of the tissues in the nose called turbinates and the over production of mucous from the activated mucous glands. The result is nasal congestion, runny nose, sneezing, and itching. It is common for the eyes to be affected as well, a condition called allergic conjunctivitis. This condition leads to tearing, redness of the eyes and intense eye itching. When both the nose and eyes are affected by allergens simultaneously, the diagnosis of allergic rhino-conjunctivitis is applied.
Allergy symptoms in children can be episodic or chronic. Pollen exposure in pollen allergic children will result in symptoms only during the relevant pollen season. These seasonal flare-ups are called hay fever by both the lay public and medical personnel, even though hay is usually not the cause, and fever is generally not present. Episodic symptoms may also result on the occasion exposure to a cat or dog. On the other hand, chronic and daily symptoms will likely result from exposure to dust mites, mold spores, and in homes where pets reside. In urban inner-city environments, allergy to cockroaches is a major cause of persistent allergy symptoms in children. Some children have both year-round, or perrineal symptoms, and seasonal allergy symptoms concomitantly. Such a child may have daily nasal congestion and runny nose, only to get acutely worse in during the spring and fall when tree, grass, and weed pollens are present in the air.
Just like the nose and eyes can be a target for allergies, so can the lungs, and more specifically the bronchial tubes. In approximately 50% of all children with asthma, the asthma is caused and exacerbated by allergies. Childhood asthma can present initially at any age, but it is often not diagnosed until after age three. Because the diagnosis of childhood asthma can be difficult to make, children presenting with symptoms compatible with childhood asthma are often given the diagnosis of reactive airways disease, or RAD. Pediatricians are reluctant to diagnose a child with asthma, but the sooner the diagnosis can be made and confirmed, the quicker one can begin appropriate childhood asthma treatment. It is very important to distinguish between allergic asthma and non-allergic asthma in children, as the treatment can vary depending on the presence or absence of allergies.
Childhood asthma can mimic other common pediatric respiratory illnesses, sometimes resulting in the delay of treatment. The most common presenting symptom of childhood allergic asthma is coughing. It may present as a recurrent or chronic nighttime or early morning cough and sometimes it is the only childhood asthma symptom. As the symptoms worsen, wheezing and difficulty breathing may be present. Symptoms tend to be made worse with exercise and upon exposure to increasing amounts of allergens and non-allergic irritants such as cigarette smoke.
Allergy testing is generally necessary to identify the allergen(s) responsible for childhood allergies. Contrary to popular belief, allergy testing can be performed at any age. Of the two reliable allergy testing methods available, skin testing is the testing method preferred by most pediatric allergists. This is because it can take less than one minute to test to 40 or more allergens, and the results are evident in just 15-20 minutes after the tests are applied to the skin. Prick skin testing is well tolerated by even very young children as its application is quick and only minimally uncomfortable. With the advent of a device called a multi-test, multiple allergens can be applied to the skin simultaneously, shortening the testing procedure while allowing multiple allergens to be tested. These tests are generally applied to the back of the child or the forearms. Once applied, the allergens are left on the skin for 15-20 minutes. During this time, positive reactions can cause local itching. After this short duration, the allergist or nurse can ascertain which inhalants or foods the child is allergic to and the severity of the allergy. Many foods can be testing by the skin prick method. In addition, inhalant allergens such as dust mites, pets, mold spores, cockroach, weed pollen, tree pollens, grass pollens, and others can be tested. It is important that children being allergy skin tested be off of all antihistamine for 3-5 days prior to testing.
Allergies can also be tested through the blood. These tests, called RAST or ImmunoCap, are used by allergists under certain circumstances. Since antihistamines do not interfere with the results of these tests, it might be used if the child is presently on an antihistamine or has been taking antihistamines within the prior 3-5 days. Also, if the child has eczema, or some other skin condition which would interfere with skin testing, then the blood test may be ordered.
No allergy test is perfect. Both skin testing and blood testing can be associated with false positive and false negative results. It is for this reason that an allergist will attempt to correlate the child’s allergy symptoms with the allergy test results in order to establish a cause and effect relationship.
The treatment of childhood allergies is no different than the treatment of allergies in an adult. Regardless of age and the cause of the allergies, the cornerstone of treatment is environmental control. Simply put, one needs to minimize exposure to known allergens to the greatest degree possible. In theory, this treatment approach is simple, but in reality it is very challenging, For instance, if a child is allergic to the family cat, the best treatment option is that the cat should be removed from the house. However, the compliance rate for this recommendation is very low due to the fact that pets are loved and they have become members of the family in many homes. Many parents also express concern over the pycho-social impact on the child that may result by the removal of the cat or dog.
Environmental control is also difficult when one is told to eliminate an allergen that cannot be seen. A case in point is house dust mites and mold spores. Fortunately, there are very effective and inexpensive allergy control products that can be very helpful in decreasing an allergic child’s exposure to these allergens. But, regardless of the challenges of environmental control, every effort must be made to maintain the allergic child in an as allergy free an environment as possible.
As important and effective as environmental control can be, there are allergens which are so ubiquitous in our environment that effective allergen reduction procedures are only minimally effective. This is especially true for pollens which the allergic child is exposed to most of the year when outdoors. These allergenic pollen grains are very light and are carried hundreds of miles by a light breeze. On a practical note, if a child is allergic to oak tree pollen and Bermuda grass pollen and in the family yard is a big beautiful oak tree and a carpet of Bermuda grass, it is not necessary to uproot the oak tree and replace the Bermuda grass. Even in the absence of the tree and grass, they will be exposed to high oak tree and Bermuda grass pollen that comes from the yards of neighbors near and far.
The second treatment option is the use of allergy medications. Allergy medications are not curative; they are used to reduce the child’s symptoms while other more critical components of the treatment plan are implemented. The most commonly recommended and prescribed allergy medication for children are antihistamines. Antihistamines have been used for many decades and they have an excellent safety profile. Historically, the main disadvantages of antihistamines were their sedative affects and the frequency which they had to be taken. Non-sedative antihistamines are now available, as well as antihistamines which can be taken once or twice a day. Antihistamines are effective in reducing the symptoms of runny nose, post nasal drip, sneezing, and nose or eye itching, but they do very little for nasal congestion. They are only minimally effective for coughing.
They other classification of medications which can be very helpful in childhood allergies are corticosteroids. Oral or injectable corticosteroids can be extremely helpful in eliminating or reducing the symptoms of allergies, but they should be prescribed judiciously in cases of difficult to control or severe allergies. Even though steroids are safe in children when taken for short periods of time, long term use should be avoided due to potential side effects. One should discuss the benefits and risks of these medications with one’s allergist or pediatrician, if they are recommended.
Topical steroids, on the other hand, are extremely safe in children, even if taken for long periods of time. These topical steroids are available as nose sprays, inhalers, eye drops, and creams and ointments for the skin. There have been some research studies which have suggested that long term use of topical steroids could slow down a child’s rate of growth, but other studies failed to establish this suggested relationship. Most allergy specialists are confident of their safety and they use these medications quite successfully in allergic children.
There are many other allergy medications available and many undergoing clinical trials. Your pediatrician or allergist will decide which medication are most appropriate, but the goal to is to keep children on as little medicine as necessary to stay well.
Even though no one should claim that there is a “cure” for allergies, the next best thing to a cure is the potential to increase a child’s tolerance to the allergen(s) to the point that they are symptom free, or at least, greatly improved. This can be accomplished through a desensitization process called immunotherapy. Immunotherapy is the only form of allergy treatment that gets to the cause of the problem, and represents a significant advantage to other “band-aid” approaches to childhood allergy treatment. This desensitization process is accomplished by exposing the child’s immune system to increasing amounts of the allergen over a long period of time. As the exposure increases, the child will likely become more and more tolerant to the allergen(s). The goal is to increase the child’s tolerance to the things that the child is allergic to so that when the child is exposed to normal amounts of the allergen(s), for example dust mites or pollen, they will not have symptoms. This form of treatment is estimated to be 80-85% effective in significantly reducing or eliminating the child’s allergy symptoms.
Immunotherapy, or desensitization, should always be thought of as a long term approach to health, and not as a quick fix. Allergy relief from immunotherapy does not happen quickly and it commonly takes 6-12 months to begin to see improvement in symptoms. If improvement is seen, then the process should be continued for 3-5 years in order to maintain long term, if not lifelong, improvement.
Immunotherapy has been administered to children for many decades. The gold standard for immunotherapy in the United States has been allergy injections or allergy shots. In Europe, however, immunotherapy has historically been given as drops under the tongue, commonly known as sublingual immunotherapy, or SLIT. American allergists have been slow to embrace the SLIT approach, but its acceptance is becoming more commonplace, especially in light of the very favorable clinical trials which have demonstrated SLIT’s effectiveness and safety. Both allergy shots and SLIT have their distinct advantages and disadvantages. One should consult their allergist concerning which desensitization process is best for their child.
For children with recurrent or chronic allergy symptoms, severe symptoms, or symptoms which do not respond to conventional therapy, consultation with a pediatric allergist should be sought. A pediatric allergist is trained to recognize the symptoms of childhood allergies, test for their causes, and to recommend the best therapy and treatment available toward the goal of totally eliminating or greatly reducing the symptoms of childhood allergies.
Sublingual immunotherapy, also called SLIT immunotherapy, or allergy drops, is slowing gaining acceptance as an alternative to allergy injections for the treatment of common respiratory allergies. Sublingual immunotherapy literally means that the allergy drops are administered under the tongue. However, any oral administration of allergy extract should likely be inferred in the following discussion.
Immunotherapy, or desensitization, is the cornerstone in the treatment of allergies. Immunotherapy has been used very successfully for many decades. Immunotherapy is the process used to desensitize those who are allergic to airborne allergens, venom from stinging and biting insects, medications, and foods. By far, desensitization to dust mites, mold spores, cat and dog dander, and weed, tree, and grass pollens are the most common allergens for which immunotherapy is recommended by allergists.
Desensitization through immunotherapy is a gradual process which lowers one’s sensitivity to the airborne respiratory allergens responsible for allergic rhinitis (hay fever), allergic conjunctivitis (allergy eyes), and allergic asthma. The process involves introducing to the allergic individual small amounts of substances to which he or she is allergic (allergens) either by injection or orally. Over time, the amount of allergen is gradually increased. Through a complex set of immunologic responses, the immune system develops a tolerance to the allergen. The result of immunotherapy is that when the allergic child or adult is exposed to the allergen, the immune system no longer sees this allergen as foreign, resulting in little or no allergic response.
In spite of the myriads of allergy treatments promoted and espoused to the public, there are only three proven and effective approaches to the treatment of allergies. They are avoidance, medications, and immunotherapy. Depending on one’s specific allergies and severity of symptoms, an allergist might recommend one, two, or all three of these approaches simultaneously.
Even though avoidance of relevant allergens and the use of medications can be very helpful, their purpose is to minimize symptoms. However, neither of these treatment modalities addresses the underlying cause of the allergy. On the other hand, immunotherapy, or desensitization, is the one and only treatment approach that does address the actual cause, i.e., the immunologic over-reaction that occurs when allergen meets antibody. And, it is in this area that many exciting advances have taken place in the treatment of allergic children and adults, including the availability of sublingual allergy drops, or sublingual immunotherapy.
Immunotherapy is administered in the western world most commonly in the form of injections, known as “allergy shots”. Even though allergy shots or allergy injections are effective and are considered the gold standard of allergy treatment, an allergy shot regimen does have its challenges. Firstly, of paramount importance to the success of allergy shot therapy is compliance. Compliance is directly related to the many logistical issues associated with injection therapy. Allergy shots must be given on a regular schedule, generally starting twice a week for several months, with subsequent weaning to weekly, every other week, every third week, and eventually monthly. The program is commonly recommended for three to five years, and it is critical that there not be a significant lapse of time during the program during which the patient does not receive injections. This schedule adds up to many injections over a long period of time. And, as might be expected, the logistical issues that must be addressed to maintain such an injection schedule results in a low compliance rate for completing the allergy shot program.
Even if compliance and logistical issues of allergy shots can be overcome, immunotherapy can be quite challenging especially in the pediatric population, the population which could and should benefit most from desensitization. Even though the injections are generally not painful, children are inherently fearful of injections, and despite coaxing and sometimes bribing, parents rightfully give up on the idea after several traumatic attempts.
Also of significant concern is the potential for a serious allergic reaction to an allergy shot, albeit infrequent. Whether it is the first injection administered or a random injection a year or two into the course of therapy, the potential always exists of one reacting to an allergy shot. It is for this reason that allergy shots should never be taken at home. They must always be administered under the supervision of an allergist and in a facility equipped to treat an allergic emergency.
Fortunately, all of these issues are lessened to a significant degree with the availability of sublingual immunotherapy, or allergy drops.
Because SLIT allergy drops can be administered by the patient or parent at home, one has good reason to believe that the compliance rate for this allergy treatment plan will be much better than allergy shots. Simply put, higher compliance means a better outcome. With sublingual allergy drops, patients simply squirt the extract under the tongue, hold it there for twenty seconds, and then swallow. This can be done anywhere; at home, on vacation, and on business trips.
And, because allergy drops have a pleasant taste, children generally do not object to this treatment. The opportunity to treat children as young as three years old with immunotherapy represents a true breakthrough in the treatment of allergies. Physicians know the importance of intervening early in the pediatric age group in order to attenuate the “allergic march”, a term which denotes the progression of allergic disease from atopic dermatitis (eczema) to allergic rhinitis and then to asthma.
Most importantly, SLIT allergy drops are extremely safe. Minor symptoms such as itching of the mouth occasionally occur, but serious allergic reactions are extremely rare. This is very reassuring for the patient, parents, and the allergist.
Sublingual oral immunotherapy is not a new treatment modality for allergies. Allergy drops have been widely used in Europe for decades and is now gaining acceptance as an alternative to allergy shots by allergists in the U.S. and other western countries. Clinical trials are now in progress to determine the optimal dose and frequency of administration. As new scientific data emerges, it is not unreasonable to suggest that over the next ten years, SLIT may become the allergy treatment of choice worldwide among both allergists and patients.
At the present time, sublingual immunotherapy is not FDA approved, although it is recommended and prescribed “off-label”. Even though the components of SLIT extract are FDA approved to be administered by injection, they have not been approved for oral administration. Most of the efficacy and safety data about SLIT are from European studies. The FDA has requested that safety and efficacy studies be performed in the U.S. This research is well underway and, thus far, the data has suggested efficacy approximating that of allergy shot therapy and a superior safety profile when compared to allergy shots.
Sublingual immunotherapy is designed to desensitize one or all of the airborne allergens to which one is allergic. Like allergy shots, all relevant allergens are be included in the allergy drops such as dust mites, cat, and pollen. There is also good evidence to suggest that immunotherapy or desensitization can prevent a child who has upper respiratory allergies from developing asthma.
The response to immunotherapy is variable and depends on several factors. Approximately 80-85% of patients who are appropriately placed on either sublingual immunotherapy or injection therapy will see significant improvement over time. Most see a significant decrease in symptoms, and some fortunate individuals will have a total resolution of symptoms.
It should be kept in mind that one may not see significant improvement for 6-12 months after beginning sublingual immunotherapy. If allergy drops are effective, the therapy will be continued for 3-5 years in order to maintain improvement for many years, if not lifelong.
Anyone with well documented allergies can take sublingual immunotherapy, but by far, the largest segment of the population to potentially benefit from allergy drops is children. Because this treatment is totally painless, very young children with significant allergies can begin allergy drops. Children as young as three years of age can take allergy drops, therefore allowing allergists to intervene early in the allergic process. SLIT is also ideal for older children and adults with busy school and work schedules.
To date, the most appropriate dose of SLIT has not been determined. This is the subject of ongoing medical research. The strength of the SLIT extract and dosing schedule will vary greatly between allergists. Like allergy shots, allergy drops are prescribed to be taken frequently at the beginning of treatment, perhaps three times a day. Over time, the frequency is gradually decreased. Fortunately, allergy drops have a pleasant taste and compliance with frequent administration is not a problem.
Sublingual immunotherapy or oral desensitization to foods is one of the most exciting developments in allergy therapy. Historically, the treatment for food allergies was total avoidance of ingestion. Now, there is reason to be very optimistic about oral desensitization in children and adults with severe food allergies. Many studies have proven that orally administered immunotherapy can result in a significant degree of desensitization, or tolerance, in severely food allergic patients. Sublingual immunotherapy is not yet being offered for those with mild to moderate food allergies, and likely will not be available through your allergist for the foreseeable future. It is presently being made available only to those with life-threatening reactions to highly allergenic foods such as milk, peanuts, and tree nuts. As opposed to sublingual immunotherapy for the desensitization to inhalant allergens, SLIT therapy for food allergies is associated with a significant amount of risk and should only be performed under the watchful eye of a board certified allergist experienced in oral tolerance induction. This form of oral desensitization is being performed at a few highly acclaimed medical centers.
The availability of sublingual immunotherapy or allergy drops has made it possible for allergists to offer real and lasting allergy relief to those who suffer from allergies, allergic asthma, and severe food allergies. This highly effective and affordable treatment has the potential to greatly improve the quality of lives of many allergic children and adults.
The question of when to consult an allergist is a frequently asked question. This is especially true in light of the fact that approximately 50 million Americans have asthma, hay fever, or other allergy symptoms. Primary care physicians, especially pediatricians, are on the front line in the recognition of allergy symptoms and in allergy treatment and asthma treatment. Fortunately, most patients present with allergy symptoms which are mild, are easy to manage with minimal intervention, and never require a referral to an allergist. But, there are cases of allergies and asthma which can be very serious and difficult to treat. These patients should be referred to an allergy specialist for evaluation and treatment.
Allergy symptoms which are recurrent or chronic, especially if they are present every day, should be evaluated by an allergist. Recurrent or chronic allergy symptoms are generally caused by dust allergies, mold allergies, food allergies, dog allergies, cat allergies, or any other types of pet allergies. Due to the ever-present nature of these allergies, such cases should be referred to an allergist for a thorough evaluation. Even though allergies generally cannot be “cured”, allergy relief is usually possible, and even highly probable, under the treatment of a board certified allergist.
Allergists are sometimes called “allergy doctors”. An allergist is a physician trained to treat many types of allergic disorders, asthma, and other immunologic disorders. The most common allergic diseases treated by an allergist include allergic rhinitis or hay fever, sinusitis, non-allergic rhinitis, nasal allergies, skin allergies including hives and eczema, and both allergic and non-allergic asthma. Allergists are also experts in the diagnosis and treatment of food allergies, stinging insect allergies, drug allergies, and a variety of allergy related issues.
Allergy doctors are highly trained. Formal training to become an allergist takes a minimum of nine years after college. After four years of medical school, one then does an internship and residency in either pediatrics or internal medicine, a process lasting 3-4 years. In order to become an allergist, one would then do a fellowship lasting 2-3 years in an approved allergy training program. An allergist would then take an exam in order to receive board certification. Board certification indicates that the allergist has reached a high level of expertise and is recognized by the public and the medical community as an expert in his or her field of medicine. Many allergists are double boarded, meaning that they have board certification in two areas, Allergy, Asthma, and Clinical Immunology, as well as either Pediatrics or Internal Medicine.
Allergists are trained to diagnose and treat allergies, asthma, and a variety of immunological disorders. Although some allergists refer to themselves as pediatric allergists, and some are referred to as adult allergists, all allergists are trained to care for both children and adults. Pediatric allergists are also pediatricians, and are thus very much focused on the special needs and concerns of children and their families. Whether one is designated as a pediatric allergist or an adult allergist, all allergy specialists generally devote a great deal of time in understanding, evaluating, and counseling their patients.
An allergy evaluation can be performed in the allergist’s office, and is generally performed in one or two visits. The allergy evaluation begins with a thorough history of a patient’s allergy symptoms and the circumstances which affect the onset, frequency, and severity of those symptoms. A physical exam is then performed, with an emphasis on the ears, nose, and throat, lungs, heart, and skin. Based on the history and physical exam, the allergist will decide whether allergy testing is indicated. The allergist has the capability of allergy testing the patient to a variety of possible allergens, including inhalants and foods, in order to better understand what is causing the patient’s symptoms. If allergy skin testing is performed, the results are available within minutes. All allergists can also perform and interpret lung function testing to assess asthma and other respiratory disorders. Imaging studies, including X-Rays and CT Scans, may also be part of the allergy evaluation.
At the conclusion of the allergy evaluation, the allergist will explain to the patient and family members the nature of the allergy diagnosis, and will suggest a comprehensive allergy treatment plan tailored to the individual patient. Allergists are generally excellent communicators. Patient education will be emphasized and questions will be encouraged, as the best outcomes can be attained when a patient is well informed and is empowered to take control of their management, in concert with the allergist.
The allergist will likely recommend excellent allergy products that can help alleviate symptoms and bring allergy relief. Effective allergy bedding is a common recommendation as it can provide relief to both allergy and asthma sufferers who are allergic to dust mites. There are also effective asthma products, such as nebulizers, which may be recommended, especially for young children. A mist humidifier is another example of a simple product that can also have a great impact, and which might be a part of a patient’s treatment plan. An allergist will guide you in determining which asthma or allergy products are right for you or your child.
There is no absolute answer for who should be referred to an allergist, but, if allergies or asthma symptoms are frequent, recurrent, or chronic an allergy consultation would certainly be appropriate. An allergy referral is also in order if symptoms are moderate to severe and they have not responded to previously recommended treatment. For those who have had life-threatening allergic reactions such as anaphylaxis or severe asthma, an allergy consultation with a board certified allergist is highly recommended.
In many cases, it is not necessary to have a physician’s referral to an allergist. Many allergy evaluations are performed after being self referred. Regardless of whether one is referred for an allergy evaluation of self referred, allergy doctors will likely send a complete and comprehensive report to the referring physician or the patient’s primary care physician.
Many studies have demonstrated the value of an allergy referral and an allergy evaluation in the care of an allergy or asthma patient. Almost all data suggests that when referred to an allergist for evaluation and treatment, the allergy or asthma patient will have a significant decrease in their symptoms, find allergy relief, and will have an improved quality of life. Such intervention is also very cost efficient in terms of higher productivity and fewer days lost from school and work, less expenditures for medication, as well as fewer emergency room visits and hospitalizations.
Allergy doctors are critical players in the approach to wellness. They and their staff spend a great deal of time communicating with patients and families about the nature of the allergic condition and the optimal allergy treatment recommended. They readily share allergy information and strongly encourage a team approach to health and wellness. Not only will they diagnose and treat the allergies or asthma, they will provide ongoing allergy information or asthma information to the patient, to keep them informed of present and future treatment options. Working in collaboration with the primary care physician, the patient, and the family, and by leveraging the benefits of environmental control through the use of effective allergy products, one can maximize the likelihood of good health and excellent control of allergy symptoms and asthma symptoms.
Allergies and their resultant symptoms can vary widely, depending on the nature of the allergic reaction and the organ systems involved. The symptoms from allergies can result from contact of the allergen with the skin, from breathing the allergen, or from ingesting the allergen.
Allergic symptoms in the skin that are the result of direct contact are usually limited to the skin itself, but, if severe, the allergy symptoms can be systemic and involve multiple organ systems. The classic example of allergy symptoms from direct contact with the allergen is the allergy rash from contact with poison ivy. Contact with the oil in the poison ivy plant results in a red, raised rash with intense itching. When severe, blisters can form with resultant weeping from the blister. This condition, called contact allergic dermatitis can also result from contact with latex, cleaning solutions, soaps, shampoos, and virtually any chemical which comes in contact with the skin.
Allergies can also result in urticaria, commonly called hives. Although commonly not caused by allergies, the symptoms produced by non-allergic causes are identical to those caused by allergies. As an example, a classic case of acute hives may result from a food allergy, such as a peanut allergy. The culprit, as in all allergic reactions, is histamine and other chemical mediators which are released in abnormal amounts. These chemicals cause the blood vessels in the skin to dilate, causing leaks between the cells in the blood vessels, allowing plasma to escape into the tissues. This results in red, raised hives which can measure from a few millimeters in diameter to many centimeters. They can be round or irregularly shaped, and sometimes they can resemble a target or a bulls-eye. They can appear isolated on one part of the body such as the face, or they be generalized and cover the entire body. These hives are characteristically very, very itchy.
Allergy symptoms in the skin can also occur with eczema, or atopic dermatitis. When mild, the allergy rash can appear as a faint pink or red dry patch on the skin. When the inflammation worsens, or if the skin becomes infected, the rash takes on a more angry red appearance and can ooze clear or pussy fluid. When chronic and long-lasting, the skin can become very thick, a process called lichenification. When moderately severe and wide-spread, the entire skin of the individual with eczema will be very dry. Like in almost all allergic reactions, itching is a particularly challenging allergy symptom in the skin.
Another form of allergy which results from contact is the allergy eye symptoms which results from exposure of pollen or other allergens in the eyes. This condition, called allergic conjunctivitis, is easy to diagnosis as the allergy symptoms it produces are quite classic in their presentation. Shortly after contact of the pollen with the lining of the eyes, histamine is released. The histamine and other chemicals released results in tearing, redness and swelling in the lining of the eyes, injection in the blood vessels of the eyes themselves, and moderate to severe itching. Allergy eye symptoms are commonly confused with an eye infection. Bacterial or viral conjunctivitis generally produce a thick yellow discharge and the eyes are somewhat painful. Allergy symptoms, on the other hand, generally produce a thin watery discharge. But, the one symptom that is almost always present in allergy eyes symptoms is itching, sometimes intense eye itching, usually in the inner corners of the eyes. Itching is such a universal presentation as an allergy symptom that, if absent, one may be hard pressed to cause the symptoms on allergies. It should be noted that allergens other than pollens can cause allergy eye symptoms. Allergies to pets, especially cats, can result in intense allergy eye symptoms. Other triggering allergens include dust mites and mold spores.
These allergy symptoms of the nose are familiar to most people. Allergy symptoms in the nose consist of a clear runny nose, sneezing, itching, and nasal congestion. These allergy symptoms can occur after an allergen is breathed onto the lining of the nose. The histamine released causes the mucous glands in the nose to produce copious amounts of mucous, resulting in severe runny nose and post nasal drip. The histamine also causes erectile tissue to swell. The structures in the nose that swell are called turbinates. When the turbinates swell, it leads to nasal congestion, either on one side of the nose, or both.
Upon inhalation of allergens in the bronchial tubes, lung allergy symptoms can occur in susceptible individuals. The allergy symptoms which are produced are dependent on the structures in the lungs that are affected. For example, an inhaled allergen can result in tightening of the smooth muscles which surround the bronchial tubes. This leads to wheezing, tightness in the chest, and sometimes difficulty breathing. Wheezing is a high pitched squeaking sound which is generally only heard with a stethoscope, but it sometimes can be audible without the aid of a stethoscope. It is most commonly heard on expiration (breathing out), but can also be heard during inspiration (breathing in).
Allergies will also cause symptoms in the lungs when swelling and mucous production occurs as a result of allergic inflammation. The diameter of the bronchial tubes through which air flows will then be compromised. Subsequent asthma symptoms can include wheezing, a sensation of tightness in the chest, and difficulty breathing. In babies and young children, it is not uncommon to see retractions of the chest wall during forced inspiration due to labored breathing.
Coughing is probably the most common asthma symptom, especially in children. This is due to the increased sensitivity which occurs with even mild inflammation in the bronchial tubes. The cough receptors become highly sensitive and can be stimulated by minor triggers. Coughing can be the only presenting symptom of asthma. As a matter of fact, asthma is one of the most common causes of a recurrent or chronic coughing in both children and adults.
Symptoms of allergies in the gastrointestinal tract are somewhat age dependent. For example, in babies, allergy symptoms to a food might present as recurrent spitting or projectile vomiting after eating, colic or irritability, diarrhea which can be bloody, abdominal pain, and even failure to thrive.
Older children will often complain of recurrent or chronic abdominal discomfort, bloating, loose stools or diarrhea, constipation, and signs of reflux. Symptoms of reflux which can be on an allergic basis might include burping, chest burning or chest pain, and other classic signs of indigestion.
Reading food labels is a critical exercise for the growing number of individuals who have a food allergy, now estimated to affect 2 percent of adults and 5 percent of infants and children in the United States. Food allergic reactions are often unpredictable in their occurrence and severity and can occur after consuming trace amounts of the food protein. Approximately 30,000 people require emergency room treatment and 150 Americans die each year due to allergic reactions to food. At present, there is no cure for food allergies. Avoidance of the inciting food thus remains essential in disease management. Reading food labels is an important part of everyday life for adults and children with food allergies.
In 2004, Congress passed the Food Allergen Labeling and Consumer Protection Act (FALCPA) to make it easier for food allergic consumers and their caregivers to identify and avoid foods that contain major food allergens. Effective January 1, 2006 the Food and Drug Administration (FDA) began to require that food labels clearly state whether food products contain any ingredients that contain protein derived from the eight major allergenic foods. These include milk, egg, peanuts, tree nuts (such as almonds, cashew, and walnuts), fish, shellfish (such as crab, lobster, and shrimp), soy, and wheat. Although there are many other food allergens, the above foods account for more than 90 percent of all documented food allergies in the United States and represent the foods most likely to result in severe or life-threatening reactions.
This law applies only to packaged foods that are regulated by the FDA. Fresh fruits and vegetables are exempt, as are refined oils derived from one of the eight major food allergens. Meat, poultry, and egg products are regulated by the United States Department of Agriculture (USDA). The labeling requirements also extend to retail and food service establishments, such as bakeries and carry out restaurants, that package and label products for human consumption. However, the requirements do not apply to foods that are placed in a container in response to a consumer’s request, such as the box used to provide a deli item ordered by a consumer.
The FDA also requires that manufacturers list ingredients in terms that are understandable to the average consumer. This new labeling will be especially helpful to children who must learn to recognize the presence of substances they must avoid. For example, if a product contains the milk-derived protein, casein, the product’s label will have to use the term “milk” in addition to the term “casein.” It is also required that the type of allergen is specified. For example, the specific type of tree nut (e.g., almond, walnut), fish (e.g., cod, tuna), or shellfish (e.g., crab, shrimp) must be included on the food label. Flavorings, colorings, or spices that contain a major food allergen must also be identified.
Although the new food-labeling law is a significant advance for people with food allergies, it also raises some questions. The law requires food allergens to be identified even in the smallest amounts. As a result, many food manufacturers are listing any and all possible food allergens, even if the allergens might not be present. This may make it difficult for people with food allergies to discriminate if a product contains enough milk or soy, for example, to cause an allergic reaction. Consequently, studies show that consumers with food allergy are actually becoming less avoidant of products with advisory labels.
A recent study confirmed that numerous food products have advisory labeling that can be confusing for consumers with food allergy. For example, only crustacean shellfish are included under this legislation, whereas mollusks (such as squid, clams, mussels, and oysters) are excluded from regulatory labeling. In addition, nonspecific terms (such as spices, natural flavors, and flavors) are frequently used without being linked to an allergen or ingredient. Other labeling uncertainties include the lack of identification of the type of flour (e.g., soy, wheat, rice) or tree nut contained in a food. Increasing the specificity of advisory labels can improve the consumer’s ability to choose safe food products without unnecessary dietary restrictions.
Although the laws designed to aid the food allergic individual are not perfect, they do help to identify potential allergens and food allergy sufferers should make all efforts to read food labels carefully.
An allergy is the immune system’s over-response or over-reaction to a normally harmless substance in the environment. This substance, called an allergen, can be inhaled, ingested, or exposure can occur through any direct contact, even through the skin. Common inhalant allergens include pollens, mold spores, and animal dander. The most common ingested allergens include foods and medicines. The oil in the poison ivy plant is the classic allergen which causes allergy symptoms upon exposure to the skin.
The classic allergic reaction is mediated through an antibody called IgE. These IgE molecules are attached to the surface of Mast Cells in the skin, the airways, and in the intestines, and they are attached to blood cells called Basophils. If and when these IgE molecules come into contact with an allergen, the subsequent attachment of the antibody to the allergen initiates a cascade of events which leads to the immediate release of histamine and other chemical mediators from the mast cells and basophils. It is the histamine and other chemicals which cause the symptoms of allergy. A mild reaction may result in sneezing, runny nose, congestion. A more severe reaction could lead to a life threatening event called anaphylaxis.
Contrary to popular belief, not everyone has allergies. Allergies are, however very common, affecting approximately 20% of the population. The tendency toward allergies does seem to be hereditary. One can certainly inherit the allergic gene, although generally not a specific allergy. When one parent is allergic, each child has a 50% chance of having allergies. That risk jumps to 75% if both parents have allergies.
Asthma in children is one of the most common medical problems in the pediatric population. According to statistics from the National Institutes of Health and the National Center for Health Statistics, childhood asthma affects over six million children under the age of eighteen and is the third leading cause of pediatric hospitalizations. Over the past decade the direct medical costs of asthma in children have exceeded a staggering eleven billion dollars, while the indirect costs (lost productivity of parents, for example) add another five billion.
The numbers of children diagnosed with childhood asthma have been increasing over the last few decades. There are many theories to explain this dramatic increase in children with asthma, but in reality, changing environmental factors, better diagnostic techniques, and an overall increased awareness of asthma by parents and medical professionals have all played a role.
Asthma in children can occur at any age, but most children will have symptoms before the age of six. Childhood asthma is more common in boys during early childhood, but by the teenage years the frequency of asthma among boys and girls is approximately equal. Compared to the overall pediatric population, African-American children are more likely to have asthma, and they have a higher incidence of severe asthma and asthma deaths.
Fortunately, deaths from childhood asthma are rare, but over four thousand people in the United States die each year from this disease. The fact is, most asthma deaths are preventable. Asthma specialists play a vital and crucial role in the recognition and treatment of childhood asthma, and more importantly, they can be very helpful in preventing asthma symptoms from occurring.
Asthma medications are often prescribed for the treatment of asthma. These medicines will be recommended by a allergy and asthma specialist who will formulate a comprehensive program to best manage a patient’s asthma. There are different types of asthma medications that work in different ways. Depending on several factors, such as the frequently and severity of asthma symptoms, and the objective measurement of lung function, the asthma specialist will decide whether the recommended asthma medicine will be controller, rescue medications, or both.
Controller medications, sometimes called preventative medications, are medicine for asthma usually prescribed for patients who have ongoing airway inflammation which usually manifests itself as asthma symptoms at least two or three days out of every week. Patients who require frequent rescue medication to control night time coughing or in whom rescue medications are not effective are commonly prescribed controller medications. Controller medications include Inhaled Corticosteroids (ICS), Combination Inhaled Corticosteroids and Long Acting Bronchodilators, Mast Cell Stabilizers, Leukotriene Blockers, Theophylline, and Xolair®.
Rescue medications, often referred to as bronchodilators, are designed to provide immediate relief of bronchial spasm and constriction. They may be given as inhalers or aerosolized to be used in a nebulizer. Rescue medications include Short Acting Bronchodilators, Long Acting Bronchodilators, and Oral or Injectable Steroids.
Most asthma medications are now available for inhalation. The inhalation method is preferable as it delivers medicine directly to the airways, the site of inflammation and bronchial constriction. The inhaled route of administration also minimizes systemic side-effects as it delivers the medication directly to the target area.
It is critical however, that any inhalation device, especially a metered dose inhaler, be used correctly. Inefficient usage is arguably the leading reason for asthma treatment failures. Fortunately, most children above 5 or 6 years of age can be taught to use an inhaler correctly. But, it is critical that every child or adult asthma patient be taught the optimal inhaler technique by the prescribing physician or nurse, and that the technique be reviewed and reinforced periodically.
Inhalation devices are available as a traditional metered dose inhaler, or as diskus inhalers, twisthalers, or flexhalers. All of these devices are slightly different and mastery of the proper technique for each device used is critical.
Many asthma medications are also available to be given through a nebulizer. A nebulizer is a small electronic or battery operated compressor which aerosolizes a liquid medication into a mist for inhalation. Nebulizers are especially beneficial for babies, toddlers, and young children who lack the coordination and maturity necessary to use an inhaler correctly. They are also very helpful to senior citizens or others with arthritis or other musculoskeletal conditions of the hands which would preclude the use of an inhaler. Nebulization treatments are also commonly used during an asthma attack due to the sustained administration of medication. A breathing treatment with a nebulizer takes several minutes, but it is a very efficient delivery system and well worth the time spent.
Many children who are too young to use an inhaler properly are commonly prescribed a spacer device. Spacers, such as the aerochamber or aerochamber with mask, are tube-like devices into which an inhaler is inserted and the medication is sprayed. It is thought that the use of this device decreases the need for coordination in the child. Even though this device may be helpful, it is not as efficient as the proper use of an inhaler without this attachment.
There are many asthma medications that are very effective. An asthma specialist will help guide a patient towards the best course of treatment for his or her asthma.
Asthma treatment should be undertaken in consultation with an allergy and asthma specialist who will be actively involved in formulating a comprehensive program to best manage asthma. This comprehensive approach to asthma treatment should include Environmental Control, the use of asthma medications, and possibly immunotherapy, or desensitization, if there are strong allergic triggers.
Environmental Control is a cornerstone in the treatment of asthma. This simply means that one has to avoid exposure to allergens or environmental irritants which can trigger or worsen asthma symptoms. For example, those allergic to dust mites need to minimize exposure to dust mites by encasing ones mattresses and pillows. If one is allergic to cats and dogs, it is crucial that they live in a pet free environment. And, it goes without saying that, all asthmatics should totally avoid exposure to cigarette smoke.
Asthma medications are a critical component to asthma control. Depending on several factors including the frequently and severity of Asthma Symptoms and the objective measurement of lung function, your asthma specialist will decide whether one needs to be on daily controller or preventative medication or only on an as needed or on a rescue medication such as albuterol.
Controller medications are usually prescribed for patients who have asthma symptoms at least two or three days out of every week. Physicians have found inhaled corticosteroids (ICS) to be the most effective controller medications. They are effective in controlling symptoms of asthma and improve lung function by reducing the inflammatory component of asthma. Due to the fact that these are preventative medications, they must be taken daily, exactly as prescribed, and not on an as needed basis. These medications have an excellent safety profile and are appropriate even for young children and senior citizens.
Non-steroidal anti-inflammatory medications are also available, but they are generally less effective than ICS in preventing symptoms. These medications are often prescribed in combination with ICS to provide additional control.
Rescue medications such as albuterol, often referred to as short-acting bronchodilators, should be available to provide immediate relief of bronchial constriction. Albuterol and other bronchodilators may be given as an inhaler or aerosolized in a nebulizer. These medications also have a place in the prevention of exercise induced asthma and are commonly recommended to be used 10-15 minutes prior to exercise.
Corticosteroids are often given to reduce the symptoms of severe airway inflammation during acute or chronic asthma. These medications are most commonly taken orally, but they can be administered by injection. Contrary to popular belief, corticosteroids are extremely safe if given for short periods of time, even for several weeks. Long term daily use of steroids, on the other hand, can be associated with significant side effects. It is important to note that the steroids used to treat asthma are not the same as anabolic steroids which are sometimes taken by athletes to build muscle mass. The use of these and all medications should be discussed with the prescribing physician.
An allergist may recommend immunotherapy, or allergen desensitization, for those whose asthma symptoms are poorly controlled with medications alone. Allergy injection therapy or sublingual (under the tongue) immunotherapy works by making the immune system more tolerant to allergens and thus decreasing the hyper responsiveness of the airway to allergens in the environment. Immunotherapy should be viewed as an important component of a comprehensive asthma treatment plan in the allergic asthmatic. Studies suggest that immunotherapy can be effective in preventing asthma from getting worse, and even preventing an allergic individual from developing asthma.
Finally, a team approach with your physician should include an asthma action plan. Your doctor may give you a list of symptoms with corresponding recommendations about when to start medications, or when to seek medical attention. In addition, the asthma action plan may include monitoring lung function at home with a Peak Flow Meter. A peak flow meters is a simple tube device that measures airway obstruction by quantifying how much air a patient can blow out of his or her lungs. This information may reveal subtle and progressive asthma, allowing one to intervene early and begin a higher level of medication treatment in order to prevent worsening symptoms.
The good news is that a well thought out asthma treatment plan can lead to excellent asthma control. Fortunately, with good asthma care and follow-up, most hospitalizations for asthma are preventable. A close relationship with an asthma specialist and an individualized asthma treatment plan can reduce asthma symptoms, leading to more symptom free days and a better quality of life for both children and adults with asthma.
Food Protein Induced Enterocolitis Syndrome, commonly known as FPIES, is a relatively rare, but potentially severe condition in newborns and infants. This condition often presents in the first few weeks or months of life, or at an older age in the exclusively breastfed baby. In exclusively nursing infants, symptoms may first present upon the introduction of commercial formula or solid foods such as cereals, which typically contain cow’s milk, soy, or another offending protein. Symptoms occur only when the newborn or infant has ingested the offending protein, and does not occur from breast milk, regardless of the maternal diet.
Symptoms typically present shortly after the ingestion of the food protein to which the child is sensitive, commonly within two hours of ingestion, but they may be delayed as long as 8 hours. Symptoms are exclusively gastrointestinal, with the most common symptoms being vomiting and diarrhea. Unlike an allergic reaction, this non-allergic reaction is not accompanied by cutaneous symptoms such as itching, hives, or swelling; nor are there respiratory symptoms such as congestion, coughing, wheezing, or difficulty breathing. Symptoms of FPIES can vary between mild and severe. When mild, minor diarrhea or mild to moderate colic symptoms may predominate. When severe, profuse vomiting and diarrhea occurs, and emergency treatment should include the replacement of fluids due to the possible rapid onset of dehydration, and even shock. Corticosteroids are sometimes administered, but the injection of epinephrine is of no benefit during this reaction.
Contrary to popular belief, FPIES is not an allergy; rather it is a gastrointestinal intolerance to a food protein. Therefore, this condition cannot be diagnosed by allergy testing, either by skin testing or by blood testing. The clinical diagnosis is generally made by a clinical history consistent with typical symptoms after eating a given food. The diagnosis is generally confirmed if and when symptoms occur each time the food is introduced to the child.
The most common foods to the cause this condition are milk and soy. However, other solid foods may also precipitate symptoms, including cereal grains (rice, oats, barley), legumes (peas, beans, lentils), and poultry such as chicken and turkey. It should be remembered that any food can cause FPIES, even in trace amounts.
Upon removing the offending food, all FPIES symptoms subside. Treatment of this condition consists solely of avoidance of the offending food. It is generally recommended that if a child has FPIES caused by cow’s milk protein formula, that soy formulas also he avoided due to the fact that soy is also a common cause of this syndrome.
Typically this condition resolves by 3 years of age. It is recommended that parents not attempt to determine if the child can tolerate the offending food at home; rather, it is recommended that an allergist or pediatrician attempt to introduce the food under close medical supervision.
Eosinophilic Esophagitis (EE) is a condition that was literally unheard of 20 years ago. However, over the last five years, the recognition and diagnosis of eosinophilic esophagitis has risen dramatically. It is difficult to say whether the increased frequency of eosinophilic esophagitis is due to an increased level of suspicion, to better diagnostic techniques, or whether the condition recognized as eosinophilic esophagitis has actually become more common.
Eosinophilic Esophagitis is an allergic reaction localized to the esophagus, the tube that transports food from the throat to the stomach. The classic pathologic feature of this condition is the presence of eosinophils, a normal and benign cell that circulates in the blood and is occasionally found in the tissues. Eosinophils are not normally found in the esophagus, but in this condition, eosinophils accumulate in the lining of the esophagus, generally in response to a food allergy. There they release chemical mediators leading to local inflammation.
Eosinophilic esophagitis commonly affects people who have a family history of allergy, especially food allergies, and conditions such as eczema and asthma. It is most common in children. Most adults who develop eosinophilic esophagitis are generally diagnosed in the third or fourth decade of life. Males are affected three times more commonly than females.
Common symptoms of eosinophilic esophagitis include heartburn or reflux symptoms that do not improve with medication, difficulty swallowing, nausea and/or vomiting, poor appetite, a sensation of food getting stuck in the throat, abdominal or chest pain, and in more severe cases, malnutrition. Diagnosis is confirmed by endoscopy, a procedure during which a gastroenterologist inserts a flexible scope to into the esophagus for direct visualization. The presence of “furrows”, “rings” or “white spots” is highly suggestive of eosinophilic esophagitis. The diagnosis is confirmed by biopsy, after which small tissue samples are examined microscopically for the presence of eosinophils. Pathology reports will commonly give an eosinophil count, but the presence of any eosinophils in the esophagus confirms the diagnosis. A high eosinophil count likely represents more severe disease.
Eosinophilic Esophagitis is now known to be caused by allergy to a food or multiple foods. Therefore, if the diagnosis of eosinophilic esophagitis is confirmed, allergy testing to foods by either the prick method or through the blood is necessary in order to try to identify which foods are responsible for the esophageal inflammation. Occasionally, patch testing to foods can be helpful. If a food allergy cannot be diagnosed by testing, an elimination diet may be necessary to help identify the causative agents. Common food allergens which have been implicated include milk, soy, wheat, eggs, peanuts, tree nuts, fish and shellfish. Sometimes an elemental formula may be recommended, after which foods are slowly reintroduced into the diet one by one to identify the food(s) responsible for symptoms.
Once food allergies have been diagnosed, elimination of the causative food from the diet is commonly the only treatment necessary to resolve symptoms of eosinophilic esophagitis. Medications such as swallowed topical steroids may also be helpful in reducing the inflammation in the esophagus.
The Delayed Food Allergy Syndrome (DFAS) is a valid and useful concept which unifies into one diagnosis symptoms so diverse and nonspecific that they are seldom thought of as a unit or as allergic. This condition occurs most frequently in childhood, but can also occur in teens and adults. Many physicians, and even some allergists, are unaware of the Delayed Food Allergy Syndrome or are doubtful of its validity. In spite of the fact that there is little data from medical research about this condition, it has gained its greatest acceptance amongst allergists who care for children.
DFAS can manifest itself in many different ways and in many organ systems. The seven most common signs and symptoms in approximate order of frequency are:
Like most syndromes, the Delayed Food Allergy Syndrome often occurs in incomplete or partial forms. Only rarely are all seven of the major signs and symptoms present. One can, however, expect three to four of them to become evident in the medical history, if one inquires carefully.
While respiratory tract allergy and fatigability may be more or less constant, the other complaints are likely to be intermittent. Headache and stomachache for example, can be assumed to occur sooner or later in almost everyone, but it is their greater than expected frequency that may be significant. Individually, each of the above symptoms may be due to many different causes. When they present in combination, however, the possibility of the DFAS should be considered.
Less frequent symptoms which have been described with the Delayed Food Allergy Syndrome include cervical gland enlargement, constipation, loose stools or diarrhea, impaired hearing, bed wetting, and mildly elevated temperature.
This syndrome is usually thought to be due to a food allergy. By far, the food most commonly responsible for this delayed allergy is milk. Both parents and physicians find it difficult to believe that foods eaten almost daily, such as milk, wheat, corn, or chocolate can be responsible for the occurrence of such seemingly unlikely symptoms. Particularly difficult to understand is the tendencies for the Allergy Tension Fatigue Syndrome to become more evident in the winter, and in some cases to almost disappear in summer despite no significant change in diet.
At the present time there is no readily available test which can reliably identify the allergens responsible for the delayed onset type of food allergy responsible for DAFS. Allergy skin testing or RAST or ImmunoCap blood tests are not helpful, as they measure only the IgE antibody, the antibody responsible for immediate allergic reactions. Research has not yet identified the antibody or antibodies responsible for delayed reactions, although there has been considerable interest and research in the possible role of the IgG antibody in the delayed allergic reaction. There is now a blood test available to measure this antibody, but its reliability as a predictor of delayed allergy has not yet been established.
The diagnosis of this type of food allergy is made by initiating an elimination diet and observing a decrease or elimination of symptoms. It is often recommended that the suspected food be totally eliminated from the diet for four week. If there is a significant improvement in symptoms, the physician may recommend that the food be reintroduced into the diet in order to see if the symptoms recur. If so, the food is once again eliminated. The elimination diet and challenge, therefore, if properly carried out, is the most reliable diagnostic tool in making the diagnosis.
If and when a food is identified as the causative agent, the food should be totally eliminated from the diet. In less severe cases, it may not be necessary for the food to be totally eliminated from the diet on a long term basis. Many food allergic patients with DFAS can tolerate minimal amounts of the allergens without developing symptoms. Exceeding one’s threshold of tolerance will, however, precipitate symptoms.
In summary, the Delayed Food Allergy Syndrome presents with a constellation of symptoms which, when appearing together, suggest to the allergist the possibility of a delayed onset food allergy, especially to milk. It is more common than is generally appreciated. It may accompany inhalant allergy, and explain inadequate response to the treatment of inhalant allergies such as a poor response to immunotherapy.
As a final note, it should be mentioned that food allergy is usually familial. The knowledge may greatly aid its recognition in a particular patient as well as other members of the family.
Cat allergy represents one of the most challenging aspects to an allergist’s practice. From the fact that so many families have indoor cats one can easily understand why cat allergy symptoms are so commonly seen in clinical practice. And the fact that the cat allergen itself is one of the most potent allergens on the face of the earth, it follows that the number of individuals sensitized to the allergen and who subsequently developed cat allergy symptoms has increased dramatically and will continue to increase.
The challenge to the allergist is even more acute when one recognizes the fact that, in so many cases, cats become bona fide and loved family members, and the suggestion to the cat allergy individual of removing one’s pets from the home is often met with a negative and nonnegotiable response. From a patient’s perspective, the realization that their allergy or asthma symptoms or their child’s symptoms are being caused by their cat can be devastating. The emotional impact of this realization is often met with denial, and subsequent avoidance of sound medical advice. A caring allergist will recognize these strong emotions and will work with the patient and family to design an environmental control program with which the patient suffering from cat allergy symptoms can take charge of improving his or her care.
It is the nature of the cat allergen itself which makes management and treatment of cat allergy so difficult to deal with. Cat allergen is extremely potent and in a highly allergic individual, it does not take much exposure to induce very bothersome, and sometimes severe, cat allergy symptoms. Besides the potency issue, cat allergen is extremely light and becomes airborne, therefore readily accessible to the eyes, nose and lungs of the allergic patient. The allergen is also very sticky, and therefore can be found just about anywhere that a cat resides; on the furniture, walls, carpeting, floors, bed, etc. Needless to say, the amount of cat allergen in homes where cats reside is plentiful and often problematic, but cat allergen is virtually everywhere! It can be found in very significant concentrations in school classrooms where children bring the allergen on their clothes, in places of business, in homes where a cat does not reside, and even in allergists’ offices!
Contrary to popular belief, the sole source of the allergen on cats is not the hair or fur. It is also present in the dander (skin scales), the urine, and the saliva. Also false is the notion that there are hypo-allergenic cats. Although some species have been reported to be less allergenic than others, all cats have the potential of inducing allergy symptoms in the highly sensitized individual.
Environmental control is the most important treatment modality in dealing with cat allergy symptoms, which can be as mild and inconsequential as minimal nasal and eye symptoms, or as severe as life threatening cat induced asthma, and everything in between. It is the severity of these cat allergy symptoms which will likely guide your allergist when making recommendations to the patient and family of the cat allergic individual.
When cat allergies are present in children or adults, they can experience chronic asthma symptoms. If the asthmatic has recurrent or persistent symptoms, or has evidence of chronic airway inflammation and airway obstruction as measured by spirometry (lung function studies), the necessary, albeit sometimes emotionally painful step, is the removal of the cat(s) from the home. The home should then undergo a thorough cleaning. Compromise approaches, such as keeping the cat out of the bedroom and avoiding direct contact, are likely not to be helpful. Not to remove the cat(s) from the homes will likely result in the patients needing to take multiple asthma medications on a daily basis just to maintain an acceptable level of lung function, and the frequent or chronic use of corticosteroid (prednisone, methyprednisolone) medication.
For less severe symptoms which do not involve asthma, compromise approaches can be helpful. These suggestions would likely include the recommendation that the cat(s) never go in the bedroom, avoiding direct contact, thorough and frequent cleaning of the home and the cat, use of medications, and possibly immunotherapy or desensitization.
It is extremely important that one create an allergy-free zone for the cat allergy patient. Since one spends approximately one third of their life in one’s bedroom, it is obvious the the allergy-free area should be the bedroom. Specific recommendations might include:
Shellfish allergy, and seafood allergy, is one of the most common causes of severe allergy reactions in adults. Approximately 12 million Americans suffer from food allergies. It is estimated that 6.9 million of them have fish allergy and/or shellfish allergy.
A seafood allergy occurs when the immune system mistakenly interprets the proteins contained fish or shellfish as a harmful substance. When a person with fish allergy comes in contact with fish, the body produces antibodies to fight the harmful substance, and this triggers an allergic reaction.
Seafood and shellfish allergy symptoms most commonly occur upon ingestion, but can also be triggered by the inhalation of fish protein while being cooked, or upon direct contact to the skin. The most common reactions include rash (atopic dermatitis), redness and swelling around the mouth, hives (urticaria), wheezing and difficulty breathing, stomachache, cramping, diarrhea or vomiting, asthma, and in extreme cases, anaphylaxis. Severe reactions generally occur within minutes after consuming the allergen. Seafood allergy, if not treated promptly, can be fatal.
Unlike most food allergies which appear in childhood and resolve later in life, seafood allergy commonly persists throughout adulthood. And, unlike many other foods, the onset of fish allergy is common during adulthood. Women are affected more commonly than men.
Seafood causing allergic reactions can be classified into three groups:
Fish allergies are most commonly caused the bony fish such as cod, salmon, pollock, snapper, eel, and tilapia, to name just a few, and cartilaginous fish such as shark. The most allergenic fish is thought to be cod. Some fish, specifically tuna and mackerel, are considered to be less allergenic than others. But, because of the high frequency of cross-reactivity, individuals with allergies to one type of fish are likely to have allergies to others. This cross-reactivity is caused by the protein parvalbumin that is present in many fish. For this reason, most people with an allergy to one fish are advised to avoid all fish, including eel and shark. Many fish allergic individuals can eat shellfish and/or mollusks, and vice versa, but one must be allergy tested before assuming that there is not an allergy to more than one seafood group.
Shellfish or Crustaceans:
This category includes shrimp, lobster, crayfish, prawn, and crabs. Tropomyosin, the protein that most commonly causes shellfish allergies, is also found in dust mites and cockroaches, and there is some evidence of cross-reactivity between shellfish and some insects.
Clams, oysters, scallops, abalone, cockle, cuttlefish, escargot (snails), octopus, squid, and mussels are included in this category.
Individuals with seafood allergy must be especially diligent about avoiding the ingestion of seafood proteins which may be in other foods. The list below, although not inclusive, demonstrates how widespread the presence of fish is in the foods we commonly eat.
Glucosamine, a dietary supplement sometimes recommended for patients with arthritis, is often made from the shells of crustaceans. The proteins that are most likely to cause food allergies are not found in the shell, and recent studies have indicated that glucosamine is safe for people with shellfish allergies; however,for those who wish to avoid glucosamine because of the fear of an allergic reaction, a vegetarian glucosamine is commercially available..
Another potential source of shellfish allergens is Omega-3 supplements, which are often made from seafood. The most common source used to manufacture these is fish (mostly cod liver), but check ingredients on the label before you take these.
There are other conditions which can mimic a seafood allergy. For example, allergy to the parasite Anisakis Simplex can masquerade as seafood allergic reaction. Anisakis simplex is a fish parasite which is found world-wide, and infests a variety of hosts along the food chain. Between 5 and 80 % of fish samples have been found to be infested in various studies. Cooking at high temperatures or storage in industrial freezers is required to kill the parasite. Anisakis can cause two major problems in humans: allergic reactions and infection with the parasite.
Anisakis simplex allergy resembles other allergic reactions to food. Allergic reactions to Anisakis simplex should be suspected when allergic-like reactions occur after eating seafood, yet the results of skin tests to seafood are negative. Reactions often occur intermittently after eating seafood, rather than on every occasion. Anisakis simplex infection, or anisakiasis, results from eating raw or undercooked seafood such as sushi. Infection can cause nausea, vomiting, and abdominal pain. Diagnosis is based on seeing the parasite using a fiberoptic telescope during endoscopy.
Scrombroid fish poisoning is another example which demonstrates that not all reactions to seafood are allergic in origin. Rather, they resemble allergic reactions. Scombroid fish poisoning is an allergic-like reaction that occurs after eating foods with high histamine content.
Scombroid poisoning is caused by the ingestion of scombroid and scombroid-like marine fish species that have begun to spoil due to the growth of particular types of bacteria, generally due to the lack of proper refrigeration. Fish most commonly involved are members of the scombridae family including tuna and mackerel, although a few non-scombridae relatives including bluefish, dolphin or mahi-mahi, and amberjack are sometimes implicated..
The suspect toxin is an elevated level of histamine generated by bacterial breakdown of substances in the muscle protein. This natural spoilage process is thought to release additional by-products, which cause the toxic effect. Unfortunately, freezing, cooking, smoking, curing or canning does not destroy the potential toxins.
Affected fish often have a metallic or peppery taste. Symptoms usually commence within 30 minutes of eating. Because the symptoms are caused by the chemical histamine, they can be identical to an allergic reaction. The most common symptoms include flushing, itching, urticaria or hives, nausea, vomiting, abdominal cramps, dizziness, palpitations and headache. Severe episodes may result in wheezing and a drop in blood pressure.
As one of the “big eight” most common food allergens, fish is covered under the Food Allergy Labeling and Consumer Protection Act (FALCPA). This requires that manufacturers label the presence of fish in clear language on food labels, either in the list of ingredients or following the word “contains” after the ingredient list. Fish is not a particularly common hidden ingredient and generally appears as its own species in ingredient lists. But people with fish allergies should learn the names of many different types of fish for maximum safety in reading labels.
There are recorded instances of severe seafood allergy symptoms due to the inhalation of aerosolized fish proteins, so people with fish allergies should avoid hibachi-style communal grill restaurants if fish is on the menu. Seafood restaurants and sushi bars are high risks for cross-contamination due to the close proximity of fish and non-fish items. Another source of potential cross-contamination is frying oil; if fish has been fried in oil, people with fish allergies should avoid eating any other food fried in the same oil.
Corn Allergy is a relatively uncommon allergy. Most corn allergy reactions are mild, but severe reactions have been reported. Corn allergy can result in anaphylaxis after the ingestion of corn or corn-related foods, but severe reactions after exposure to cornstarch in surgical gloves have also been reported.
Corn is a cereal grain with proteins that are similar to those in other cereal grains such as wheat. Unlike wheat, which is a common food allergen, allergic reactions to corn are much less common. Corn allergy symptoms can occur as a result of eating both raw and cooked corn. Those with corn allergy may also have typical allergic rhinitis and/or asthma, upon exposure to corn pollen, grass pollen, and cornstarch.
As with other food allergies, avoidance of corn and corn-related foods is the main way to prevent future reactions.
It is important to remember that food manufacturers may change the ingredients in the product without warning. It is a good idea to always read the product label before consuming the product. It is much easier to prevent a food-allergic reaction than to treat one.
these foods are less likely to cause sensitivity
Anaphylaxis is the most severe of all allergic reactions and can result in difficulty breathing, a sudden drop in blood pressure with subsequent anaphylactic shock, and even death. Anaphylaxis is a medical emergency that requires immediate recognition, prompt medical treatment, and follow up care by an allergist.
It has been estimated that up to 15% of the population is at risk for anaphylaxis. Anaphylaxis can occur within minutes after exposure to a substance to which one is severely allergic. The most common substances that trigger anaphylaxis are foods, medications, and insect stings.
Anaphylaxis is triggered when an allergen (food, medicine, insect venom, etc.) comes in contact with antibodies (IgE) in the blood or tissues previously formed by prior exposure to the allergen. This antigen-antibody reaction results in a rapid cascade of cellular events leading to the immediate release of large amounts of histamine and other chemical mediators.
These chemical mediators, when exposed to the smooth muscles of the lungs, can quickly lead to constriction of the bronchial smooth muscle causing wheezing, tightness in the chest, and difficulty breathing. Exposure to blood vessels generally causes urticaria, or hives, and can lead to vasodilatation of the peripheral circulation resulting in low blood pressure and possibly shock. Reactions usually begin within seconds to minutes of exposure, but may be delayed. In general, the quicker the onset of symptoms, the more severe the reaction may be. Sometimes symptoms resolve, only to recur or progress a few hours later.
Anaphylaxis is, by definition, “systemic”. It therefore can affect multiple organ systems, including the skin, respiratory, circulatory, and gastrointestinal systems. Symptoms of anaphylaxis can vary from mild to severe, and are potentially deadly.
The following is a list of possible symptoms that may occur alone, or in any combination:
A recent study done at the Mayo Clinic found that food allergy is the most common cause of anaphylaxis. In their study of patients presenting to the emergency room over a ten year period, 33% of anaphylaxis cases were caused by foods. Insect stings accounted for 19% and medications caused 14% of all anaphylactic reactions.
In addition to the administration of rapid acting antihistamines, the effective medical treatment of anaphylaxis requires the immediate administration of epinephrine (adrenalin). Patients with a history of anaphylaxis or those identified as high risk for anaphylaxis should carry an epinephrine auto-injector, such as Epipen, with them at all times. The quicker epinephrine is given to the onset of symptoms, the better likelihood of successful treatment. It is sometimes necessary to give a second or even a third dose if symptoms persist. While medical treatment is being initiated, medical assistance should be sought as further therapy may be necessary. Even after receiving immediate medical treatment on site, one should be transported to a medical facility or hospital for further evaluation.
Any person who has had an anaphylaxis episode should consult an allergist in order to:
Sesame allergy is now recognized as a significant cause of severe allergic reactions among both children and adults.
Tiny in size, the sesame seed can pack a serious allergy punch. Incredibly, the ingestion of just one sesame seed can cause the symptoms of sesame allergy. Sesame is in a family of seeds that also includes poppy seed, flaxseed, sunflower seed, buckwheat, mustard, and pine nut. In the entire family of seeds however, sesame causes the majority of allergic reactions. And, the incidence of sesame allergy is on the rise. This is likely due to the increase in popularity in the use of seeds, including sesame, in the American and Mediterranean diet.
Sesame allergies share many similar properties in terms of the clinical allergy symptoms, severity, and persistence with peanut, tree nut, and shellfish allergies. Despite these similar characteristics, sesame is not “yet” considered one of the “big 8” food allergens. As a result, sesame allergy has not received much attention as a dangerous allergen until recently.
Certain types of diets, most notably the Mediterranean diet, use sesame in a variety of applications, including oils, pastes, confections, baked goods, and cosmetic products. The use of sesame in the United States has rapidly increased in recent years and ranges from use in obvious sources such as hamburger buns, bagels, and other baked goods, to more hidden uses such as lip balm.
However, the increased use of sesame as an ingredient within certain cultures is not the sole cause for a rise in sesame allergy. For instance, a society like India, whose culture uses sesame frequently in the diet, has a low rate of sesame allergy while others, like Israel, have a high rate of allergy. This has led investigators to study the effects of how food processing affects rates of allergy, which likely explains why there are wide cultural variations in rates of peanut and tree nut allergy, as well as sesame allergy.
Sesame and other seeds are plant derived products, and have a number of different proteins that can cause an allergic response. Unfortunately, patients can react to one or all of the different proteins. Most of the allergenic proteins in sesame are shared by many plant derived foods, including peanut, legumes (including soybean), tree nuts, buckwheat, mustard seeds, kiwi, and certain spices.
Recent food allergy surveys in England and Australia found that sesame allergy was more commonly reported than allergy to any tree nut, and an Israeli study found that sesame allergy was more commonly reported than peanut allergy. Compared to the big 8 allergens in the United States (milk, egg, soy, peanut, tree nut, shellfish, fish, wheat), there is far less reported sesame allergy.
Outside of the United States, sesame allergy often occurs by age two, but this is highly influenced by countries that feed their young a sesame rich diet. In the United States, sensitization to sesame is seen in young children, although not to the same extent as in certain countries like Israel. There is data indicating that sesame allergy is less frequent in the 15-20 year old age group. In contrast to low rates in teenagers, sesame allergy is being detected at a higher than expected rate in adults, although it is unknown if these individuals developed new sesame allergy or this was just previously undetected.
As detailed in the preceding paragraph, processing may be the most significant factor influencing sesame allergy, as is the case with tree nuts and peanut. This fact may ultimately influence any conclusion that can be drawn about the natural history of this allergen. As well, there is some difference in the amount of allergen content among the 3 varieties of sesame seeds, with white seeds containing more allergen than the black or brown variants. Regardless, it is abundantly clear that despite protein content differences, all 3 seed types induce allergic reactions in sensitive individuals, and all 3 should be avoided in sesame allergic individuals. Sesame seed, flour, noodle, meal and oil all contain very potent allergen amounts, and there is no safe form or preparation of sesame for a sesame allergic individual to come in contact with.
Sesame is associated with life-threatening anaphylaxis in susceptible individuals! Again, this is very similar to tree nut, peanut, and shellfish allergy, and sesame sensitive individuals are recommended to avoid any amount of contact. Clinical allergy can manifest as eczema, contact dermatitis, asthma, hives, and oral allergy syndrome. Symptoms have been noted to affect the eyes, nose, mouth, lips, tongue, throat, lungs, skin, GI tract, bladder, and the circulation including the heart.
Note: this list is adapted from Gangur et al, Ann Allergy Asthma Immunol 2005, and only provides examples of how sesame can be found in foodstuff.
Like any other food allergy, the treatment of choice for a systemic allergic reaction is epinephrine (EpiPen® or Twinject®) plus an antihistamine. Sesame allergic individuals are at risk for potential life threatening allergic reactions and should have a personal source of self-injectable epinephrine with them at all times. Strict avoidance is very strongly recommended, and care should be taken to avoid potential cross-contamination from preparation surfaces, cooking utensils, pots, pans, plates, and surfaces.
Hand washing after eating is recommended from anyone who dines with any food allergic individual, including sesame allergic. It may be beneficial to avoid certain cultural/ethnic restaurants that may use a lot of sesame in preparing their food. Sesame allergic individuals must take care to avoid unintended exposure through the numerous pharmaceutical and cosmetic use of sesame.
To test for sesame allergy, processed extracts are available for application as a skin test. Because there are several sesame protein allergens that exist, and not all of them have been proven to be captured on skin testing, allergy blood tests (RAST or ImmunoCAP®) are highly recommended if the skin test is negative. It is well established that there is a high degree of cross-reactivity to sesame with peanut, tree nut, legumes, and other seeds, but not all of this is clinically relevant. Many allergists therefore chose to screen sesame allergic individuals with the blood test for the presence of cross reactivity with these other foods, and vice versa.
Sesame is an allergen on the rise in western countries, such as the United States. The European Union and the Canadian Food Inspection Agency have recently put sesame on their allergen watch lists, but the FDA has yet to do the same. This means that sesame does not have to be labeled in “plain English” on packaged goods produced and sold in the United States. Because sesame allergy has not been as well identified and studied as some of the other allergens, more research is needed to define the characteristics of this entity. Very little about the long term outcome is known, except that nearly 80% of sesame allergic individuals taking part in an Israeli study retained their allergy into adulthood.
The Oral Allergy Syndrome is the most common food-related allergy in adults. In actuality, the oral allergy syndrome is not a direct food allergy. Rather it represents cross-reactivity between distant remnants of tree or weed pollen still found in certain fruits and vegetables. Therefore, the oral allergy syndrome is only seen in those allergic to tree and weed pollen. The oral allergy syndrome is commonly called oral allergy or mouth allergy by those who suffer from this aggravating condition. Fortunately, symptoms of the oral allergies are generally mild and transitory, and rarely does it progress to a severe systemic allergic reaction such as anaphylaxis.
Oral allergy syndrome symptoms are classically itching of the throat, mouth, and tongue. The itchiness of the throat commonly results in the patient trying to relieve this symptom by rubbing the tongue against the soft palate making a characteristic “clucking” sound. These symptoms present within several minutes of ingestion of uncooked fruits and vegetables. Symptoms are almost always localized to the upper oral tract. Lip swelling can occasionally occur.The vast majority of patients experience symptoms within five minutes of ingestion. Depending on the time of year, the presentation can be affected by the particular pollen season.
Oral allergy symptoms result from ingestion of fruit or vegetable proteins that cross-react with antibodies of tree or weed pollen proteins. It should be emphasized that this is not a direct allergy to the fruit or vegetable, but rather a reaction to the tree or weed pollen with which it cross-reacts. Therefore, allergy testing to the fruit or vegetable itself rarely yields a positive result. Testing to its corresponding pollen however, will be highly positive.
By definition, persons with oral allergy syndrome have allergy to either tree or weed pollens. The oral allergy syndrome can occur in individuals allergic to any tree or any weed species. Studies suggest that 25%-75% of pollen allergic individuals will have oral allergy symptoms. Both children and adults can be affected by the oral allergy syndrome.
Essentially, any raw fruit or vegetable can potentially elicit symptoms in tree or weed allergic individuals. However, this has been described most often with the following:
It is also important to mention a related entity, the Latex-Fruit Syndrome, which operates under very similar circumstances. Latex is tree derived and its primary allergen shares similarities with fruit proteins. Latex is an ubiquitous allergen in our environment, and there is high degree of contact in day to day activities.
The following food proteins have demonstrated cross reactivity with latex proteins:
The treatment strategy for any food allergy, including the oral allergy syndrome, is avoidance. This condition is limited to ingestion of only uncooked fruits or vegetables.Cooked fruits and vegetables are generally well tolerated, as the heating process breaks down the allergenic proteins.
Antihistamines are generally very effective in reducing or eliminating the throat itching that occurs with ingestion. An allergist may recommended that individuals with oral allergy syndrome carry an EpiPen® or another epinephrine auto-injector for the rare occasion whereby a more serious reaction would occur. Anaphylaxis is very rare with the oral allergy syndrome. Immunotherapy, or desensitization, is not indicated for the treatment of oral allergy symptoms, although some patients on immunotherapy which includes the relevant allergens may see some improvement in oral allergy syndrome symptoms.
To help you manage your or your child’s allergy symptoms most effectively, your allergist must first determine what is causing your allergy. Once the specific allergen(s) causing symptoms have been identified through allergy testing, you and your allergist can develop a treatment plan aimed at controlling or eliminating your allergy symptoms.
Allergy testing can be performed on the skin or through the blood, but most allergists prefer skin testing because the patient can be tested to large numbers of allergens at one visit and the results are available immediately.
Allergists usually begin with prick (also called percutaneous) testing. Using a plastic “pick”, or a device called a multitest, the surface of the skin is lightly pricked and the allergen, previously placed on the tip of the device, is introduced into the skin.
After this simple application of the allergen(s), one waits 15-20 minutes in order to see if there is a skin reaction in the form of a wheal (swelling) or a flare (redness). The size of the reaction is then measured to determine the degree of allergy. The larger the skin reaction, the stronger the allergy.
This test is usually performed on the back, but it may be performed on the forearm. This test may include one or more relevant allergens, or a standard panel of the most common allergens including trees, grasses, weeds, and molds, dust mites, and pet hair. Foods are also tested by this method.
Most patients tolerate percutaneous testing extremely well. There is no pain involved but young children sometimes report minor discomfort. The most common complaint is itching from wheals that can develop over 15 to 20 minutes. These wheals and itching usually resolve over thirty minutes.
Intradermal tests are usually performed if the patient does not demonstrate significant reactivity on prick testing of suspected allergens. This test introduces a stronger concentration of allergen under the skin, and will often diagnose allergies that the percutaneous test did not reveal.
Intradermal testing involves injecting, with a very tiny needle, a small amount of allergen under the skin of the arm. These tests are mildly uncomfortable and are commonly described as momentarily stinging like an ant bite. Because of this, only a handful of tests are usually performed by this method. Like prick testing, results are determined by measuring the size of the wheals which develop over 10-15 minutes. Intradermal testing is generally used for the diagnosis of inhalant, venom, or drug allergies, but is not used for testing to foods.
Sometimes your allergist may do a blood test, called a RAST (radioallergosorbent) test or ImmunoCAP test.
These blood tests are accurate predictors of allergy, but they have some disadvantages to skin testing:
Allergy tests through the blood are generally used in cases in which skin tests can not be performed, such as with very young children, in patients taking certain medications which may interfere with the results, or those with skin conditions that may interfere with skin testing.
Challenge testing: Challenge testing involves introducing small amounts of the suspected allergen by the oral, inhaled or other routes. With the exception of food and medication, challenges are rarely performed. When they are performed, they must be closely supervised by an allergist.
Elimination/Challenge tests: This method is utilized most often with foods or medicines. The patient is instructed to modify his/her diet to totally avoid the suspected allergen for a period of time. If the patient sees significant improvement while avoiding the suspected allergen (food or medicine), he/she is then sometimes “challenged” by reintroducing the allergen in order to see if the symptoms can be reproduced.
Patch testing: This form of testing is indicated to help ascertain the cause of skin contact allergy, or contact dermatitis. Adhesive patches, treated with usually a number of different chemicals or skin sensitizers to which people are most commonly allergic, are applied to the back. The skin is then examined for possible local reactions at least twice, usually at 48 hours after application of the patch, and again two or three days later.
Unreliable tests: There are other types of allergy testing methods that the American Academy of Allergy, Asthma, and Immunology considers to be unacceptable.
These unreliable allergy testing methods are:
Xolair (Omalizumab) belongs to a class of medications called “biologic therapies”. Xolair acts early in the allergic-inflammatory process in people with allergic asthma by blocking the allergy antibody IgE from causing the reactions that can lead to asthma attacks and symptoms.
Xolair is a medication used to treat very severe allergic asthma. Usually after being on this medication for a period of time, asthma symptoms improve and patients can decrease the use of some of their asthma medications.
This medication is administered as a subcutaneous (under the skin) injection. Xolair injections are usually given once or twice a month. The dose is based on one’s allergy antibody level and weight. The injections are usually administered at your allergist’s office, but they can be given under the direction of a home health care company at your home. Your physician will help decide how long to take this medication based on your response and level of asthma control.
Do not discontinue any of your asthma medications after starting Xolair without first speaking to your physician.
Xolair is usually well tolerated. The most common reported side effects include, but are not limited to:
Malignant neoplasm was observed in 20 of 4127 (0.5%) patients treated with XOLAIR compared with 5 of 2236 (0.2%) control patients in clinical studies.
Oral steroids or injectable steroids are potent anti-inflammatory medications. They work by turning off the body’s production of mediators that cause inflammation and subsequent symptoms of swelling, irritation, itching and pain. Common conditions that require the use of oral or injectable steroids include asthma, moderate to severe allergic reactions, including allergic rhinoconjunctivitis and hives, as well as severe sinus conditions and skin reactions. They are strong medications that usually start working within hours to days.
It is important that you take these medications exactly how your physician prescribes them. They are most often given for periods of several days to two weeks, but some patients may require longer courses. If taken for longer than a week or two, your physician will likely recommend a weaning schedule. This schedule will instruct you or your child to take a gradually smaller dose each day to allow your body to gradually wean off the medication. Steroids can be given as an injection or administered in tablet or liquid forms.
The most common corticosteroids prescribed are prednisone and methylprednisolone.
Oral or injectable steroids that are prescribed by physicians treating allergies or asthma are not related to performance enhancing medications (anabolic steroids) used by athletes or body builders.
Despite rumors to the contrary, steroids are safe medications when taken for short periods of time. They can also be used safely on a recurrent basis, although your allergist will monitor the amount of steroids prescribed and will try to minimize their use.
Steroids can have both short and long term side effects. Short term side effects can include, but are not limited to, increased appetite, weight gain or fluid retention (usually temporary), red or flushed cheeks, mood changes and irritability, stomachache, and possibly temporary elevations of blood pressure or blood sugar levels.
If it is recommended that you or your child need to be on long term, daily corticosteroids, your physician will discuss with you the benefits and risks of long term use. Long term side effects can include, but are not limited to: weight gain, osteoporosis, fractures of the bones, cataracts, increased intra ocular pressure or glaucoma. Patients on long term steroids (months to years) may experience easy bruising, thinness of the skin, hair growth and increased blood pressure.
Since steroids can temporarily lower your resistance to infections, they should be avoided, or minimized, with known infections such as chicken pox, shingles, or influenza.
In general, oral steroids should be taken with meals to minimize any stomach discomfort.
Nasal corticosteroids, or nasal steroid sprays, are one of the most effective medicines used to treat allergic and non-allergic rhinitis, as well as nasal polyps and chronic sinusitis. They are designed to reduce inflammation in the mucosal lining of the nose. Nasal corticosteroids work by turning off the production of mediators that cause inflammation, swelling, and mucous production. When taken regularly as a preventative, they can even decrease nasal “hyper- reactivity”, or the tendency for the nose to react upon exposure to allergens or non-allergic irritants.
Because nasal steroids are preventative, or prophylactic, they should be taken daily and over long periods of time, exactly as prescribed by your physician. Most nasal corticosteroids are dosed once daily. Patients can usually expect to see results from nasal coritcosteroids within one to two weeks.
Nasal steroids are considered very safe, even for long term use. Chronic use of the recommended doses of nasal steroids rarely causes systemic symptoms. However, the occasional nose bleed is not uncommon, particularly when the relative humidity is very low. This is most common in the winter months when the heat is on. The likelihood of such nose bleeds can be reduced by directing the nasal inhaler nosepiece toward the lateral (outside) walls of the nose and away from the nasal septum (the cartilage dividing the nostrils).
Your allergist will periodically examine the nasal cavity of individuals on long-term nasal steroids looking for the very uncommon complication of mucosal ulceration.
Nasal Steroids are not related to performance enhancing medications (anabolic steroids) sometimes used by athletes or body builders.
Leukotriene modifiers (LTMs) are medications designed to block a chemical mediator in our body (leukotrienes) that causes mucous production, swelling of the lining of the sinuses and lungs, spasm of the lungs, and recruitment of cells that contribute to allergic inflammation. Some leukotriene modifiers work by blocking production of leukotrienes while others block the receptor for the inflammatory mediators.
Leukotriene modifiers are approved to treat both nasal allergies and asthma. Leukotriene Modifiers are available in the form of a pill or chewable tablet, however there is one leukotriene modifier that also comes as granules that can be mixed in food for young children.
Currently available leukotriene modifiers are:
Take this medication exactly as instructed by your physician. Leukotriene modifiers are used as a preventative for allergy or asthma symptoms and therefore should be taken daily.
Singulair (Montelukast) is well tolerated, can be taken with most other medications, and has a very good safety profile.
Accolate (Zafirlukast) has been associated with liver damage on rare occasions. If Accolate is taken concurrently with certain other medications, the effects of either drug could be increased, decreased, or altered. It is especially important to check with your doctor before combining Accolate with the following:
Although rare, Zyflo (Zileuton) has been associated with elevations in liver function tests. All patients should have liver functions checked before they start this medication, as well as periodically during its use. If Zyflo (Zileuton) is taken with certain other drugs, the effects of either could be increased or altered.
It is especially important to check with your doctor before combining Zyflo (Zileuton) with the following:
Overall the most common side effects reported for these medications include:
Inhaled corticosteroids (ICS) are one of the most effective medicines used to treat recurrent or chronic asthma. They are designed to reduce inflammation in the bronchial tubes of individuals with asthma. ICS work by turning off the lung’s production of mediators that cause inflammation, swelling, mucous production, and eventual constriction or blockage of the medium to small airways in the lungs.
When taken regularly, they will even decrease bronchial “hyper-reactivity”, or the tendency for the bronchial tubes of asthmatic patients to spasm or constrict when exposed to allergens or irritants.
Inhaled corticosteroids are available in a meter dose inhaler (MDI or “puffer”) form, a dry powder inhaler, or as a nebulized medication.
Because inhaled corticosteroids are preventative, or prophylactic, they should be taken daily and over long periods of time, exactly as prescribed by your physician. Most inhaled corticosteroids are dosed once or twice daily. Patients can usually expect to see results from ICS within one to two weeks. These medications should not be used for acute or sudden onset of asthma symptoms.
Your physician or nurse will direct you or your child in proper inhaler on nebulizer technique. For young children, a spacer device (aerochamber or Inspirease) may be recommended to help facilitate delivery of medication to the lungs. All patients should rinse their mouth and throat out with water or mouthwash after using these medications in order to prevent minor side effects, such as oral thrush.
In general, inhaled corticosteroids are considered quite safe. Because the medicine is inhaled directly into the lungs, resulting in minimal systemic absorption, and the fact that the dose delivered is so small, steroid side effects are minimized. The most common adverse effects include sore throat, hoarse or husky voice, and thrush (yeast infection of the throat). Rinsing thoroughly after each use will minimize the likelihood of these side effects.
High dose and long term use of medications in the steroid family may affect bone growth, the density or strength of bones, and promote the growth of cataracts. Patients on high doses of inhaled corticosteroids should have their growth monitored (for children), as well as bone density testing eye exams periodically.
For the overwhelming majority of children who are on inhaled corticosteroids for asthma and/or nasal steroids for rhinitis, or nasal disease, height will not be affected. There is some evidence that children on inhaled corticosteroids may actually have some decrease in growth velocity in the first year of treatment. However, other studies of large numbers of children have shown that with years of inhaled corticosteroid use, expected final adult height was attained.
Bronchodilators are asthma medications designed to relieve asthma symptoms by relaxing the muscles that tighten around the airways. They act rapidly (usually within fifteen minutes to one hour) opening the airways, letting more air come in and out of the lungs. As a result, breathing improves. Bronchodilators also help clear mucus from the lungs. As the airways open, the mucus moves more freely and can be coughed out more easily.
Most bronchodilators are delivered to the lungs by a metered dose inhaler (MDI), dry powder inhaler device, or by nebulization. Meter dose inhalers are sometimes used with a spacer or chamber device to help facilitate delivery of medication, especially in children. In younger children, your physician may prescribe a bronchodilator to be used in a nebulizer (a machine that aerosolizes or mists a liquid form of the medication). Nebulization treatments can also be extremely helpful during an asthma exacerbation.
Bronchodilator medicines, also called beta 2-agonists, come in both a short and long acting preparation. The short acting forms are recommended to be used for “rescue” or to relieve the acute symptoms of coughing, wheezing or shortness of breath. Short acting bronchodilators may be helpful for patients with exercise induced asthma if used approximately ten to fifteen minutes prior to exertion.
Atrovent is another type of bronchodilator called an anti-cholinergic drug. It is available in both a metered dose inhaler and nebulizer solution. For asthma, it works best when used with a short-acting beta 2-agonist bronchodilator. It is important to note that it is not a quick relief medicine because it takes about 60 minutes before it begins to work. It is generally not as effective as beta 2 agonists in treating asthma.
The long-acting forms of beta 2-agonists are used to provide control, not immediate relief, of asthma. These drugs take longer to begin to work, but their effects last longer, even up to 12 hours. The long acting forms are designed to be almost exclusively used in conjunction with an inhaled steroid and often come in the same inhaler as a combination product (Advair, Symbicort). Long acting bronchodilators should be used exactly how your doctor prescribes them, usually once or twice a day and on long term basis.
Long-acting Beta 2-agonists Bronchodilators include:
Patients taking bronchodilators have reported nervousness, shakiness, rapid heart rate or palpitations. On rare occasions, patients may complain of headache or nausea. Exceeding the recommended dose can elevate blood pressure or heart rate.
Theophylline is another type of bronchodilator that is occasionally used in difficult-to-control or severe asthma. Although it is rarely prescribed, it is sold under the brand names Uniphyl, Theo-Dur, Slo-Bid, and Theo-24, and is available as a pill or liquid. It is long-acting and is used to prevent asthma attacks. Theophylline must be taken daily to be effective.
Possible Theophylline side effects include:
Antihistamines are medications prescribed to treat multiple allergic conditions, including seasonal and year round nasal allergies, itching, hives, eczema, and allergic reactions. Antihistamines work by blocking the action of histamine, a substance produced by our bodies during allergic reactions. Histamine is the major chemical mediator responsible for many allergy symptoms including itchiness, sneezing, runny nose or eyes, and swellings. Antihistamines commonly come in pill or liquid form but occasionally may be given during an emergency as an injection.&nb