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Daily Dose

Penicillin Allergy

1:30 to read

Has your child ever been labelled “penicillin allergic”?  Interestingly, up to 10% of people (of all ages) report having a penicillin allergy, but only about 1% are truly allergic. I see this often in my own practice, especially when seeing a new patient and inquiring about drug allergies, and the parent replies, “ she is penicillin allergic, and developed a rash when she was younger”.  In many if not most of those cases the child is not allergic to penicillin.

 

Penicillins are a class of antibiotics known as beta-lactams and include not only penicillin but  amoxicillin, augmentin, oxacillin and nafcillin, just to name a few.  If you are incorrectly identified as penicillin allergic, when your doctor needs to prescribe an antibiotic they may resort to another class of antibiotic, which are not only more expensive but often may cause more side effects.  

 

Penicillins are the antibiotic of choice and the first line treatment for many pediatric bacterial illnesses including otitis ( ear infections ), strep throat, and sinus infections. They are not only effective, but they are typically inexpensive and have few side effects….which includes allergic reactions.

 

Penicillin allergy is an immune - mediated reaction which usually causes hives ( raised rash ), face or throat swelling, difficulty breathing and in some cases life threatening anaphylaxis.  Intolerance to penicillin is different than being allergic, and in this case symptoms are more likely nausea, diarrhea, headache or dizziness, which may make you uncomfortable but are not immune mediated. 

 

In pediatrics, many children present with a viral illness that includes several days of fever and upper respiratory symptoms, and are then also found to have an ear infection. They are given a prescription for amoxicillin and several days later develop a rash. Many viral infections in children also cause a rash, which is typically red, flat and covers the trunk, face and extremities and does not cause any other symptoms which are seen with a true penicillin allergy.  This rash is benign, but unfortunately many young children will be seen at an urgent care or even an ER due to the rash. The parents are told that their child is penicillin allergic and the antibiotic is changed…and the label “pen allergic” sticks….for many years or even life.  I even saw this rash occur in one of my own sons while on an antibiotic. He is NOT allergic!

 

The good news is that most children are truly not penicillin allergic, and if possible I try to see all of my patients who report a rash while they are on an antibiotic. At times this is not possible, and now with the advent of “smart phones” I have parents send me a picture of the child and the rash. This often helps in determining if the rash truly appears allergic and to identify if there are other symptoms.  Back to the “get a good history”. 

 

If I see an older patient who has had a rash on amoxil when they were little and had no other adverse effects (get a good history), I will sometimes try using a penicillin again, as most people also “outrgrow” their sensitivity after about 10 years. If it is my patient and I have seen the rash I tell the parents that this is not a “pen allergy” and I will use penicillins again.  Some  patients will report a “pen-allergy” but say I can take “augmentin” which is penicillin derivative, so that makes it easy to know they are not allergic.  If I am unsure if a child has had a true penicillin allergy I will refer them to a pediatric allergist for skin testing.  Skin testing is not painful and is an important method for documenting a true allergy. 

 

 

   

Daily Dose

Diagnosing Food Allergies

1.15 to read

Food allergies continue to be a problem in the pediatric population and I often get calls or see a patient for an office visit with a parent who has a concern that their child “may have” reacted to something they ate. Their question is, are they allergic?  

There is a great resource for physicians entitled “The Guidelines for the Diagnosis and Management of Food Allergy in the United States”.  Not all adverse reactions to foods are allergic and it sometimes takes a bit of “detective work”, which is a good history and physical exam, to begin to determine if a child has a food allergy.   

So, when a parent tells me that their child gets a rash on their chin or cheek after eating “xyz” food the questions begin.  Was it the first time they had ever been exposed to that food? Describe the rash and how the child was acting?  Did they have other symptoms with the rash? Was the rash just on a cheek or was it all over? Was it hives? This list of questions go on and on.   

The most common food allergens are egg, milk, peanut, tree nuts, wheat, shellfish and soy. I also ask if this was a one time occurrence, and  If they have tried the food again did it happen every time? Many times hard to tease out what a child has had to eat when they have a mish-mash of food on their plate and nothing is new!  

Is there a family history of allergy or asthma?  Does your child have eczema as well?  If so there is a greater chance of developing a food allergy.  

After a detailed history, and if I do think that the child has a good history for a food allergy, there are tests (skin prick and blood) that may help determine if an allergy may exist.  BUT, with that being said, there are several caveats.  Number one, your doctor should not test for “every” food allergen, only for the suspected food or foods, as there are many false positive tests when you just check all of the boxes for testing IGE levels for an allergy.  For example, if your child eats eggs and has had no problem but the IGE level comes back a bit high for egg allergy, what does that really mean?  In other words, I just test for the suspected culprit. So, I do not test for tree nuts if the parents only had concerns with a peanut product.   More to come on this topic. 

Daily Dose

Diagnosing Celiac Disease

How do you diagnose celiac disease. I received an email via our iPhone App from a mother who was concerned because her 2 year old son had skinny arms and legs, but a “big tummy” and she thought this might be a symptom of celiac disease.  Most toddlers have “big tummies” even if they are skinny kids as their abdominal musculature (future 6 pack) is not developed.

I often have questions from concerned parents whose children are growing perfectly normally, but their “belly sticks out”.  This is often a comment made about little girls (gender specific concerns already!) and I tell the parents that there are not many toddlers that don’t have protuberant little tummies. If you go to the pool in the next several months, check out the baby pool,  as this is not a good age to wear a bikini or “speedo” with that big tummy pushing down the bottoms,   save that look for later on. Now, what do you typically look for in  child who you suspect might have celiac disease?  Celiac disease typically causes failure to thrive in young children. I know this well,  as I got this question wrong on my oral boards many years ago, and have spent the last 20 years making sure never to miss a case. (maybe I should leave that little tidbit out?) At any rate, you see symptoms like persistent diarrhea, weight loss or failure to gain weight, a large protuberant abdomen, and a lack of appetite (no, being a picky eater does not count).   Because celiac disease is an auto-immune disease where the body responds abnormally to a protein (gluten) found in foods like wheat,  rye, barley and many other prepared foods, it differs from a food allergy.  A food allergy typically causes symptoms like hives, wheezing or vomiting. The first step in testing for possible celiac disease will be a blood test on your child.  This will show if there are elevated levels of antibodies, called tissue-trans-glutaminase (tTG), in the blood. If a child has high levels of these antibodies (tTG), then a biopsy of the small intestine may be taken to confirm the diagnosis. A small bowel biopsy is done while a child is sedated, through an endoscope, and actually takes a small piece of the lining of the intestine to see if the villi are flattened and damaged.  The gluten in the diet of a child with celiac disease causes these changes to the intestine, and once gluten is removed from the diet the villi will return to normal and normal absorption of food will take place. If a child is confirmed to have celiac disease (which is as lifelong problem) they have to remain on a gluten free diet, which means restricting many foods and drinks.  A gluten free diet, while seemingly difficult to adhere to at first, will allow the child to grow and develop normally and your child will typically have more energy and feel better in general.  After being on a gluten free diet another blood test may be done to confirm that the tTG level has come down. With the advent of more gluten free products it has become easier for parents and children to follow a gluten free diet. There are many websites that help teach a family to read labels (similar to those with a food allergy) and to also provide resources for recipes or products that are gluten free. Although I continue to look for a patient with celiac disease, I have yet to diagnose one, and remember to consider the diagnosis in any child who is having “failure to thrive”. That's your daily dose for today.  We'll chat again tomorrow! Send Dr. Sue your question now!

Daily Dose

What Causes Circles Under a Baby's Eyes?

I received an email from a patient who had just weaned her your-baby from breast milk to formula. She was concerned because the your-baby sometimes looked as if she had circles under her eyes.I recently received an email from a patient who had just weaned her your-baby from breast milk to formula. She has a beautiful eight-month-old daughter and she was concerned because she thought the your-baby sometimes looked as if she had circles under her eyes. She felt like the your-baby was getting plenty of sleep, did not seem sick or tired but was concerned about the circles. She thought it might be allergies from changing from breast milk to formula. She was also concerned that she might have seasonal allergies.

In looking at her your-baby I really did not notice the circles, as you know mothers are the most critical about their own children. (Sorry Mom, I think my own Mother talks about my circles too!) At any rate, infants do not manifest symptoms of milk allergy with circles beneath their eyes. They have diarrhea, or vomiting or blood in their stools or failure to thrive. I do not think that the change in milk was the cause of the discoloration she described. Infants also do not develop seasonal airborne allergies until they are over the age of two or three and then they may present with the classic "allergic shiners" beneath their eyes, and the crease of the allergic salute across their nose, clear runny nose and often itchy eyes. I think this precious your-baby just had familial thin skin beneath her eyes with superficial veins that led to the appearance of circles. They were not always visible, and it would also depend on the position the your-baby slept in etc ...as to how much you might notice them. Will have to see if they bother her as she gets older, as there is always concealer and I use a lot of it when around my own Mom. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Relief During Allergy Season

1.30 to read

It's the worst allergy season in years and I'm seeing a lot of children complaining of nasal congestion, sneezing, itchy and watery eyes.Achoo!  Yes, it has been a particularly bad allergy season and (I'm afraid to say) it seems like it's going to be like this for a while. I have been seeing a lot of children complaining of nasal congestion, sneezing, itchy and watery eyes. 

The surge in allergies this year has been due to a very wet winter and the weather this spring has brought erratic temperatures and lots of wind. The perfect storm for the "allergic cascade" to inflict itself on everyone's nasal mucosa. The best preventative for nasal allergy symptoms (allergic rhinitis) has been the use of intranasal steroids. These steroid sprays have been used for the past 15 years and clinical studies have shown that intranasal steroids are superior to oral antihistamines. Intranasal steroids function by inhibiting the production of chemical mediators such as histamine and prostaglandin that cause inflammation and mucous production. In other words they are more of a preventative medication, while an antihistamine is treating the histamine that was released once you inhaled the offending tree or grass pollen. Intranasal steroids may also help eye allergy symptoms too. The problem is getting young kids to let you use a nose spray on them. The same holds true for the older tween and teen crowd who complain that they "just don't have the time to use it everyday" (it must take all of 15 seconds to use on yourself!) They have been shown to be effective within 3-12 hours, although will reach their maximum effectiveness after several days to weeks of use, so using it daily and throughout the allergy season is going to give you the maximum therapeutic effect. There are many different brands available and everyone seems to have their favorite. If one spray seems to bother your child due to scent, or intensity of the spray ask your doctor to try another brand. Many times they will have a sample and give you several to try and then prescribe the one that is easiest to get your child to use. It may be trial and error, but finding the right nasal steroid may just change your allergy season. That's your daily dose, we'll chat again tomorrow. Oh, God Bless You! Send your question to Dr. Sue!

Daily Dose

Good News About Peanut Allergies

1:15 to read

There has been a lot of news recently about peanut allergies and good news on all fronts. For several years there had been recommendations that children should not be given any peanut products until at least two years of age due to concerns about children and peanut allergies. At the same time, some physicians even recommended that breastfeeding mothers not consume peanut products. This was a difficult scenario for both parents and children as what young child did not eat peanut butter?

Many children's parents would not even let peanut butter in the house and were consumed with reading labels looking for peanut products. Remember, this was not in a peanut allergic child, or even in a family with a history of peanut allergies. I would have failed as a mother during this time as my kids ate peanut butter sandwiches almost daily.

I can remember a patient coming over to my house for one of those "house calls" I frequently do and at the end of the visit I offered her child (about 22 months) a peanut butter cookie that I had just baked. As she took the cookie from me, ready to take a big bite, the mother screamed, "She has never had peanut butter, don't let her have that!" Before you could even grab the cookie she took a big bite, a grin spread over her face and lo and behold, she ate the rest. (I am a good cookie baker, if I do say so myself.) No reaction, happy child and now the mother was convinced her child would not die if she ate peanut butter before two. Well, the recommendations have changed and children may have peanut butter, or peanut products before they are even one and seem to actually have a lower chance of developing peanut allergies. They should not eat a whole peanut, for risk of choking, but other products are fine.

I had never been convinced that withholding peanuts seemed to make a difference, and peanut butter is a childhood staple, full of good protein. Now, news from Duke University is also showing that very peanut allergic children may be de-sensitized to peanuts by giving them miniscule amounts of peanut protein on a daily basis. After 8 to 10 months of gradually increasing doses of peanut powder several of the children were able to tolerate peanuts in their regular diet and several more were able to tolerate up to 15 peanuts at a time without serious reactions. This is significant data for those children suffering from peanut allergies, and who have the risk of developing anaphylaxis and even death if exposed to peanuts. It seems that scientists are making inroads into developing oral immunotherapy to de-sensitize children with food allergies, and further studies are underway.

That's your daily dose, we'll chat again tomorrow. More Information: Experimental Treatment Gives Hope to Children with Peanut Allergies

Daily Dose

Diagnosing Food Allergies

1.15 to read

Food allergies continue to be a problem in the pediatric population and I often get calls or see a patient for an office visit with a parent who has a concern that their child “may have” reacted to something they ate. Their question is, are they allergic?  

There is a great resource for physicians entitled “The Guidelines for the Diagnosis and Management of Food Allergy in the United States”.  Not all adverse reactions to foods are allergic and it sometimes takes a bit of “detective work”, which is a good history and physical exam, to begin to determine if a child has a food allergy.   

So, when a parent tells me that their child gets a rash on their chin or cheek after eating “xyz” food the questions begin.  Was it the first time they had ever been exposed to that food? Describe the rash and how the child was acting?  Did they have other symptoms with the rash? Was the rash just on a cheek or was it all over? Was it hives? This list of questions go on and on.   

The most common food allergens are egg, milk, peanut, tree nuts, wheat, shellfish and soy. I also ask if this was a one time occurrence, and  If they have tried the food again did it happen every time? Many times hard to tease out what a child has had to eat when they have a mish-mash of food on their plate and nothing is new!  

Is there a family history of allergy or asthma?  Does your child have eczema as well?  If so there is a greater chance of developing a food allergy.  

After a detailed history, and if I do think that the child has a good history for a food allergy, there are tests (skin prick and blood) that may help determine if an allergy may exist.  BUT, with that being said, there are several caveats.  Number one, your doctor should not test for “every” food allergen, only for the suspected food or foods, as there are many false positive tests when you just check all of the boxes for testing IGE levels for an allergy.  For example, if your child eats eggs and has had no problem but the IGE level comes back a bit high for egg allergy, what does that really mean?  In other words, I just test for the suspected culprit. So, I do not test for tree nuts if the parents only had concerns with a peanut product.   More to come on this topic. 

Daily Dose

Allergic to a Baby Wipe?

1.15 to read

Most parents with young children find themselves wiping their children’s faces several times a day, at the minimum. In the “olden days” I remember my own mother wiping my face with a bit of “her spit” on her finger which she used as as a washcloth, when there was nothing else available. (I swore I would never do that myself, but of course, never say never).  But in this century, most parents have the luxury of using a wet wipe/baby wipe rather than a mother’s spit.

Interestingly, there are now several reports of an allergic contact rash developing in some children who have had their faces wiped with wet wipes.  Not only are children having their bottoms wiped, it seems that people of all ages are now using wet wipes for washing hands and faces.  They travel well and are being heavily marketed for their convenience.

It seems that the culprit in these new cases is methylisothiazolinone (MI) a chemical found in certain brands of wet wipes. Previously, baby wipes contained a lower percentage of MI, but in recent times the concentration of MI has increased by more than 25 times, as it was not thought to cause sensitization.

This small study of 8 children, and another study from Australia also showed that once the children stopped using the wipes, their “mystery” rash resolved.

The American Contact Dermatitis Society has named the chemical MI the contact allergen of the year. Somewhat like being named “most likely to succeed”

So, doctors and parents need to be on the lookout for unusual rashes that appear to be red, eczematous and sometimes impetiginous, that do not resolve with usual treatment.  It might be worth looking at what kinds of wipes a family is using and if they contain the chemical MI (which may also be found in some soaps and shampoos).  In the study, all of the patients had rapid resolution of their rash, within about 2 days after discontinuing the use of wipes. Most of the children had experience symptoms for 1-12 months before being appropriately diagnosed.  

Hmmm..who knew spit would be better tolerated.  

Daily Dose

Achoo! Control Indoor Allergens

Part 3 of our special allergy series. Today we talk about how to control dust, pollen and mold from invading your home.As we continue our allergy series, we thought it would helpful to offer a few tips on how to keep many pesky allergens from bothering your kids in your home.

There are an array of things that can trigger an allergy attack in your home including dust mites and mold. Working fulltime and raising three boys, I know how hard it is for busy families to find time to clean (my least favorite thing to do). But spring is the best time to get a jump on controlling indoor allergies. Start with washing all bedding at least once a week.  Throw your linens in water at least 130 degrees.  Place dust mite covers on mattresses and pillows.  While changing sheets, vacuum the mattress as well. Carpeting harbors plenty of items, so if there is someone very allergic, consider replacing carpets with hard surfaces such as hardwood or tile. By doing so, this can eliminate as much as 90% of dust mites.  If you can’t live without carpet, think about buying low pile not shag. Get rid of any mold!  Mold is caused by moisture and can hide in your kitchen, bathroom and basement.  Keep things as dry as possible to avoid any mold build up. One thing many people miss? Turn on the ventilating fan or open a window in the bathroom.  Try to keep humidity below 50%.  Too much moisture is a breeding ground for mold and mildew. I know how much families love their pets (we love our yellow lab Maggie and treat her like a member of the family).  But Maggie and your pet can track pollen into your home from the outside.  Also, many children can be allergic to pet dander.  Here’s a trick: wipe your pet down with a dryer sheet! It will pull the dander and any loose pollen off your pet. Spring cleaning means de-cluttering, so go ahead and box up those knickknacks.  They are very decorative but are a magnet for dust. And, check your air filters.  Every 1st of the month, clean or replace your air conditioner, furnace or dehumidifier filter.  It will inhibit dusty air from circulating throughout your home. Try these tips and let me know how it works out for your family.  I’d love to hear from you. Tomorrow, we’ll talk about food allergies as they are on the rise in children.

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