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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

Epi Pen Controversy

1;30 to read

I have more than several patients who have had serious allergic reactions (anaphylaxis) to a variety of things…including insects (fire ants, bees) as well as foods (peanuts, tree nuts, fruits, shellfish). All of these children need to have epinephrine auto injectable pens (EpiPen) on hand in case of “accidental” exposure to the allergen and a subsequent life threatening allergic reaction.  These medical devices are seldom used ( thank goodness), but need to be replaced every 12-24 months and should always be readily available in case of an emergency.

For the longest time it was not a “big” issue (cost wise) to write prescriptions for these allergic children and to make sure that they had several EpiPens on hand. This included having them available at home, school, in the mothers purse or in the car or in the gym bag…many people also wanted “extras” to have at the grand- parents house or at the lake house…etc.  So….I would write a script for the EpiPen 2 pack and the family might get 4-5 sets to disperse to the appropriate people. Prior to 2009 the cost was less than $100/two pack. 

It was several years ago that a few families started talking to me about the expense of these devices and also how quickly they seemed to expire…in fact we started asking the pharmacist to look at the expiration dates and to try and dispense the ones that had the longest expiration, in hopes of saving some expense.  At that time there were also two companies that were making the epinephrine devices.  

Then in the last year parents started calling me complaining that the EpiPens were becoming cost prohibitive and “did they really need to keep filling them?”….especially seeing that they had never needed to use one?  Of course I replied that “by the grace of God” and their vigilance they had not needed one, but YES, they indeed needed to continue to have them on hand.  In many cases families reduced the number that they bought and tried to make sure that they handed them off if their child left home….terribly hard I would think to keep up with.

This issue came into view most recently as parents across the country started complaining to not only their physicians, but to the pharmacy, their insurers and the drug maker Mylan Pharmaceuticals….why in the world had the price jumped to over $600? In retrospect, the price had been raised 15% twice a year over the past 2 years!  ( It was also pointed out that this was a 6 fold price increase in the past decade).

I do know that epinephrine has been around for a long time and the drug itself is not that expensive, and is used everyday in hospitals around the country….but the EpiPen auto injector which allows “anyone” to inject the medicine into a muscle without any measuring etc. has become cost prohibitive for many families, even some of those with insurance. It seems that Mylan Pharma  is setting prices “based on whatever the market may bear” and not on the fact that the drug is new or expensive to produce…

This is one of the times that all parents with children who need to carry an EpiPen need to contact their representatives in Congress, as well as their insurers to see if the public can be influential in trying to remedy this situation.  The public will have to let their concerns and voices be heard…

Just as I am writing this, Mylan has announced an “instant savings card” for those people who are paying out of pocket and help for those who do not have the means to buy the EpiPen….but this does not correct the problem as a whole. While the discount may be helpful for some, but not all, it is not the answer to the ever growing problem of exorbitant drug costs in this country. I have several families who are going to try and buy the EpiPen while on trips to Mexico and Canada. I have no idea of the costs there…but worth a try.  

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 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

Use Nasal Saline to Combat Spring Allergies

Spring allergy season is in full swing around the country and we probably have four to six more weeks ahead of us. So many people are having a hard time with allergies this year, and many people are being affected that have never even experienced allergies previously. Check the pollen counts in your area, but ours in the Dallas-Fort Worth area have been sky high and tremendous amount of wind continuing to spread the pollens.

I know I have emphasized the use of steroid nasal sprays in the prevention of allergic symptoms. These need to be taken on a regular basis to provide maximum benefit. But nasal saline irrigation is being shown to be more and more helpful in controlling allergic symptoms. The use of nasal saline has been around for years, originating in India, and allergists have long promoted its use. With endorsements this year by Oprah, the use of the Netti pot has soared and many patients are feeling relief from clogged nasal passages and sinuses that irrigation may provide. Pediatricians have used a form of nasal irrigation for years in infants and young children when they have a cold. The bulb syringe that every parent receives on discharge from the hospital is a mini-Netti pot. By using a small amount of salt-water solution placed into the nostril of an infant, the parent can suction mucous out of an infants nose that they are unable to blow. Young children seem reticent to learn how to blow their nose (although I am convinced that girls acquire this ability before boys who find it perfectly appropriate to wipe it on their sleeve), and many children may be in elementary school before they are capable of effectively blowing their noses. So during this allergy season, you might consider adding a Netti pot (or competitors product, there are many out there) to facilitate removing pollens and other allergens from the nose and sinus cavity. Once you have tried using it, children are even surprised at how much better they feel. I told a little boy today, using the warm water in the nose is a leap of faith, just try it once, the same way you tried riding a bike, and you may find relief from that allergic nose wiping. That's your daily dose, we'll chat again tomorrow.

Daily Dose

It's Allergy Season!

1:30 to read

WOW!  A busy week in the office and while I was on call in the evening,  the biggest problem right now seems to be allergies!  While some parts of the country may still be experiencing cold and a few snow flake, many states are warming up and the trees and grasses are starting to spread their pollens. In fact, my backyard is covered in yellow oak tree pollen, and some of it is so thick it looks like tumbleweeds. This cannot be good for anyone.

While I am finally seeing fewer and fewer children with the multitude of winter upper respiratory infections I see every year, the allergy season is looking “wicked” this year.  Seasonal allergies due to pollens from grasses and trees are typically not seen in children until they are over 24 months of age.  At times it is difficult to distinguish the last of the cold viruses from early allergy symptoms. But at this time of year, a good history is important (always) as well as a family history of allergies.

The good news is, there are a lot of medications available to help relieve the symptoms of itchy eyes, scratchy throat, cough, and drippy nose.  While the non-sedating antihistamines like Claritin, Zyrtec, and Allegra have been available over the counter for quite some time, intra-nasal steroids are now available as well. 

Intra-nasal steroids are one of the mainstays of allergy treatment, as they are a preventative medication. When used on a daily basis they help to prevent the “allergic cascade” that occurs when you inhale all of those pollens blowing in the wind.  They work best when used every day for the duration of allergy season which is really dependent on where you live. Allergy sufferers in the northeast will typically have symptoms later in the spring/summer than those in the “sunbelt”.

So you can now pick up Flonase and Nasacort over the counter and use them daily, even in children.  Make sure you try to aim the spray toward the outer side of the nostril and not toward the nasal septum (middle). This will allow the steroid spray more coverage as well as to try and help nosebleeds which may be a side effect of a nasal steroid spray. 

Lastly, with all of the kids playing outside in the “yellow mist” of pollen, make sure to bath/shower them and wash their hair when they come in.  This will help to reduce some of the itching and rubbing of their eyes and nose as well!

Daily Dose

Allergy Suffering Continues

Allergy suffering continues with itchy eyes, nasal congestion and sneezing. Dr. Sue explains how to treat season allergies.With pollen blowing across the country and “the worst spring allergy season in 10 years” in the headlines I thought I would follow up with a second blog on treating seasonal allergic rhinitis (SAR).

As discussed previously I typically begin seeing seasonal allergic symptoms of runny nose, sneezing, itchy eyes and cough in children after the age of 2, and more typically around 4 years of age.  Prior to that most physicians think that recurrent viral respiratory infections account for many similar symptoms in the toddler age group. Parents who are convinced that their 8 month old baby has allergies this spring are most likely facing their child’s first “cold” as allergic symptoms to pollens are brought on after repeated exposure, so we therefore see the symptoms later on.  Allergies do seem to be hereditary so a child who has two allergic parents has between a 50-80 % chance of developing those seasonal allergies. Seasonal allergies at this time of year are typically due to pollen from trees, and will then be followed by grass and weed allergies. By far the best way to prevent the misery associated with SAR is to begin a nasal steroid spray early in the spring in order to help prevent the histamine release that occurs when  microscopic pollen particles enter the nasal passages.  For children with known allergies I typically begin nasal steroids in mid March. The histamine release in the body following exposure to the offending pollens will cause all of the seasonal allergic rhinitis (SAR) symptoms.  On top of using a nasal steroid children who have classic allergic shiners (darkened areas beneath their lower eyelid), clear watery nasal discharge with frequent sniffing and/or blowing or throat clearing, cough and sneezing may benefit from taking a daily anti-histamine. (in other words to fight the histamine release that has already occurred).  There are both 1st and 2nd generation anti-histamines. The 1st generation antihistamines are the older drugs that often cause sedation or drowsiness but are still excellent antihistamines.  Examples of these are Benadryl (see recall info for this product), Tavist, Dimetapp, and Triaminic products that are all available over the counter.  I use Benadryl (see recall info for this product) most frequently as there are so many different choices as to dosing methods. Many allergists also feel that if one class of anti-histamine does not work to try another, so many people have their own favorite medication. The newer 2nd generation antihistamines such as Claritin, and Zyrtec (se recall info for this product) are now available OTC also and come in both liquid and chewable preparations.  There are also prescription products in this group such as Allegra, and Clarinex and Xyzal.  These antihistamines are labeled non-sedating and are usually given once a day.  Again, one child may prefer one brand over another and some do not have a chewable or liquid option so are used in older children and adolescents. There are also other drugs that are used to combat allergy symptoms and these drugs may be used in combination with antihistamines and nasal steroid sprays.  Decongestants help constrict blood vessels and shrink the nasal mucous membranes and may improve nasal congestion.  The most common medications are Sudafed which is pseudoephedrine (now found behind the medicine counter) and Sudafed-PE which contains the decongestant phenylephrine.  These decongestants may also be found in nasal sprays to use topically, but if used locally within the nose may cause actual rebound symptoms of more congestion so are not recommended for use as a nasal spray for more than 3-7 days. Therefore it is preferred to use systemically to avoid that problem.  Decongestants may also cause hyperactivity and insomnia so I rarely recommend them for use in the evening in children. Singulair which is a leukotriene inhibitor (anti –inflammatory) may help relieve nasal allergic symptoms as well as the allergic cough, especially in children who have frequent night time coughs during allergy season. It comes as both granules, chewables and pills and may be given to children down to 2 years of age, especially those that have asthma as well as nasal allergies. Lastly, there are antihistamine nasal sprays now available but they have the problem of “really tasting badly” and I find most children will not use them. There are also several good eye drops for those that get seasonal allergic conjunctivitis (SAC) several of which, Zaditor and Patanol are now available OTC and older children find them quite helpful. Despite this huge armamentarium of products, no one (or two or three) will totally prevent symptoms. So make sure that your child bathes or showers after playing outside, including washing their hair, to get the pollen off of their skin and hair.  It is also helpful to wipe off the dog or outside cat with a dryer sheet to get some of the pollen off of the pets. While I love to sleep with the windows open and ceiling fans going, if your children suffer from SAR you are better off keeping windows closed and the AC on. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Allergy Nasal Sprays

1:30 to read

Since we are in the throes of allergy season (even though there was a recent late snow event in the midwest and northeast) I thought I would provide some additional information on steroid nasal sprays.  In fact, the climate changes that we are seeing are predicted to increase the length of pollinating seasons and therefore increase the amount of pollen produced, which will only make those with allergies (and children with developing allergies) even more miserable with symptoms of runny nose, sneezing, throat clearing and itchy eyes.  

Although I recently discussed the use of non sedating and sedating anti-histamines for intermittent allergy symptoms, the use of intranasal steroids have been found to be far more effective in controlling allergy symptoms.  The first thing to remember is that unlike an antihistamine, intranasal steroids require several days of consistent use before you will see any real change in allergy symptoms (I must repeat that line 10 times a day, especially to my teenage patients who want instant gratification!).  For anyone who knows the season for their allergies (depending on the pollen one is sensitive to), I recommend starting the intranasal steroid spray 1-2 weeks before their symptoms typically begin. (Which means if you are allergic to tree pollens - you should have already started by now). Using the nasal spray daily and continuing throughout the allergy season will provide the best results.  Watching the pollen counts in your area will be important to time the use of intranasal steroids.

Although some children seem to be more sensitive about using a intranasal steroid spray, it is well tolerated by most with few side effects.  Prescription intranasal steroid sprays have been approved for use in children as young as 2 years and the over the counter sprays for children 4 years and older.  The most commonly reported side effects are nasal irritation, burning and bloody noses.  I always try to show my patients how to use the spray properly and to “aim” the spray towards the outer aspect of the inside of the nostril rather than towards the septum (middle) which may help reduce irritation and bloody noses. By spraying towards the outer aspect you also maximize the amount of area that is covered by the spray.  Everyone seems to have their “favorite” intranasal steroid as some are an aqueous spray and others are an aerosolized puff….but in many cases the product choice may be based on the age of the patient, prescription vs OTC, insurance coverage and cost.  Although there are many to choose from there have been no head to head studies with these medications and their efficacy is generally thought to be comparable….but discuss your choices with your own pediatrician.

Lastly, there was a study done in 2014 published in The Journal of Allergy and Clinical Immunology, which measured growth rates in children between 5 and 8 years of age who were treated with an intranasal steroid (specifically fluticasone furcate - Veramyst ) as compared to a placebo. The study did show a significant improvement in nasal allergy symptom scores, but there was a 0.27 cm (0.65 inch ) reduction in growth rate over the course of the year as compared to placebo.  Due to this study, I use the lowest effective dose for the shortest amount of time in younger patients, and explain the reasoning to their parents.  Again, you can read the study and discuss this with your pediatrician before beginning intranasal steroids.   

Just make sure you use the intranasal spray consistently during the height of allergy season…I tell my own family, it doesn’t work as well if it sits on the counter for a few days between use!


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Fall Allergies & Your Kids

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!


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