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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

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

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!

Your Baby

Pets May Protect Infants Against Allergies

1.30 to read

Fluffy or Fido may protect your baby from developing allergies later in life. Many owners will tell you that their pet is like a family member. A new study suggests that those four-legged family members may reduce a child’s risk of developing allergies.

For years allergists have warned parents that some pets may actually cause allergies, but a new study published in the journal Clinical & Experimental Allergy suggests that early exposure to pets, during an infant’s first year of life, appears to provide an actual defense against allergies later in life. Lead study author Ganesa Wegienka, Ph.D., of Henry Ford Hospital in Detroit noted, “Exposing children to cats and dogs in the home is not going to increase the risk of sensitization to these animals. It might even decrease the risk.” Interesting revelations were found in the study such as; 18 year old males, who lived with a dog in the house when they were an infant, reduced their risks of developing allergies by half,  but not so with girls. Cats, on the other hand, seem to affect both sexes. Infant boys and girls who lived in a home with cats reduced their risks of developing allergies –by about 48%- by the age of 18 years. Another finding of the analysis showed that both males and females delivered by C-section had a 67 percent less likelihood of developing a dog allergy when a dog was present in the home during their first year of life. Wegienka said that this could be due to the fact that babies born by cesarean section are not exposed to the diverse microflora that babies born vaginally are. The long held idea that pets may cause allergies led Wegienka, and her colleagues, to study what effects childhood exposure to cats and dogs had on the risk of developing allergies to them. For their study, the researchers analyzed blood samples of more than 500 children taken during the Detroit Childhood Allergy Study from 1987 to 1989 that followed participants from birth. The focus of the analysis was to look for the presence of an antibody known as animal-specific IgE, which would indicate that a child was sensitized to that animal. In addition, follow-up among children in the study at age 18 included additional blood samples and pet histories. The histories indicated that 184 participants had a dog, and 110 of the children had a cat, during their first year of life. Pet allergy is an allergic reaction to proteins found in an animal's skin cells, saliva or urine. Signs of pet allergy include those common to hay fever, such as sneezing and runny nose. Some people may also experience signs of asthma, such as wheezing and difficulty breathing. Severe allergic reactions can be deadly. Pet allergy is often triggered by exposure to the dead flakes, or dander, that a pet sheds. Any animal with fur can be a source of pet allergy, but the most common pets are cats, dogs, rodents and horses. Wegienka pointed out that the study does not definitively indicate that having a family pet will prevent infants from developing allergies later in life, as it only found an association between a reduced risk for allergies and exposure to cats and dogs at an early age. Wegienka cautioned, “We don't want to say that everyone should go out and get a dog or cat to prevent allergies.” She then added, “More research is needed, though we think this is a worthwhile avenue to pursue. How does having a dog or a cat change the home environment? And, how does that affect allergy risk?" If you have an infant and a pet sharing the house, it’s a good idea to keep an eye on your little one to make sure that he or she is able to tolerate pet dander.

Daily Dose

Treating Summer Insect Stings

1:30 to read

I am sure there is a purpose for stinging insects in the animal kingdom, but they are quite a nuisance in the human kingdom during the summer months.Staying with the subject of summer ills, I thought it was also appropriate to discuss stinging insects. Stinging insects belong to the order Hymenoptera that includes honeybees, bumble bees, yellow jackets, hornets, wasps and fire ants. I am sure there is a purpose for these insects in the animal kingdom, but they are quite a nuisance in the human kingdom during the summer months.

The stinger of the insects delivers their venom to the victim. A honeybee can only sting one time and then dies, while wasps, hornets and yellow jackets may sting multiple times. Bees are actually docile, not very aggressive and typically do not sting, while yellow jackets and hornets are very aggressive (kind of like different types of people). Fire ants, which are so common in the southern and central U.S., also deliver multiple stings by anchoring their little jaws and actually pivoting while they are biting you. Again, the most common reactions to insect stings are local reactions with pain, redness, and swelling at the sting site. These symptoms usually resolve within several hours and require treatment with the local application of cold compresses, a paste of baking powder or meat tenderizer and analgesia with acetaminophen or ibuprofen.

There are also cases of marked local swelling and redness that develops over 12 -24 hours and may be quite large. Again, if this occurs within in the first one to two days following an insect sting, it is unlikely to be due to a bacterial infection. It may take up to five to 10 days to totally resolve and is not dangerous, but may be quite uncomfortable. In some cases a short burst of oral steroids may be required to reduce the inflammation. A systemic allergic reaction “anaphylaxis” to an insect sting is defined as “causing signs and symptoms in at least two organ systems distant from the site of the sting”. These symptoms may be cutaneous such as generalized, hives, swelling of lips, mouth or tongue and itching, or involve respiratory tract with difficulty breathing, hoarseness and difficulty swallowing. The symptoms may also involve GI tract with vomiting, nausea and abdominal pain, or circulatory system with dizziness, decrease in BP and loss of consciousness. Although children have a lower frequency of anaphylactic reactions to insect stings than adults, the above symptoms are a medical emergency and require immediate intervention.

If your child has ever had a systemic, anaphylactic reaction to an insect sting they should be prescribed an autoinjectable epinephrine device (Twinject/Epipen) and an anaphylaxis treatment plan for its use. Recent evidence also supports prescribing these devices for children who have experienced a generalized acute hive like rash after a sting because of the 10% risk of a more severe reaction from a future sting. It should be emphasized that multiple doses of epinephrine may be needed (in one study 16 -35%) in treating an anaphylactic reaction after a sting and therefore anyone who has used their own epinephrine should seek immediate medical care as they may require more doses. Children should also have action plans for school, camp etc and should wear a medical identification bracelet.

That’s your daily dose, we’ll chat again tomorrow.

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Allergies

Fall Allergies & Your Kids

Your Baby

Starting Baby on Solid Foods

Your goal over the next few months is to introduce a wide variety of foods. If your baby doesn't seem to like a particular food, reintroduce it at later meals. It can take quite a few tries before kids warm up to certain foods.Starting baby on solid foods can be an exciting and perplexing time for parents. What foods should I start with? How much? How often?

The American Academy of Pediatrics currently recommends gradually introducing solid foods when a baby is about 6 months old. Your pediatrician, however, may recommend starting as early as 4 months depending on your baby's readiness and nutritional needs. Be sure to check with your pediatrician before starting any solid foods. Is your baby ready? Breast milk or formula is the only food your newborn needs. Within four to six months, however, your baby will begin to develop the coordination to move solid food from the front of the mouth to the back for swallowing. At the same time, your baby's head control will improve and he or she will learn to sit with support — essential skills for eating solid foods. If you're not sure whether your baby is ready, ask yourself these questions: •       Can your baby hold his or her head in a steady, upright position? •       Can your baby sit with support? •       Is your baby interested in what you're eating? If you answer yes to these questions and you have the OK from your baby's doctor or dietitian, you can begin supplementing your baby's liquid diet. What Foods to Start With. Continue feeding your baby breast milk or formula as usual. Then: •       Start with baby cereal. Mix 1 tablespoon (15 milliliters) of a single-grain, iron-fortified baby cereal with 4 to 5 tablespoons (60 to 75 milliliters) of breast milk or formula. Many parents start with rice cereal. Even if the cereal barely thickens the liquid, resist the temptation to serve it from a bottle. Instead, help your baby sit upright and offer the cereal with a small spoon once or twice a day. Once your baby gets the hang of swallowing runny cereal, mix it with less liquid. For variety, you might offer single-grain oatmeal or barley cereals. Your baby may take a little while to "learn" how to eat solids. During these months you'll still be providing the usual feedings of breast milk or formula, so don't be concerned if your baby refuses certain foods at first or doesn't seem interested. It may just take some time. Do not add cereal to your baby's bottle unless your doctor instructs you to do so, as this can cause babies to become overweight and doesn't help the baby learn how to eat solid foods •       Add pureed meat, vegetables and fruits. Once your baby masters cereal, gradually introduce pureed meat, vegetables and fruits. Offer single-ingredient foods at first, and wait three to five days between each new food. If your baby has a reaction to a particular food — such as diarrhea, a rash or vomiting — you'll know the culprit. •       Offer finely chopped finger foods. By ages 8 months to 10 months, most babies can handle small portions of finely chopped finger foods, such as soft fruits, well-cooked pasta, cheese, graham crackers and ground meat. As your baby approaches his or her first birthday, mashed or chopped versions of whatever the rest of the family is eating will become your baby's main fare. Continue to offer breast milk or formula with and between meals. Foods to Avoid for Now. Some foods are generally withheld until later. Do not give eggs, cow's milk, citrus fruits and juices, and honey until after a baby's first birthday. Eggs (especially the whites) may cause an allergic reaction, especially if given too early. Citrus is highly acidic and can cause painful diaper rashes for a baby. Honey may contain certain spores that, while harmless to adults, can cause botulism in babies. Regular cow's milk does not have the nutrition that infants need. Fish and seafood, peanuts and peanut butter, and tree nuts are also considered allergenic for infants, and shouldn't be given until after the child is 2 or 3 years old, depending on whether the child is at higher risk for developing food allergies. A child is at higher risk for food allergies if one or more close family members have allergies or allergy-related conditions, like food allergies, eczema, or asthma. Introducing Juice. Juice can be given after 6 months of age, which is also a good age to introduce your baby to a cup. Buy one with large handles and a lid (a "sippy cup"), and teach your baby how to maneuver and drink from it. You might need to try a few different cups to find one that works for your child. Use water at first to avoid messy clean-ups. Serve only 100% fruit juice, not juice drinks or powdered drink mixes. Do not give juice in a bottle and remember to limit the amount of juice your baby drinks to less than 4 total ounces (120 ml) a day. Too much juice adds extra calories without the nutrition of breast milk or formula. Drinking too much juice can contribute to obesity can cause diarrhea. Infants usually like fruits and sweeter vegetables, such as carrots and sweet potatoes, but don't neglect other vegetables. Your goal over the next few months is to introduce a wide variety of foods. If your baby doesn't seem to like a particular food, reintroduce it at later meals. It can take quite a few tries before kids warm up to certain foods.

Daily Dose

Follow Up on Food Allergies

A food intolerance is not an allergic event, in other words, it is not immune mediated.We had a lively and informative discussion on food allergies on the show yesterday. We were fortunate to have a pediatric allergist as a guest along with an ER doctor whose son was diagnosed with numerous food allergies when he was an infant. Between the two of them, they were a wealth of information for anyone who is concerned about the possibility of food allergies in their children. We had a lot of good phone calls, but unfortunately did not have the opportunity to answer all of the questions as we ran out of time, so will hit a few of the high points here.

One of the take home messages was to identify the difference between a true food allergy and food intolerance. A food intolerance is not an allergic event, in other words, it is not immune mediated. People who have a food intolerance may complain of nausea with a certain food, or abdominal cramps. They do not demonstrate allergic symptoms such as hives, swelling of the lips or tongue or breathing or wheezing problems seen with a food allergy. With anaphylaxis you also have a drop in blood pressure and it is a life-threatening emergency. Food allergies usually present early in life, often when the child has their first known exposure to the offending food, and they usually have symptoms within minutes to an hour after ingestion. Several callers today wanted to know what to do if they think that their child had had "a" reaction to a food. If the allergic reaction was significant, you have probably already been through an emergency room and have been referred to a pediatric allergist. If you are unsure if they have had an allergic reaction, make an appointment with your pediatrician to discuss the history. History is the most important part of the puzzle, but there are screening blood tests that may be done to look at allergic antibodies to foods (most commonly nuts, milk, eggs, fish). The gold standard for diagnosis is an evaluation and skin testing with a pediatric allergist and then most importantly education about food allergies. That's your daily dose, we'll chat again tomorrow.

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