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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

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

Diagnosing Food Allergies

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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. 

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Allergies

Fall Allergies & Your Kids

Daily Dose

Epi Pen Controversy

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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

Penicillin Allergy

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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

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

Allergy Nasal Sprays

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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!

 

Your Baby

Pets May Protect Infants Against Allergies

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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.

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