Food Allergies: What Patients Want to Know

Transcription

1 Lead Stry Article authr Jhn Pulcini, M.D., recently jined Acadia Allergy & Immunlgy, which is part f Greenville Hspital System (GHS) University Medical Grup (UMG), the system s multispecialty physician grup practice. Fd Allergies: What Patients Want t Knw Dr. Pulcini, a clinician-researcher with a special interest in fd allergy, is bard certified in pediatrics and in allergy/immunlgy. Here, he answers questins that patients frequently pse abut fd allergies. What are fd Fd allergies are an imprtant health cncern affecting children and adults. A fd allergy is an adverse health effect arising frm an immune respnse that invlves a specific IgE antibdy. This immune respnse shuld recur n expsure t a certain fd. An example is a child wh, when expsed t milk prtein, develps hives. What are cmmn symptms patients suffer with fd Cmmn symptms are dermatlgic (rash, swelling), respiratry (cughing, wheezing, thrat tightness, change in vice quality), gastrintestinal (abdminal pain, vmiting, diarrhea) r circulatry (hyptensin, syncpe). The mst cncerning prblem is anaphylaxis, a serius allergic reactin that is rapid in nset and may cause death. Anaphylaxis mst ften invlves at least tw bdy systems but any reactin that invlves a bdy system beynd the skin is cncerning. Within minutes, a dermatlgic reactin was recrded t item #4 f the skin prick test. Are there ther disrders that invlve fd allergies besides anaphylaxis? Yes. A third f patients wh have mderate t severe atpic dermatitis (eczema) have a fd allergy trigger. Patients wh suffer frm esinphilic gastrintestinal disrders (such as esinphilic esphagitis) frequently have a fd allergy cmpnent. Als, cntact urticaria, cntact dermatitis and fd prtein-induced enterclitis all invlve fd allergies. 2

2 Hw d fd intlerances differ frm fd Much cnfusin surrunds fd intlerances versus fd allergies. As nted earlier, fd allergies are an immunlgic reactin that invlves specific IgE usually t a fd prtein. Fr instance, an individual wh is allergic t cw s milk because f a reactin t milk prtein has a true fd allergy. On the ther hand, fd intlerances are defined as nn-immunlgic adverse fd reactins. An example is a persn wh may have intlerance t cw s milk because f an inability t digest the sugar lactse. Althugh lactse deficiency can lead t gastrintestinal symptms frm an inability t digest lactse, the respnse wuld nt be classified as a fd allergy since it is nt immune based. Hw are fd allergies diagnsed? As with any disease, the first step in diagnsing fd allergies starts with a detailed medical histry and physical exam. If the histry is cnvincing fr what appears t be an allergic reactin, tw main methds can help identify the causative fd skin testing r bld testing. A skin prick test (usually perfrmed in an allergist s ffice) r an allergen-specific serum IgE (perfrmed in sme primary care ffices) is crucial in evaluating fd allergies. Smetimes these tests are entirely negative and further evaluatin with fd eliminatin diets r even an ral fd challenge is necessary fr an accurate diagnsis. In additin, nn-standardized testing is smetimes perfrmed by cmplementary medicine prviders. Hwever, these tests including IgG4 bld testing, applied kinesilgy, hair analysis and cyttxicity assays are neither validated nr recmmended in the rutine evaluatin f fd allergies. Tp Pediatric & Adult Fd Allergies Milk Eggs Peanuts Sy Wheat Tree Nuts Fish Hw are fd allergies managed? The key issue with fd allergies, particularly in children, is preventin and educatin. Any patient with an identified fd allergy whether it causes a flare f eczema r full-blwn anaphylaxis shuld avid that fd. The first line f treatment fr any fd allergy reactin that invlves anaphylaxis is prmpt administratin f intramuscular epinephrine. Fr nn-severe fd allergic reactins, antihistamine use is the first therapy. In additin, all patients with a histry f anaphylaxis shuld have rescue epinephrine (such as an Epi-Pen ) with them at all times. In abut 20% f cases f anaphylaxis, a secnd injectin is needed after apprximately 10 minutes if symptms d nt imprve ne pen (such as Twinject ) with tw separate dses is available as well. Hw cmmn are fd Fd allergies affect abut 6% f children and 3.5% f adults. Recent U.S. studies indicate that the prevalence f fd allergies is increasing. Fr children, the mst significant fd allergies are milk, egg and peanuts with prevalence rates f 2.5%, 1.3% and 0.8%, respectively. Rates f fd intlerances are much higher than true IgEmediated fd allergies. The key issues with fd allergies, particularly in children, are preventin and educatin. 3

3 This simple yet cmprehensive actin plan was develped by Drs. Pulcini and Greene f GHS Acadia Allergy & Immunlgy. Yu may cpy fr yur use. Children with multiple allergies shuld have a separate plan cmpleted fr each allergy. EMERGENCY ACTION PLAN PATIENT: DATE: DIAGNOSIS: FOOD ALLERGY TO: BEE STING ALLERGY FIRE ANT ALLERGY ANAPHYLAXIS The abve listed patient shuld have access t injectable epinephrine at all times due t a lifethreatening allergy. The prescribed Epipen, Twinject r Adrenaclick shuld be kept in a cl, dark place and shuld be refilled annually. Patients shuld carry a small amunt f antihistamine with the injectr in the event f an accidental ingestin. Patients under lbs. shuld have available a 0.15 mg ( Jr. ) dse; patients ver lbs. shuld have the 0.30 mg dse. Shuld an allergenic ingestin r bee sting ccur, fllw these steps: 1. Lcate yur Epipen /Twinject /Adrenaclick. 2. Take an antihistamine immediately. Preferably, this shuld be Zyrtec r Benadryl, which have the quickest nset f actin. Suggested dse f Benadryl: Zyrtec: 3. Get arund ther peple, wh can assist yu if yur reactin prgresses. AT THE FIRST SIGN f any symptms f severe hives and swelling, difficulty swallwing, speaking r talking, thrat swelling, severe wheezing, cugh, shrtness f breath, r if cllapse ccurs, immediately inject Epipen, Twinject r Adrenaclick int the upper uter thigh f the patient and hld fr 10 secnds. Epinephrine must be given in the muscle fr quickest absrptin. If the reactin is wrsening after 10 minutes r s, administer a secnd dse if available. The patient shuld then be taken t the ER fr further evaluatin. A fllw-up appintment with a pediatric allergist shuld be scheduled sn thereafter t review what happened. Remember, it is nly necessary t give the rescue epinephrine (Epipen/Twinject/Adrenaclick) if the reactin is prgressing in a serius manner as described abve; fr simple itchiness r mild hives, n further actin is necessary. Often, nly an antihistamine will be needed. Remember, stings and accidental ingestins happen when yu least expect them, s be prepared. Have yur Epipen, Twinject r Adrenaclick clse by at all times.

4 Finally, Fd Allergy Actin Plans ften are prvided fr parents t distribute t ther adult caregivers (such as in schls, day care centers and church nurseries) t guide ptential fd allergy reactins. This management plan is a vital cmpnent f cmprehensive care fr all patients with fd allergies particularly schl-age children wh spend a cnsiderable amunt f time withut their parents and rely n ther adults fr supervisin. Please refer t the Emergency Actin Plan (left) develped by Dr. Pulcini and clleague Charles Greene Jr., M.D. Hw persistent are fd allergies, and when can yu reintrduce an allergic fd? Studies shw that mst children utgrw their fd allergies but it depends n the type f fd in questin, age f the child and intervening medical histry. Abut 85% f children wh are allergic t milk and eggs usually tlerate thse fds smewhere between ages Hwever, peanut and tree nuts are much mre persistent, with nly 20% f children develping tlerance t peanuts. In adults, shellfish is a very persistent fd allergy. Mst allergists perfrm annual fllw-up testing fr patients with fd allergies and then decide n the curse f actin usually a fd challenge in the ffice if the patient s testing is negative. What abut preventing fd allergies: Are there any recmmendatins n when parents shuld intrduce ptentially allergic fds in a child s diet? American Academy f Pediatrics (AAP) guidelines n that subject have changed f late. The AAP nw recmmends that all infants be exclusively breastfed until 4-6 mnths ld. The AAP des nt recmmend restricting fds frm the maternal diet during pregnancy r lactatin as a strategy t prevent the develpment f fd allergies. Guidelines d recmmend hydrlyzed infant frmulas, as ppsed t cw s milk frmulas, as Acadia Allergy & Immunlgy acadiaallergy.cm With features such as nine treatment rms, n-site lab, cnference rm, walkup injectin area, children s playrm and separate waiting rm fr patients needing allergy shts, Acadia Allergy & Immunlgy s staff f 10 serves an average f 27 patients and administer 20+ shts in the walk-up injectin area each day. This spacius 7,800-square-ft facility pened in March. The practice recently relcated t 10 Haltn Green Way in Greenville. 5

5 a strategy fr preventing develpment f fd allergies in at-risk infants wh are nt breastfed. (At-risk children include thse with pre-existing severe allergic disease and/r a family histry f fd allergy). Finally and this is a significant change frm previus guidelines the intrductin f slid fds shuld nt be delayed beynd 4-6 mnths f age, including the intrductin f ptentially allergic fds. Will there be a cure fr fd A few research centers thrughut the cuntry have children and adults enrlled in trials invlving ral and sublingual immuntherapy. This therapy, in which patients with allergies are given small but increasing amunts f the fd they are allergic t, shws prmise. Right nw, significant debate exists as t whether this therapy might lead t a permanent change in the patient s immune system r just a temprary state f tlerance. What supprt is ut there fr patients, families and primary care physicians regarding fd The Fd Allergy and Anaphylaxis Netwrk (FAAN) is a lay rganizatin that prvides educatinal materials t assist families and physicians n all aspects f fd allergies. Tw natinal allergy assciatins the American Academy f Asthma, Allergy and Immunlgy (AAAAI) and the American Cllege f Allergy, Asthma and Immunlgy (ACAAI) have great websites fr patients and physicians cncerning fd allergies. Finally, the lcal chapter f FAAN hlds meetings the last Mnday f each mnth t help parents tackle fd allergies, particularly when it cmes t schl-age children. Resurces American Academy f Allergy, Asthma and Immunlgy: American Cllege f Allergy, Asthma and Immunlgy: Fd Allergy and Anaphylaxis Netwrk: Fd Allergy and Asthma Supprt Grup: meets 7-8 p.m. the last Mnday f the mnth at Five Frks Plantatin Clubhuse in Simpsnville. Fr mre infrmatin, cntact dlfrank71@yah.cm. Readings 1. Pulcini JM, Sease KK, Marshall GD. Disparity between the presence and absence f fd allergy actin plans in ne schl district. Allergy and Asthma Prceedings. March 2010;31(2): Byce J., Assa ad A, Burks AW, et al. Guidelines fr the diagnsis and management f fd allergy in the United States: summary f the NIAIDspnsred expert panel reprt. J Allergy and Clin Immunlgy. December 2010;126(6):S1-S Greer FR, Sicherer SH, Burks AW, et al. Effects f early nutritinal interventins n the develpment f atpic disease in infants and children: the rle f maternal dietary restrictin, breastfeeding, timing f intrductin f cmplementary fds, and hydrlyzed frmulas. Pediatrics. 2008;121: Meet Dr. Pulcini Jhn Pulcini, M.D., hails frm Evansville, Ind., and went t medical schl at the Indiana University Schl f Medicine. He cmpleted his pediatric residency at GHS in 2008 fllwed by an Allergy-Immunlgy fellwship in Jacksn, Miss. In additin t fd allergies, Dr. Pulcini has special interests in esinphilic esphagitis, general allergic rhinitis and atpic dermatitis. Dr. Pulcini returned t Greenville in 2010 t jin Charles (Chuck) Greene Jr., M.D., wh als treats pediatric patients, in frming Acadia Allergy & Immunlgy (frmerly UMG Allergy/ Immunlgy). Dr. Greene Dr. Pulcini can be reached at (864) ; his fax number is (864)