Peanut Tainted Cumin

February 26, 2015

The FDA has warned that peanut allergen has been detected in several cumin-containing products.  Individuals allergic to peanut should avoid products containing cumin.  Many have been recalled, including spice mixes and marinades.  Whole Foods has recalled more than 100 products and Goya has recalled some brands of black bean soup.  Individuals with severe peanut allergy need to be particularly careful when eating in restaurants that use cumin as an ingredients including Indian and Mexican restaurants.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person. If you have a medical problem, please contact your doctor.

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The Risk For Allergy: Beyond The Hygiene Hypothesis

February 3, 2012

A recent study found that children born at term to woman with gestational diabetes are significantly more likely to have eczema (odds ratio 7.2) and to have positive allergy testing to common foods allergens as well as common environmental allergens.  This is of particular interest since it points to factors other than those relating to the hygiene hypothesis that may be contributing to the increased incidence of allergy in children.  Maternal obesity is associated with the development of gestational diabetes and we are currently witnessing increased rates of obesity and the metabolic syndrome as well as allergy in western societies.  The findings of this study suggest that there might be an early life link between these two medical problems.  This link could be the result of the stress that gestational diabetes places on the developing infant, especially during the third trimester.  Stress can definitely impact the developing immune system and potentially drive the developing immune system toward allergy.  Another recent study found an increased level of IgE (the allergen antibody) in infants born to woman who experience chronic interpersonal trauma compared to woman who report not experiencing any interpersonal trauma.  The impact of both physical and psychological stress on the immune system and the development of allergy needs to be more fully explored.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Antibiotic Use In Infancy And The Risk Of Asthma

January 9, 2012

A recent study of 193,412 children from 29 countries reported that children who received antibiotics in the first year of life had an increased risk of having asthma symptoms at 6 to 7 years of age.  The odds ratio for asthma in children who received antibiotics compared to children who did not receive antibiotics in the first year of life was 1.7-1.96.  It is unclear whether this association and increased risk is based upon cause and effect or reverse causation.  In other words, is this the result of the direct effect of antibiotics on the complex balance of the more than 500 species of microbes in the body and a subsequent impact on atopy (allergy) and asthma?  Or, were children who were predisposed to asthma or had early symptoms of asthma, more likely to be given antibiotics in the first year of life because of respiratory symptoms thought to be related to infection?  In any case, the association seems to be real and is definitely of interest.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Asthma and Exercise

January 7, 2012

It is essential for children and adults with asthma to exercise.  Asthma that is not well controlled from an inflammatory perspective will tend to cause symptoms with exercise, particularly aerobic exercise.  The answer is NOT to avoid exercise, it is to get the inflammation under control and continue exercising as if you did not have asthma.

The health benefits of exercise for people with asthma are numerous including improved fitness level, improved quality of life, reduction in the need for medications, fewer emergency room visits and less absenteeism from school (J Allergy Clin Immunol 2005;115:928-34).   On top of that, it is important that children with asthma do not perceive themselves, or are not perceived by others, as being different or in some way disabled.  A sure fired way of having a child feel different is by creating a situation where the child needs to avoid regular play, sports and other exercise.   This may not only result in psychological problems, but may contribute to a tendency for weight gain and obesity.

The American College of Sports Medicine and the American Thoracic Society both recommend exercise for patients with asthma.   In general, most studies show exercising 3-5 times a week for at least 20-30 minutes while reaching 60-75% of age predicted maximal heart rate is helpful in maintaining and improving pulmonary health in asthmatics.  This kind of goal works for adults.  For children, the goal should be to engage in play and sports in the same way as children without asthma.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Sunscreen Update

August 3, 2011

The following is from the 2011 Environmental Working Group report on sunscreen.  It is consistent with my opinion that physical sunblock with titanium or zinc is preferable to the various chemical sunscreens on the market, especially for children and any person with sensitive skin.

“Pick your sunscreen: nanomaterials or potential hormone disruptors.

The ideal sunscreen would completely block the UV rays that cause sunburn, immune suppression and damaging free radicals. It would remain effective on the skin for several hours and not form harmful ingredients when degraded by UV light. It would smell and feel pleasant so that people use it in the right amount and frequency.

Unsurprisingly, there is currently no sunscreen that meets all of these criteria. The major choice in the U.S. is between “chemical” sunscreens, which have inferior stability, penetrate the skin and may disrupt the body’s hormone systems, and “mineral” sunscreens (zinc and titanium), which often contain micronized- or nano-scale particles of those minerals.

After reviewing the evidence, EWG determined that mineral sunscreens have the best safety profile of today’s choices. They are stable in sunlight and do not appear to penetrate the skin. They offer UVA protection, which is sorely lacking in most of today’s sunscreen products. Mexoryl SX (ecamsule) is another good option, but it’s sold in very few formulations. Tinosorb S and M could be great solutions but are not yet available in the U.S. For consumers who don’t like mineral products, we recommend sunscreens with avobenzone (3 percent for the best UVA protection) and without the notorious hormone disruptors oxybenzone or 4-MBC. Scientists have called for parents to avoid using oxybenzone on children due to penetration and toxicity concerns.”

When looking for a sunscreen, look at the active ingredient list and choose a product that contains only titanium and zinc.  The following products are examples of sunblocks that are available with only titanium and/or zinc as the active ingredients:

– Neutrogena Pure and Free Baby Sunblock

– Blue Lizard Baby

– Vanicream SPF 60 Sensitive Sunscreen

– California Baby SPF 30 Sunscreen

– Fallene COTZ SPF 58

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Do Not Delay: More Evidence Against Delaying The Introduction Of Foods In Infants

April 23, 2011

There is increasing evidence that delaying the introduction of foods in infants contributes to an increased risk of developing food allergy.  A recent study of 2,589 infants showed that delaying the introduction of egg into the diet of infants results in an increased risk of egg allergy.  The odds ratio of developing egg allergy was 3.4 in the group that had egg introduced into the diet at greater than 12 months of age compared to those with egg introduced at 4-6 months of age.  An odds ratio greater than 1 means that the outcome is more common in that group.  See related  blog entries from 12/15/10 and 4/18/10.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Spring Is Here: Tree Pollen Allergy Refresher

April 15, 2011

Tree pollen allergy is the main cause of symptoms for early and mid spring allergy sufferers.  Some people are allergic to pollen from a single tree genus such as Oak (genus: Quercus) or Birch (genus: Betula).  Others have problems with pollen from many different types of trees.  In most cases tree pollen from one genus does not cross react with pollen from other genera of trees. Therefore, those people who are sensitive to one or two types of trees will have a shorter period of symptoms compared with those who are sensitive to seven or eight different types of trees.  In other words, some people with tree pollen allergy will have bad symptoms for one or two weeks in April or May and others will have symptoms from early March through early June.

Medications to relieve symptoms (reprinted from 4/7/10 post):

Despite the fact that there are many good medications to control and treat seasonal pollen allergy, people continue to suffer unnecessarily.  Here are some helpful hints:

1. If non sedating over-the-counter antihistamines are not controlling your symptoms, see your allergist.  There are a variety of prescription medications including oral antihistamines, oral leukotriene antagonists, nasal steroid sprays, nasal antihistamine sprays and an assortment of eye drops that can be used.

2. Use combinations of medications.  If one medication is not working, most people stop that medication and try another one.  Often a combination of medications is what is needed.  Usually this is done by combining together medications that act in different ways or at different sites.  This should be done with the help of your allergist.

3.  Learn exactly which pollens you are allergic to and start your medications before those pollen counts get too high and before you have symptoms.  If you know you are allergic to a specific pollen, you can anticipate when the counts of that pollen will be high.  Trees, grasses and weeds pollinate on a fairly regular schedule each year.  That schedule varies by geographic region.  It is more difficult to reverse symptoms that are already in full force as opposed to preventing severe symptoms in the first place.

Environmental Control Measures (reprinted from 3/25/10 post):

Although you can’t avoid tree pollen, there are some things you can do to reduce exposure.  Here are some tips:

1.  Sleep with the windows closed and the air conditioner on with the vent closed to the outside.  Although it is great to feel and smell the spring air, if you sleep with the windows open, the pollen levels in your bedroom will be higher than they need to be and you will have more symptoms.

2. When riding in a car, keep the windows closed and put the air conditioner on with the vent closed to the outside.  If you don’t need the air conditioner, still keep the vents closed to the outside.  You want to minimize the amount of outdoor air and pollen you are bringing into the car.   When riding in a car, you are exposing yourself to significantly more pollen than when you are sitting on a park bench or hanging out on your front porch.  This is because the volume of air you are exposed to is higher and that volume increases as you increase your speed.

3. Pollen counts tend to be higher in the morning than in the afternoon.  If you like outdoor sports activities, do them in the afternoon instead of the morning.  In fact, people with severe tree pollen allergy might want to consider only engaging in sporting activities indoors during the peak of the pollen season.    As is the case with riding in a car, running, jogging and cycling result in particularly high pollen exposure.

4. When you come home at the end of the day, hop in the shower, rinse your hair and change your clothes.   Pollen will settle on your clothes and hair and it is helpful to try to reduce the amount of pollen you are bringing into your home, and especially into your bed.

5. Do not leave clothing outside for any length of time and especially do not attempt to dry clothing outside during the pollen season if you are allergic.

Tree Pollen Allergy and Foods (reprinted from 4/9/10 post):

Certain fruits, vegetables and nuts contain allergens that cross react with tree pollen, specifically the pollen of birch and alder.  These foods include the following:

Nuts: Almond, Hazelnut

Fruit: Apple, Apricot, Cherry, Kiwi, Nectarine, Peach, Pear, Persimmon, Plum, Orange

Vegetables: Carrot, Celery, Fennel, Potato

Although most people with tree pollen allergy can eat these foods without any problem, up to 1/3 of people who are allergic to tree pollen will develop symptoms of what is called the Oral Allergy Syndrome.  The most common of these symptoms is itchiness of the mouth and throat.  A small minority of people who have symptoms of the Oral Allergy Syndrome will have more widespread symptoms seen in other forms of food allergy and it is sometimes difficult to differentiate those who will have just the oral and perioral symptoms from those who have more general allergy symptoms.   Most people with the Oral Allergy Syndrome are only allergic to a few of the foods listed above and not all of them.  In my experience the most common foods to cause symptoms are apples, carrots, cherries and peaches.   Having said that, I do have patients who react to all of the foods.

It is very important to point out that the tree pollen cross reacting allergens in these fruits and vegetables are generally not the major allergens of the foods, but are minor allergens that tend to be heat labile.  That means that these minor allergens lose their effect as allergens with exposure to heat and usually people with this form of food allergy can eat the food in a cooked form without any problem.  So raw apples are a problem, but apple pie, apple sauce and apple juice are usually OK.  It is not unusual for me to see a patient in my office who thinks they are allergic to the skin of the apple or to a pesticide sprayed on the apple because they know they are fine with cooked apple.   Invariably these are people with tree pollen allergy and they are experiencing the Oral Allergy Syndrome.  Also, these allergens tend to be acid labile which means that they lose their effect as allergens when they are exposed to stomach acid.  That is one reason why the symptoms are usually confined to the mouth.

There is some evidence that the common nasal and eye allergy symptoms that people with tree pollen allergy have, may get worse with exposure to these foods in people with the Oral Allergy Syndrome.  I usually recommend that people who have oral itchiness with exposure to one or more of these foods avoid those foods completely in the raw form, especially during the pollen season as it can make their other pollen allergy symptoms worse.

It is important to speak to your allergist about this form of food allergy in order to determine if you need to avoid the foods completely or only in the raw form.  Remember a small percentage of people with this form of food allergy can have more widespread symptoms of an allergic reaction or anaphylaxis with exposure.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Guidelines for the Diagnosis and Management of Food Allergy in the United States: A Summary of the New NIAID-Sponsored Expert Panel Report

December 15, 2010

The new NIAID-sponsored Guidelines for the Diagnosis and Management of Food Allergy in the United States were released on December 6, 2010.  I thought it might be helpful if I provided a summary of the highlights of the report.  The full guidelines can be downloaded on the NIAID website at http://www.niaid.nih.gov/topics/foodallergy/clinical. 

The release of these guidelines has received significant media attention, although there is really very little, if any, new information included in them.  Much of the most recent information in the literature regarding such issues as component testing, extensively heated egg and extensively heated cow’s milk as well as decision trees based on IgE Immunocap blood testing or skin testing for performance of oral challenges in food-allergic children is only alluded to and unfortunately not really addressed in the guidelines. 

The following is a list of what I consider the most pertinent and clinically relevant statements and recommendations in the guidelines.  There is much more information in the full report.  I have included in parentheses additional information not included in the guidelines but that I think may be of interest.  This list is in no particular order of importance.

1. Atopic Dermatitis/Eczema:  Up to 37% of children under 5 years of age with moderate to severe atopic dermatitis have IgE mediated food allergy.  Food allergy testing should be considered in this group of children.  Infants who develop atopic dermatitis within the first 3 months of life are most often allergic to cow’s milk, egg and peanut.  Mutations of the skin barrier protein filaggrin, seen in a subset of patients with atopic dermatitis, may increase the risk for transcutaneous food allergen sensitization when infants come in contact with food allergens.  (There are reports in the literature that suggest this is especially true if the food is introduced to the immune system through the skin prior to exposure through the GI tract.  Initial GI tract exposure is more likely to induce tolerance.)

2. Severity of an Allergic Reaction: The severity of a future reaction to a food allergen cannot be accurately predicted by the severity of a past reaction, or by the level of specific IgE or the size of a skin prick test wheal.  One study showed that 44% of patients with documented peanut allergy who did not have an initial reaction that was life threatening, had subsequent reactions that were potentially life threatening.  (The higher the level of specific IgE and the larger the skin prick test wheal, the more likely it is that a patient will have clinical food allergy.  However, the severity of the allergic reaction associated with that allergy can not be predicted based on these test results.) 

3. Diagnosis of Food Allergy: The gold standard for the diagnosis of food allergy is a double blind placebo controlled food challenge, but single blind or open challenges may be considered.  (From a practical perspective, blinded placebo controlled food challenges are really only done in a research setting.  I perform open challenges in the office.)

4. Diagnosis of Food Allergy: Skin prick test results or food-specific IgE alone cannot be used to make a diagnosis of clinical food allergy.  They only indicate sensitization.  The test results must be considered within the context of a comprehensive history.  To diagnose a clinical food allergy, or rule it out, in a situation where there is a positive test result and no history of reaction to the food, an oral challenge must be performed.  (The problem of what to do with a positive result in a child who has never consumed the food allergen tested is a difficult one and underscores the need to do history-guided testing and to be cautious when ordering IgE Immunocap tests.  Unnecessary avoidance of foods to which a child is sensitized, but not clinically allergic, can lead to nutritional problems.)  

5. Gastrointestinal Issues Related to Food Allergy: Food allergy should be considered in infants and young children with eosinophilic esophagitis, enterocolitis, enteropathy and allergic proctocolitis.

6. Natural History of Food Allergy: The guidelines provide information on the natural history of food allergy in infants and children and at what age infants and children might outgrow a clinical allergy to foods such as cow’s milk, egg and soy.  The guidelines provide very little specific information on when to consider an oral food challenge in a child with a documented allergy to these foods.  (There is information in the literature referencing food-specific IgE levels and skin prick wheal sizes that address this.  My approach is to evaluate this information in conjunction with a comprehensive history and make a risk-benefit assessment on whether and when to do an oral challenge under supervision in my office, on a case by case basis.)

7. Cross Reactivity of Foods: The guidelines provide statistics on allergic cross reactivity of various foods such as the fact that at least 12% of individuals with tree nut allergy are clinically allergic to more than one tree nut.  It also states that 35% of infants with one food allergy develop an allergy to another food.  However, little specific guidance is given as to whether or not to do additional food allergy testing in infants and children with a documented allergy to a specific food.  (I approach this on a case by case basis and generally do some additional testing in children with a documented allergy to a specific food.  I generally confine additional testing to cow’s milk, soy, egg, wheat and peanuts as well as the foods that significantly cross react with the food to which the child is documented to be allergic.)

8. Breat Feeding: The guidelines recommend exclusive breast feeding for all infants for the first 4-6 months of life.  For infants at risk of developing food allergy (first degree relative with history of atopy including allergic rhinitis, asthma, atopic dermatitis or food allergy), the guidelines recommend hydrolyzed formula for the first 4-6 months if breast feeding is not possible.  Soy formula as an alternative is specifically not recommended.  (This is consistent with the American Academy of Pediatrics recommendations published in Pediatrics in January 2008: Pediatrics 2008;121;183-191)

9. Prevention: There is no evidence to recommend delaying introduction of any specific solid food, including those considered highly allergenic such as eggs, fish or peanut, beyond 4-6 months of age.  This applies to infants and children in general as well as infants at risk for food allergy.  There are no specific recommendations given for how to proceed in a child who already has one documented food allergy.  (This too is consistent with the American Academy of Pediatrics [AAP] recommendations published in Pediatrics in January 2008.   These recommendations are different from the AAP recommendations published in 2000 where a schedule of delayed introduction of foods was recommended.  The change in this recommendation is based on epidemiologic data indicating that there is no benefit in delaying the introduction of developmentally appropriate foods and even some data pointing toward an increased incidence of allergy when the introduction of food is delayed [see January 12, 2010 post on this blog as well as other food allergy posts on this blog]. )

10. MMR Vaccine: The MMR (measles, mumps and rubells) vaccine is safe for children with egg allergy, even for those with severe reactions.  (This is consistent with the most recent AAP recommendations.)

11. Influenza Vaccine: The guidelines state that there is insufficient evidence to recommend administering influenza vaccine routinely in patients with a history of hives, angioedema, allergic asthma or systemic anaphylaxis resulting from allergy to eggs.  The guidelines highlight that in one recent study 5% of patients with egg allergy and negative skin prick test results to influenza vaccine had systemic reactions to vaccination.  The guidelines discuss various approaches to giving influenza vaccine to children with egg allergy.  (I address this in my practice on a case by case basis doing a risk benefit analysis based upon the specific history and the results of IgE Immunocap and skin prick test results and an extensive discussion with the parents.  I have almost never had a patient who I have chosen to vaccinate after this type of comprehensive evaluation develop a systemic reaction to the influenza vaccine.)

12. Education: The guidelines state that people with food allergy and parents of children with food allergies need to be educated on how to properly read and evaluate a nutritional label.  The guidelines specifically recommend that people avoid foods with precautionary labeling such as “this product may contain trace amounts of allergen”. 

13. Treatment:  Epinephrine is the drug of choice for anaphylaxis and should be administered as first line therapy.  Fatalities from anaphylaxis are associated with delayed administration or improper use of epinephrine.  The use of antihistamines is the most common reason reported for not using epinephrine.  The highest risk groups for food allergy related anaphylaxis are adolescents and young adults, people with a prior history of anaphylaxis and patients with asthma.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Extensively Heat Egg and Egg Allergy

October 25, 2010

Egg allergy is one of the more common food allergies in children under the age of 3 and is especially common in children with atopic dermatitis.  Most children will outgrow egg allergy, but  it is often difficult to determine exactly when that is going to happen.  Although it is relatively easy to avoid whole eggs in the form of scrambled eggs, omelettes, souffles and quiche, it is more difficult to avoid eggs that are present in baked goods such as cookies and cakes.   

Many children with egg allergy can tolerate extensively heated eggs in oven baked goods, even though they react to cooked or partially cooked eggs in other forms.   Recent research has shed some light on how doctors can differentiate those who are able to tolerate egg in baked goods and those who can’t.  There are over 20 different glycoproteins that make up the allergenic component of egg white.  Ovomucoid is the glycoprotein associated most closely with reactions to extensively heated egg as it is highly stable in heat.  

There is a blood test available that can measure IgE (allergen antibody) against ovomucoid as well as other egg white glycoproteins.  The level of IgE can help your doctor determine if it is reasonable to do an open challenge with extensively heated egg.  The higher the level of IgE against ovomucoid, the less likely someone is to tolerate egg in baked goods.   Some “cut off values” for challenges have been established based on research looking at IgE levels in children with egg allergy.  IgE values can also be used to determine if it is appropriate to do an open challenge with whole egg as well.

Please note that challenges should always be done in a doctor’s office and never at home.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.


Vitamin D And Asthma

July 31, 2010

There have been several recent studies that indicate that vitamin D deficiency might have a negative impact on asthma.  The studies have mainly looked at true vitamin D deficiency defined as serum levels of 25-hydroxyvitamin D3 of less than 30ng/ml.  This can be measured by your doctor in a blood test.

Various studies have indicated that vitamin D supplementation in patients with low levels of vitamin D might prevent the development of wheezing in infants and young children, reduce asthma severity in patients with asthma and enhance the response of patients with asthma to inhaled steroids.

Studies looking at cohorts of infants followed from birth have shown that the higher the maternal vitamin D intake during pregnancy, the lower the risk of recurrent wheezing episodes and asthma in childhood.  The effect is felt to be a result of a lower risk of early childhood respiratory infections and wheezing noted in infants of mothers with higher vitamin D intake and infants with higher cord blood levels of vitamin D.

The National Health and Nutrition Examination Survey (NHANES) is a program of studies by the CDC looking at the health and nutritional status of adults and children in the United States.  Analysis of the Third NHANES showed that those with vitamin D deficiency with levels less than 10ng/ml had a higher risk of upper respiratory tract infections compared to individuals with normal vitamin D levels over 30ng/ml.  Also of interest in this survey is the fact that the difference was greatest in people with asthma.  Upper respiratory tract infections are a major cause of exacerbation of asthma in all age groups and a major cause of wheezing episodes in infants.

Several studies have shown that asthmatics with normal levels of vitamin D respond better to in haled steroids compared to asthmatics with vitamin D deficiency.  This enhanced steroid responsiveness would theoretically mean that those without vitamin D deficiency would require less medication than those with vitamin D deficiency to obtain the same level of asthma control.

More studies are needed to fully understand how vitamin D impacts asthma.  For now though, it seems reasonable to me that individuals with 25-hydroxyvitamin D3 levels less than 30ng/ml could benefit from vitamin D supplementation either through changes in dietary habits or the use of vitamin supplements themselves.

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.