Archive for January, 2010

“Doctor, Do You Believe In The Flu Vaccine?”

January 26, 2010

Each fall when the flu vaccine becomes available I am asked, on a fairly regular basis, “Doctor, do you believe in the flu vaccine?”  Although I am used to being asked that question, I always find it somewhat strange.  I know the person asking the question is really asking me whether or not I think they should get the flu vaccine, or whether or not I think the flu vaccine is effective, or whether or not I think the side effect profile of the vaccine is too high.  But, invariably, they ask if I “believe” in the vaccine.  Nobody would ever ask if I “believe” in the flu, since science has established that the flu exists and that people can get very sick from it.   Not “believing” in the flu would be tantamount to not “believing” that HIV causes AIDS.  It is a matter of scientific fact and not belief (although there are still people out there who actually don’t believe that HIV causes AIDS).  Likewise, it is not really a matter of belief as to whether or not there is a vaccine that can protect against the flu.  It exists, and it is available.

However, the question is being asked and it does have importance since it underscores a strange bias that exists in a segment of the community toward vaccines.  It is a bias that comes from a vocal and hyped “belief” that vaccines can cause all sorts of medical problems, from autism to actually giving people the diseases they are meant to prevent.    It is a bias that comes from the “belief” that an immune system that is bombarded on a daily basis with all sorts of microbes and antigens, somehow can’t deal with being exposed to a few specific antigens in the form of vaccines, even if this targeted exposure is meant to result in a specific protective immune response.   In the age of the internet, these “beliefs” are given credibility in the form of blogs and websites.  On-line, almost everything looks authoritative.  And so, there can be scientific evidence that autism is not linked to vaccinations, and yet, the question will continually be posed on-line and in the lay press.  Pediatricians deal with this issue on an almost daily basis.   Belief systems are important.  I just wish that when it came to science, facts would always trump beliefs.

There is no doubt in my mind that immunizations would be high up on any credible list of the most significant medical advances in the history of mankind.  Their importance is irrefutable.   So, the next time you have a question about the effectiveness of a vaccine or about potential side effects, ask about those things directly.   If you don’t really understand why it is important for you or your child to receive a specific vaccine you should ask about it.   If you are concerned about taking a vaccine that has just been approved, you need to have a conversation with your doctor about that.   If you are unclear as to what the difference is between a live attenuated viral vaccine and and a killed viral vaccine, please ask.  Those are good questions and they are worthy of real discussion.  With the answers you will be able to decide, with the help of your doctor, what is right for you.

Nasal Saline Irrigation

January 25, 2010

Nasal irrigation is an effective way to improve sinus drainage, promote nasal mucosal ciliary function, decrease nasal mucosal swelling and clear the nasal passages of bacteria and allergens.  Saline nasal irrigation can decrease symptoms of chronic sinusitis and reduce the use of medications.  It is an ancient personal hygiene practice used for centuries in parts of Asia and the Middle East.   Before starting nasal irrigation on a daily basis, please see my January 7, 2010 blog entry with some new interesting information.

Traditionally, nasal irrigation is done using a small vessel called a neti pot.  Neti pots can be purchased in select health food stores and through yoga institutes.  Two on-line sources through which you can buy a traditional neti pot that I recommend are: www.sinucleanse.com and www.himalayaninstitute.org.  Although I recommend these two sources for purchase of the neti pot, I do not specifically endorse the various solutions they may also have available to use with the neti pot. 

Instructions: The most important aspect of an effective nasal wash is holding your head in the proper position. Lean over the sink so you are looking directly into the basin and rotate your head to the side so that one nostril is directly above the other. The forehead should remain slightly higher than the chin.  If the forehead is not higher than the chin the saline solution will flow into the frontal sinuses (sinuses above the eyes) and this can cause a headache.  If the forehead is too much higher than the chin, the saline will drain into your mouth.  If you rotate your head too much, the saline may drain into your eustachian tube which will cause you to feel like your ear is a little clogged. 

Gently insert the spout into the upper nostril so that it forms a comfortable seal. Keep your mouth open and raise the handle of the neti pot so that the solution enters the upper nostril and drains out through the lower.  You should be able to comfortably breathe through your mouth during the wash.  You should rinse each nostril with the volume of saline solution that fits into one pot.  When the pot is empty, rotate your head so you are looking into the sink and exhale through both nostrils to clean them of excess mucus and water.

www.himilayaninstitue.org has a good instructional video for proper use of the neti pot. 

Saline Solution for one pot:

Distilled water to fill the pot

¼ heaping teaspoon of plain salt such as kosher salt (not iodized and not sea salt)

A pinch of pure baking soda (sodium bicarbonate) (Optional)

Mix to dissolve salt

Cat And Dog Allergy: Did You Know….

January 17, 2010

Did you know that cat and dog allergen can be present in environments where there are no cats or dogs?  Studies looking at allergens in day care centers and schools have shown that significant levels of cat and dog allergen can be present in those settings.  It is thought that children with cats and dogs in the home bring the allergens to school mainly on their clothing.  They can also bring them in on their hair.  Studies have shown that the level of cat or dog allergen in schools and day care centers correlate directly with the number of students and staff who have these animals at home.  Carpeting can act as a reservoir for these allergens and levels of allergens are higher in carpeted or upholstered areas.

Children can unknowingly become allergic as a result of this type of exposure and children who are already allergic can develop symptoms from exposure in this way.

Reading Over-The-Counter Cold and Allergy Medication Labels

January 17, 2010

There are many different over-the-counter allergy and cold medications available.  It is often very confusing figuring out what to buy in the drug store with so many different products on the shelves.   The key to making a decision is looking at the active ingredients of the products. The active ingredients are always listed on the label of the medication.  It is much more important to read the active ingredients, than to pay attention to the fancy labels and packaging.

Over-the-counter allergy and cold medications basically contain one or more of five major types of medications: 1)Antihistamines, 2)Decongestants, 3)Pain medications, 4)Cough suppressants and 5)Expectorants.

1. Antihistmines: There are two major types of antihistamines that are available over-the-counter, those that make most people drowsy and those that don’t.  The most common antihistamines available that make most people drowsy are Diphenhydramine, Chlorpheniramine and Brompheniramine.  Diphenhydramine is the active ingredient in Benadryl.  There are two over-the-counter antihistamines that do not cause drowsiness,- Loratadine and Cetirizine. Loratadine is the active ingredient in Claritin and Cetirizine is the active ingredient in Zyrtec.   Cetirizine may cause some drowsiness in a small percentage of people.

2. Decongestants: The major decongestants available in over-the-counter medications are Phenylephrine and Pseudoephedrine.

3. Pain medications: The major pain medications available in over-the-counter cold and allergy preparations are Acetaminophen (the active ingredient in Tylenol) and Ibuprofen (the active ingredient in Advil or Motrin)

4. Cough suppressants: Dextromethorphan is the main cough suppressant you will see in preparations.

5. Expectorants: Guafenisin is the main expectorant you will see in preparations.

Cold and allergy medications that call themselves non-drowsy, usually will not contain a sedating antihistamine.  In fact, they might not contain any antihistamine at all.  If you are mainly taking the product for allergy reasons, you would want to take an antihistamine.  Products labeled HBP (high blood pressure) usually do not contain decongestants since decongestants can cause an elevation of blood pressure.

The amount of each ingredient is indicated on the label in milligrams (mg).  You can compare dosages of specific ingredients milligram for milligram.  For instance, a product that contains 120mg of pseudoephedrine has 4 times as much of that ingredient in it than a product that contains 30mg of pseudoephedrine.  Since pseudoephedrine can cause potential dose related  side effects, your doctor might not want you to be on that higher dose.

You can not compare the milligram dosages of one ingredient with that of another ingredient. It is wrong to think that a higher milligram dosage of one ingredient is stronger than a lower mg dosage of another ingredient.  For instance, 30mg of one medication could be stronger, weaker or equivalent to 5 mg of another medication.  This is true for any class of medication.

It is important to take the medications as indicated on the label or to ask your doctor if you are unsure of how much to take.  It is also important to be careful about combining different products since there might be overlapping active ingredients that could result in taking too much of one medication.  For instance, if you are taking a cold medication that contains acetaminophen, you would want to be very careful about the milligram dosage of acetaminophen in that medication before taking Tylenol along with it.

Food Allergy May Not Always Be Caused By Ingestion Of Food

January 12, 2010

The exact reason an infant develops an allergy to a particular food is not known.  There is no doubt that genetics has a lot to do with it, and infants who have parents or siblings with allergies are at increased risk.  There are many theories as to what may contribute to the development of a food allergy in an infant.   When you think about how many different kinds of foods and potential food allergens an infant is exposed to, it becomes obvious that the development of an allergy to a food is somewhat of a rare occurrence.  The usual course of events is that the consumption of a food leads to a tolerance of the food by the body.  Nature favors this as food is so important for continuation of life.  When an allergy to a food develops, the immune system of the body is reacting against the food with an allergic reaction.

One theory is that food allergy may occur if the body is exposed to the food through the skin, before exposure through the gastrointestinal tract.  The immune system of the skin processes the food allergen differently than the gastrointestinal tract and this results in the development of allergy.   Skin exposure to food proteins in the environment can occur through contact with tabletops that have food proteins on them, the hands of a family member, aerosolized dust of food proteins or from exposure to moisturizers that contain food products.  Most moisturizers for infants do not contain food products, however moisturizers used by adults can contain various food products such as almond, apricot or sesame.  If the mother of an infant uses a moisturizer that has a vegetable, fruit or nut as an ingredient, when the infant comes in contact with its mother’s skin, an allergic sensitization can occur.

Think about the following fact.  The United States and England are two countries where peanuts are generally consumed in large quantities, but where, until recently,  it had been common practice to delay the introduction of peanuts into the diet of infants, with a family history of allergy, for the first 2-3 years of life.  In Israel, it is common practice for infants to be given peanuts at a younger age as peanut snacks that are safe for infants are available.  The rate of peanut allergy in Jewish toddlers in England is about ten times the rate of peanut allergy in Jewish toddlers in Israel.  The above theory would explain this by pointing out that the infants and young children in England are likely exposed to peanut proteins in their environment and through their skin before exposure through the gastrointestinal tract and therefore are getting sensitized in an allergic way.  This is just a theory, but it is curious that two genetically similar groups have such very different rates of peanut allergy, with the group that is having peanut consumption delayed to an older age having much higher rates of allergy.

Another interesting fact is that children with eczema have increased rates of food allergy.  However, we don’t know what came first.  Does the food allergy develop because of breaks in the skin that make it more likely for these infants to have exposure to food products through their skin and thus more readily develop allergy?  Or, do these children have a higher rate of food allergy resulting in the development of the eczema?  In other words, what came first, the chicken or the egg?

Dust Mite Environmental Control

January 11, 2010

Dust mites are tiny microscopic organisms that are not visible to the human eye. They live in upholstered furniture, beds, drapes, old clothes, stuffed animals, pillows, carpets and bedding. They live off of naturally shed human skin and need humidity to grow. Their presence in your house has nothing to do with your level of cleanliness. No matter how clean you keep things, dust mites will be present. Dust mite droppings and decaying bodies are highly allergenic. They are relatively heavy allergens and do not get aerosolized readily, however they do get aerosolized when vacuuming.

Direct contact with dust mites result in the most significant allergic symptoms. Direct contact occurs in many different ways including sleeping on a mattress containing dust mites or lying on a dust mite laden carpet. Dust mite allergy can cause nasal allergy symptoms, eye symptoms, asthma or worsening of eczema.

Exposure to dust mites can be reduced in the following ways:

1. Encase your pillow, mattress and box spring in special dust mite proof covers. Place your regular sheets and pillow cases over the dust mite proof covers. Not all products are the same. The products sold through Mission Allergy (www.missionallergy.com) are of a high quality that I can recommend.  Products can also be purchased through various on-line sources such as http://www.allergycontrol.com, http://www.natlallergy.com or http://www.achooallergy.com, or at local retail stores.

2. Wash all bedding, including blankets, in hot water (130 degrees) once a week. All stuffed animals or toys must be able to be washed in hot water as well.

3. Remove carpeting from bedroom if possible.

4. Do not lie down and especially do not sleep upon upholstered furniture or carpets. Use area rugs that can be washed weekly in hot water.

5. Use leather, vinyl or wood furniture whenever possible and especially in the bedroom.

6. Try to keep the relative humidity in your home, and especially in the bedroom, as low as possible and ideally below 40%. Air conditioners and dehumidifiers can be used to help keep the humidity at a lower level. Do not use a humidifier.

7. Tannic acid, used as directed, can help denature and neutralize dust mite and pet allergens. This can be purchased through the on-line sources listed above.

8. Use a vacuum cleaner with a HEPA filter. The dust-mite-allergic person should not be involved in vacuuming or dusting unless absolutely necessary.

9. HEPA filtered air purifiers are helpful for animal allergen exposure in the home but are less helpful for dust mite allergy.

Cow’s Milk Allergy And Accidental Exposure

January 10, 2010

There is an interesting recent study out of Madrid looking at reactions to cow’s milk protein after accidental exposure in a group of young children known to be allergic to cow’s milk protein.   Eighty eight children with a mean age of about 2 1/2 year were followed for one year.

Forty percent of the children, or 35 children, had 53 reactions over the course of the year.  Almost 50% of the accidental exposures took place at home with about 20% at a neighbor’s home and another 25% at daycare/school.  15% of the reactions were classified as severe, meaning that they involved symptoms of respiratory distress or symptoms related to a drop in blood pressure such as dizziness or passing out.  All children were successfully treated for their reactions with 20% requiring ER treatment.  Two children needed to be hospitalized.

Children who had severe reactions had significantly higher allergy blood test results (level of cow’s milk specific IgE) compared to children with mild reactions.  Those with severe reactions had a median IgE of 37.7 compared to a median IgE of 3.3 in those who had mild reactions.

Twenty eight percent of the reactions were the result of eating dairy products such as cow’s milk, yogurt or cheese.  Fifty five percent of the reactions were the result of eating foods that contained cow’s milk as an ingredient.   Labels were not read in 1/3 of these cases.  Eight reactions resulting from eating cold cuts that contained cow’s milk proteins.   Seven reactions occurred because cow’s milk was not listed as an ingredient in the food eaten.  It is important to note that this study took place in Madrid.   In the United States food labeling regulations are more strict and it is likely that cow’s milk would have been listed as an ingredient for these foods in the United States.

The take home messages from this interesting study are as follows:

1. Accidental exposure to cow’s milk protein in young children allergic to cow’s milk is common.

2. Almost 50% of reactions occurred at home.

3. Children with higher levels of cow’s milk specific IgE, as determined by a blood test, are more likely to have severe reactions.

4. It is extremely important to read ingredient lists on purchased food products carefully.

Daily Nasal Saline Irrigation: Too Much Of A Good Thing May Not Be Good

January 7, 2010

Saline (salt water)  irrigation of the nasal passages can improve nasal mucociliary clearance.   Many patients with chronic nasal and sinus problems use nasal saline irrigation with a neti pot or spray on a daily basis to treat congestion and mucous build up.  A recent study presented at a national allergy and immunology meeting showed that when patients used nasal saline irrigation on a daily basis for a year, they had 60% more acute nasal/sinus infections over the course of the year, compared to not using the nasal saline irrigation on a daily basis.

It is appropriate and most likely helpful to use nasal saline irrigation on an intermittent basis when you have a cold, or are developing a cold, to help improve clearance of already infected mucus.  For this purpose it can be used for a week or 10 days and most of my patients report that it helps.  I prefer the use of a neti pot, rather than a spray, since a neti pot rinses the sinuses with passive flow of the saline whereas a spray introduces an element of positive pressure.

Although the short-term use of nasal saline irrigation can be helpful and should be considered a good thing, this study shows that the daily use of nasal saline irrigation over longer periods of time might be harmful.  It is possible that ongoing enhanced clearance of uninfected “good” mucous might end up making it more likely that an infection develops.

I think this is important information since the lay public and many physicians often assume that they don’t need to worry about bad side effects from a medical intervention that does not involve a “medication” but instead involves a “natural” substance, like salt water.   This study shows that even “natural” therapies can have potential side effects.

One caveat:  This is one study and it should be repeated to assure that the results are accurate.

Cold Air And Asthma

January 7, 2010

I was walking through midtown Manhattan this afternoon in the frigid cold, and I thought today would be a good day to say something about cold air and asthma.   Cold air is a common exacerbating factor for asthma and the impact of the cold air can be worsened by exercise.   If you are on inhaled steroids as a chronic controller medication for your asthma, and you are the type of asthmatic who is affected by cold air, it is sometimes helpful to up your inhaled steroid dose if you know you are going to have exposure to cold air for an extended period of time.  Optimizing your anti-inflammatory medication can take the edge off the cold, so to speak.  Another option is to wear a scarf or bandana around the mouth and nose when outside, thereby humidifying and warming the air before it hits the lungs.  This can prevent the bronchospasm associated with cold air exposure.  Always remember to have your bronchodilator medication with you, in case you need it.

Visiting A Home With A Cat

January 5, 2010

In the United States about 93 million cats reside in one-third of all households.  It is not unusual for a person with cat allergy to be a guest in a home with cats.  How that should be handled is something I am regularly asked by my cat-allergic patients.

First off, I think it is important to tell your friend or host that you are allergic to cats and to ask if the cat can be kept in a bedroom or other room away from the common areas.  It does make a difference to have the cat physically in another room during the visit.   If you are visiting a good friend, asking them to do a little extra cleaning and vacuuming in the room you will be in can be helpful.  Try to find out where the cat usually hangs out in the home and stay away from that area.  For instance, if the cat usually likes to rest on a particular sofa or chair, that would not be a great place for you to sit during the visit.   Try to place your coat somewhere the cat does not have access to, and stay away from any linen or towels the cat might have come in contact with.  It all seems like common sense, but you need to think about these things and ask the questions.

On top of that, you need to take the appropriate medications to prevent symptoms.  Do not wait for symptoms to take medications, but take the medications prophylactically, at least 1-2 hours prior to the visit.  Generally speaking if your symptoms are localized to the nose, a nasal steroid in conjunction with a non-sedating antihistamine will suffice.  If you have ocular (eye) symptoms as well, then adding an allergy eye drop prior to the visit would be an important addition.  If you have allergic asthma from cat allergy, then it will be important to also take either Singulair or an inhaled steroid prior to the visit.   Cat allergy manifests differently in each person, so the prophylactic medication regimen should be individualized with your allergist’s help.  Most of my patients, even those with relatively severe cat allergy, can get through a dinner without significant symptoms if they follow these suggestions.

When you get home, take off the clothes you were wearing at the home with the cat and throw them in the clothes hamper to be washed.  It is a good idea to take a quick shower prior to going to bed as well.  You want to do whatever you can to prevent bringing the cat allergen into your home and especially into your bed.