“At what age can my child get tested for allergies?” This is a question I often get asked by parents of young children. Many parents and some healthcare providers believe that allergy testing cannot be done until 3 years of age. This is not true. This belief comes from the fact that most children begin developing seasonal allergies around age 3. However, many children have already developed allergies to other things (ie. indoor allergens and/or foods) by then.
Allergy skin testing is a technique that can detect allergic antibodies present in the blood by placing a small amount of the allergen on the skin and monitoring the response. Allergic antibodies can develop at any age. So if symptoms are consistent with an allergic process, allergy testing can be done. Although I prefer to wait to do a skin test around 1 year of age, many infants particularly those with severe eczema or a possible food allergy need to have some form of allergy testing done much earlier-and it can be done!
Many parents (myself included!) have found it very helpful to know what specifically their child is allergic to, even if they aren’t ready to start on allergy shots. This information can help clarify what time of year it is critical to give allergy medications daily, and when they may used on an as needed basis. Also, if a child is allergic to indoor allergens (ie. dust mite or dog) we can work on ways to decrease exposure to those allergens, thereby decreasing symptoms, which may then decrease the need for allergy medications- which is always desirable, especially for little ones!
An exciting new study on food allergy was recently published in the New England Journal of Medicine. This study, called the LEAP (Learning Early about Peanut Allergy) study, has been much anticipated in the allergy world. It basically reinforces recent recommendations about how we introduce highly allergic foods to our children. In the past, delaying introduction of milk, eggs and peanuts was the norm. Newer information has suggested that we should not delay introduction of these highly allergenic foods in most infants, and this study confirms these recommendations.
The LEAP study involved over 600 children who were considered high risk for peanut allergy (moderate-severe eczema and/or egg allergy). After skin testing these children and performing oral challenges, they were placed into two groups; one group ate high dose peanut products (equivalent of about 8 peanuts) 3 times per week and the other group avoided peanut completely. They then re-evaluated the prevalence of peanut allergy at age 5. There was a remarkable difference in the prevalence of peanut allergy between these 2 groups, with the group eating peanut regularly having significantly less peanut allergy (13.7% in the avoidance group and 1.9% in the consumption group). Some of these children even had evidence of allergic antibodies to peanut at the beginning of the study, but no clinical reaction (sensitization). Those children sensitized to peanut, but who regularly ate peanut over the course of the study had a 70% reduction in the prevalence of peanut allergy as compared to those children sensitized to peanut, but who completely avoided peanut. This indicates that we may be able to prevent the development of peanut allergy in children who have no evidence of peanut allergy, as well as in children who have evidence of allergic antibodies to peanut, but no clinical reaction.
This study should still be interpreted with caution for several reasons. Oral food challenges were done prior to introducing peanut and some kids had reactions. Also, it was limited to children with eczema and/or egg allergy. What about children with other food allergies or other risk factors? Do kids have to eat high dose peanut or can lower doses less frequently provide the same benefit? What happens down the road over the next several years? There is another study in the works, LEAP-On, to answer some of these questions. For now, it is important to remember this this study does not promise a cure for peanut allergy, but shows that we may be able to prevent the development of peanut allergy, at least in some patients. Very exciting stuff!
It appears that this may be a “bad” season for influenza. Every year the flu vaccine is made months ahead of the flu season. Experts must try and predict the influenza strains that will circulate in the upcoming flu season based on trends seen in other parts of the world. Although it is still early in the season, samples collected from people infected with the flu this fall show only about 50% of the strains detected were included in this year’s vaccine, indicating the virus has mutated. The director of the CDC, Dr. Thomas Frieden, has said that the most prevent strain this year (H3N2) has in the past been associated with severe infections, particularly for high risk patients. However, it is still important to get the flu shot, if you haven’t already. Even if you are infected with a strain not covered in this year’s flu shot, your symptoms are likely to be less severe if you have gotten the flu shot.
It is also important this year in particular to call your doctor if you think you have the flu, so you can start on anti-viral medications. These medications may help decrease the severity of the infection and reduce the chance of complications related to influenza.
This year Halloween will likely be different for many kids with food allergies. The Teal Pumpkin Project is an awareness project promoted by FARE. It was actually started by a group in East Tennessee, but this is the first year it has gone national! The idea is to place a teal pumpkin that is visible to trick-or-treaters indicating that “allergy-free” items are available. On their website FARE states “The Teal Pumpkin Project is designed to promote safety, inclusion and respect of individuals managing food allergies – and to keep Halloween a fun, positive experience for all.” FARE has a list of candy alternatives on their website. Ideas include glow bracelets, stickers, pencils, erasers and spider rings. The traditional Halloween candy is still available, but there is also a safe alternative for children with food allergies. More information can be found on the FARE website.
Fall in Tennessee means ragweed pollen season is upon us. Next to tree pollen in the springtime, ragweed is the outdoor allergen that causes the most acute misery in our area. Treatment options for ragweed allergy, just like other allergies, include avoidance, medications and immunotherapy — either sublingually (under the tongue) or via injection. Until recently there have been no FDA-approved products for sublingual use. Now, as we have blogged about before, there are a couple of new options that have been approved by the FDA. I’ve written about the grass tablets specifically, so in this post I’ll tackle the ragweed tablet, Ragwitek, and try to lay out the pros and cons as I see them.
When evaluating a new treatment, the two questions you must answer are 1) Is it safe? and 2) Does it work? In the case of the new ragweed tablet, the answers to those questions are 1) Yes. and 2) Yes, but…. First off, all forms of sublingual immunotherapy (SLIT) are generally safer than shots. Though SLIT reactions are rare, they are not unheard of and the package insert for Ragwitek clearly states that it has the potential to cause severe reactions. Because of this, the first dose of Ragwitek must be given in a physician’s office and the patient must be observed for 30 minutes afterward. Though the risk for severe systemic reactions is low, studies reported significant local side effects, including itching of the ears, tongue, mouth and throat, in 5-20% of patients. One study reported tongue swelling in 19% of patients, swelling of the upper airway in 5%, and irritation of the throat in almost 30%. Most of these side effects get better over time, and while the majority of patients were able to complete the studies, a significant minority of patients (25-30%) did not complete the trials for various reasons, including side effects and adverse events.
The effectiveness question is a bit more complicated. Study patients using Ragwitek generally showed around a 25% reduction in symptoms when compared with placebo. That’s a great number, but it is not clear whether the response seen in the study patients is applicable to the average ragweed allergic patient. The problem is, these studies excluded patients who had non-ragweed allergies that required treatment during the ragweed allergy season. Since patients requiring ongoing treatment for cat or dog allergy, allergies to dust mites or molds, or allergies to other weeds were excluded from the study, it is unclear whether such patients would derive any benefit from Ragwitek. Because it is so rare to find a patient who has ragweed as his or her only significant allergen during ragweed season, it is difficult to draw conclusions from these studies that apply to the general allergy population. In selected patients, however, Ragwitek does appear to have benefits in both reducing symptoms and medication usage.
Another hurdle for Ragwitek is the timing of administration. The effectiveness of Ragwitek when started during ragweed season has not been established. Instead, it has to be started 12 weeks prior to ragweed season and continued during the season. In Tennessee that means starting some time in May and continuing daily treatment until the first frost, which is usually in late October or early November. This adds up to around 6 months of daily therapy. So if you’re looking for relief this season, you’re out of luck.
Finally, a word about cost. Ragwitek is an expensive product. Each pill wholesales for $8.25, so for 180 days of therapy the cost comes out to $1,485.00. And that’s just for a single season of allergies related to just ragweed. This, of course, represents the cost to the insurance company, not the patient who will, however, have to bear the top-tier pharmacy co-payment for each monthly prescription. Since allergy shots are covered by insurance without a co-paymant, treat all of a patient’s allergies, and give long-term desensitization, they are a comparative bargain.
In summary, Ragwitek has been shown to be safe enough for home administration and has been shown to be effective at reducing allergies due to ragweed in a very select patient population. It does have frequent, significant side effects and the cost is not inconsequential. Because of the numerous complexities surrounding Ragwitek, I would strongly recommend consulting with a board-certified allergist if you are considering this potential therapy.
It’s that time of year again, when we pack our children’s backpacks and start a new school year. For parents of children with food allergies it can be a particularly stressful time, as they worry about their children having a reaction while at school. Food allergies have become more common in the past 20 years. Most of us grew up not knowing anyone with a food allergy. That’s not true these days. It seems most classrooms have at least one food allergic child.
What can parents do to prepare for the upcoming school year? It is very important to meet with the school nurse and the child’s teacher to review his or her food allergy. You should find out what protocols are already in place at the school to prevent and to treat accidental exposures. Fortunately, most schools already have protocols in place. You should also have a Food Allergy Action Plan on file at the school that tells the staff about the child’s food allergy, what symptoms he or she might develop, what treatment to give, and contact information on whom to call after treatment has been initiated.
Be aware of field trips or other times your child might be exposed to an allergen, such as a class party or class project. Discuss with the teacher how these activities will be handled.
It’s also important to teach your child how to talk about symptoms he or she might experience during an allergic reaction and what to do if he/she has a reaction. Help your child get in the habit of asking if the food allergen is in the food before taking any food from an adult or other child.
More information on sending your food allergic child to school can be found on the FARE website under “Tools and Resources” for parents.
Local honey is very tasty. I love it on a bagel with peanut butter or in a good marinade. But should it be on your menu of allergy treatments, too?
The notion that local honey can be utilized to treat allergies is not new. In fact, it has been a common topic of conversation with my patients since my days as an allergy fellow. The idea is that a small amount of pollen carried by bees makes its way into the honey and that regular ingestion of the pollen leads to desensitization. It’s a tempting notion, to think that you could treat your allergies with a natural, sweet treat, but the reality is slightly bitter.
First, the pollens that bees carry are not significant allergens. To make honey, bees collect nectar from flowering plants and in the process become coated with the pollen from these plants. As they buzz from plant to plant, they spread the pollen, which allows the flowering plants to reproduce. Since these pollens are carried largely by bees and not the wind, the pollens rarely come into contact with the human nose and eyes and, hence, do not cause allergy symptoms. Conversely, plants whose pollens cause allergies are wind-pollenated and are not major sources for nectar and bee pollen.
Second, oral immunotherapy doesn’t work for nasal allergies. Numerous clinical trials have looked at oral immunotherapy (swallowed allergens) as a possible treatment for this problem. These trials used large doses of purified allergens, far more than would ever be found in bee pollen, and still failed to show a benefit. (Note: this is different from sublingual immunotherapy where the allergen is held under the tongue). So, even if allergy-causing pollens are found in honey, the act of swallowing them is unlikely to improve allergies.
What if there’s something about honey itself that is beneficial for allergies? This final question was answered over a decade ago by researchers in Connecticut who did a blind, randomized trial comparing the effects of local, unfiltered, unpasteurized honey, commercial honey, and honey-flavored corn syrup on seasonal allergies. They found no benefit for either honey group compared to the corn syrup group. In other words, honey is literally and figuratively, a simple sugar pill.
You may have heard that there are some new allergy treatments available. The FDA just recently approved 2 different grass tablets (Grastek and Oralair) and a tablet for ragweed allergy (Ragwitek). There are differences between these tablets, including allergens contained in each, age restrictions and dosing schedule. However, all three of them provide a sublingual (“under the tongue”) form of immunotherapy. Certainly, these products are not right for everyone, but for the right patient there is a new treatment that may be worth discussing with your allergy provider.
We all know stress isn’t good for our health. It increases the risk of developing high blood pressure and diabetes and contributes to increased levels of anxiety and depression.
Now a study in the Annals of Allergy, Asthma and Immunology shows that people who are experiencing stress are more likely to have a flare of their allergies. Many of the patients in the study reported an allergic flare within days of the increased stress. Additionally, allergy suffers with more chronic stress experienced allergy flares more often.
The authors recommend ways to alleviate stress, such as meditating, making time for relaxing and adopting a healthy lifestyle. Certainly decreasing stress is good for your overall health, but be sure to see a board-certified allergist to get a comprehensive plan for managing your allergies.