New Allergy Guidelines for People Over 12 Years Old

If you or your kids suffer from allergies, I'm sure you want to know how to best manage them. In addition to limiting exposure, medications can be a big benefit. 

The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (AAAAI and ACAAI) have published new guidelines in the Annals of Internal Medicine for the initial medical treatment of seasonal allergies in people 12 years and older.

The recommendations essentially state:

• Use steroid nasal sprays first without an oral or nasal antihistamine. Many intranasal steroids are available over the counter without a prescription. A great list is included on the AAAAI website. (Be careful to not to confuse them with the nasal antihistamines, which are in the same chart but identified in the column titled "Class".) 
• In those over 15 years, the nasal steroid is preferred over a leukotriene receptor antagonist (ie Singulair or montelukast). For those with asthma, the leukotriene receptor antagonist might offer an additional benefit for asthma, but it is not the preferred treatment in either allergies or asthma. (I think the age change is simply due to the ages studied but it was not specified.)
• In moderate to severe allergic conditions, a combination of nasal steroid and nasal antihistamine can be considered. 

These recommendations are based on a review of many studies to show what treatments worked and what didn't. They also took into consideration the fact that oral antihistamines can cause sedation and the nasal antihistamines do not. In general the nasal steroids worked better than other treatments. They did note that for people who do not tolerate nasal sprays, alternates would be oral antihistamines or leukotriene receptor agonists.

Itchy, sneezy, puffy - All signs of allergy. What can you do?

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what's out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:

• Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

• Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine. Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age. 

• Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Most insurance companies don't cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 

• Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple weeks, they usually don't need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

• Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

• Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)

• Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

• Wash towels and sheets weekly in hot water.  

• Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 

• Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 

• There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 

• Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  

• Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 

• If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 
• Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don't smoke near them.  

What if all of the above isn't helping?

• Maybe it's really not allergies. 

• Allergies to things other than foods are rare before 2 years of age.

• Viruses can cause very similar symptoms to allergies. 

• Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   

• Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!

• Wrong medicine or wrong dose. 

• Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

• Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 

• Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

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"It's just my allergies." Is it?

I've seen many parents over the years who complain that their allergies are really giving them (or their children) problems. They insist it's just allergies though when I suggest that maybe they're sick. Why do they think it's allergies and I think they might have a virus-- and why does it matter?

Allergies can cause runny nose, watery eyes, sneezing, headache, ear pain or popping, cough and sore throat from postnasal drip.

Viruses can cause the same symptoms, so it's very confusing which is the culprit sometimes. If there's a fever or body aches, it is more likely from illness, not allergy, but not everyone with an infection gets a fever, especially older kids and adults. Not everyone with fever needs an antibiotic. Many people think clear mucus is certainly allergies and discolored mucus is bacteria, but that isn't always the case. The color of mucus depends on how long the mucus is in the nose and sinuses and how much your immune system is fighting back. It is common after a few days for the mucus to be yellow, even if it's not a bacterial sinus infection.

I've seen people treated by allergists for years for allergies only to find out with allergy testing that there aren't any allergies. It's hard for even the experts to know sometimes!

Why do I suspect these parents (or kids) have a virus and not allergies?

• Time of year. Allergies can occur year round, but there are typical times that various pollen counts go up. If it's not a high pollen count time (or other possible exposure to allergen such as a new cat), I wouldn't expect a sudden increase in allergy symptoms. 
• Their child is sick. If a child is sick with fever, runny nose, cough, ear infection, or other similar symptoms, it is common for them to share with the parent (and siblings). Parents and older kids often get colds without fever, so no fever doesn't rule out an infection.
• The community is sick. When we're seeing a lot of upper respiratory tract infections in the community, it is at least something to consider.

Why does this all matter anyway?

• Not all treatments for allergies work well for viruses. Treating the symptoms with the proper treatment is important (although there really isn't a wonder treatment for most upper respiratory viruses). When people think they become tolerant to their allergy medicine because it doesn't work for their symptoms, they are likely to not use it when appropriate for allergies. They might switch to a more expensive medicine for the wrong reasons. Bottom line: If the allergy medicine works for allergies, it can be used for allergies, but don't expect it to work for your cold.
• If people presume it's allergies they aren't as careful to wash hands to prevent the spread of infections. This is especially important to infants, young children, immunocompromised, and the elderly. What is a minor cold for you can be a significant illness to others.

So the short of it is, if you think your allergies are flaring, still be careful to not spread germs. It is fine to use allergy medicines, but if they aren't working, consider that you might have a cold. Even if they do help, it doesn't mean that you aren't contagious, so still wash your hands often, especially after blowing your nose!

Swollen Eyelids: Causes, Treatments, and When to Worry

There are many causes of swollen eyelids in kids (and adults). The good news is that the most common ones are usually not serious. Some swellings herald warning though and should be properly evaluated and treated by a doctor. Warning signs include vision changes, pain, protrusion of the eye, fever, difficulty breathing, abnormal eye movements (or loss of movement), foreign body that cannot be removed, or signs of anaphylaxis (swollen tongue or throat, difficulty breathing, hives). Any warning signs deserve prompt medical attention.

Allergies can make the eyelids puffy due to the histamine reaction. This is usually accompanied by itching, red eyes that are watery. Treatment involves either oral allergy medicines, topical allergy medicine (eye drops) or a combination of both. Washing the face, hair, and eyes after exposure to allergen can also be an important part of treatment.

Anaphylaxis is a more serious allergic reaction. It involves swelling of the eyelids, throat, and airways. This is a medical emergency. If epinephrine is available, use it. Call 911.

Blepharitis is an inflammation of the eyelids that can cause swollen lids, often with flaky eyelid skin and loss of the lashes. This chronic condition should be managed by an eye care specialist.

Bug bites are the most common cause of swollen eyelids we see in our office. Usually there is a known exposure to insects and there may be other bug bites on the body. Bug bites on the eyelid tend to itch rather than hurt despite the significant swelling they produce. There should be no fever or other signs of illness. The eyeball should move freely in the socket. (See "orbital cellulitis" below.) Treatment of bug bites involves cool compresses and oral antihistamines. Occasionally oral steroids are required for significant swelling, but they require a prescription. If the swelling is concerning to you or your child, bring him in to be seen.

Conjunctivitis, also known as pink eye, causes inflammation of the surface of the eye ball and sometimes a puffy appearance to the eye lids. It can be from bacteria, virus, or allergies. Bacterial conjunctivitis causes the whites of the eyes to look red and includes a yellow discharge from the eye. Viral conjunctivitis causes the white of the eye to look red, but there is no yellow discharge. Allergic conjunctivitis is described above under "allergies." If unsure which type your child has, or if it is probably bacterial, see your doctor.

Contact lenses can contribute to swollen eyes if they are dirty or damaged. See your eye doctor in this case.

Crying can cause the eye lids to become puffy. The lacrimal glands produce an overflow of tears, so the fine tissues around the eyes absorb the fluid, causing them to appear swollen. This is compounded by the autonomic nervous system increasing blood flow to the face during times of strong emotion and rubbing the eyes to wipe away the tears. This cause of swelling is short lived. Cool compresses and avoidance of rubbing can help decrease the swelling.

Graves' disease can cause swelling of the eyelids and protruding eyes. Sometimes a drooping eyelid or double vision occurs. It is caused by thyroid problems, which also can cause problems with appetite, fatigue, heat intolerance, and more. These symptoms should be evaluated by a doctor.

Kidney problems can lead to fluid retention. If the eyes are puffy along with puffiness of the ankles or swelling of the abdomen, kidney problems should be considered. Children can develop this suddenly from infections, like certain diarrheal illnesses or Strep throat. The urine may look tea colored or like it has blood in it. This is a medical emergency and you should seek care immediately.

Sinus infections can cause puffy eyelids. Congestion, runny nose, headache, postnasal drip, and cough are typical symptoms. See your doctor if you suspect sinusitis.

Styes look like a swelling at the edge of the eyelid, often red or pink with a small white central area. It is caused by a blockage in one of the small glands in the eyelid. Another swelling from blockage of oil glands of the eyelid is a chalazion. Both a stye and a chalazion can start as painful bumps, but after a few days they no longer hurt. They can cause the whole eyelid to swell. Applying warm packs to the area several times per day often helps treat styes. Chalazions more often need to see an ophthalmologist for treatment. If a stye persists beyond a few months or the lid swells to cover the pupil, see your doctor.

Trauma of the eye or nose, like any trauma, can cause swelling. A broken nose can cause swelling and bruising to the eyelids. Any significant trauma to the eye or nose should be seen by a doctor. Symptoms may include vision changes, chemical exposure, foreign body in the eye, blood in the eye, severe pain, or nausea or vomiting after injury.

Ocular herpes is an infection of the eye by the herpes virus. (Not all herpes infections are sexually transmitted!) It can appear initially like a blister or cluster of blisters near the eye. It can lead to permanent damage to the eye, so prompt care by an ophthalmologist is important.

Orbital cellulitis is a potentially serious infection of the eyelids. The infection can extend behind the eyes, causing meningitis. It is suspected when there is painful swelling of the upper and lower eyelids, fever, bulging eyes, vision problems, and pain with eye movement (or inability to move the eyes). This is a medical emergency and if suspected, prompt medical attention is warranted. Treatment involves iv antibiotics. To assess the extent of swelling or to differentiate between pre-septal cellulitis (which is not into the deep tissues) and orbital cellulitis, imaging is often done.

Ptosis, or drooping of the eyelid, can look like a swollen lid. There are many causes and this should be evaluated by a doctor.

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Learning and Behavior Series Part 3: Nutrition, Elimination Diets, and Vitamins

This is the third article in a series on Learning and Behavior. It covers some diets that have been recommended for various learning and behavioral benefits, including elimination diets and supplements that might benefit. There will be another part focused on supplements.

Most of us have heard of the claims of cures for all sorts of ills, including behavioral problems (especially ADHD and autism) with simple dietary changes (with and without supplements).

Fears of side effects from long-term medication or a history of medication failures cause families to look for alternative treatment options for child behavior issues. Diet modification and restriction is intriguing for parents since it fits into the ideal of a healthy lifestyle without added medicines and their potential side effects. However, there is a lot of controversy as to whether these restrictions help except in a small subset of children who have true allergy to the substance.

In general if a simple solution through diet was found, everyone would be doing it. That just isn't happening.

I do think that we all benefit from eating real foods -- the ones that look like they did when they were grown, not processed and packaged. Fruits, vegetables, protein sources, whole grains, and complex carbohydrates should be the basis for everyone's diet. It's just good nutrition. But the direct effect of special diets on learning, behavior, and conditions such as ADHD shows limited effects.

Natural does not equal safe. When my kids were young and picky eaters I never would have considered stimulating their appetite with organically grown marijuana. While it is all natural (even organic!) and it might increase their appetites, it would have risks, right? In this case I don't think the risks would outweigh the benefits. But so often parents think that if it's natural, it's healthier than something made by man. Drugs have been tested. They have risks too, but those risks are a known. Some natural therapies have not been as thoroughly tested and they are not regulated, so the label might not correctly identify the contents. For this reason, I think that healthy foods are a great option for everyone, but I hesitate to recommend a lot of supplements, especially by brand.

Over the years there have been many foods or additives that have been blamed for causing learning and behavioral problems. Some of the proposed problematic foods:

• food dyes
• refined sugars
• gluten
• salicylate and additives
• dairy products
• wheat
• corn
• yeast
• soy
• citrus
• eggs
• chocolate
• nuts

I'm sure the list goes on, but I've got to move on.

Food additives have long been blamed for learning and behavior problems. Back in 1975, Dr. Ben Feingold hypothesized that food additives (artificial flavors and colors, and naturally occurring salicylates) were associated with learning disabilities and hyperactive behavior in some children. Since then many case reports of similar claims have continued to surface, but those do not have the same weight as a double-blinded control study. Most studies done in a scientific manner have failed to show a benefit. There are studies that show improvement in some children who avoid artificial dyes. In my opinion it never hurts to eliminate artificial dyes in your child's diet. If it helps, continue to avoid them. But if no change is noted, don't continue to rely on dye avoidance as a treatment plan.

Another elimination diet that I would not recommend is the GAPS (Gut and Psychology Syndrome) diet, designed by Dr. Natasha Campbell-McBride. She asserts that a wide variety of health problems  (autism, ADHD, schizophrenia, depression, and more) are from an imbalance of gut microbes. Not only has it not been proven to work, I worry that it restricts healthy foods, such as fruits, and kids will develop other problems on this diet. I cannot go into details in this space, but for more information visit Science Based Medicine: GAPS diet.

Gluten is in the news to be the base of many problems. It seems to be a fad to go gluten free for just about any ailment you can think of. There are a subset of people who are really sensitive to gluten, and they benefit greatly from a gluten free diet. But the large majority of people gain no direct gluten free benefit from this expensive and restrictive diet. One indirect benefit of the diet is that it is nearly impossible to eat pre-packaged and processed foods, which leaves real fruits, vegetables, and other high quality foods. (As more people are going gluten free there are more pre-package products made gluten free. I wonder if the benefits people have noticed previously will wane when they eat these foods. ) Talk with your doctor before deciding if going gluten free will work for your child.

Sugar is often blamed on hyperactivity. By all means, no child needs extra sugar, so cut out what you can. Well controlled studies did not find a behavioral difference in kids after refined sugars. Interestingly though, parents still perceived a change (despite researchers finding none) in at least one study (Wolraich, Wilson, and White. 1995).

Food allergies are now commonly thought to be related to behavior and learning problems. In some children with true allergies, foods can affect behavior. However, most children do not have food allergies and avoiding foods does not alter behavior. It can be challenging to determine if there is a food allergy since some of the tests offered are not reliable. It is a small subset of kids that food avoidance helps, but in the large majority studies do not support avoidance of foods. If you think your child benefits from avoiding one or two foods, it probably isn't a big deal to restrict those foods. But if you suspect your child is allergic to everything under the sun, you will need to work with your doctor and possibly an allergist and a nutritionist to determine exactly what your child must avoid and how they can get all the nutrients they need to grow and develop normally. 

Supplementation with vitamins, minerals, and essential fatty acids [arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA)] is gaining popularity. There are some studies that show people with ADHD have low levels of certain vitamins and minerals. More studies are being done to determine if supplementing helps symptoms. There is growing evidence for vitamin supplementation, but there are no standard recommendations yet. For children without a known vitamin deficiency, a standard pediatric multivitamin can be used. Clinical trials using various combinations of high dose vitamins such as vitamin C, pantothenic acid, and pyridoxine suggest that these have no effect on ADHD. I don't recommend high dose vitamin supplements unless a specific deficiency is identified (and I don't routinely screen for deficiencies at this time). I have no problems with anyone taking a multivitamin daily, but cannot recommend any specific brand since none of them are regulated by the FDA and there are many reports that show the label often misrepresents levels of what is really in the bottle. My advice is to buy a brand that allows independent lab testing of their products if you choose to buy any vitamin or supplement.

The following is adapted from the University of Maryland Medical Center with the help of ADDitude Magazine and Natural Medicines Comprehensive Database.

• Magnesium -- Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Some experts believe that children with ADHD may be showing the effects of mild magnesium deficiency. In one preliminary study of 75 magnesium-deficient children with ADHD, those who received magnesium supplements showed an improvement in behavior compared to those who did not receive the supplements. Too much magnesium can be dangerous and magnesium can interfere with certain medications, including antibiotics and blood pressure medications. Talk to your doctor. 

• Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make and use brain chemicals called neurotransmitters. These include serotonin, dopamine, and norepinephrine, the chemicals affected in children with ADHD. One preliminary study found that B6 pyridoxine was slightly more effective than Ritalin in improving behavior among hyperactive children - but other studies failed to show a benefit. The study that did show benefit used a high dose of B6, which could cause nerve damage, so more studies need to be done to confirm that it helps. If it is found to help, we need to learn how to monitor levels and dose the vitamin before this can be used safely outside of research centers. Because high doses can be dangerous, do not give your child B6 without your doctor's supervision. 

• Zinc -- Zinc regulates the activity of brain chemicals, fatty acids, and melatonin, all of which are related to behavior. Several studies show that zinc may help improve behavior, slightly. Higher doses of zinc can be dangerous, so talk to your doctor before giving zinc to a child or taking it yourself.  

• Iron -- Iron deficiencies can occur in children due to inadequate dietary sources (kids are picky!) and many other causes. Iron is needed for the synthesis of dopamine, norepinephrine, and serotonin- all neurotransmitters in the brain. Low iron has been linked to learning and behavior problems. Too much iron can be dangerous, so talk with your doctor if you want to start high dose supplements. (Regular multivitamins with iron should not cause overdose if used according to package directions.) It is important to follow labs to be sure the iron dose is not too high if supplementation with higher than standard doses of iron are given. For information on sources of iron in the diet, labs done to check for iron, and more, visit Iron Deficiency Anemia.

• Essential fatty acids -- Fatty acids, such as those found in fish, fish oil, and flax seed (omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are "good fats" that play a key role in normal brain function. The results of studies are mixed, but research continues. If you want to try fish oil to see if it reduces ADHD symptoms, talk to your doctor about the best dose. Some experts recommend that young school aged kids take 1,000-1,500 mg a day. Kids over 8 years should get 2,000-2,500 mg daily. For ADHD symptom control it is often recommended to get twice the amount of EPA to DHA.

• L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the body produce energy. One study found that 54% of a group of boys with ADHD showed improvement in behavior when taking L-carnitine, but more research is needed to confirm any benefit. Because L-carnitine has not been studied for safety in children, talk to your doctor before giving a child L-carnitine. L-carnitine may make symptoms of hypothyroid worse, and may increase the risk of seizures in people who have had seizures before. It can also interact with some medications. It should not be given until you talk to your child's doctor. It is not generally recommended at this time.

• Vitamin C -- Vitamin C can help modulate the dopamine levels in the brain. It can affect the way your body absorbs medications (especially stimulants for ADHD) so it is best to avoid vitamin C supplements and citrus fruits that are high in vitamin C within the hour of taking medicines. Preliminary evidence suggests that a low dose of vitamin C in combination with flaxseed oil twice per day might improve some measures of attention, impulsivity, restlessness, and self-control in some children with ADHD, but more evidence is needed before this combination can be recommended.

• Proteins -- Proteins are great for maintaining a healthy blood sugar and for keeping the brain focused. They are best eaten as foods: lean meats, eggs, dairy, nuts and seeds, legumes, and fish are high protein foods. Most people in our country eat more protein than is needed. If your child does not eat these foods in good quantity, there are supplements available, but talk with your doctor to see if they are appropriate for your child. Many of the supplements are high in sugar and other additives. Some have too much protein for children to safely eat on a regular basis.

In general I think we all should eat a healthy diet that is made up primarily of fruits, vegetables, lean proteins, and complex carbohydrates. If children are on a restricted diet due to allergy or sensitivities to foods or additives (or extreme pickiness), be sure to discuss their diet with your doctor and consider working with a nutritionist to be sure your child is getting all the nutrition needed for proper growth. If supplements are being considered, they should be discussed with your doctor so he or she can help decide which are right for your child.

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

Allergy testing: When to Use It and When to Not

As food allergies have gotten more common, more parents than ever want testing. There are definitely reasons to test, but testing can be expensive, and not all tests are equal. There are also differences between food allergies and food insensitivities. A true allergy occurs when the immune system reacts to something that really is not a threat, but causes measurable symptoms.

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Food allergies are reaction to food proteins because the body's immune system is reacting to something that really shouldn't be a threat. They are different from food insensitivities or intolerances, such as diarrhea and gas from lactose intolerance or red cheeks after eating tomato sauce.

There are three main types of food allergies: immunoglobulin E (IgE)–mediated (immediate) reactions, non–IgE-mediated (delayed) hypersensitivity reactions, and mixed reactions. IgE-mediated reactions are the type we often think about when we hear about a food allergy-- hives, itchy skin, wheezing, vomiting, throat swelling, and anaphylaxis. These reactions can occur immediately following exposure. Non-IgE-mediated allergic reactions can cause localized or generalized reactions, such as a skin rash or stomach upset, or even Celiac disease. Some allergic disorders have components of both IgE and non-IgE mediated types, such as eczema.

Determining if there is a food allergy requires both a history of symptoms with exposure and confirmation testing. In general, there are two different types of allergy testing. Children and adults can be tested by either method, depending on symptoms and other considerations. Both types of testing can lead to false positive results, meaning there is a reaction that makes a person look allergic to that trigger, but they really aren't. That means we have to look at symptoms along with the tests. No one should undergo testing "just to know" if there really aren't specific symptoms to evaluate. This can lead to overestimation of allergies, which can result in patients being on a severely restricted diet and lead to nutritional deficiencies. It also uses healthcare resources inappropriately and drives up healthcare costs.

Available testing:

• The first step is a careful history of exposures and symptoms. This may include a food elimination diet to help diagnose allergies.  
• Skin testing involves scratching a small amount of suspected allergens onto the skin or injecting a small amount of allergen into the skin. It is typically done in an allergist office, though some primary care doctors will offer it. (If you do this type, be sure the doctor has adequate training and does it routinely-- it requires a lot of expertise!) Results are generally known within minutes, based on local reactions to the various allergen areas. It can be uncomfortable for children, but many tolerate it just fine. This type of testing is often less expensive than blood panels. Patients must be off of their allergy medicines for this type of testing, which can be difficult for some severely allergic people. It can also be difficult in people with extensive eczema or other skin conditions. 
• Blood testing involves drawing a sample of blood and running many tests on a single sample. This may be preferred in children who cannot tolerate being off their allergy medicines (they can stay on medicines before testing blood) or in those who will not tolerate multiple skin scratches for the skin testing. It is generally more expensive than the skin testing and results can take a week or so to learn results. Blood tests that are recommended for allergy testing involve testing IgE, one of our immunoglobins that triggers allergy symptoms. There are health care providers who recommend IgG testing for food allergies. These are NOT proven to be of benefit. More on that below.   
• Oral challenges (giving the suspected food to the person and watching for a reaction) is often the best test for food allergies, but obviously can be very risky and should only be done in an experienced doctor's office.

Our website has information on the testing we offer from our office on the Allergy Test Results page. I don't want to duplicate all of that information here.

The driving force to write this post is the number of patients who come to me requesting that I order tests that were recommended by another healthcare provider. I always refuse to order tests that I do not think are indicated or worth while. It is difficult in the space of an office visit to go into all the details of why we don't want to order the labs, but a simple "they aren't recommended" doesn't sit well with families when they have their hopes set on finding answers. Insurance rarely covers non-proven tests, so if you're warned that insurance might not cover testing, that is a red flag that you should investigate further.

What are some of the tests that are not recommended?

There are medical providers who will order IgG panels for food allergies. This is simply not an appropriate test. Both allergic and non-allergic people will have IgG antibodies. They are the normal antibodies used to fight off infections and it is thought that when a food is eaten, the body makes IgG antibodies as a normal response. When food allergic people have been in clinical trials to desensitize their food allergies with immunotherapy, the IgG levels actually go up, despite lessening of clinical symptoms. IgG antibodies show exposure to foods—not allergy. For this reason most people who are tested react to MANY foods and are erroneously told they are allergic to those foods. This severely restricts the foods they are told are safe to eat. I worry that kids will suffer from nutritional deficiencies with such restricted diets. Of course, many of the providers who offer this testing also sell nutritional supplements, so they make money from the "allergies"... Think about it awhile. Do they really care if the test is valid or not? They know the numbers look convincing. They also know the more a person reacts to, the more money is to be made. Maybe they really believe in the tests and their procedures. Maybe they feel it helps. I don't agree and neither do the studies.

Hair analysis is another test that some people will recommend to look for allergies. It simply isn't helpful. At all.

I've had a few patients who have been tested by holding the food while the "specialist" measures arm strength. Supposedly if they are weakened by holding the food they are allergic to it. This is called applied kinesiology and has not been shown to help at all in identifying allergies.

People will take your money. They are usually good sales people. They will claim that labs can't lie and it is based on science. Ask to see the research. Learn to evaluate research first, because sometimes they will show fancy graphs that don't really support anything. But they look impressive. Beware! For some information on how to help learn to be a good judge of whether information is scientifically valid or not, see some of the links below.

Want to learn more? There is a lot of information available!

• More about how blood tests work and why they have false positives: Foodallergy.org 
• More on how skin prick testing works and why they have false positives: Foodallergy.org
• More on IgE testing: ScienceBasedMedicine.org
• More on other unproven diagnostic tests: FoodAllergy.org
• Guidelines for the Diagnosis and Management of Food Allergy in the United States is a comprehensive summary for patients and parents of the guidelines outlining testing for as well as management of allergies. It is important to note that it was published in 2011. (I can't find an update.) The recommendations for influenza vaccine for those with egg allergy has changed since then. It is now recommended to give the influenza vaccine despite an egg allergy. For more information on egg allergy and influenza vaccine, see this update.
• Want to know if what you're reading on the internet is reliable? Take this quick tutorial from the National Library of Medicine. It's free and only takes about 15 minutes!
• Still want to learn more about how to evaluate science? Take a look a the many resources on www.ScienceOrNot.net.

Allergy Tips

photo source: Shutterstock

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. I registered on (and recommend) Pollen.com for free alerts at the beginning of the season to anticipate the need to treat before symptoms begin. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:

• Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. 

• Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. 

• Nasal spray antihistamines are available over the counter and as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 

• Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

• Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

• Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)

• Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

• Wash towels and sheets weekly in hot water.  

• Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 

• Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 

• There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 

• Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  

• Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 

• If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 

What if all of the above isn't helping?

• Maybe it's really not allergies. 

• Allergies to things other than foods are rare before 2 years of age.

• Viruses can cause very similar symptoms to allergies. 

• Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   

• Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!

• Wrong medicine or wrong dose. 

• Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

• Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 

• Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.