Peanut allergy prevention

For years pediatricians told parents to avoid peanuts for the first years of life to help prevent peanut allergies. 

It appears we were wrong.

Studies for the past several years have supported giving infants peanut products as early as 4 months of age as long as there was no increased risk of allergy to peanuts. This seemed to help prevent them from becoming allergic to peanuts. I know I was nervous for at least a year every time I told parents it was okay to start peanut products during that first year of life since I had preached caution for 10 years in practice. Not only was it an allergy risk, but also a choking risk for infants. In the years that I've recommended it, I do think the number of kids I see with peanut allergy has dropped and I haven't heard of any problems with early introduction.

And it gets better...

A newer study shows that even in children at high risk for peanut allergy, giving peanut products starting at 4 months might prevent them from developing allergy. Of course if there is a family history of peanut allergy or if the child has significant eczema or egg allergy, parents should use caution and talk with their pediatrician to see if skin prick testing should be done before starting peanut products. Skin prick testing can be done to show if they are allergic before introducing peanuts. If they are allergic, they must avoid peanuts and carry an epinephrine device at all times in case of accidental exposure until they are desensitized and given clearance by an allergist. But if they aren't yet allergic, giving peanut product regularly seems to prevent the allergy from developing in 86% of the high risk children by age 5 years. They even show a 70% reduction in peanut allergy among those who were sensitized to peanut (positive skin prick test) at the beginning of the study. In the study, a group of children ate a peanut-containing snack at least three times a week while the other group did not eat any foods containing peanut. By the age of 5, just 3% of the children who ate the snack developed peanut allergy, while 17% in the avoidance group developed peanut allergy. Future studies will be done with those children who were high risk but without allergy to peanuts stop the peanuts for a year to see if they develop allergies later in childhood.

Families of allergic children live in fear of accidental exposure and must change lifestyles to prevent deadly exposures. It can even be difficult for families without allergic children because they must avoid a list of foods that cannot be served at school parties. This new research showing that there's a way to prevent this potentially deadly allergy is very exciting!

Take away points:

• If your child is high risk of having a peanut allergy due to moderate to severe eczema, egg allergy, or family history of peanut allergy, talk to your pediatrician before your baby starts peanuts to decide if allergy testing is recommended.
• If there are no risk factors for peanut allergy, it is okay to begin peanut products (such as peanut flour, thin peanut butter, peanut butter in baked goods) when other foods are introduced, between 4 and 6 months of age. Offer peanut products several times each week.
• Do not give any texture of food that increases choking risk to your baby, such as a thick layer of peanut butter or hard nuts.
• I'm waiting for the US food industry to start making baby peanut products... I'm sure they'll see money in it. The study from Israel mentioned above used Bamba. I'm waiting for those to enter our market!
• Talk to your pediatrician with any questions!

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.

Created at http://www.wordle.net

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.