Allergy & Asthma Care of Fairfield County

Parental sucking of pacifier may prevent allergy in children

Allergies are very common in industrialized countries. It has been suggested that exposure to harmless bacteria during infancy may be protective against the development of allergy. However, it has been difficult to pinpoint which bacteria a baby should be exposed to, and at what time and by which route this exposure should ideally occur.Swedish researchers at the Sahlgrenska Academy, University of Gothenburg, now report that a simple habit may give significant protection against allergy development, namely, the parental sucking on the baby's pacifier.

In a group of 184 children, who were followed from birth, the researchers registered how many infants used a pacifier in the first 6 months of life and how the parents cleaned the pacifier. Most parents rinsed the pacifier in tap water before giving it to the baby, e.g., after it had fallen on the floor. However, some parents also boiled the pacifier to clean it. Yet other parents had the habit of putting the baby's pacifier into their mouth and cleaning it by sucking, before returning it to the baby.

It was found that children whose parents cleaned the pacifier with their mouths were three times less likely to suffer from eczema at 1.5 years of age, as compared with the children of parents who did not do this. When controlled for other factors that could affect the risk of developing allergy, such as allergy in the parents and delivery by Caesarean section, the beneficial effect of parental sucking on the pacifier remained. Pacifier use per se had no effect on allergy development in the child. Boiling the pacifier also did not affect allergy development in a statistically proven fashion.

Saliva is a very rich source of bacteria and viruses, and the researchers believe that oral commensal microbes are transferred from parent to infant when they suck on the same pacifier. When the composition of the bacterial flora in the mouth was compared between infants whose parents sucked on their pacifiers and those whose parent did not, it was found to differ, supporting this hypothesis. According to "the hygiene hypothesis," the development of allergy can be attributed in part to a paucity of microbial stimulation during early infancy. "Early establishment of a complex oral microflora might promote healthy maturation of the immune system, thereby counteracting allergy development," says professor Agnes Wold who led the study.

Source: B. Hesselmar, F. Sjoberg, R. Saalman, N. Aberg, I. Adlerberth, A. E. Wold. Pacifier Cleaning Practices and Risk of Allergy Development. PEDIATRICS, 2013

Sublingual immunotherapy effective at high doses not currently available in the US.

The Journal of the American Medical Association published a review of the effectiveness of sublingual immunotherapy (allergy drops) in the March 27, 2013 issue. The review analyzed several databases of medical literature through December 2012. They found 63 studies that could be analyzed, and found moderate grade evidence the sublingual immunotherapy decreases nasal and ocular symptoms by more than 40%. Efficacy in asthma was found as well. The conclusion was that the studies analyzed do support the effectiveness of sublingual immunotherapy, but that high quality studies are needed to answer questions regarding optimal dosing. 

An important point made is that there are no sublingual forms of immunotherapy extracts approved for use in the United States. Because of this, sublingual immunotherapy performed in this country is NOT FDA APPROVED. Extracts used in Europe for sublingual immunotherapy are higher dose than those used for injection immunotherapy, other studies have found that the doses required for sublingual immunotherapy are 50-300 times higher than those given by injection. The studies analyzed in this summary used these higher doses, and lower doses have been found in other studies to be ineffective.

Since there are no extracts approved for sublingual immunotherapy, providers offering this in the US use the injectable extracts that are far weaker than required for sublingual immunotherapy. The resulting doses have been shown to have minimal or no effectiveness, far less effective than the doses used in Europe. Unfortunately, some practitioners continue to offer this form of therapy with inadequate doses, which as unnapproved therapy is not covered by insurance and can cost upwards of $1500/year.

High dose sublingual immunotherapy is likely effective, though some studies have shown it is not as effective as injection immunotherapy. When adequate strength extracts are approved and available in the United States, Allergy & Asthma Care will be happy to offer this therapy to our patients. Until then, we will not offer unproven therapy with inadequate doses simply because some other, less scrupulous practitioners do so. The only extracts currently available in the United States are not adequate for effective sublingual immunotherapy. We continue to offer injection immunotherapy for appropriate patients. There are also many other options for controlling allergy symptoms. Our office can be reached at (203)259-7070.

Spring pollen season is here

With the arrival of warm weather (finally,) spring pollen season has arrived as well. For those of you with tree pollen allergy, now is the time to be taking measures to control your allergy symptoms. Avoidance measures, such as keeping windows closed and A/C running, showering in the evening to remove pollen that has collected in your hair before bedtime, and avoiding outdoor activities on high pollen days can all help. Taking your medications on a regular basis is also very important, especially nasal corticosteroid sprays (such as Nasonex, Flonase, Veramyst, etc,) which only work well if taken daily. Taking anthistamines daily is also more effective than taking them only as needed. If you receive allergen immunotherapy (allergy shots,) make sure you are sticking to your schedule. Please see this spring allergy information sheet from the AAAAI for more information. Call us at Allergy & Asthma Care of Fairfield County if your allergies are not well controlled.

Allergy & Asthma Care excited to offer glutathione

We are excited to announce that we have been provided for our patients free samples of glutathione from the premier manufacturer of medical grade glutathione. Glutathione is a natural supplement that is a component of every cell in the body. It is a powerful antioxidant, but also an intracellular "regulator" that is used to regulate many functions in the body, including inflammation. Dr. Harry Demopoulos, founder and CEO of The Glutathione Corporation, patented an exclusive method that converted ordinary glutathione into a form that can be absorbed through the gastrointestinal tract, allowing oral administration. Glutathione is available over the counter as a natural supplement, but only Dr. Demopoulos's patented formulation has been proven to be absorbed orally. A number of excellent publications demonstrate that it safely reduces the levels of IgE (allergic antibody) in the body, leading to improvement in allergic rhinitis and asthma. His glutathione has been confirmed to be safe by the FDA in the FDA file IND 45012. Dr. Demopoulos has provided a large number of samples for us to provide for our patients, and we are happy to offer this for improved control of asthma and allergies. Please schedule an appointment if you are interested in pursuing this safe, non-prescription treatment option. For more information, you can visit www.glutathionescience.com

Oral desensitization for milk allergy loses effectiveness over time

At the recent American Academy of Allergy, Asthma, and Immunology annual meeting, Dr. Robert Wood of Johns Hopkins Medical Center presented data that oral desensitization / immunotherapy for milk allergy appears to lose effectiveness over time:

SAN ANTONIO  --  Among children who underwent oral immunotherapy for milk allergies, fewer than half were able to regularly consume milk without symptoms in the long term, according to updated results from an earlier trial. After 4 to 5 years of follow-up, only 43% of the children in the trial, ages 6 to 16, were able to consume a single serving of milk a day after oral immunotherapy for milk allergy, according to Robert Wood, MD, of Johns Hopkins University, and colleagues.

In addition, some of the participants became far more reactive than they had been earlier in the course of the oral immunotherapy, the authors said. Intolerance of milk consumption was accompanied by frequent reactions in 40% of the kids, systemic reactions in 30%, and the need for epinephrine in 20%, Wood said during a press conference at American Academy of Allergy, Asthma, and Immunology (AAAAI) meeting. "Some of the more dramatic failures were the kids who looked like absolute successes at the end of the study, where they were tolerating huge amounts of milk and they were ... as close to cured as we could possibly imagine," Wood noted, adding that some participants had to go back to strict milk avoidance.

Preliminary results of the study, which compared oral immunotherapy treatment against sublingual dosing of milk proteins, were reported during the 2011 AAAAI meeting. In the earlier presentation, researchers found oral immunotherapy allowed nine of 15 (60%) of severely milk-allergic participants to drink an 8 oz glass of milk during the treatment challenge compared with one of 10 patients treated sublingually. AAAAI president Wesley Burks, MD, who was a co-author on the initial study done from 2006 to 2007, noted that the results gave families and researchers "hope that something could be done, but we're really not there yet."

As part of the study follow-up in 2012, researchers analyzed 13 participants' daily milk consumption status, regular and intermittent adverse reactions, and evaluated predictors of outcome at a median 4.5 years from the start of the study through a phone, in-person, or email interview, as well as a blood sample test for immunoglobulin E (IgE) and immunoglobulin G4 (IgG4). At follow-up, seven of 16 participants were able to consume at least one serving of milk daily, while four could consume some uncooked milk, two would only tolerate minimal amounts of milk, and three could not take any milk. Only 25% could consume milk without symptoms at 3 months, they reported. More than half of the follow-up participants reported frequent symptoms accompanying milk consumption including six systemic reactions and two reactions requiring epinephrine. One participant, who was not symptomatic after passing a 16-gram challenge during the study, became reactive at follow-up and presently only consumes minimal milk.

Long-term outcomes were not associated with baseline or follow-up milk IgE, follow-up milk IgG4, threshold during the food challenge experiment, or results of tolerance challenge after milk avoidance. At baseline, the initial oral food challenge threshold for milk protein for the participants was 40 mg (range 40-1,350 mg). Only food challenge threshold at 3 months of maintenance differed between the groups (P=0.03):

• Group without symptoms: median 8,140 mg (range 4,140-8,140 mg)
• Groups with symptoms or milk avoidance: median 6,140 mg (range 1,340-8,140 mg)

 In the latter two groups, 38% reached full challenge dose.

"We're really worried that the [participants] will leave the study with a false sense of security," Wood said, adding that he'd seen participants lose protection in as early as 1 week off therapy. "Compounded with the fact that these kids don't like the foods they've been allergic to, there's a real inherent risk we need to recognize, and that risk actually scares me a lot more than the recognizable short-term risk" which patients face with monitored dose-escalation, he said. Wood noted that oral immunotherapy "is not yet ready for clinical practice," and that more research is needed with longer follow-up.

Primary source: American Academy of Allergy, Asthma, and Immunology.  Source reference:
Keet C, et al "Long-term outcomes of milk oral immunotherapy in children" AAAAI 2013; Abstract 467

Dr. Kenneth Backman of Allergy and Asthma Care of Fairfield County comments: "Sublingual or oral desensitization for food allergy remains an exciting area of research, and we are very hopeful that this may be a clinical option in the near future. However, the above data emphasizes that much more remains to be learned about this procedure, and for now it is 'not ready for prime time,' and remains appropriate only in research settings."

Peanut oral immunotherapy not ready for clinical practice

In this month's Journal of Allergy and Clinical Immunology: In Practice, Dr. Hugh Sampson, world renowned expert in food allergy, reviewed the medical literature on oral immunotherapy / desensitization for peanut allergy. He concluded that, while some studies have been promising, the current evidence is insufficient to support its use in clinical practice. Specifically - safety, efficacy, and appropriate protocols have not been adequately worked out. The following is the abstract (summary) from the article:

"The prevalence of peanut allergy in the United States and other Westernized countries has tripled in the past 15 years, now affecting more than 1% of the population. Strict peanut avoidance is the current standard of care. In the past decade, a number of small, largely uncontrolled clinical trials have suggested that oral immunotherapy (OIT) can effectively desensitize most children with peanut allergy. Some in the allergy community now feel that OIT is ready for clinical practice. In this review, the evidence base in the medical literature is examined. Although peanut OIT shows promise, the evidence currently available on its effectiveness, risk benefit, and potential long-term consequences is insufficient to support its use in clinical practice. Appropriately designed, prospective clinical trials are urgently needed to determine whether OIT is a safe, effective form of therapy for food allergy." To read the full article, click here.

Reference: J Allergy Clin Immunol: In Practice 2013; 1:15-21. 

Dr. Katherine Bloom of Allergy & Asthma Care of Fairfield County comments: "The prospect of performing immunotherapy / desensitization for food allergies is exciting and promising. However, studies to date have been too small, and there is insufficient safety and efficacy data, to offer this in clinical practice. Until larger studies have been done, this unproven therapy should remain limited to clinical research. When it is proven safe and effective, Allergy and Asthma Care will be excited to offer this treatment to our patients."

Limited supply of influenza vaccine available

Allergy & Asthma Care of Fairfield County is pleased to announce that we have obtained a small number of additional doses of influenza vaccine for ages 4 and up. Unfortunately, we were unable to obtain any additional vaccine for younger children. If you are a current patient of our practice and have not yet received your flu shot, please call our office today. We expect this supply to run out quickly.

Allergen avoidance in infancy reduces asthma risk to age 18

This study published in the journal Thorax (2012;67(12):1046-1051) demonstrates that multifaceted allergen avoidance in infancy can help prevent the risk of asthma in childhood and up to age 18. The interventions studied included breast feeding on a low allergen diet, or using extensively hydrolysed formula(such as Alimentum or Nutramigen.) Dust mite avoidance was also performed through the use of environmental controls that included allergen-impermeable mattress and pillow encasings. The study found a significantly reduced risk of asthma in the active intervention group. Dr. Kenneth Backman of Allergy & Asthma Care comments: "This study helps demonstrate the effectiveness of allergen avoidance measures not just in reducing symptoms, but in actually preventing allergic diseases such as asthma."

Background Asthma is a chronic disease that often starts in childhood. The key risk factors are a child's environment and their genetic characteristics. The aim of this study was to evaluate the efficacy of environmental modification in the first 12 months of life on the prevalence of asthma in high-risk individuals. 

Methods Children (n=120) considered at high risk of allergic disorders (either dual heredity or single heredity and a high cord total IgE), were enrolled in a single-blinded, randomised controlled trial. Infants in the intervention arm were either breast fed with the mother on a low allergen diet or given an extensively hydrolysed formula. Exposure to house dust mite allergen was reduced. The control group followed standard advice. Children were assessed at ages 1, 2, 4, 8 and 18 years for the presence of asthma and atopy.

Results At 18 years of age, there was a significantly lower prevalence of asthma in the prevention group compared with the control group (OR: 0.23, 95% CI 0.08 to 0.70, p=0.01), primarily due to asthma that developed during childhood but persisted until age 18 years. Repeated-measure analysis showed that there was an overall reduction in asthma prevalence from 1 to 18 years (OR: 0.51, CI 0.32 to 0.81, p=0.04). Prevalence of atopy was not significantly different between the two groups at age 18.

Conclusion Comprehensive allergen avoidance in the first year of life is effective in preventing asthma onset in individuals considered at high risk due to heredity. The effect occurs in the early years, but persists through to adulthood.

Source: http://www.medscape.com/viewarticle/774797

Our thoughts are with the people of Newtown, and all the victims of this horrible tragedy.

Pesticides in drinking water may cause food allergies

A recent study published in the journal Annals of Allergy, Asthma and Immunology has found that pesticides in drinking water, which contain a chemical known as dichlorophenol, may be the culprit of some food allergies.

"Our research shows that high levels of dichlorophenol-containing pesticides can possibly weaken food tolerance in some people, causing food allergy," said study author, allergist Elina Jerschow, M.D., M.Sc. "This chemical is commonly found in pesticides used by farmers and consumer insect and weed control products, as well as tap water."

The study looked at 10,348 subjects who participated in the U.S. National Health and Nutrition Examination Survey between 2005 and 2006, 2,548 of whom had dichlorophenols detected in their urine. The researchers found that 411 of these participants, which included an additional 2,211 study participants with dichlorophenols in their urine, had food allergies, while 1,016 of the subjects had environmental allergies.

Jerschow noted that both food allergies and pollution is on the rise, and opting for bottled water might not be completely effective in warding off allergies due to the fruits and vegetables that are treated with pesticides.

Food allergy facts
The Centers for Disease Control and Prevention notes that nearly 4 to 6 percent of children and teenagers who are under 18 years old have food allergies. Nearly 90 percent of all food allergies pertain to cow's milk, eggs, peanuts, tree nuts, fish, shellfish, soybeans and wheat. Some symptoms of food allergies include hives, tingling in the mouth, swelling in the tongue and throat, abdominal cramps, vomiting or diarrhea, dizziness, losing consciousness, eczema, coughing or wheezing.

Ann Allergy Asthma Immunol. 2012:109;420-425

Dr. Kenneth Backman of Allergy & Asthma Care remarks: "We know that food allergies are on the rise, and this interesting study identifies one possible explanation for this. More research in this area is needed."

 

Fast facts about asthma in CT

See the link below. Asthma continues to have a major impact on many of us, and society as a whole. Despite the availability of many excellent treatment options, many people with asthma continue to live with symptoms unnecessarily. If you or a loved one continues to suffer from asthma symptoms, please make an appointment, with us or another asthma specialist, and get appropriate medical care. Asthma is controllable for the vast majority of patients. Our office can be reached at 203-259-7070.

Download 3_Fast Facts About Asthma in CT_2012

Stopping inhaled corticosteroids can lead to worsening asthma

ACAAI 2012 Annual Meeting, Anaheim, California — People whose asthma is stable and who decide as a result to stop taking their controller inhaled corticosteroid are putting themselves at increased risk for an exacerbation of their disease, researchers said here at the American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting.

Current asthma guidelines suggest that patients and their healthcare providers think about decreasing or stopping regular use of controller medications when the asthma is stable, said Matthew A. Rank, MD, from Mayo Clinic, Scottsdale, Arizona. But according to his research, this may not be such a good idea in some patients. "We found an increased risk for asthma attacks in patients who stop their chronic asthma medicines, but also found a large population of people with asthma who do very well after stopping their chronic asthma medicine," Dr. Rank told Medscape Medical News. "We believe that treating patients with the least amount of medicines that controls their symptoms and reduces asthma attacks to an acceptable level is the best way to manage asthma over the long term," he said. Such a treatment plan often involves decreasing or even stopping the long-term use of asthma medicines.

"We wanted data to help patients and their providers make informed decisions about the risks involved in stopping chronic asthma medications," Dr. Rank said. He and his team identified studies that randomly assigned people either to continue or to stop their low-dose inhaled corticosteroids. They then pooled the data to form estimates of risk. The 7 trials in the meta-analysis all had a stable asthma run-in period of 4 weeks or longer and a follow-up period of at least 3 months. According to data pooled from the trials, with a mean follow-up of 27 weeks, individuals who stopped taking their medication after being stable for at least 4 weeks were more than twice as likely to have an asthma exacerbation compared with those who continued to take their medication. The pooled absolute risk showed that 16% of patients who continued their medication had an asthma attack in the next 6 months compared with 38% of patients who stopped their medication ( P < .001). "Doctors can tell their patients who are controlled on low doses of inhaled steroids that their chances of having an asthma attack in the 6 months after stopping are about 1 in 3, while their chances if they continue are about 1 in 6," Dr. Rank said.

Dr. Katherine Bloom of Allergy & Asthma Care of Fairfield County comments: "This article emphasizes the chronic, inflammatory nature of asthma. While some patients are able to stop inhaled corticosteroids after their asthma is controlled, many are controlled because of the inhaled steroids, and stopping treatment leads to a loss of control. It is important to only make changes in medications after discussion with your physician."

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract 40. Presented November 11, 2012.

Effect of inhaled corticosteroids in childhood on adult height

The use of inhaled corticosteroids in children is known to cause a temporary reduction in growth velocity in children. Previous studies have found a reduction in growth in children of 1 to 2 cm, but have also shown that children "catch up" later and reach their predicted adult heights. A new study in the New England Journal of Medicine (NEJM Sept 3, 2012) examined the final adult height in 943 of 1041 participants in the Childhood Asthma Management Program. At the age of 5 to 13 years, patients had been randomly assigned to receive 400 mcg budesonide, 16 mg nedocromil, or placebo daily for 4 to 6 years. Adult heights for each treatment group was compared, adjusting for other patient characteristics and height at trial entry. Mean adult height was 1.2 cm lower in the budesonide group, an inhaled corticosteroid, than in the placebo group. The reduction in height was similar to that seen after only 2 years of treatment. The conclusions of the study were that the initial decrease in attained height associated with inhaled corticosteroids in pre-pubertal children persisted as a reduction in adult height, but the decrease was not progressive or cumulative.

Dr. Kenneth Backman of Allergy & Asthma Care comments: "We've long known that inhaled corticosteroids lead to an initial decrease in growth, but prior studies had suggested that catch-up occurs, and no long-term growth suppression is seen. This study finds an average of 1.2 cm of loss in height in patients treated with moderate dose inhaled steroid for 4 to 6 years starting at ages 5 to 13. While this may at first be alarming, 1.2 cm is less than half an inch. We of course would prefer to see no growth suppression, but loss of less than half an inch in final adult height is a small price to pay for controlled asthma, reduced exacerbations, and ability to play sports and function normally. Oral corticosteroids have a more dramatic effect on growth, so the goal is to avoid the need for these whenever possible. At Allergy & Asthma Care, we always strive to use the least medication necessary to control asthma."

FDA OK's "talking" epinephrine injector

WASHINGTON  --  The FDA has approved the first voice-guided epinephrine injection device (Auvi-Q) for treatment of severe allergic reactions. The device, which gives verbal step-by-step instructions, can be used by children weighing at least 33 pounds who are at risk for, or have a history of, anaphylaxis.

Developed by Sanofi US, the Auvi-Q 0.15 mg/0.3 mg auto-injector comes in a rectangular box that is roughly the size of a credit card, and guides a user through the injection process with audio-visual instructions as well as or written directions. Most epinephrine auto-injectors are in a wand-like form. A video demonstration of the device on the manufacturer's website shows a young user removing the device's outer case, which triggers an audio cue  --  two beeps, followed by the instructions, "If you are ready to use, pull off the red safety guard." The user removes the safety guard and the device then says, "To inject, place black end against outer thigh, then press firmly and hold in place for 5 seconds."

Once the device is firmly pressed, a loud click signals the injection has begun and the device audibly counts down for 5 seconds, alerts the user that the injection is complete, and that the patient should seek emergency medical attention and refill the prescription. A written guide with the same instructions is printed on the side of the box and an "alert light" goes off once an injection is completed. The device contains a retractable needle mechanism that prevents accidental needle sticks after use. The injector will be available in two dosages, with a 0.15 mg dose indicated for patients weighing 33 to 66 pounds. and a 0.3 mg dose indicated for patients weighing more than 66 pounds. The device has not been studied in patients weighing less than 33 pounds. It will be packaged with two epinephrine-containing injectors and an inactive training injector. Each injector contains a single dose of epinephrine. The drug injection system was shown to be bioequivalent in a clinical trial comparing the device with the EpiPen auto-injector.

The device should only be used on the outer thigh. Patients who inject other parts of their body should seek emergency medical attention.Patients taking other medications may be at risk of developing serious adverse events with administration of epinephrine, including increased heart rate, irregular heartbeat, sweating, nausea, vomiting, difficulty breathing, paleness, dizziness, weakness, headache, apprehension, and anxiety.

Dr. Irena Veksler of Allergy & Asthma Care of Fairfield County comments:"It will be good to have another option of epinephine autoinjector available to our patients. The smaller size will be better for people who need to carry the device in their pocket, and the voice instructions should reduce mistakes with administration."

Oral immunotherapy promising for children with egg allergy

Oral immunotherapy represents a promising therapeutic intervention for children with egg allergy, according to a study published in the July 19 issue of the New England Journal of Medicine.

A. Wesley Burks, M.D., from the Duke University Medical Center in Durham, N.C., and colleagues conducted a double-blind, randomized, placebo-controlled study involving 55 children (aged 5 to 11 years) with egg allergy who were allocated to receive oral immunotherapy (40 children) or placebo (15 children). Initial dose-escalation, build-up, and maintenance phases preceded an oral food challenge at 10 and 22 months with egg-white powder. At 24 months, children underwent an oral food challenge to test for sustained unresponsiveness, and those who passed were placed on a diet with ad libitum egg consumption.

The researchers found that, after 10 months of therapy, 55 percent of those who received oral immunotherapy passed the oral food challenge, compared with none who received placebo. After 22 months, desensitization was observed in 75 percent of children in the oral-immunotherapy group. At 24 months, 28 percent of the oral-immunotherapy group passed the oral food challenge and were considered to have sustained unresponsiveness. All children who had passed the 24-month oral food challenge were consuming eggs at 30 and 36 months. Small wheal diameters on skin-prick testing and increases in egg-specific immunoglobulin G4 antibody levels were the immune markers that correlated with passing the oral food challenge at 24 months.

"These results show that oral immunotherapy can desensitize a high proportion of children with egg allergy and induce sustained unresponsiveness in a clinically significant subset," the authors write.

Dr. Kenneth Backman of Allergy & Asthma Care of Fairfield County comments: "This is an exciting study that demonstrates the effectiveness of oral desensitization for food allergies. However, the author points out that further research is needed to determine the risks of this treatment, as well as the optimal dosing, and so for now this remains an experimental treatment not recommended for patients."

Baked egg tolerance in many egg allergic patients

Most egg-allergic patients will ultimately outgrow their allergy over time. However, new studies suggest that in addition to an overall increase in food allergies over the past 20 years, there appears to be progressive delays in the development of tolerance in these individuals. We have known for several years that the majority (up to 70%) of egg-allergic patients can tolerate egg in an extensively heated (baked) form. What was not clear is whether eating baked egg would help or hinder the person’s natural ability to outgrow their egg allergy. Furthermore, more studies needed to be done to determine which patients might be tolerant of baked egg and whether performing oral challenges with baked egg would be safe. Until now, the majority of baked egg challenges have been offered as part of a clinical trial and have been performed in hospital settings. In the latest issue of the Journal of Allergy and Clinical Immunology, new data from the Jaffe Food Allergy Institute at the Mount Sinai Medical Center provides helpful information regarding which patients are eligible for baked egg challenges and that open challenges are safe to do in an allergy office. 

Allegy & Asthma Care of Fairfield County is pleased to begin offering baked egg challenges in our office for those that are eligible based on their past history and testing results.  We are thrilled to be able to offer this service to our egg-allergic patients.  For those that pass, this will not only benefit them by expanding  their diet, leading to positive effects on nutrition and quality of life, but may also accelerate the development of tolerance to egg in all forms. Please call to schedule an appointment to see if a baked egg challenge is appropriate for you or your child. Do not try baked egg at home, as some egg allergic patients can have severe reactions.

Vitamin D insufficiency may increase risk of adverse effects of corticosteroids on bone

Inhaled and oral corticosteroids are often used to treat acute and chronic asthma. The negative effects of corticosteroids on bone mineral density are well established, particularly when given orally or intravenously. Vitamin D insufficiency, a condition present in about 55% of the US population, has also been associated with decreased bone density. However, the combined effect of vitamin D insufficiency and exposure to corticosteroids on bone health in people with asthma has not been well studied.

In their article in The Journal of Allergy & Clinical Immunology (JACI), Tse et al examined whether children with asthma who have lower vitamin D levels were more susceptible to the adverse effects of corticosteroids on bone mineral accretion, which represents the average gain of bone mineral density over time. A total of 780 children were followed over a period of approximately four years as part of the Children Asthma Management Program (CAMP) trial and had their bone mineral density measured at the beginning and the end of the trial.

The researchers found that vitamin D insufficiency at the beginning of the trial exacerbated the negative effect of oral corticosteroids on bone mineral accretion over the four years in boys. This effect was most notable in boys taking the equivalent of two or more courses of oral corticosteroids per year. The combined effects of vitamin D insufficiency and exposure to oral corticosteroids were not seen in girls, possibly due to their overall more advance pubertal and bone maturational stages, which can lead to decreased susceptibility to the negative effects of vitamin D insufficiency and corticosteroids on bone density.

These findings by Tse et al may have important clinical implications given the high prevalence of vitamin D insufficiency and the common usage of oral corticosteroids in children with asthma. Further research is needed to explore whether vitamin D supplementation can confer clinical benefits on bone health in this situation, especially in boys with poor asthma control. 

Early life skin contact with peanut may increase risk of peanut allergy

A recent study published in Allergy, the European Allergy Journal, found that early life skin exposure to peanut may increase the risk of peanut allergy. Researchers at the Guy’s and St. Thomas’ NHS Foundation Trust, St. Thomas’ Hospital in London, looked at the blood cells of children with peanut allergy and compared them to children who are not allergic to peanuts. They found immunologic signals on peanut reactive lymphocytes, white blood cells involved in allergy, that point to skin as the first site of exposure to peanut. (Chan SM, Turcanu V, Stephens AC, Fox AT, Grieve AP, Lack G. Cutaneous lymphocyte antigen and α4β7 T-lymphocyte responses are associated with peanut allergy and tolerance in children. Allergy, Vol. 67, Issue 3, pages 336-342, March 2012)

Dr. Irena Veksler of Allergy & Asthma Care of Fairfield County comments: "Previous studies have found evidence that early skin exposure to peanut allergens may increase the risk of peanut allergy, and this study provide evidence of an immunologic mechanism for these findings. This is an exciting area of research that will hopefully lead to further understanding of how people develop new food allergies."

CT Magazine again names Dr. Backman a Top Doc

Kenneth Backman, MD, who is board certified in Adult and Pediatric Allergy and Immunology, has again been selected as one of the "Top Doctors In Connecticut" by Connecticut Magazine. Dr. Backman received his bachelor of science in Biology with distinction from Yale University, and his medical degree from Cornell University Medical College. Allergy and Asthma Care of Fairfield County is located in Fairfield and Monroe. Connecticut Top Docs

Sublingual Immunotherapy drops - still little evidence for effectiveness in US

March 7, 2012 (Orlando, Florida) — A keen interest in sublingual immunotherapy (SLIT) for allergy is evident here at the American Academy of Allergy, Asthma and Immunology (AAAAI) 2012 Annual Meeting, but the reported increased use of this therapy in nonresearch settings is "disturbing," according to one expert who spoke at the meeting." SLIT is used in many parts of the world. It is commonly used in Europe, but in the United States, there are no FDA [US Food and Drug Administration]-approved SLIT medications," explained Michael Blaiss, MD, speaking at a State-of-the Art session on SLIT in the United States. Dr. Blaiss, who is a clinical professor of pediatrics and medicine at the University of Tennessee Health Sciences Center in Memphis, said it is disturbing to witness the use of SLIT in the "remote practice of allergy," meaning by nonallergists. "Even more disturbing to me is seeing more and more board-certified allergists doing SLIT off-label in the United States." I think it's still less than 10%, but we do know there's a growing use of SLIT by groups of otolaryngologists around the country, and by family physicians," he told Medscape Medical News. About 6% of allergists use SLIT, according to 2 surveys — one conducted in early 2007 by the American College of Allergy, Asthma, and Immunology and the other conducted in late 2009 by the Joint Council of Allergy, Asthma, and Immunology, he noted. "There are lots of people giving extracts that are approved for subcutaneous use...sublingually. I have concerns about that because we don't know the true efficacy or the true safety," he said. Many studies have found that these low doses are ineffective.

In the United States, most SLIT is being used (non-approved) for allergic nasal disease; much less is being used for food allergy, confirmed Wesley Burks, MD, president-elect of AAAAI and chief of pediatric allergy and immunology at Duke University in Durham, North Carolina. Dr. Burks is involved in several trials of SLIT — for milk and for peanut allergy — but he said it will be important to confirm its safety before people think about using SLIT in clinical practice. "What we don't really understand is the safety profile. It was originally thought to be very benign. What we've seen in our studies, although the numbers are small, is that there are a few people who really will have systemic allergic reactions to it. If they take the drops and they cough or they aspirate in any way, you can have a serious systemic allergic reaction. It has happened in several instances," he warned. In addition to questions about safety, there is the question about efficacy, said Dr. Blaiss.

"Patients need to be informed this is off-label; it's not approved by the FDA and we don't have clear data that this particular product has the levels of allergen that will work to control the condition. What the studies show is that if [the patient] isn't given enough of the allergen, [he/she] is not going to show clinical benefit." He sees a long road ahead before SLIT is approved by the FDA. "It's really still not clear from the FDA what is going to be required for the approval of SLIT in the United States. There's a much higher hurdle, compared with typical treatments and medication [in allergy], because what we're talking about here is not a medication — we're really talking about a vaccine."For vaccines, the FDA is going to set a higher standard as far as efficacy and safety, Dr. Blaiss said. With few good studies to date, many questions remain, such as the optimal dose and when it should be given, particularly with seasonal allergies, he said. "Most of our patients are polysensitized; when we're treating subcutaneously, they are getting multiple different allergens. What happens when we do this with SLIT? One study showed that the efficacy was not the same when SLIT used multiple allergens."

If and when the FDA starts to move in the area of immunotherapy, approval will likely come first for oral (tablet) immunotherapy, Dr. Blaiss said. Either way, the concept of immunotherapy is an exciting one because of its disease-modifying potential, he explained. "Can the use of SLIT in children with atopic rhinitis prevent or block the atopic march? Can it prevent the development of asthma and other allergies? The future for us and SLIT...is definitely exciting," he said. American Academy of Allergy, Asthma, and Immunology Annual Meeting, Orlando, Florida, March 2012

Dr. Irena Veksler of Allergy & Asthma Care comments:"Sublingual immunotherapy drops remain unproven, and the extracts used (off-label) in this country have been shown to be ineffective for allergies. While some unscrupulous offices may offer this treatment, until highly potent drops are available and proven safe and effective, this treatment should not be used in the United States. If and when these effective extracts are available, we will be thrilled to offer them to our patients."

Reflux meds no help for children with asthma

According to a study published in the January 25 issue of the Journal of the American Medical Assocation (JAMA), the commonly used reflux medication lansoprazole (Prevacid), part of the family of medications known as proton pump inhibitors (PPIs,) does not help control asthma in children who do not experience reflux symptoms. A previous study found that esomeprazole (Nexium,) another PPI, did not help asthma in adults.

 Children with asthma that is difficult to control are often prescribed these medications, with the hope that control of "silent" reflux will help improve asthma control. This study, unfortunately, found that this practice is ineffective in children who have not displayed signs of reflux related symptoms. Even when looking only at children with proven reflux by pH probe monitoring, there was no improvement seen in asthma control when taking PPIs. Since children in this study who were taking reflux medicine had a higher rate of respiratory infection, and showed a trend toward an increased rate of activity-related bone fractures, this treatment may be incurring some risk without clear benefit. Martinez FD "Children, asthma, and proton pump inhibitors: costs and perils of therapeutic creep" JAMA 2012; 307: 406-407.

Dr. Kenneth Backman of Allergy & Asthma Care points out: "While this is only one pediatric study, it raises important questions about the clinical benefit of PPIs in asthma control, when patients do not experience reflux symptoms. If asthma improvement is not clearly seen on PPI treatment, it is worth considering a trial off these medications."

Epipen cap warning issued by distributor

Taking the cap off an EpiPen incorrectly when treating a severe food allergy could potentially result in failure to deliver the drug, the distributor of the device says.

Health Canada said Friday that Pfizer Canada, distributor of the EpiPen and EpiPen Jr autoinjectors, says the blue safety cap on the device should be removed by pulling the cap straight up while holding the orange tip downward.

"It has recently come to our attention that removal of the blue safety cap the wrong way by pulling it sideways or bending and twisting it off may prevent the device from working properly and potentially result in failure to deliver the drug," the company said in a release Thursday.

The company also said patients should:

• Continue to carry their EpiPen or EpiPen Jr at all times.
• The blue safety cap should not be removed until you need to use the medication.

Patients are advised to review the safety information regularly and check that the device hasn’t been unintentionally activated, Health Canada said

Allergy injections as effective as medication as early as first season

A recent study published in the Journal of Allergy and Clinical Immunology (JACI) found that allergen specific immunotherapy (allergy injections) were at least as effective as medications as early as the first season of treatment. The study involved a review of meta-analyses (large scale statistical analyses) of large well controlled tirals of immunotherapy. They analyzed outcomes of the patients involved in the studies, comparing those on medication vs. those on allergen injections. Improvement on immunotherapy exceeded that of several medications, and was similar to mometasone nasal sprays, even during the first season of treatment. (JACI October 2011, pp791-799)

Dr. Kenneth Backman comments: "The effectiveness of allergy injections has been demonstrated in many well controlled trials, and we know that over time, the improvement often exceeds that seen with medications alone. We also know that the effects often persist for many years after injections are discontinued, and this long-lasting effect is a major advantage of allergen immunotherapy over other treatment options. This study demonstrates that effectiveness can be seen within the first season of treatment, which is faster than we often expect. Of course, some patients may not see improvement for over a year, but most will see marked improvement in symptoms within 1 1/2 years." Please call Allergy & Asthma Care of Fairfield County for more information about allergy treatment options.

Mold exposure during infancy increases asthma risk

ARLINGTON HEIGHTS, Ill. (August 2, 2011) – Infants who live in “moldy” homes are three times more likely to develop asthma by age 7—an age that children can be accurately diagnosed with the condition. Study results are published in the August issue of Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI).

“Early life exposure to mold seems to play a critical role in childhood asthma development,” says Tiina Reponen, PhD, lead study author and University of Cincinnati (UC) professor of environmental health. “Genetic factors are also important to consider in asthma risk, since infants whose parents have an allergy or asthma are at the greatest risk of developing asthma.”

UC and Cincinnati Children’s Hospital Medical Center researchers analyzed seven years of comprehensive data for 176 children to evaluate the effects of mold exposure in early life. The children were part of the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS), a long-term population-based study that included more than 700 children from the Greater Cincinnati area. CCAAPS looked at the effects of environmental particles on childhood respiratory health and allergy development. Participants were identified during infancy as at high risk to develop allergies based on family medical history.

Eighteen percent of children enrolled in CCAAPS were found to be asthmatic at age 7. It is estimated that about 9 percent of school-age children in the United States will develop asthma; however, studies have shown that rates are often higher in children from poor, urban families.

”The symptoms of pediatric asthma range from a nagging cough that lingers for days or weeks to sudden episodes of shortness of breath and wheezing that require emergency treatment,” says allergist David Bernstein, MD, study co-author, UC professor of internal medicine and ACAAI fellow. “If a young child’s symptoms persist and keep coming back, that’s a clue that it could be asthma.”

According to the ACAAI, common symptoms of asthma include:

• Coughing, especially at night
• Wheezing or whistling sound, especially when breathing out
• Trouble breathing or fast breathing that causes the skin around the ribs or neck to pull in tightly
• Frequent colds that settle in the chest

“This study should motivate expectant parents—especially if they have a family history of allergy or asthma—to correct water damage and reduce the mold burden in their homes to protect the respiratory health of their children,” adds Reponen.

Be food allergy ready this school year

Starting the conversation with schools about food allergy preparedness can be a challenge, but it's an essential step in creating a safe and healthy environment for everyone. The Food Allergy Initiative and the Food Allergy & Anaphylaxis Network have teamed up to create new training and preparedness programs for teachers, administrators, and school personnel. Find it at allergyready.com.

Dr. Kenneth Backmand of Allergy & Asthma Care of Fairfield County comments: "This is a wonderful resource for school personnel to become familiar with the complex and very important issues surrounding food allergy in school."