Nobody likes getting a shot, especially children.
However, US health guidelines recommend annual influenza vaccination of
children, especially those with asthma, and including those with egg allergy.
Live attenuated influenza vaccine (LAIV) is an intranasal vaccine administered
via the nose licensed for use in children. However, this vaccine contains egg
protein and it is currently suggested that it not be used on children with egg
allergy. Furthermore, North American guidelines recommend against its use in
children with asthma. Thus, asthmatic or egg allergic children receive a
traditional flu shot.
In a study recently published online by The Journal of Allergy and Clinical
Immunology (JACI), Turner and colleagues present the results of the
SNIFFLE-1 Study. In this study, 433 doses of LAIV intranasal flu
vaccine were administered to 282 children with egg allergy. Two thirds of
the children also had a physician diagnosis of asthma/recurrent wheezing and
41% had experienced a prior anaphylactic (severe allergic) reaction to egg.
The study found that influenza vaccination using LAIV was safe in egg-allergic
children – including those with a prior history of anaphylaxis – with no
systemic allergic manifestations seen. Eight children experienced mild short
lived symptoms, which may have been due to an IgE-mediated allergic
reaction. However, noting the intranasal reaction thresholds to egg, the
authors suggest these reactions were not likely to have been caused by egg
protein and were probably due to other ingredients in the vaccine.
Importantly, in those children with a history of asthma or recurrent wheezing,
there was no significant increase in respiratory symptoms requiring medical
treatment in the 72 hours following vaccination with LAIV. This suggests that
the current guidelines may be unnecessarily over-restrictive in terms of this
vaccine’s use in patients with asthma or egg-allergy. This study may help lead
to changes in the current guidelines and make an annual flu vaccine more
pleasant for kids with asthma and egg allergy.
have become an increasing public health issue. Recent studies now indicate that
nearly 1 in 13 children are diagnosed with food allergy. Food allergies are
triggered when the immune system make a special type of antibody, called IgE,
directed against foods. On re-exposure to the food, the IgE antibody can
trigger severe, even life threatening allergic reactions.
The diagnosis of
food allergy is typically done through a combination of a detailed medical
history coupled with specific food allergy testing. Classically, such testing
is through skin prick testing where a small amount of the food is applied to
the skin and the skin is then pricked with a small sterile probe, allowing the
liquid to seep under the skin. After about 20 minutes, a hive (a bump similar
to a mosquito bite) may form indicating allergy. More recently, a blood based
test commonly referred to as RAST or Immunocap testing has grown increasingly
popular. Unfortunately, these blood based tests can be overly sensitive and
have false positive results. This can lead to misdiagnosis of food allergy
which leads to unnecessary food avoidance, unnecessary medication
prescriptions, and increased cost.
In a recent
study in Journal of Pediatrics, Bird and colleagues at the University of
Texas Southwestern Medical Center and Dell Children’s Medical Center in Dallas
reviewed the charts of 797 patients referred for evaluation of possible food
allergy. They selected patients in whom the primary care provider had ordered a
standard panel of food-specific IgE tests. Such a panel was done in 284 (35%)
of all patients. Of these, only 90 patients (32.8%) had a history that
warranted such testing.
altered in 126 of patients based on the initial testing. Of these, 72 did not
have histories suggestive of food allergy and all of these individuals were
found to not have food allergy. In total, 112 (88.9%) of the 126 patients who
were avoiding foods were able to reintroduce at least one food. It was
estimated that the cost associated with those patients whose history did not
warrant food allergy testing was $79, 412.
The diagnosis of
food allergy hinges on a detailed history and physical exam. Food-specific IgE
testing is a vital tool used to confirm food allergy. This study, however,
highlights that panels of food specific IgE tests have little utility as a
screening tool. Such panels often result in the over-diagnosis of food allergy.
A ‘positive’ test does not automatically translate into clinical food allergy,
as a significant proportion of individuals with a positive test are not
Partners physicians are Board Certified Allergist-Immunologists. This means
that they have undergone two to three years of specialized training in the
diagnosis, treatment and management of allergic diseases, including food
allergy. They have expertise in the interpretation of food allergy test results
and are equipped to offer food challenges which are the definitive test for the
diagnosis of food allergy. If you are concerned about food allergy, contact
your Allergy Partners physician.
Source: Bird JA,
Crain M, Varshney P. Food Allergen Panel Testing Often Results in Misdiagnosis
of Food Allergy. J Pediatrics 2014:166(1):97-100.
Food allergies are due to an immune system reaction that occurs
soon after eating a certain food. They affect about one in twenty
Americans, with cases occurring at any age, but most commonly in babies and
young children. While any food may cause an allergic reaction, eight types of
food account for about 90 percent of food allergies: milk, egg, soy, wheat, peanuts,
tree nuts, shellfish and fish.
of a food allergy vary significantly from person to person, as does the amount
of food needed to trigger an allergic reaction. While most food-related
symptoms occur within two hours of ingestion, in some rare cases, the reaction
may be delayed by four to six hours or even longer. Common symptoms of a
food-related allergic reaction include: digestive
problems, hives or swollen airways. The most severe allergic reactions
may result in anaphylaxis, which can impair breathing, cause a dramatic drop in
blood pressure, and affect heart rate to a fatal degree.
patients may experience an itching and/or tingling feeling in their mouths
after consuming certain fruits, which is referred to as pollen-food allergy
syndrome or oral allergy syndrome. For example, patients allergic to birch
pollen can have this reaction when eating an apple. In rare cases, pollen-food
allergy syndrome can lead to anaphylaxis.
diagnosis of a food allergy generally requires a thorough medical history of
the patient including what and how much you ate, how long it took for symptoms
to develop, what symptoms you experienced and how long it lasted. Your doctor
may order skin and/or blood tests in making a diagnosis. However,a “positive”
result on any one test is not an absolute indication of a food allergy.
Allergists rely on their experience to properly interpret the results of tests
within the overall context of the patient’s medical history and properly
diagnose a food allergy. If you suspect you have a food allergy, talk to your
Allergy Partners physician to determine what method of diagnosis is most
this test, a tiny amount of liquid containing suspected food is placed on the
skin of your arms or back. The skin is then pricked with a small sterile probe,
allowing the liquid to seep under the skin. After about 20 minutes, a hive (a
bump similar to a mosquito bite) may form and will be compared to the bump at
the site of the control, where a liquid not containing any allergen is placed.
blood test (commonly known as RAST or ImmunoCAP) detects the presence of
allergen-specific antibodies known as
immunoglobulin E (IgE) antibodies. Additionally, a relatively new test,
called a “component test” can be ordered to gain more specific information and
is mostly used for peanut allergies. Blood tests have been used extensively but
often are not specifically based on patients’ detailed diet diary. When not
properly utilized, the results of a blood test can be very confusing and may
lead to unnecessary food restriction. Allergy Partners allergists use their
experience to determine when a blood test may be helpful and to properly
interpret the results of the blood test.
are a number of non-standardized tests that are advertised as helping diagnose
food allergy. These tests include allergen-specific IgG blood tests, antigen
leukocyte cellular antibody tests, hair analysis, and applied kinesiology.
Their use in the diagnosis of food allergy is not advised.
an oral food challenge, small increment amounts of food are fed to the patient
over a period of a few hours to determine if a reaction occurs. Due to the
possibility of a severe reaction, it must be conducted under medical
supervision by an experienced doctor and in a facility with emergency
medication and equipment on hand. The gold standard for a food challenge is one
that is double-blind and placebo-controlled, though it may still have very good
diagnostic value when lacking these conditions.
allergies can be challenging and stressful, so knowing what you or your child
is eating is an important first step. If you have doubts about a possible food
allergy, err on the side of caution until you have a chance to speak with an
Allergy Partners physician.
Sleep apnea is a common disorder in which you have one or more pauses in
breathing or shallow breaths while you sleep. Breathing pauses can last from a
few seconds to minutes and they may occur 30 times or more an hour. Typically,
normal breathing then starts again, sometimes with a loud snort or choking
sound. Sleep apnea usually is a chronic (ongoing) condition that disrupts your
sleep. As a result, the quality of your sleep is poor, which makes you tired
during the day. Sleep apnea is a leading cause of excessive daytime sleepiness.
More importantly, sleep apnea can increase your risk of high blood pressure,
heart attack, stroke, diabetes and obesity.
There is evidence
suggesting that a relationship exists between asthma and obstructive sleep
apnea. A recent study in the Journal of the American Medical
Association investigated if having asthma increased the risk of developing
obstructive sleep apnea (The
Association between Asthma and Risk of Developing Obstructive Sleep Apnea. JAMA
2015: 313 (2):156-164.).
This study used a population that consisted
of adults who had overnight sleep studies completed at 4 year intervals
starting in 1988 (The Wisconsin Sleep Cohort Study). Asthma and additional
information was assessed during these studies through March 2013.
The results found that participants with
bronchial asthma had a significantly higher incidence of developing obstructive
sleep apnea (27%) at their first 4 year follow up interval sleep study, versus
16% of the participants without asthma who developed sleep apnea at that
interval. Using all 4 year interval studies, there was also a significantly
higher percentage of participants with bronchial asthma who developed
obstructive sleep apnea (27% ), versus 17% of non-asthmatic participants who
developed obstructive sleep apnea.
In summary this study found that
preexistent asthma was a risk factor for an asthmatic patient developing
clinically relevant obstructive sleep apnea over a 4 year period. It was also
found that the longer the time a patient had bronchial asthma, the more likely
that the patient would develop obstructive sleep apnea.
Therefore, obstructive sleep apnea should
be considered in asthmatic patients with symptoms suggestive of sleep apnea,
and especially those patients who have a history of long-standing bronchial
asthma. Symptoms of sleep apnea include snoring, choking or gasping while
sleeping, daytime sleepiness, or not feeling well rested after sleep.
Identifying and treating obstructive sleep apnea in asthmatic patients has been
found to be beneficial, since another study has shown that treating obstructive
sleep apnea in patients with asthma leads to improvement in asthma symptoms,
improved air movement and improved quality of life.
If you think you have a sleep problem, consider keeping a
sleep diary for 1 to 2 weeks. Bring the diary with you to your next doctor’s
appointment. Write down when you go to sleep, wake up, and take naps. Also
write down how much you sleep each night, how alert and rested you feel in the
morning, and how sleepy you feel at various times during the day. This
information can help your doctor figure out whether you have a sleep disorder.
SLIT is an alternative method of allergen desensitization in
the management of atopic conditions such as asthma and allergic rhinitis, which
does not involve a series of injections. The protocol for SLIT involves
an allergist determining a patient’s sensitizing allergens, typically by skin
testing, followed by small doses of these allergens placed under the tongue
daily in the form of tablets or drops. This causes a decrease in the
body’s natural production of specific allergic antibody, called IgE.
Though SLIT is widely accepted and standard in Europe, not
all SLIT therapy is approved in the US by the Food and Drug Administration
(FDA). A tablet form of SLIT for patients with grass and ragweed allergy
(GRASTEK, ORALAIR, RAGWITEK) has been FDA approved and is currently available
for physicians to prescribe. While yet to be approved by the FDA,
sublingual drop therapy formulated by your Allergy Partners physician is
available for “off label” use.
Does it Work?
There is mounting evidence that SLIT is an effective treatment
strategy in the management of allergic conditions. A recent systematic
review in the Journal of the American Medical Association states: “The overall evidence provides a moderate grade level of
evidence to support the effectiveness of sublingual immunotherapy for the
treatment of allergic rhinitis and asthma, but high-quality studies are still
needed to answer questions regarding optimal dosing strategies.”1Though
evidence supports SLIT being more efficacious compared to some traditional
treatment strategies, it is very clear that subcutaneous injection
immunotherapy (allergy shots) is favorable to SLIT in reducing allergy
What Are the Side Effects?
In general, SLIT is well tolerated. Patients may have
oral itching or mild tongue swelling after the first 3-4 doses. However,
these symptoms typically subside. Other potential side effects
include: trouble breathing, throat tightness, throat swelling, dizziness,
rapid heartbeat, severe stomach cramps, vomiting, diarrhea, and severe flushing
of the skin. As there is risk for anaphylaxis, all patients on SLIT
therapy should have access to an epinephrine pen and be trained on its use and
the first dose of SLIT is administered in a physician’s office.
Is it For Me?
There are certainly advantages to SLIT. Published data
does demonstrate clinical efficacy and you can expect to see improvement in
your allergy symptoms. For patients with busy schedules, SLIT makes
immunotherapy less cumbersome as treatment can be given at home. For
children with “needle phobia,” SLIT provides an alternative option to avoid
weekly injections. Although allergy shots are the most efficacious form
of immunotherapy, there undoubtedly is a role for SLIT in the management of
allergic disease. Talk to your Allergy Partners physician about whether
SLIT is the best option for management of your allergy symptoms.
Sublingual immunotherapy for the treatment of
allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013 Mar
Food allergy is estimated to affect 5 to 7% of infants and 1
to 2% of adults. Currently there is no cure for food allergy and patients must
adhere to a strict regimen of dietary avoidance of foods to which they are
allergic. Despite the best of intentions, accidental exposure to food allergens
remains a significant cause of allergic reactions. To avoid such exposure, food
allergic patients and their families rely on food package labels to identify possible
The Food Allergy Labeling and Consumer Protection Act of
2004 requires packaged foods sold in the United States to clearly list the
eight primary food allergens in plain English on the ingredient label. These 8
foods are milk, egg, wheat, soybean, peanut, tree nuts, fish and shellfish.
However, for foods that may accidentally contain small amounts of allergens-
such as being produced in a factory that handles the allergen- precautionary
labels may be applied to food products as well. Such precautionary labeling is
neither consistent nor regulated. Food allergic patients have varying levels of
tolerance to allergens and such precautionary labels could lead to confusion
and unnecessary risk taking behavior.
In January, Medical News Today reported on a study published
in the Journal of Allergy and Clinical Immunology (January 2015) by the
research team led by Clare Mills, PhD of the Institute of Inflammation and
Repair at the University of Manchester in the UK. Researchers sought to better
define the threshold doses of 5 major food allergens (peanut, hazelnut, celery,
fish and shrimp) in a European population. What researchers were able to
demonstrate was that for these foods there is threshold dose below which only
10% of allergic subjects will react. Though more research is needed, such new
data could help better identify allergen doses that are safe versus those doses
which may trigger a reaction. This information would help improve patient
safety through refined product labeling.
These new findings highlight how essential it is for
patients with suspected food allergy to be evaluated by an allergist who will
not only assess but help minimize the risk for future food reactions.
“Study identifies levels at which five foods may
trigger allergic reactions” Medical News Today. January 2015.
Mills C et al. How much is too much?: Threshold
dose distributions for 5 food allergens. J Allergy Clin Immunol 2014, published
online January 2015, abstract.
Peanut allergy can result in severe, and at times fatal,
allergic reactions. Unfortunately, peanut allergy has become more and more
common over the years. A new study, however, gives hope that early
interventions may decrease the risk of developing peanut allergy.
A recent study published in the New England Journal of
Medicine suggests that early exposure to peanuts helps to prevent peanut
sensitization in high risk children. The study was performed in response
to the significant increase in the incidence of peanut allergy worldwide,
especially in westernized countries, such as the United States. The most
recent recommendations by the American Academy of Pediatrics (AAP) came in
2000, in response to outcomes from infant feeding trials conducted in Europe
and the United States. At that time, the AAP recommended refraining from
introduction of peanuts to children until age 3. Despite this recommendation,
the incidence of peanut allergy continues to rise, and in 2008, the AAP
retracted its recommendation due to insufficient evidence. Since that
time, multiple observational studies have found that early introduction of
peanut protein, as well as cow's milk and egg, result in decreased incidence of
these food allergies.
In a new study by Du Toit et al., Learning Early about
Peanut Allergy (LEAP), investigators studied over 500 infants at high risk of
peanut allergy (severe eczema, egg allergy, or both). Half of the
children were randomly selected to consume peanuts and the other half, to avoid
peanuts. At age 5, the children underwent peanut challenge to determine
if they were allergic. Results indicated that the prevalence of peanut
allergy in the peanut-avoidance group was significantly higher at 17.2%,
compared to 3.2% in the group that consumed peanuts.
The trial went on to compare two groups: one group of
infants with skin prick test (SPT) that was initially negative to peanut, and
another with mildly positive results (wheal of 1-4mm). Infants with a
wheal of >4mm were excluded from the study (about 10%). In infants
with an initially negative SPT, prevalence of peanut allergy was 13.7% in the
avoidance group and 1.9% in the consumption group. For infants with
mildly positive SPT, the prevalence of peanut allergy was 35.3% in the
avoidance group and 10.6% in the consumption group.
Although many questions still remain, early testing of
infants at high risk for peanut allergy in the first 4-8 months of life, along
with early introduction of peanut protein or in-office peanut challenge may
have the potential to prevent peanut allergy in the future.
Allergy Partners’ board certified allergists are experts in
the diagnosis and treatment of food allergies. If you have questions regarding
food allergies, contact your local Allergy Partners physician.
Asthma is a condition due to
airway inflammation often associated with an allergic component. It is
characterized by symptoms that can include chest tightness, cough, shortness of
breath and wheezing, which may be intermittent or persistent. Proper diagnosis
requires a thorough history, physical examination, appropriate lung function
testing and allergy testing.
Acute, or severe asthma, can
present as a rapid or gradual increase in symptoms resulting in an acute attack
or exacerbation. Chronic asthma, or persistent asthma, may present with
intermittent symptoms or even nocturnal awakening.
Control of asthma is defined
as an absence or decrease in asthmatic symptoms and improvement in the quality
of life. A 5-question survey known as the ACT defines uncontrolled asthma on
the basis of a score of less than 19 out of a possible 25.
The key to controlling asthma
is through the regular use of asthma controller medications such as inhaled
corticosteroids, antileukotrienes, or combination inhalers containing inhaled
corticosteroids and long-acting bronchodilators. These drugs treat the
underlying cause of asthma, namely airway inflammation. They are most often
delivered by inhalers with the exception of the antileukotrienes, which are
taken orally. Short-acting bronchodilators such as albuterol, are considered
relievers and are meant to be used on an as-needed basis or before
exercise. The need for a reliever inhaler more than 2 days a week or 2
nights a month is a sign of poorly controlled asthma.
Recent studies have
demonstrated adherence to asthma medications averages only 50%. In other words,
one-half of patients do not take their controller medicine regularly. This is
extremely important, as improved adherence is associated with less asthma attacks
and an improved quality of life and more symptom-free days. Thus non-adherence
is associated with a lack of asthma control, poor health outcomes and increased
The reasons for the lack of
regular use of asthma control drugs are varied. The cost, co-pays and coverage
for these drugs varies widely and high costs can be a barrier for many people.
Some patients are worried about ‘being dependent’ on daily medications while
many people simply find it hard to remember to take medication once or twice a
day. Additionally, correct inhaler technique is vital to ensure that the
medicine, when taken, is effective.
relationship is vital in improving adherence. Understanding, trust and mutual
respect are absolutely necessary between a patient and physician. For example,
patients should understand the difference between an oral steroid like
prednisone and an inhaled corticosteroid in terms of their safety and
efficacy. Patients should feel confident in why they are taking certain medications
and in how they are taking it. Regular follow up visits are vital. Asthma can
have fluctuations that require adjusting therapy up or down depending on the
situation. Thus prescribing or changing an asthma regime requires feedback to
insure safety, efficacy and compliance. Adjustments in dosing, if needed,
can be made on subsequent visits, usually 4-6 weeks apart, or as long as 90
Newly developed electronic
monitoring devices have the potential to be a very important asset to remind
and reinforce with patients when to take their medication. Such devices may
even provide vocal reminders that the medicines are due. Documenting the
regular use of these medications is of great use to physicians as well as to
In addition to devices that remind
us to take medication, the future of asthma therapy will no doubt include lung
function peak flow monitoring via the smart phone. This will allow both
patients and physicians to get a much fuller picture of an individual’s asthma
and allow far greater individualized care.
Managing asthma successfully
hinges upon using controller medications, such as inhaled steroid, regularly.
Regular use improves symptoms and quality of life and reduces the risk of
asthma exacerbations. For many, however, adherence can be challenging.
Effecting behavior change is quite difficult and time consuming. It requires
reinforcement and even such devices as peak expiratory flow meters to be used
by the patient at home. Technology should lead the way in helping patients and physicians
alike improve asthma control. In recent years we have all seen tremendous
advances in technology that have not only made our lives better, but improved
the quality of our lives. Such an outcome would be welcome in the care of our
asthmatic patients. As Leaders in Allergy and Asthma Care, Allergy Partners is
actively working to bring this technology to our patients.
Remembering to take medications every day can be
difficult for many people. For asthma patients, forgetting to take daily
controller inhalers can lead to more asthma exacerbations. New technology,
however, may help asthmatics remember their medications and keep asthma under
On June 3rd, 2014, a New Zealand company, Nexus6,
announced it received marketing clearance for SmartTouch, an inhaler monitoring
device. In the recent December issue of the Journal of Allergy and
Clinical Immunology a study was published titled Inhaler
reminders improve adherence with controller treatment in primary care patients
with asthma by Foster et al. It used the SmartTouch
device to measure asthma medication adherence. The device, which can connect to
the internet via smart phones and other devices, records doses and provides
reminders for missed doses. At six months, adherence in the reminder group was
double (60%) that of the non-reminder group (29%) whose adherence data was
collected covertly. The reminder group also had a statistically significant
reduction in severe exacerbations (11% versus 28%) compared to the non-reminder
group. Such data will help health care providers distinguish patients that
are refractory to treatment versus treatment failures due to non-compliance.
A similar device appears on their website for nasal sprays.
Per the company website, the SmartinhalerAppTM is available on iPad, iPhone and
Android devices although it was not found in the iTunes App Store as of January
14. It appears the SmartTouch device is preparing for U.S. markets given the
product section of the company website has a color matching device
for most American branded inhaler products available.
The availability of a "Smart Inhaler" should
benefit both patients and physicians. We may eventually see devices that can
alert pharmacies when your inhaler is running low. The physician can be
alerted if rescue inhaler usage has exceeded the recommended amount. Can't
recall if you took your scheduled controller last night? Check the log.
No more over or under reporting of medication use based on what a patient
thinks the physician wants to hear. Patient reminders and accurate adherence
records will help improve asthma control as we continue to become further
Have you ever wondered what to make of those air quality
warnings you hear on the news? These warnings are intended to help you
take action to avoid harmful air, but it is not always clear what they really
mean and what actions are reasonable and necessary. Here is a brief
history of the system behind the Air Quality Index (AQI), and education
regarding how these warnings can help you breathe better.
The AQI was developed by the Environmental Protection Agency
in 1968. It measures the levels of 5 major air pollutants regulated by
the Clean Air Act: particle pollution, ground-level ozone, carbon monoxide,
sulfur dioxide, and nitrogen dioxide. Of these, ozone and particle
pollution pose the greatest risk to your health.
The AQI is a number from 0-500 for each of these pollutants,
and anything below 50 is considered good. From 50-100 only very sensitive
people will be affected. Above 100 more people will begin to experience
problems, especially people with allergies, asthma, COPD, heart disease, the
elderly, and children. Above 150 even healthy people might begin to have
Health effects of air pollution include irritation of the
nose, throat, and lungs, worsening asthma, increased susceptibility to
respiratory infections, and even long term damage to these areas if the
exposure is high and prolonged.
So what action should you take when the AQI is
elevated? The first step is to build awareness of how your own body
reacts to air pollution, by keeping track of air quality (www.airnow.gov or the AIRNow app), and seeing
what symptoms you experience. You may find you need to take precautions
in the Yellow or Orange range. Everybody should take precautions once
levels are in the Red range or worse. Precautions include avoiding
exercising outdoors when AQI is poor, and limiting your children’s outdoor
play. Go to the gym or walk at the mall instead of jogging
outdoors. Use the air conditioner in your home and auto to help filter
the air. If you have asthma or allergies you may need to take extra
precautions. Discuss this with your Allergy Partners physician and make a
plan to maintain optimal health.
Welcome to our blog site! Stay tuned to get the latest news. We
will share tips and techniques for living with and managing your Allergies &
Asthma. We look forward to sharing useful resources with our patients!