Thursday, December 17, 2009
Turns out, it may have been a step off a cliff.
A recent study from Georgetown University Hospital School of Medicine suggests that although as-needed use of saline irrigation is beneficial, daily long-term use of nasal saline irrigation (NSI) by patients with recurrent rhinosinusitis (RS) can increase the frequency of acute infection by as much as 60%.
Why is this? The researchers postulate that daily sinus irrigation depletes the sinonasal cavities of a protective layer of mucous which has infection-fighting properties (both due to a barrier function and immunologically active cells and molecules). Washing this "good mucous" away regularly exposes the mucosa (the wet skin lining the inside of your nose and sinuses) to bacteria and other irritants, increasing the likelihood of infection.
When you have an active infection, the short-term (1-2 weeks) use of sinus irrigation helps to wash away the infection-laden mucous. However, once you are well again, it makes sense to leave your protective mucous layer undisturbed.
In the researchers study, the rate of infection decreased significantly in patients who discontinued daily use of saline irrigation.
This elegant study highlights the dangers of assuming that just because a therapy is "natural", it's 100% safe.
My recommendations for patients?
Use saline sinus irrigation 1-2 times daily at the first sign of an upper respiratory infection, and continue until you feel well again. However, if you're still feeling sick 10-14 days into your illness, stop rinsing and see your doctor- you may need an antibiotic.
Wednesday, December 9, 2009
I think the respiratory goblins have arrived at my home. Serves me right.
Although I always tell my patients to resume their child's respiratory controller medicine around one month before their "bad season" is due to begin, I deliberately ignored my own advice and tried to hold out for as long as I could before resuming Baby's inhaled steroid this fall/winter. This I did despite knowing better than anyone that my child is probably destined to become asthmatic.
Why did I make such a ridiculous decision?
Am I concerned about medication side effects?
At the low doses of controller medication that my 16-month old requires, hardly.
Is the medication too expensive?
Umm, I'm an asthma expert with a closetfull of samples and (thanks to my husband's job) excellent insurance coverage. Access to medication, luckily for me, is not an issue.
Am I lazy?
DING DING DING! I hate struggling with a squirmy child (with very strong leg muscles, mind you) who would rather do anything than have a silicone mask pressed up against his face. I hate arguing with my mother who thinks that just because I'm a physician, I think drugs are the answer to everything and am therefore over-medicating my children. In other words, there is really no excusable explanation.
And, because inhaled steroids take around 2 weeks to start working and 6 weeks to reach maximal effect, my poor little guy will have to suffer with inflamed airways for approximately one more month. Bad allergistmommy!
I am what Son #1 would refer to as a "dumb-dumb".
Don't be like me and wait it out. Start controller meds early enough to avoid a bad winter. Your children will thank you for biting the bullet and taking your physician's advice.
Thursday, December 3, 2009
Thanks to the JCAAI for the following alert:
The CDC has received reports of fraudulent emails (phishing) referencing a CDC sponsored State Vaccination Program.
The messages request that users must create a personal H1N1 (swine flu) Vaccination Profile on the cdc.gov website. The message then states that anyone that has reached the age of 18 has to have his/her personal Vaccination Profile on the cdc.gov site.
The CDC has NOT implemented a state vaccination program requiring registration on www.cdc.gov. Users that click on the email are at risk of having malicious code installed on their system. CDC reminds users to take the following steps to reduce the risk of being a victim of a phishing attack:
•Do not follow unsolicited links and do not open or respond to unsolicited email messages.
•Use caution when visiting un-trusted websites.
•Use caution when entering personal information online.
Additional information can be found at http://www.cdc.gov/hoaxes_
An example of the Phishing email follows:
|Subject: State Vaccination Program|
You have received this e-mail because of the launching of the
You need to create your personal H1N1 (swine flue) Vaccination Profile on the cdc.gov website. The vaccination is not obligatory, but every person that has reached the age of 18 has to have his personal Vaccination Profile on the cdc.gov site. This profile has to be created both for the vaccinated people and the not-vaccinated ones. This profile is used for the registering system of vaccinated and not-vaccinated people. Create your Personal H1N1 Profile using the link:
Tuesday, November 24, 2009
• This affected batch was not distributed in the United States. The affected Canadian batch has been recalled.
• Allergic reactions to a vaccine occur within 30 minutes to an hour after vaccination, so those who received the affected vaccine do not need to worry about the potential for a lingering reaction.
• People with asthma are at high risk of serious complications from influenza infection, including H1N1. Vaccination can significantly reduce this risk.
• Most individuals with egg allergy can receive H1N1 and seasonal influenza vaccinations. An allergist/immunologist is the best qualified physician to evaluate and administer the vaccine in egg allergic or suspected egg allergic people.
• For the most complete and up-to-date information on H1N1 and allergic conditions, visit www.aaaai.org
Saturday, November 21, 2009
me: "Put your toys away, or I'll take them away."
him: "You're a bad mommy!"
me: "TV off, kiddo. You've watched enough."
him: "I'm not going to be your son anymore!"
me: "I know you don't want to leave, but we have to go home now."
him: "I don't want to go home with you. Just send me to outer space. I'll live with the friendly aliens."
Now, I know these statements make my kid sound like a spoiled brat, but to be honest, he's actually a very well-behaved little boy. I've come to recognize this phase as proof that my child understands that threatening to withdraw affection is the worst punishment you can inflict on someone who loves you. This is an important lesson, because it will reinforce to him how important family bonds actually are.
In fact, his most recent retort proved to me how quickly he is maturing:
me: "You can't wear your pajama's all day. Please get dressed."
him: (bristling with anger) "Mommy, just because I love you doesn't mean I love you soooo much!"
Hey, as long as he gets his clothes on, that's a comeback I can live with. :)
Friday, November 20, 2009
Used to be, if you wanted to bake an allergy-friendly holiday dessert, you had to pull out a cookbook, make substitutions, and hope for the best. Not my style. Although I love it when other people slave away all day in the kitchen, I'm not really a "from scratch" kind of gal.
So, you can imagine my delight when a patient's mother introduced me to Cherrybrook Kitchen (http://www.cherrybrookkitchen.com), which has created a line of dairy, egg, and peanut-free mixes for cookies, cakes, brownies, pancakes, and more. (Frostings, too!) They're now even offering wheat and gluten free items. Best of all, the result is something even someone without allergies would like to eat...
Thanks, Cherrybrook! Now I can make goodies for my son's class without any little voices piping up, "This tastes like concrete!"
Wednesday, November 18, 2009
I'm thankful that I practice medicine in a country where I have access to the most helpful and novel innovations with which to heal my patients.
I'm thankful for compassionate nurses and assistants who put the patient first.
I'm thankful for experienced and competent managers who keep small medical practices running during difficult economic times.
I'm thankful for front desk staff who are always friendly and helpful, even though they have numerous stressors.
I'm thankful for intelligent, thoughtful colleagues with whom I can discuss complex medical questions.
I'm thankful for sane, grounded colleagues with whom I can share my frustrations.
I'm thankful for the social media networks which allow physicians from all over the nation to interact as though we were neighbors.
I'm thankful for information technology which makes prescribing medications faster and safer.
I'm thankful for medication samples to share with my patients who simply cannot afford the cost of prescriptions.
I'm thankful for patients who value me as an educator rather than as a prescriber.
I'm thankful that despite all of the doctor-bashing that occurs in Washington and the media, my patients still trust me to safeguard their health and that of their children.
Yes, there's plenty wrong with healthcare... but there's also plenty right. In our rush to enact a "fix", let's not fix the parts that ain't broke.
Friday, October 30, 2009
Well, here's some good news from GlaxoSmithKline, the makers of Pandemrix, one of the H1N1 vaccines currently being distributed and administered around the world. A single shot may be sufficient to confer protective immunity! The study is not yet complete, but preliminary results look promising... Son #2, who was none to happy with me when I gave him seasonal influenza vaccine 1 of 2 on Wednesday, would be pleased (if he had any idea what any of the fuss was about)!
Wednesday, October 28, 2009
Yep. It's the candy part that gets our undies all in a knot.
Never mind the damage all that sugar does to those little teeth (Here's an idea-our dentist buys back candy at $1 per pound and sends it to our troops overseas!).
For the parent of an allergic child, the concern is more about the damage that the hidden food allergen might do to our kids. The zombie costumes are ghoulish enough- do we really need to amp up the freakishness with hives and giant swollen lips?
The American Academy of Allergy, Asthma & Immunology offers some Halloween tips here:
I think these ideas are a great start, but I do doubt the practicality of distributing your own safe snacks to neighbors in advance of trick-or-treating. (Not really fair to expect them to keep track- or even be able to recognize your kid if he or she is in costume!)
Here's my tip to add to their list (modified from our dentist's plan): "Buy back" questionable treats from your allergic child. In exchange for giving up what may easily amount to half of the trick-or-treating stash, offer your child a coupon for a trip to the movies, the toy he's had his eye on, or a special spa day for your little princess. Be creative- and let your child participate in the deal ahead of time- the anticipation of the value upon trade-in will make giving up all that candy much less painful!
Wednesday, October 21, 2009
MILWAUKEE – With the Centers for Disease Control and Prevention (CDC) reporting that an initial analysis of 1,400 adults hospitalized for H1N1 found that 26% had asthma, how can the more than 34 million Americans with asthma protect themselves from the virus and complications?
An article set to appear in The Journal of Allergy and Clinical Immunology (JACI) recommends that people with asthma who have suspected or confirmed influenza should be strongly considered for antiviral medications because of their increased risk of developing a complication such as bacterial pneumonia.
Additionally, most patients with asthma should be vaccinated with the seasonal and 2009 H1N1 inactivated vaccines.
“People with asthma are at high risk of serious complications from influenza infection, including H1N1, but vaccination can significantly reduce this risk. If you have asthma, seasonal influenza and H1N1 vaccination is recommended. Be sure to get the injectable vaccines, not the vaccine nasal spray,” said James T. Li, MD, PhD, FAAAAI, one of the article authors.
The live attenuated influenza vaccine, which includes the nasal spray FluMist®, is not recommended for patients with asthma due to concerns about triggering an asthma exacerbation.
Vaccinations for both the seasonal flu and 2009 H1N1 are among the best prevention tools available to prevent complications from the flu, especially for individuals with chronic conditions such as asthma. But what if you are allergic to a substance in the vaccines?
Asthma patients with an egg allergy or history of an allergic reaction to the influenza vaccine should see an allergist/immunologist for proper testing and evaluation, according to the American Academy of Allergy, Asthma & Immunology (AAAAI).
The AAAAI offers a comprehensive library of resources on the novel H1N1 virus—especially as related to allergic diseases—including treatment recommendations, vaccine news and information for patients. Subscribe to the RSS feed to be notified of the latest updates as they happen.
The AAAAI (www.aaaai.org) represents allergists, asthma specialists, clinical immunologists, allied health professionals and others with a special interest in the research and treatment of allergic and immunologic diseases. Established in 1943, the AAAAI has nearly 6,500 members in the United States, Canada and 60 other countries. To locate an allergist/immunologist, visit the AAAAI Physician Referral Directory at www.aaaai.org/physref.
Wednesday, September 16, 2009
Certainly, it is wonderful to have a lower-cost alternative to EpiPen and TwinJect. (Tier 1 co-pay on Aetna and Cigna!) Many parents cough up $70 or more out of pocket for epinephrine autoinjectors that end up being thrown away. Now, don't get me wrong- I think it's much better to spend the money and throw it away than not spend it and be without life-saving medication if you should need it. But when you need one for home, one for school, one for grandma's house, etc... it adds up.
On top of that, I like to prescribe epinephrine for my immunotherapy patients, and they aren't thrilled about the co-pay either, especially when the prescription is only a precaution.
However, just because the medication inside the syringe is the same doesn't mean that device is equivalent to the branded drug. The beauty of epinephrine autoinjectors is just that- they auto-inject. You don't see the needle until it comes out of your leg, the risk of sticking yourself is lower, and the risk of accidentaly squirting your life-saving medication into the air is lower as well. Try as I might, I cannot find a photograph of Adamis's epinephrine "PFS". Their website doesn't describe the product/device, except to state that "While an extremely important piece of Adamis Labs’ product development strategy, Epi PFS serves as an introduction for the commercialization identity, and as a precursor, to its more long-term and higher potential revenue generating products."
Hmmm... Sorry, Adamis Pharma. Your public statements do very little to convince me that you really care about making a quality alternative to the existing market leader. It's possible that your product may have promise for adult patients who are unlikely to actually need it. However, until I can get my hands on your device and feel confident that it is both easy and safe for my patients and parents to use, my prescriptions will continue to be marked, "Dispense As Written".
Antibacterial Treatment Does Little to Reduce Staph Colonization, but Reduces Eczema Severity Nonetheless
The mainstays of antibacterial therapy for control of staph aureus colonization are: oral antibiotics, nasal antibiotics, and dilute bleach baths. The traditional thinking has been that implementing these measures would reduce the bacterial burden, thereby improving the condition of the skin.
Now, a fascinating study in the September issue of Pediatrics has turned the traditional wisdom on its head. Sure enough, patients treated with the anti-staph cocktail therapy had better outcomes than those treated with oral antibiotics alone, but there was no decrease in the levels of staph aureus colonization (80% before treatment, 82% after)!
So, the question is: why does the antibacterial regimen work if the bacteria are still there? The only explanation I can come up with is that perhaps the anti-staph treatments decreased the production of superantigen toxins which increase staph's infective ability and predispose patients to increased allergy in the skin. I'd be interested to see the results of a study examining the effects of bleach baths and intranasal antibiotics on staph superantigen production...
Saturday, August 29, 2009
Son #1: Mommy, look I made a picture for-
Me (interrupting): It's beautiful, honey! Thank you!
Me (thinking to myself): Oh gosh, he's going to be so proud of this one... How am I going to recycle it without him noticing?
Son #1: Mommy, it's not for you. I made this picture for Selena Gomez (Disney teen queen).
Me: Oh! Okay... well, it's very nice. I'm sure she'll love it.
Me (thinking to myself again): Oh no. I have just been supplanted as my son's most loved woman. Selena Gomez, you better watch your back, little lady.
Thursday, August 20, 2009
A Japanese study published in the Journal Chest examined rates of allergic sensitivity to this fungus in asthmatics and non-asthmatics, as measured by presence of IgE antibody in the blood specific for trichophyton.
32.4% of patients with severe asthma were sensitized to trichophyton, 15.8% of patients with moderate asthma were allergic, and only 4.9% of patients with mild asthma were sensitized.
Interestingly, the rates for allergic sensitization to other common environmental allergens (cat, dog, mixed molds) did not differ significantly between the different groups of asthmatics.
Similar associations between trichophyton and asthma have been noted in Venezuela and Turkey as well. Antifungal treatment in these patients has been shown to improve asthma severity.
Bottom line? Although probably not a major issue for well-controlled asthmatics, severe asthmatics in my office will now be asked to remove their socks.
Monday, August 17, 2009
The Food and Drug Administration (FDA) is warning healthcare professionals and the public about a shipment of a nebulizer medication that was recently stolen. The American College of Allergy, Asthma and Immunology (ACAAI) and Allergy & Asthma Network Mothers of Asthmatics (AANMA) urge patients using the nebulizer medication Albuterol Sulfate Inhalation Solution 0.083% to check the medication's lot numbers (see "What to look for," below).
Police reported that on approximately Aug. 5 a tractor-trailer containing a 35,760-carton shipment of Albuterol Sulfate Inhalation Solution 0.038% belonging to the RiteDose Corporation was stolen in McKinney, TX.
Anyone who comes across this product should notify the authorities immediately (see contact information below). The product is now illegal and may not be safe for human use because it might not have been stored in the proper temperature-controlled environment after it was stolen.
What to look for:
The stolen medicine included cartons of generic albuterol sulfate unit-dose vials for use in nebulizers. If you come across this product, look for the National Drug Code (NDC) number 49502-697-29. Each carton displays the brand name "DEY," is labeled "Albuterol Sulfate Inhalation Solution 0.083%, 2.5 mg/3 mL" and contains 30 3-milliliter single-dose vials. The lot numbers of the stolen products are 9G01 and 9FE2.
Click here to visit the Dey website.
What to do:
· If you have purchased or received an offer to purchase this product, contact:
FDA's Office of Criminal Investigations (OCI)
· If you have any information about this case, contact:
Officer Rutledge, McKinney Police Department (Be sure to mention the incident number 094587309C)
(972) 658-4234 or firstname.lastname@example.org
Monday, August 10, 2009
My son and I shared a Reese's peanut butter cup yesterday.
As parents of peanut-allergic children know, this is no small victory.
I am hopeful that in the not too distant future, oral immunotherapy will make the above scenario a reality for more children.
Tuesday, July 28, 2009
Image via WikipediaEpinephrine is the first-line medication for the immediate treatment of anaphylaxis (sometimes referred to as "killer allergy"). Intramuscular injection of epinephrine is superior to subcutaneous injection in terms of how fast peak plasma levels of the life-saving drug are achieved. Consequently, epinephrine auto-injectors are deigned to deliver the medication to the large muscle of the anterior thigh (called the vastus lateralis).
A recent study published in the July issue of the Journal of Pediatrics, however, suggests that intramuscular injection may not be achieved in a significant percentage of children with the current needle lengths of epinephrine auto-injectors (EpiPen and TwinJect). Ultrasound measurements of the thickness of subcutaneous tissue in children indicated that the needle lengths of the auto-injectors may be too short to penetrate into the muscle.
When the outcome that one is attempting to prevent is death, this is no small issue.
However, as the study authors themselves note, the method of measurement was not an exact approximation of the injection technique. Ultrasound generally uses light pressure, which may overestimate the depth of tissue that a needle needs to traverse to reach the muscle. Injection of epinephrine using an auto-injector, however, requires a firm hand. When I demonstrate the proper use of autoinjectable epinephrine, I generally end up with bruises on my thigh. Therefore, when used properly, the current needle lengths may be sufficient to deliver the mediation to its desired location after all.
That said, I often note that patients seem to be timid when it comes to auto-injected epinephrine- both in terms of using it in the first place, and also in terms of not being aggresive enough with the amount of pressure applied during administration. This is why adequate training for this medication is so vitally important. It is simply not enough to be given a prescription for an EpiPen- the patient, family and caregivers MUST be trained in the use of the injector with a demonstration device.
The study authors have recommended increasing the needle length for auto-injected epinephrine. More research likely needs to be done before the manufacturers of these devices will increase the needle lengths. Until that time, the only way you can ensure that your child will receive an intramuscular injection is to have excellent technique.
If you have an EpiPen for your child, please ask your physician for guidance and a demonstration of the proper way to administer this important medication. It just may be the most important training you ever have!
Thursday, July 23, 2009
I am writing to you today as a physician, a patient, a mother, and as an American voter.
It is difficult for me to put into words how deeply hurtful your characterization of physicians during your most recent press conference was, both professionally and personally. Your portrayal of the American physician as self-serving was both inaccurate and counter-productive.
The vast majority of physicians in this nation hold themselves to the highest standards of ethical behavior- I believe I speak for my colleagues when I state that I care not only for the physical health of my patients, but also care deeply about how my medical recommendations impact their financial health. To imply that I, or any of my colleagues, would routinely consult a fee schedule before making a medical decision implies that we value our pocketbooks over our patients’ welfare.
I sincerely hope that this is not the opinion you want the American public to have of the individuals who have sacrificed their youth in the service of others, missed many a night with their own children in order to care for another’s, worked repeated 30 hour shifts with no breaks or sleep for what amounts to minimum wage, amassed hundreds of thousands of dollars in educational debt… all to have the privilege of becoming a physician. If Americans can’t have faith in their physicians, who will they turn to when they need care and counsel- their elected officials in
I still consider it an honor to be able to go to work every day with the confidence that my medical training and experience give me a unique set of skills that truly contribute to the greater good. I felt that way when I cared for your own daughter, and I feel the same way now as a Board-Certified Allergist and Immunologist, caring for adults and children with asthma, allergy, and immune deficiency. I know that my colleagues similarly value their respective opportunities to preserve and improve the health of the American people.
Your recent words have expressed to Americans your low opinion of those who have committed their lives to the health of the nation. Although this slight may have been intended as an example only, the end result was the mischaracterization of a noble profession. When the President stands in front of the nation and essentially claims that physicians are the ones who ail us rather than heal us, it is difficult to find hope for the future of healthcare in
Mr. President, I believe you owe the nation’s physicians an apology. I recognize that you do not need the votes of physicians to stay in office, or even to pass the current version of healthcare reform. That’s not what this is about.
To adapt a famous quote: “Mr. President, you have bigger problems than losing my vote. You just lost me as your physician.”
Tuesday, July 21, 2009
Read about the study here: http://www.nzherald.co.nz/health/news/article.cfm?c_id=204&objectid=10585257
Apparently, you don't need to eat a stick of the stuff to obtain benefit- 10grams (just a few pats) may do the trick!
Just wait until this gets out- my dad (who refuses to even touch anything that's not "real butter" because it "just doesn't taste right") and father-in-law (who forwards me emails about how margarine is "one molecule away from plastic") are going to be thrilled.
Wednesday, July 15, 2009
Turns out all my worries about "metal-mouth" were largely unwarranted. For the most part, you can't see the shiny new molars, unless my kiddo's laughing hysterically or screaming his brains out. (Which means that we do see them at least a few times each day... as life with a 4 year old is equal parts giggle-fit and hissy-fit.)
Although I'm glad it's done and that my child doesn't hate me, I'm still disappointed that I wasn't able to ward away the caries despite excellent dental hygeine. Brushing, flossing, fluoride rinsing... why did this still happen to my baby?
The dentist blames genetics. But I think that secretly, he blames me.
Or is it that, not-so-secretly, I still blame me? Such is the perpetual angst of motherhood.
Sometimes, our best may not be enough to change the inevitable. Difficult for any parent, to be sure. And as a physician, an especially tough pill to swallow...
Tuesday, July 7, 2009
"The Children’s Memorial Food Allergy Study is a large, family-based food allergy study and holds great potential for scientific discovery and clinical translation. It is gaining momentum with the support of the National Institutes of Health (NIH), the Chicago Community Trust, Food Allergy Initiative, and generous donors."
Your participation will advance knowledge regarding the genetic basis of food allergy, environmental contributors to food allergy, the possibility of predicting and/or preventing food allergy, and the optimal treatments for this condition. Participation will not alter your child's current medical treatment.
This is an excellent opportunity to contribute to the knowledge about a condition that affects so many of our children.
For more information, visit http://www.childrensmrc.org/allergy/, call 1-888-573-1833 or email email@example.com.
Wednesday, July 1, 2009
Read the Department of Justice press release here: http://www.usdoj.gov/usao/iln/pr/chicago/2009/pr0629_01.pdf
For shame! This type of malpractice is unconscionable, unethical, and DANGEROUS! However, suboptimal allergy testing and treatments are offered by all manner of self-proclaimed "experts", many of whom aren't even M.D.'s or D.O's. It's easy to be swindled the the title "Dr." and a white coat.
This is all the more reason to ensure that you are evaluated, and your allergy treatment is being designed and supervised, by a Board-Certified Allergist and Immunologist. Find one here: Find an Allergist, Find Relief
Tuesday, June 16, 2009
FDA Recommends Removal of Zicam from Market- Proof that Just Because It's Labeled as Homeopathic, Doesn't Mean It's Safe
This morning, The Food and Drug Administration (FDA) held a news conference warning physicians and consumers about Zicam Cold Remedy intranasal products, indicating “these products may pose a serious risk to consumers who use them.” Specifically, the FDA has received more than 130 reports of anosmia (loss of sense of smell, which in some cases can be long-lasting or permanent), associated with use of these products. Some individuals also report loss of sense of taste.
Included in the warning are: Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Gel Swabs, and Zicam Cold Remedy Swabs, Kids Size. All are administered by direct application to the nasal cavity, and as described in the labeling, are intended for use in “adults and children 3 years of age and older (with adult supervision). These products are available without a prescription, and they contain zinc gluconate (identified as zincum gluconicum on their labels) as their active ingredient.
These OTC’s are marketed as homeopathic and therefore are not subject to FDA approval. However, given the risk, the FDA has issued a warning letter to Matrixx Initiatives, Inc, makers of the products. During the news teleconference, the FDA indicated they have asked Matrixx to work with the FDA in removal of the products from the market.
Monday, June 15, 2009
However, on Friday, June 12, an exchange between reporters and White House press secretary Robert Gibbs made it clear that the President has not yet kicked the habit. http://blogs.suntimes.com/sweet/2009/06/obama_may_still_be_smoking_war.html
C'mon now, Mr. President! Your daughter is asthmatic- and you're still puffing away?
From the sounds of it, it seems that his sole aid in the fight to quit is Nicorette gum. Really? The leader of the free world, and all he can come up with is Nicorette? OK, maybe mood-altering medications like Zyban and Chantix are not the most appropriate for someone with his job description... but surely, counseling is allowed? If the Prez is getting professional help with this struggle to quit, I think he should proudly announce it, so as to decrease the reluctance of other smokers to seek help.
And if he's not, what is he waiting for? He had the perfect opportunity this morning- maybe he should have asked the auditorium full of doctors for a consult.
Monday, June 8, 2009
After the tolerated accidental ingestion and negative skin test, I knew the risk of a reaction was low, but I still wanted to follow the protocol and do it right. So I spent a little over 2 hours feeding him incrementally larger amounts of creamy peanut butter. (Disclaimer- in all seriousness, please do not do this at home. Food challenges can be dangerous, and should be performed by a medical professional trained to immediately recognize, and equipped to treat, the symptoms of a life-threatening allergic reaction. Luckily for me, I just so happened to fit the bill.)
So, picture me chasing a 4 year old around every 30 minutes with a measuring spoon.
Me: "Come on, honey. One more bite, okay?"
Son #1: "You can't catch me, Mommy! I'm fast!"
Me: (out of breath) "Slow...down...or... I'm calling...your...father."
Son #1: (reluctantly) "Aaah. Eeew- sticky! "
Normal vital signs, no rash & an awake, alert, happy kid who apparently isn't a big fan of peanut butter. That's OK. All I needed was confirmation that he can tolerate peanuts without turning into a swollen itchy blob. He doesn't need to become the spokesboy for Skippy.
I'm the AllergistMommy. My work here is done.
(Nevermind, Son#2 just tried to eat dice. My work here is just beginning.)
Thursday, June 4, 2009
Tuesday, June 2, 2009
So, when we discovered that Son #1 was allergic to peanuts, cashews, and pecans (luckily limited to a mild reaction- hives), I figured that we were due for a lifetime of avoidance. And we have been really good about strict avoidance, for the most part...
A few weeks ago, however, he was able to tolerate some accidental peanut exposure, so I decided to retest him last week.
Imagine my delight when skin tests to peanut and pecan were negative, as well as a subsequent prick-prick test with peanut butter-- my kid is possibly in the lucky 30% of children who outgrow peanut allergy!
An open food challenge is yet to be done- mainly because my son refused to eat any peanut butter ("Mommy, I can't eat peanut butter- I'm ALLERGIC!"). I may have to devise a blind challenge for him...
Tuesday, May 19, 2009
Naturally, my 4 year old's allergic conjunctivitis is starting to rear its ugly head. This morning, I found him rubbing his watery little eyes as we were getting ready for a visit to the pediatrician.
As I went to grab a Kleenex for him, I passed by my 9 month old and caught a whiff of his unusually pungent diaper. Aah, the sensory joys of motherhood...
Upon hearing me call his brother a "stinky butt", my son decided to embellish his story, as 4 year olds are wont to do:
"Mommy, I think he pooped in my eye."
The visual had me cracking up all the way to the pediatrician's office... I secretly prayed that he wouldn't share his theory about the cause of his conjunctivitis symptoms, lest she believe I am allowing my baby to use his brother as a potty.
Thursday, May 7, 2009
The Case for Good Nutrition and Playing Outside... low Folic Acid and Vitamin D Levels Associated with Allergies, Asthma
#1) A retrospective study performed at Johns Hopkins and recently published in the Journal of Allergy and Clinical Immunology tracked the effect of folate levels on respiratory and allergic symptoms, as well as levels of the allergic antibody IgE. They reviewed the medical records of over 8000 patients ranging from toddlers to octogenarians. The researchers found that patients with serum folate levels at the higher range of normal had lower rates of high IgE, atopy, and wheeze than those patients with lower levels, even though some of the patients with lower levels were technically within the normal range for serum folate. Bottom line? Folate levels on the high side of normal may be protective against some allergic disease, but blinded prospective studies are needed before we begin recommending supplementation for this purpose alone.
#2) A cross-sectional study published in the May issue of the American Journal of Respiratory and Critical Care Medicine examined the relationship between vitamin D levels and markers of asthma severity in a population of Costa Rican children. Interestingly, low levels of 25-hydroxy vitamin D were found in 28% of the studied children. To me, this was a surprising result in kids who are probably getting plenty of sunlight. Lower levels of vitamin D were associated with increased IgE, eosinophilia, and a 10-log increase in vitamin D levels was found to decrease the odds of recent hospitalization, antiinflammatory medication use, and airway hyperreactivity. Bottom line? There's been a lot of talk about the role of vitamin D in allergy/asthma prevention, and this study certainly supports the concept. However, we are still lacking data on exactly how much supplementation would be needed to prevent allergic disease- it's likely to be more than what's currently recommended for bone health. That said, I still give my baby vitamin D supplementation, and will continue to do so even after he has transitioned to vitamin D fortified milk.
Wednesday, May 6, 2009
I was wrong.
Yesterday morning, it was time to go to school, and I couldn't find clean pants for Son #1. So, I decided that it was warm enough to break out his summer wardrobe. Last year's summer wardrobe.
Kids grow fast.
I hurriedly squeezed him into an oversized pair of blue shorts. They didn't look oversized on him, though. Maybe that's because they were made for an 18 month old. I convinced myself that as long as no one looked at the label, it would be okay.
However, when we pulled into the parking lot, Son #1 refused to get out of the car. His explanation? "I don't want anyone to see me like this. I look like I'm going to the beach." Poor kid kept pulling the shorts down to his knees and sheepishly found a place on the floor during "circle time".
This is the first time that I've embarrassed my kid at school. I felt awful, and vowed to buy him some summer clothes that fit. Or, at least wash his pants.
I really hope my husband isn't reading this.
Friday, May 1, 2009
Tuesday, April 28, 2009
At our last visit ~6 months ago, he was found to have areas of decalcification ("almost-cavities") between his molars. At that point, he was still not the best at cooperating with tooth-brushing and used to swallow the toothpaste, which meant that we couldn't use fluoride-based toothpaste. We were instructed to optimize the brushing, start flossing, and switch to fluoride toothpaste.
We did great! Well, the flossing could have been a little better, but otherwise, we did great! Twice a day, without fail, spending plenty of time focusing on the molars. Very limited juice, candy only on Halloween and birthdays... our only weakness was ice cream, but he always drank water afterwards.
Despite our best efforts, half of the areas of decalcification have progressed to cavities, and now we're facing having the teeth fixed with a pulpotomy and the placement of ugly stainless steel crowns, which will remain until the baby teeth fall out (probably another 6-8 years from now).
Needless to say, I feel as though I have failed in my motherly duty to keep my kid healthy. Being a pediatrician makes the failure all the more acute, because after all, aren't I supposed to be a parenting and health expert? I felt only marginally better when the dentist told me that his own child required the same treatment (his wife was really mad at him, or so I'm told)...
I agree with our dentist that we can't allow to decay to progress unchecked... children's enamel is much thinner than adults, and the oppositional surface area of the molars is also larger than in permanent teeth- this means that this risk of cavity progression and abscess formation is theoretically larger. I'm not keen on waiting until it hurts to eat, drink or brush. A root canal? No, thanks!
However, the thought of replacing my child's beautiful little smile with a mouthful of gray metal is decidedly unappealing. My son's dentist (a pediatric specialist) does not offer esthetic (tooth-colored) posterior crowns, because he feels they are not as durable as stainless steel.
I'm incredibly disappointed, and concerned that a mouthful of metal is going to affect my son's self esteem at a very sensitive time in his social development. I know I should be more concerned about his health than his appearance, but I can't help it.
I am going to look into a second opinion, and will post updates as I learn more.
Tuesday, April 21, 2009
These oligosaccharides are known as "prebiotics", and they supply a nutrition source for the "good bacteria" (probiotics) that colonize our gastrointestinal tracts shortly after birth.
The microbial environment in the gut may be an important factor in the risk of developing allergic disease, such as atopic dermatitis (eczema).
The interesting thing about this study is that it demonstrated that despite the overall decrease in antibody levels, the immune response to vaccinations was preserved. This is important, because antibodies are essential to protecting us from infection, and a decrease in allergic risk at the expense of adequate immunity against infection would not be not especially helpful.
So, should we be rushing to supplement the diets of our infants with prebiotics to skew the developing immune systems of our kiddos towards a less-allergic phenotype?
Breastmilk has plenty of oligosaccharides, and there's not evidence that infant formula supplemented with oligosaccharides is any better at preventing allergy than breastfeeding.
So when worried expectant moms come to me and ask what they can do to decease allergy and asthma risk in their soon-to-be-born babies, this is what I recommend:
1) Don't worry too much about what you eat during pregnancy- sensitization does not appear to occur in utero.
2) Actually, don't worry too much during pregnancy in general! (see my previous post about stress during pregnancy increasing asthma risk)
2) Try to have a vaginal delivery, so that your baby's gut can be colonized with beneficial bacteria as soon as possible.
2) Breastfeed!!! (but don't delay the introduction of solids beyond 6 months)
3) If you must transition to formula, consider a partially hydrosylated formula with prebiotics.
The evidence is emerging and recommendations continue to evolve- this is definitely an area of allergy which I will continue to follow closely...
Thursday, April 16, 2009
Being hospitalized is always stressful, even when for a joyous occasion such as for the birth of a child. You're out of familiar surroundings, usually not in the best of health, sometimes in pain, and certainly NOT in control of what happens to you, at least not in the way that you are accustomed to being. You and your family are eager to get home as soon as possible. Under these circumstances, the inefficiencies and "unique" communication issues in our healthcare system can be frustrating at best.
So, here are my insider tips for optimizing communication in the hospital setting.
1) Please be patient. I know, not what you want to hear. But it's important to realize that the physicians and nurses caring for you and your loved ones are also responsible for the medical care of many other patients as well. If they had to drop everything to discuss a patient's treatment according to each individual family's timetable, they would never be able to attend to their most important task- helping your loved one get well!
2) Have your loved one's medical history available at all times- this is easy to do with a flash drive and a .doc file. Include the most essential information: Name, date of birth, active medical conditions, past surgical history, immunization history, food and drug allergies (include what the reaction is), current medication list (include generic names and doses), immediate family medical history (we don't need to know about Aunt Edna's bunion surgery), and names and contact information of primary care physician and specialists. Have the primary care physician review the document for accuracy at least once a year, and note the date of review on the document. Print a few copies to distribute to the ER physicians and consultants who may be asked to see your family member during his/her hospital stay. This will ensure that all doctors have the most accurate, up to date historical medical information- and will free up their time to focus on the issue at hand (and spend more time answering any questions you may have!).
3) Make friends with your nurses! Your R.N. is an integral part of the healthcare team, has a direct line of communication to the physicians, and is trained to be your advocate. Treat your nurse with the respect that his/her training deserves, and you will not be disappointed with the care and valuable information you receive. (Tip- if you have a child or an elderly family member who has delicate veins, kindly ask your nurse if she can hold off on placing the IV line until the physician has determined which labs to order. That way, labs can be drawn from the IV before fluids are infused. This cannot always be done, but if it can, your nurse is usually happy to oblige.)
4) Designate one adult family member as a "point-person" for healthcare communication, preferably someone with a cool temperment and perhaps even a medical background. This person is responsible for relaying information from the healthcare team to other family members. In my opinion, it is unreasonable to ask the physician or nurse come in to repeat the same information each time a new relative comes to visit and wants to know what's going on. As I mentioned earlier, this diverts resources from their primary task- caring for the patients!
5) At your first visit with each of your physicians, ask if they have a window of time during which they expect to round, so you can plan to be present to be apprised of the plan of care, and to ask any questions you may have. Most physicians tend to round on their patients at around the same time each day- usually in the morning, but not always.
6) If no one from the family is available during the times when the healthcare team is rounding, arrange to have a notebook where you can leave your most pressing questions for the doctors. Ask your nurse to have the team look at the notebook each day. Although liability reasons may prevent the team from writing answers to your questions in the notebook, the answers can be relayed to your nurse or "point-person" verbally. Also include in the book the name and contact information of your "point-person", so the team knows who to call.
7) As the time for discharge home approaches, ask your physicians and nurses if there is anything your family can do to facilitate getting home as smoothly as possible. Most hospitals have discharge coordinators who will be happy to discuss the issues with you and ensure that you are as prepared as possible.
I hope you don't have to deal with a hospital admission anytime soon. But if you do, the tips above will help you and your family stay informed, and simulateously improve your relationship with the healthcare team.
Wednesday, April 15, 2009
Why might this be the case? Maternal stress hormones, such as cortisol, may have a negative-feedback effect on the developing fetal adrenal glands, leading to relatively low levels of anti-inflammatory hormone production in the child.
Makes one wonder... knowing that women tend to display higher levels of anxiety than men during times of economic downturns... will the current economic crisis result in increased pediatric asthma rates a few years down the road? One can only speculate, but it certainly makes the case for prenatal yoga!
Tuesday, April 7, 2009
A European study published in the Journal of Allergy & Clinical Immunology has shown an increased risk of asthma in normal weight (odds ratio 1.45) and overweight (odds ratio 1.91)women using oral contraceptives.
Lean women (with a body mass index of >20 kg/m2) taking OCPs, however, were less likely than their non-OCP-taking counterparts to have asthma.
These findings support the theory that metabolic status may influence how susceptible a woman is to the effect of sex hormones on the airways.
However, the study authors take care to note that women should not abruptly discontinue OCPs without first discussing their concerns with their physician, as the health risk of an unexpected pregnancy may be greater than the small increase in asthma risk associated with oral contraceptives.
I agree. But although I won't be recommending blanket discontinuation of OCPs, I'll definitely consider that possibility that hormonal supplementation might be contributing to asthma, or exacerbations thereof, especially in those patients interested in losing a few pounds!
Tuesday, March 31, 2009
Weather News, a Japanese weather information company, has installed hundreds of globe-shaped light-emitting "robots" throughout the country, which estimate pollen levels and glow a different color based on the concentration of pollen in the air. Allergy sufferers can tell with a quick glance how miserable their day is likely to be, and can also sign up for pollen counts to be text-messaged to their cell phones each morning...
Although not nearly as George Jetson-like in its appeal, allergic folks state-side can also access up to date pollen conditions from the National Allergy Bureau. We don't use robots, though. Pollen counts in the U.S. are done manually, by volunteers!
To access airborne allergen information for your area, visit the National Allergy Bureau website.
Thursday, March 26, 2009
You may have seen this story on the morning/evening news programs, or read about it in your local paper or online. Certainly, parents of my patients have been coming in asking if I can provide this therapy for their food-allergic children in my office.
They are invariably somewhat disappointed when my answer is: "Sorry, not yet."
Let me explain why.
Although the prospect of inducing some measure of tolerance to a food allergen is exciting, there are a number of things to keep in mind:
1) To date, the peanut immunotherapy studies have evaluated relatively small numbers of children (<40), although larger controlled studies are in the works.
2) Of the 33 children enrolled in the initial phase of the peanut study, 4 (~12%) dropped out due to allergic adverse events (as determined by either the parents or investigators). This is not something that should be attempted in the home setting!
3) We're still not completely sure if the tolerance induced by food allergen oral immunotherapy is temporary (effective for only as long as the maintenance therapy is continued) or permanent (with lasting benefit after the discontinuation of maintenance administration). Until these questions are answered, it is inaccurate to say that oral immunotherapy "cures" food allergy. At best, we can state that oral ummunotherapy appears to increase the threshhold for food reactivity, potentially reducing the risk to a child from accidental exposure. This is not a license to consume peanuts with abandon...
4) Oral immunotherapy is still considered investigatonal, and the major insurance plans specifically state in their policies that oral immunotherapy is not a covered procedure. FDA approval is probably ten years away, because large-scale, placebo-controlled studies will be needed, and long-term effects of the treatment will need to be evaluated before the therapy can be considered safe for widespread use.
That said, as an allergist, and as the mother of a peanut-allergic child, I do believe that oral immunotherapy holds great promise. When it is ready for prime-time, I will be pleased to offer it to my patients.
For more information, please visit the American Academy of Allergy, Asthma & Immunology at http://www.aaaai.org
Wednesday, March 18, 2009
As my family, friends, and patients know, I am a huge proponent of breastfeeding. Nursed Son #1 for a little over a year, and going on 8 moths with Son #2. Benefits definitely outweigh the occasional inconveniences. But yesterday, my dedication to "La Leche" was certainly tested.
Any nursing mother who works outside the home is intimately familiar with "The Pump". At work, in a restaurant, in the car (preferably not while driving, although I've been known to attempt such multitasking madness in the past) - you name it, we've pumped there.
Planning a trip away from baby is never easy, but when you're nursing, it complicates matters. Rather than pump and dump, I elected to store the milk and bring it back home for baby. I did a good deal of planning: arranged for a large fridge in the hotel room, packed plenty of bottles, bottle brush, a zillion little plastic storage bags, coolers, ice packs... even checked with the TSA website, which stated that I could carry onboard the aircraft " a reasonable quantity" of breastmilk.
Well, reasonable for me was a little over 100 ounces, all packed up in 6 ounce ziploc storage bags. I knew that the milk might need to be tested with a little device that checks for vapor from liquid explosives- as long as they don't touch the milk, I'm okay with it. That's why I deliberately packed some of the milk in easily opened bottles.
What I didn't anticipate was the following conversation:
TSA guy: "Ummm.... okaaay. Hmmm. Can I get a supervisor over here, please?"
Me: "What's wrong?"
TSA guy to me and the supervisor: "This breastmilk is testing positive."
Supervisor: "Really? Well, that's never happened before."
Me: "Please don't make me dump it. I'll cry."
Supervisor: "Don't worry, ma'am. We'll just have to open some of these bags at random, though."
So, I ended up have to mess up my awesome system, upack the nicely stored bags, open them up to be vapor tested, and somehow get them bag in the cooler befoe my plane took off without me. It took a while. Good thing I was early!
Luckily, the TSA supervisor was really nice. Turns out his wife is a member of La Leche League, and actually had something to do with getting the TSA rules changed to allow more than 3 ounces of breastmilk onboard if you didn't have baby with you.
He also gave me this little tidbit: hand lotion has a chemical in it that causes the explosives testing machine to test falsely positive. Turns out the hotel was dry, and I was using hand cream a few times a day. It must have gotten onto the bags of milk as I packed them, hence the positive explosives test.
All is well that ends well. The TSA folks treated me with dignity, I made my flight, and I will never use hand cream before flying again.
Tuesday, March 17, 2009
Eosinophilic esophagitis results from abnormal accumulation of inflammatory cells in the lining of the esophagus (food pipe), and has a strong relationship to food allergy.
If you or your child have heartburn symptoms which have not improved with a proton pump inhibitor (examples include Prilosec, Prevacid, or Protonix, among others), you may be experiencing more than reflux. Ask your primary care physician if you might benefit from a referral to a gastroenterologist for an endoscopy (a video evaluation of the inside of your esophagus, stomach, and/or intestines).
If a biopsy reveals high numbers if eosinophils (specialized white blood cells which are highly involved in allergic inflammation), you may benefit from further evaluation and dietary management. Approximately 75% of patients managed with a specialized diet (based on food prick and patch testing) had significant clinical improvement.
Eosinphilic esophagitis is rare, but the prevalence of the disease appears to be growing. Because the symptoms can be confused for severe reflux, the diagnosis is often delayed. This delay can in some cases lead to severe scarring and stricture (narrowing) of the esophagus, resulting in a lifetime of difficulty eating.
Learn more about this condition at http://www.apfed.org/
Monday, March 16, 2009
The amount of research and clinical information presented at this meeting is enormous, and is already starting to show up on Good Morning America, the New York Times, etc...
* Avoidance of milk, egg, and peanut for the first few years of life may not be protective against the development of food allergies in at-risk children.
* Oral immunotherapy to milk, egg and peanut is showing promise in children.
* Atopic dermatitis (eczema) benefits from proactive treatment with an antiinflammatory ointment twice weekly, even when the skin is clear.
And so much more! I will discuss these issues in more depth in upcoming posts- as always, nothing is ever as simple as it seems on the news or in the paper. Each patient's case is unique, so do not act on anything you hear or read before discussing it with your physician. Talk to your allergist about what they have learned at recent meetings... we'll be happy to share with you!
Wednesday, March 11, 2009
Yep, in all their wisdom, the feds decided that all those asthmatics puffing away on their albuterol inhalers were creating a larger hole in the ozone layer than a gazillion automobiles or horrendously outdated factories. Don't get me started.
Well, don't puff on that new HFA inhaler within 5 minutes of getting pulled by the police over while you're speeding down the highway in your SUV... turns out that some of the HFA inhalers include ethanol, and it just might transiently raise your breath alcohol (less so than a drink of wine, though). Or so report researchers from Australia in a recent issue of the journal Respirology.
To be honest, if you need to urgently take albuterol, maybe you should just pull over for a while.
So... how long before the Hollywood lawyers start using the "inhaler-defense" at DUI trials?
Wednesday, March 4, 2009
My husband is out of town for work nearly every week, and it certainly makes parenting two young boys an adventure, especially when we're dealing with illness. But this time, dear hubby is sick as well, and all alone on the road. So, he called Son #1 from his hotel room to commiserate this evening. Here's a rough transcript of the telephone conversation.
Dad: How are you, buddy?
Son #1: Daddy, I throwed up. A lot.
Dad: Yeah, I'm throwing up too.
Son #1: Come home, Daddy. I will take care of you, and then you will feel better. You can puke in my bucket, okay?
Son #1: I throwed up in my bucket that Dadi (grandma) gave me. You can do it too. We can puke in it together. Then we will feel so much better.
Dad: Okay, buddy. Thanks! Feel better- I love you.
Son #1: I love you too, Daddy. Bye.
Father and son puking their brains out into a shared plastic bucket... the symbolism just melts my heart.
The imagery, however, makes me want to join them.
Wednesday, February 25, 2009
A recently published study in PLoS One has supported an association between maternal exposure to airborne byproducts of burning fuel (polycyclic aromatic hydrocarbons) and a parental report of asthma symptoms before age 5.
Turns out that prenatal exposure to this type of air pollution is associated with an alteration of certain DNA sequences- which are, in turn, associated with higher odds of reported asthma symptoms.
Although this study only shows an association, and does not confirm causality, it is very interesting. We already knew that air pollution is a key contributor to asthma exacerbations, but now we have evidence that traffic-related pollution may be contributing to the development of the disease itself. This may help explain why inner-city children have such high rates of asthma.
In any case, we now have yet another reason to contact our state and federal representatives and urge them to push for more stringent vehicle emissions standards.
Monday, February 23, 2009
However, a new study published in the Annals of Allergy, Asthma & Immunology has raised some important concerns. 345 women were followed from early pregnancy through their child's first birthday. Associations between acetaminophen use during pregnancy and the development of wheezing during the first year of life were investigated.
What was found is the following:
Acetaminophen use during early pregnancy was unrelated to respiratory events during the first year of life. However, acetaminophen exposure during mid to late pregnancy was associated with nearly double the risk of wheezing (odds ratio 1.8) and slightly more than double the risk of wheezing that caused sleep disturbance (odds ratio 2.1) during the first year of life.
Why might his be the case?
Acetaminophen depletes an imprtant antioxidant (glutathione) from the body. When glutathione is depleted, oxidative inflammation increases. This may be the reason why another recent study published in the British medical journal Lancet found a dose-response relationship between childhood acetaminophen exposure and developemnt of asthma and allegric disease.
Although acetaminophen is still appropriate for fever or pain that is causing significant discomfort, use it cautiously beyond mid-pregnancy and in young children whose immune systems are still developing. The overuse of acetaminophen (both as a comfort measure in the absence of significant fever or pain, or as part of recently discouraged OTC children's cough and cold preparations) may be playing a role in the rise of asthma and allergic disease in our kids.
Thursday, February 19, 2009
I initially couldn't figure out what the problem was, but it became clear when I switched on the light during a diaper change- little munchkin was covered in an itchy red bumpy rash! He's had eczema and hives before, but it resolved completely with the elimination of strawberries from my diet almost 3 months ago (I'm still nursing, and he is allergic).
This morning, after giving him a bath, lubing him up with hydrocortisone and petroleum jelly, and forcing some Zyrtec into his mouth, the detective work began. Hopefully, writing down my process here will help you understand how your allergist determines which exposures are most likely to be triggering allergic symptoms in you or your kids.
Rash is generalized (on face and body)- so it could be either something ingested (food sensitivity) or something applied to the skin topically (lotion, detergent, etc...)
Let's start with topical exposures, because they're easier to pinpoint:
Cleanser- Johnson Baby Wash- been using it since birth without problems, unlikely to be the culprit
Moisturizer- Burt's Bees for Sensitive Skin- been using it since birth without problems, unlikely to be the culprit
Laundry- All Free Clear liquid, no fabric softener, hot water, extra rinse cycle- can't get much more hypoallergenic than that!
OK- topicals cleared. Moving on to systemic exposures...
48 hours ago- immunizations! But baby tolerated the same vaccinations beautifully twice in the past. Besides, allergic reactions to vaccines generally present as immediate urticaria (hives) rather than delayed skin reactions.
Now comes the hard part- food diary! No new foods for baby this week, so let's document everything mommy has consumed over the past 72 hours. Although baby's rash appears partly eczematous (a reaction that generally occurs 48-72 hrs after exposure), it also has elements of an urticarial eruption (hives that usually occur with 4 hours of exposure). So, the culprit could be anything consumed in the 72 hour time frame. Also, we should keep in mind that food proteins generally take around 4 hours after ingestion to show up in breastmilk.
Skipped breakfast (bad mommy!)
Lunch: cream of broccoli soup, grilled chicken salad, a pear, half a can of Pepsi
Snack: 2 bites of a strawberry Nutrigrain bar before I realized it was strawberry (oops!)
Dinner: Portillo's hot dog, breadsticks with marinara sauce
Breakfast: Cheerios and milk, potato paratha (yum!), plain yogurt
Lunch: 1/2 cheeseburger, orange juice
Dinner: lentil stew and rice
Breakfast: Cheerios and milk, cumin cookie, orange juice
Lunch: Ground beef and vegeatbles, Italian bread, orange juice
Dinner: Lamb stew with potato, rice, yogurt, orange juice
None of these foods are new to me or my itchy little bundle of joy, but as you can see highlighted above, I seemed to have quite a craving for OJ over the last 48 hours!
Oranges and other citrus fruits have the ability to induce histamine release from mast cells (white blood cells) in the skin when consumed in sufficient quantities, even if you're not truly allergic. This is known as non-specific mast cell degranulation.
Although I have been able to drink the occasional glass of orange juice or eat a clementine here and there, it appears the my recent orange juice binge has exceeded baby's threshhold. The timeline fits too- I loaded up with OJ all day, but kiddo didn't get exposed until late evening when I returned hom from work. Rash developed overnight and improved markedly after the interventions listed above. This means that it was predominantly immediate in nature, and that I need to watch my intake of citrus. I'll abstain completely for a couple of weeks, and then slowly reintroduce it in small amounts until I determine how much son #2 can tolerate.
In addition, once the Zyrtec leaves his system (at least 5 days), I'll probably skin test him to orange. If it's negative (which is pretty accurate at predicting that it's not allergy) and baby has tolerated reintroduction, my focus on citrus may have been misplaced. But for now, I think it's the most plausible explanation.
Hope this peek into the allergist's thought process has been helpful!