Wednesday, February 25, 2009

Prenatal Exposure to Traffic Pollution May Increase Asthma Risk

We are learning more and more about how life in Mommy's womb affects our health later on in life.

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

Son #2 Shows the Dust Mite Who's Boss

Only an allergist would give her kid a stuffed dust mite to play with.

Acetaminophen May Increase Risk of Wheezing, Asthma, Allergies

As a parent and pediatrician, I have considered acetaminophen (Tylenol) to be one of the medications I could pretty much always safely use for my children and patients.

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.

Bottom line?

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

The Importance of a Detailed Food Diary...

Son #2 did not sleep well last night- lots of whining and refusing to sleep anywhere but my lap... :(

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.

Monday:
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

Tuesday:
Breakfast: Cheerios and milk, potato paratha (yum!), plain yogurt
Lunch: 1/2 cheeseburger, orange juice
Dinner: lentil stew and rice

Wednesday:
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!

Tuesday, February 17, 2009

How to Ensure that Your Child Gets Made Fun of at School

My Take on Vaccinations

Just returned from Son #2's 6 month check-up, where he received a couple of jabs to his chubby little thighs. (brave boy- hardly even cried!)

I am often asked about the safety of vaccines by concerned parents who are frightened that they are putting their children at risk of adverse reactions by following the recommended immunization schedule. I fully understand the sentiment behind not wanting to take a risk (even if it is only a perceived risk) when the diseases we vaccinate against seem like ancient history.

Let me put it plainly- the fact that these illnesses: polio, mumps, measles, diphtheria... seem like history is testament to the enormous public health success of immunizing children. Immunizations are the reason that we don't lose our precious children to horrible diseases like epiglottitis, meningitis, and measles at the alarming rates seen in previous generations.

Let me use measles as an example, as the U.S. Court of Federal Claims recently delivered decisions on the Omnibus Autism Proceeding:

Measles is still a very real threat in many parts of the world. In poor countries, this virus is responsible for the death of approximately 250,000 children per year.

People in developed countries like ours easily become complacent, and think that their children will be protected by herd immunity (which is a nice way of saying that you'll let other people vaccinate their kids so you don't have to vaccinate yours). But guess what? Herd immunity is only as good as the number of people who actually get immunized. And as more and more parents "conscientiously object" to vaccinating their children, herd immunity disintegrates.

The decision to leave children unvaccinated is to blame for recent epidemics of measles seen in both the U.S. and Europe. It starts like this- someone travels overseas, and contracts the highly contagious measles virus. Then they bring it back on the plane, exposing who knows how many people during the trip. Once back home, they infect even more people. Guess who gets sick as stink? The vast majority of those who contracted measles in the U.S. in 2008 (during the biggest measles outbreak in 10 years) were unvaccinated.

No one wants their children (or anyone else's, for that matter) to become seriously ill. No one wishes developmental challenges or regression upon any child. But it's unfair to pin the blame for conditions such as autism on vaccination without proper evidence- the scientific literature simply does not support an association between immunization and autism. This is not a conspiracy cooked up by pediatricians and drug companies. If it was, you wouldn't see us vaccinating our own children.

That said, there are occasionally good reasons not to pursue certain vaccinations.

Some children who are immunodeficient cannot tolerate live-virus vaccines such as MMR, oral polio or varicella, because they might actually contract the illness from the weakened virus in the immunization. These are the children whose lives truly depend on herd immunity.

Other children are truly allergic to components of vaccines, such as egg protein or gelatin, and need to be immunized in a stepwise fashion, under the supervision of an allergist.

If you're concerned about vaccinating your child, please have an open conversation with your child's doctor. Too many parents are afraid to broach the subject for fear of being chastised, and then they end up getting bad information which scares them even more. Pediatricians are trained to have this discussion with parents, and they will work with you to give you all the information you need to feel comfortable with immunizations, how they work, and what to expect from vaccines. You're not going to booted out the door for having questions. At the end of the day, we all have the same agenda- keeping children as healthy as possible.

If you need a reliable source for information about vaccines, visit the Centers for Disease Control and Pevention, at http://cdc.gov/vaccines

Sunday, February 15, 2009

C-section Increases Asthma Risk

According to a study recently published in Thorax, children born by caesarean section have a higher risk of asthma than those born by vaginal delivery, particularly children of allergic parents. The odds of having a diagnosis of asthma at 8 years of age was almost 1.8 times higher for children born by C-section than for children born by vaginal delivery.

A proposed reason for this association is that babies who do not pass through the birth canal on their way into the world take longer to become colonized with the usual bacteria- or that, in essence, they are too clean. :) The bacteria are thought to keep the immune system geared in a non-allergic direction, and when you don't have the right balance of bacteria, your risk of allergic disease (like asthma) increases. This is the crux of the so-called "hygeine hypothesis", which seems to be garnering more and more support as the evidence accumulates.

Guess who has two C-section babies? No asthma yet, but son #2 has wheezed a few times already... makes one wonder, will probiotic supplementation reverse the risk in these squeaky clean kiddos? I'll expound on this issue in a future post...

Friday, February 13, 2009

On Being a "Good-Enough" Mother...

I read in a magazine the other day, "You don't have to be perfect to be be their perfect mother." I just about hugged the magazine to my chest and cried. It feels good to be validated once in a while, doesn't it?

So, in honor of the upcoming Valentine's Day holiday, here is my love letter to mothers everywhere:

You rock.

Don't feel bad if you used disposable diapers instead of washing poop out of cloth nappies 5 times a day. Odds are, your child is not going to get butt cancer.

Don't feel guilty about not saving every piece of unidentifiable artwork that your child brings home from school. Son #1 has brought home at least 23 versions of the same drawing of a rainbow and pot of mashed up fruit over the past 2 months. I gush over them, and promptly send them to the recycling bin. Trust me, he'll make more.

Don't feel like you're neglecting your kids if you have to work and they spend some time in daycare. God bless you for providing for their needs, and guess what? Being around kids your own age is good for you- it teaches you that while you may be the center of Mommy's universe, you're not the center of everybody's universe. This makes for a much more tolerable grown-up, which means that one day, someone will agree to marry your kid and he won't have to live in your basement.

Using the television to distract your kids on occasion is OK. They won't become miscreants or start swearing like sailors if you lay down some ground rules- like, no Law and Order SVU or Dog the Bounty Hunter, for example. God will forgive you if your kids ended up watching Dora for 20 minutes while you washed the puke out of your hair. Heck, you don't want them to think that it's normal to smell like puke, do you?

Don't despair if you don't make a home cooked meal 7 nights a week. I'm lucky if I can do 3 nights a week! Nourishing your children means putting reasonably healthy food in their bellies, and doing it lovingly. Your kids are not going to remember if dinner was made 100% from scratch, but they will remember sitting down to eat it with you, and that dinner time was family time. Go ahead, order a pizza or bring home some chicken nuggets and fries once in a blue moon. And remember, buying $5 bottles of organic ketchup does not mean that you love your kids any more than anyone else- it just means that you apparently have an extra $3 burning a hole in your pocket.

And finally, it's enough for you to put your kids first most of the time. Anyone who puts her kids in front of herself all of the time is doing herself a disservice. Your kids need to see that you appreciate yourself, so that they can learn to appreciate themselves too. They will not feel any less loved if you get a massage or get your nails done- it took me a long time to figure this out. Too long- I was starting to look pretty scraggly. My husband is thankful for the epiphany.

To all the "good-enough" mothers out there with living, breathing, smiling, beautifully imperfect children... congratulations! I'm proud to be among your ranks!

Wednesday, February 11, 2009

Free or Discounted Food Allergy Education Kits for Schools- Help Keep Your Kids Safe!

If your child has severe food allergies, you know that even sending them to school can be stress-inducing on occasion. What if they mistakenly ingest something that they are allergic to, and you're not there to protect them? Cutting those apron-strings is difficult for any parent, but when your child has a potentially life-threatening health condition that can come on so suddenly, it's even harder.

You've done all you can to educate your child about their food allergies and have taught them to advocate for themselves (Son #1 states on a regular basis, "I can eat pistachios, but I don't eat peanuts because they will make me sick!").

But how can you be sure that your child's teachers and school nurses know to take food allergies seriously, can recognize the early stages of a food allergy reaction, and know how to provide quick, effective treatment?

This is your opportunity! The Food Allergy Anaphylaxis Network (FAAN) has available a limited number of excellent food allergy education programs designed especially for schools. FAAN's School Food Allergy Program (SFAP) is a comprehensive, multimedia program that includes a video, EpiPen® trainer, poster, and binder filled with more than 100 pages of information and standardized forms.

It is available free of charge to schools in Illinois and Ohio, and for a nominal charge of $75 to schools in other states.

Ask your school nurse to request the education program via the FAAN site: http://www.foodallergy.org/school/sfap.html (or click the title of this post)

Additionally, consider asking your child's allergist if he/she would be interested in giving an educational presentation on food allergies at an upcoming PTA meeting. Most physicians would be happy to take an hour or two of their time to educate the community and potentially promote their practice at the same time!

Tuesday, February 10, 2009

Unsolicited Medical Advice- Is Holding One's Tongue Always the Right Choice?

My family was invited to a religious function followed by dinner at our place of worship tonight, and sitting with us was an adorable one year old girl with a horrible case of eczema all over her face. The meal consisted of egg-covered chicken, a peanut-based stew, and a coconut-flavored dessert. (As you can probably guess, son #1 didn't do a whole lot of eating at this event...) ;)

The little girl's mom offered her bites of the meal, which the baby promptly refused. Throughout the dinner, I was distracted by the thought that the child's skin condition may very well have its roots in the food she was being fed. It was all I could do to keep from blurting out, "I'm sorry, but I noticed that your daughter has a pretty severe case of eczema. Has she been tested for food allergies?"

Now, I know that this sounds like an unabashed plug for my profession. That's why I never said anything... and now, I am kicking myself. I feel like I let slip away from me an opportunity to truly help a suffering child.

As a physician, I struggle with these boundaries on a fairly regular basis. I certainly don't want to overstep my bounds and offend someone, or seem as though I'm fishing for business. However, I also don't want to ignore a problem that seems to be screaming for my attention- what if this child's pediatrician isn't aware that approximately one-third of children under the age of 3 years with moderate to severe eczema have clinically significant food allergies? Wouldn't this mom want to know? If it would help my child, I'd want to know...

I hope I see this family again at a future function- maybe next time, I'll take a deep breath, offer my opinion, and hope that I don't get clocked in the face (after all, I am still recovering from the grocery cart fiasco!).

Monday, February 9, 2009

How I Busted My Nose Open at the Grocery Store- Or, Why Being a Doctor Doesn't Necessarily Mean that You're Smart

My husband, Mansoor, and I were discussing a few weeks ago how sad it was that we essentially gave up entertaining after the birth of our first child (nearly 4 years ago!). We determined that in order to convince our friends that we're not horrible mooches, we really should invite people over more often.

That was the conversation that begat the onslaught of weekly dinner parties stretching from February 7th to March 7th.

So while Mansoor distracted son #1 at the zoo, I took the baby with me to the grocery store to pick up some supplies. This was my first mistake (I make quite a few in this story- we'll keep count, just for kicks).

Baby's snoozing- so not wanting to wake him, I elect not to remove him from the carseat. Rather, mommygenius decides to maneuver the entire gigantic plastic bucket baby holder into the grocery cart. Carseat + baby = 23 lbs. (mistake #2)

OK- let's get these foodstuffs quickly, before baby wakes up! Oops... grocery cart already full of baby and his bulky crash protection- guess the food will have to go on the tiny little shelf under the cart. (mistake #3)

Oh no- baby's awake (and hungry, to boot)! Until this moment, I never realized that there are no places to sit inside a grocery store... no "give your feet a rest" benches, no "take a load off" chairs, and definitely no "nurse your screaming infant here" seats. That's OK, we made it to the checkout line- only a few minutes and we'll be on our way. Quickly, quickly... get those groceries onto the conveyor. (mistake #4)

Bend down, grab the chicken, lift head- SMACK! between the eyes on the cart handlebar! THUD! onto still conveniently padded derriere! Room spinning, head pounding, baby still screaming, little old lady behind me saying "Sweetheart, you're bleeding...", you've got to be kidding, and I still have to make enchiladas suizas tonight!

Still a little woozy, and more than a little confused- I managed to make it back to the car (did have to ask for help pushing that second cartful of groceries- baby filled up the first one, remember?). On the way back, the bagboy actually asked if I was going to sue them! :)

Once I stopped the bleeding and regained my composure and bearings, we made it safely back home so I could feed my wailing little angel. I finally get him out of the car, and wouldn't you know it- fast asleep.

Next time, I'm using Peapod.

Welcome to the Allergist Mommy Blog!

Do you refuse to leave the house without: (1) Kleenex (2) Benadryl (3) some form of peanut/tree-nut-free snack? Welcome to my world.

My name is Sakina Bajowala, and I am a "Dr. Mom". An allergist-mommy, to be precise.

Back in the days of medical school, I decided that it didn't make much sense to go through all of the time and effort to become a physician if you weren't going to be able to take care of your own kids. So, I became a pediatrician.

Then I decided that it didn't make much sense to have the knowledge to treat my kids if there wasn't anything wrong with them. So, I gave them my genetic propensity for allergies and asthma and became an allergist. :)

This blog is my account of life as a smoothie: Equal parts mommy, wife, and physician.

I'll discuss the latest in allergy evaluation and treatment, share tips for finding something good to eat for kiddos who like to turn red and scratch themselves, and allow my foibles to remind us all that whoever invented the term "Supermom" is just plain evil.

Enjoy!