Monday, December 6, 2010

Food Allergy Guidelines Released!

December 6, 2010 — The first food allergy guidelines were issued today by the National Institutes of Health's National Institute of Allergy and Infectious Diseases (NIAID).

These guidelines have been a long time coming... the emphasis is on:
1. Appropriate diagnosis based on correlation with the clinical history and not simply a positive blood or skin test- food allergy is often overcalled on the basis of testing without proper interpretation
2. Not summarily restricting vaccines such as MMR and influenza in egg-allergic patients
3. Not unnecessarily restricting the maternal diet in an attempt to prevent food allergies in the fetus and infant
4. Prompt use of intramuscular epinephrine in the event of anaphylaxis

The full report (58 pages): http://download.journals.elsevierhealth.com/pdfs/journals/0091-6749/PIIS0091674910015666.pdf
The summary report (44 pages): http://www.niaid.nih.gov/topics/foodAllergy/clinical/Documents/FAGuidelinesExecSummary.pdf

A synopsis of the guidelines, written in plain English, will be available on the NIAID website in early 2011.

Click here for a one-page "What's in It for Patients?" document.

Monday, October 25, 2010

How to Teach a Young Child to Blow a Nose

It's here- cold season.

All over town, boogery kids are wiping snot on their sleeves, their hands, and us.  One of the most important things you can teach your child is how to properly blow his/her nose.  It's one of the "skills" I check for whenever a young child comes to my office with symptoms of an upper respiratory infection.  I'm always amused by the number of kids blowing air out of their mouth!

Here are my tips for getting the "highest yield", so to speak, from a nose blow.

1. Get some saline nasal spray.  If you're doing this in the morning, we have crust to loosen before we get this party started. (If you have a pressurized can of saline with a gentle spray nozzle, all the better.  There are multiple brands- they all work pretty well.)  Instill the saline into each nostril- enough so that it starts dripping out.

2. Dab the drips with a tissue.

3. Have your child take a deep breath.

4. With your finger on the tissue, apply enough pressure on one nostril to effectively close it off.

5. Instruct your child to close his/her lips tight (curling them in works well) and blow as hard as possible through the nose. Make sure your tissue is in place!

6. Examine the products of your efforts: Wow- how did all that fit inside your little head?!?!?

7. Repeat on the opposite side.

This whole process can be completed in under 20 seconds.  I like to do this in the morning, and before sleeping (naps and bedtime).  Your child will quickly grasp the concept, and by age 5years, should be able to take care of business without assistance (most kids will continue to need help with the saline part, though).

Good luck!

Monday, October 18, 2010

A Lesson in How Not to Surprise Your Kid

The setting- breakfast table on Saturday morning
The cast of characters- the Allergistmommy and Son #1

Me: I have a surprise for you! We're going somewhere special today!
Son #1 (eyes lighting up): Are we going to Hawaii!?!!?
Me: Umm... no.  We're going to the pumpkin patch.
Son #1: Oh, okay.

(He loved it anyway, even if it wasn't paradise on earth.)

Wednesday, September 22, 2010

Chinese Herbal Formula to Protect Against Food Allergy Ready for Phase 2 FDA Trials

One of the most exciting recent developments in the treatment of food allergy is the development of Food Allergy Herbal Formula 2 (FAHF-2), a combination of nine herbs from traditional Chinese medicine.  The therapy is based on a traditional formula called Wu Mei Wan (used for gastrointestinal parasitosis), but has since been modified to remove some ingredients and add others, in an effort to improve the safety profile and increase effectiveness for food allergy. Wu Mei Wan is one of the classic herbal formulas taught to students of traditional Chinese medicine.  Over time, it has become apparent that the active ingredients may have utility beyond the original application.


Previous animal studies have demonstrated that FAHF-2 not only protects severely peanut-allergic mice from reactions during peanut challenge, but also that the beneficial effects may last for up to 6 months after discontinuing treatment.  Phase 1 human trials in the United States have shown promise that FAHF-2 will be both safe and effective as protection against severe food-allergy reactions, but longer trials with a larger number of subjects are needed to prove long-term safety and efficacy of the therapy.

To this end, the researchers are now enrolling patients in the phase 2 clinical trial.  This study will be conducted at Mount Sinai and Arkansas Children’s Hospital Research Institute (Little Rock). Participants, aged 12-45, with allergy to peanut, tree nuts, fish, shellfish, and sesame, may be eligible. For more information, please write to: pediatricfoodallergyresearch@gmail.com.

What is most exciting to me about FAHF-2 is that it presents a scenario where we are utilizing a rigorous evidenced-based approach to evaluating traditional medicine's safety and effectiveness.  It is my hope that this scientific approach can be used to bring other alternative therapies into the mainstream, and create a truly complementary approach to healing.

My expectation is that pediatric trials will be next on the horizon.  This is good news, because the heart of a parent is where the deep-rooted desire for a safe treatment for severe food allergy is most fervent. 

Saturday, August 21, 2010

The Grotesquely Swollen Apple of My Eye- What to do When Bugs Attack Your Child's Face

Son #2 woke up this morning looking like a streetfighter!


Dramatic swelling of the eye(s) such as this can occur for a variety of reasons:
1. Allergic reaction to ingested food or drug (generally affects both eyes)
2. Direct contact with environmental allergen or food allergen (can affect one or both eyes)
3. Hereditary or acquired angioedema (can affect one or both eyes)
4. Injury (usually affects one eye)
5. Low protein levels (generally affects both eyes)

6. Infection (generally affects one eye)
7. Insect bite (can affect one or both eyes)

In this case, my little one endured a mosquito bite at the outer corner of his left eye yesterday afternoon.  It was mildly swollen at the time, and became progressively worse as the night wore on.

Does this mean he has a mosquito allergy? Actually, no more than anyone else.  Certain areas of skin, such as around the eyes and on the lips, are more loosely attached to underlying tissues and muscles than skin elsewhere on the body.  This allows these areas extra "give" and elasticity when reacting to the inflammatory enzymes in mosquito saliva.

How to treat a reaction like this?  My vote is conservatively:
1. Over the counter oral antihistmaine, such as Benadryl
2. Cool wet compresses
3. Ibuprofen if the area is tender
4. A three day course of oral steroids would be appropriate if the eye is sufficiently swollen that the child's vision is affected (your physician will likely want to evaluate your kiddo in person if this is the case). Because the eyes are a sensitive area of the body, I am generally reluctant to apply medium to high potency steroids directly to the skin surrounding the eye.

The above regimen should help even the most pronounced swelling go down within a couple of days.  Happily, the vast majority of these localized reactions can be managed in the home setting with excellent results, without the need for a doctor's visit or trip to the emergency room.

However, if you note generalized symptoms of an allergic reaction (such as swelling of other areas of the body, generalized hives, or shortness of breath), do not delay seeking medical attention, as there may be real risk of rapid progression of symptoms!

Friday, August 6, 2010

Saturday, June 26, 2010

Summertime Tips for Food-Allergic Partygoers

Excellent Article from the American College of Allergy, Asthma & Immunology- reposted with permission.

Summer Means Barbecues, Picnics – and Food Allergies
Ants, bees and rain aren’t the only things that can put a damper on a picnic or barbecue. For more than 12 million Americans food allergies can ruin the fun too, by causing problems ranging from the mild (itchy bumps and stomach aches) to the severe and life-threatening (swelling of the throat and difficulty breathing).
Be food allergy savvy at your next picnic, whether you are planning the event or have food allergies yourself. The American College of Allergy, Asthma and Immunology offers the following tips for keeping food allergies off the menu:
  • Consider condiment packs – Instead of large containers of condiments, use individual-sized packets of ketchup, mustard, relish and mayonnaise. These condiment packs will prevent cross contamination that can occur when sharing large containers.
  • Pack foods separately When preparing for a get-together away from home, pack allergic and non-allergic foods in separate containers.
  • Use a plastic tablecloth – In addition to dressing up your barbecue or picnic, a tablecloth prevents guests from coming in contact with any allergy-causing food particles left on the table from previous meals.
  • Provide a serving utensil for each food item – Separate utensils help reduce cross contamination between dishes. And be sure you have enough plates, cups, napkins and utensils so no one will have to share.
  • Carry medications – If you or a loved one has had allergic reactions to food in the past, be sure to have emergency medications on hand just in case unrecognized food allergens are hiding in picnic treats.
  • Serve allergic guests first – Grill foods for guests with allergies first, or cook the items on a fresh piece of aluminum foil.  Also, allow guests with allergies to dig into the food first, before cross-contamination of items can occur.
  • Remember the wipes – For get-togethers in forest preserves and other natural areas, soap and water might be tough to come by, so come prepared with disinfecting wipes and anti-bacterial gel.   Cleaning hands and faces after eating helps reduce the likelihood of allergy-causing food particles being passed during play.
  • Check cell phone coverage – If your picnic or barbecue is away from home, be sure you can get a cell phone signal in the area to call 911 if someone has a severe allergic reaction.
If you are a loved one experience an allergic reaction to food, it’s important to see an allergist, who can pinpoint which food is causing the reaction and develop a plan for avoiding it.
For more information about allergies and asthma, visit www.AllergyAndAsthmaRelief.org.

Saturday, June 12, 2010

Illinois State Board of Education Publishes Food Allergy Guidelines!

Thanks to the Mothers of Children Having Allergies (MOCHA) group for the following update!

Illinois State Board of Education (ISBE), in conjunction with the Illinois Department of Public Health (IDPH), has released the Guidelines for Managing Life-Threatening Food Allergies in Illinois Schools.


According to State Law, each local school board is required to have a policy based on these guidelines in place by Januray 2011- a sample policy based on these guidelines will be made available to all school districts in August. With any luck, the school boards will simply adopt the recommended sample policy- this is the expectation.

The guidelines and associated forms are available online at: http://www.isbe.net/nutrition/htmls/food_allergy_guidelines.htm The sample policy will be available to member school districts and to any non-member school district that requests a copy.

Even if you don't live in Illinois, this can be an excellent starting point as your food-allergic child prepares to enter the school system. If your school administrators feel uncomfortable with developing their own policy for protecting children with life-threatening food allergies, they may be able to request a copy if ISBE's policy to implement.

Wednesday, June 9, 2010

Antibiotic Choices in Acute Ear Infections- Does Convenience Lead to Treatment Failure?

Macrolide antibiotics (such as azithromycin) are popular choices when treating acute ear infections in children due to a short (5 day) course of treatment, once-daily dosing, and low incidence of gastrointestinal side effects.

However, macrolide antibiotics, while generally effective against the most common pathogens in acute ear infections in children (streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis), are quickly losing effectiveness as resistant strains of bacteria increase. A 2007 study by the CDC demonstrated a 22.7% rate of macrolide resistance among strep. pneumoniae isolates (the most common cause of ear infections).

2004 recommendations from the American Academy of Pediatrics and the American Academy of Family Physicians advised against the use of macrolides for acute ear infections unless a patient has an immediate-type allergic reaction to penicillin. However, the rate of macrolide prescription continues to dwarf the documented rate of immediate-type penicillin allergy.

A recent meta-analysis (a study of a compliation of other studies) published in The Annals of Pharmacotherapy confirmed that this is not a good trend. Although the rate of side effects (including diarrhea) was lower in the patients treated with macrolides when compared to those patients treated with the recommended antibiotics (amoxicillin or amoxicillin/clavulate), the macrolide-treated patients were more likely to still have untreated infection present at 10-16 day follow-up.

So, when your child is diagnosed with an acute ear infection, ask the following questions:
1. Does this infection require treatment with antibiotics? (over the age of 2 years, your physician may recommend 48 hours of watchful waiting before antibiotics are given)
2. Can my child be treated with amoxicillin or amoxicillin/clavulanate?
3. What can I do to decrease the chances that my child will experience untoward side effects from the antibiotic therapy? (I generally recommend taking the medication after a meal, and often add probiotics and yogurt to decrease the risk of gastrointestinal symptoms)

Don't fall into the convenience trap- it may cost you (and your little one) in the long run!

If a drug allergy is suspected, don't hesitate to consult a Board-certified Allergist & Immunologist- I often find that patients have spent many years avoiding a particular medication and using inferior substitutes due to overdiagnosis of drug hypersensitivity.

Wednesday, May 26, 2010

Son #2 Sleeps like a Big Boy, Mommy Sleeps like a Baby!

Hallelujah!

Angels sang this morning, as my husband and I awoke to find that for the first time in almost 5 years, there was no pint-sized human barrier separating us.

Son #2 slept through the night! In his own crib, without waking even once!

There is no credit to take for this miracle, only thanks to give... and fingers to cross hoping that this new development sticks!

Wednesday, May 12, 2010

Be Aware of the Generic Epinephrine Autoinjector

Thanks to the American Academy of Allergy, Asthma & Immunology, and the American College of Allergy, Asthma & Immunology for the following update.

It has come to our attention that there is a generic epinephrine autoinjector (without a specific name) that is being distributed by Greenstone (a generic division of Pfizer). According to Greenstone's website, this injector is identical to a product named Adrenaclick, distributed by Shionogi Pharma. Apparently Shionogi has authorized Greenstone to distribute the same device as an unbranded or "generic" item.

We call your attention to this because it may result in substitution by the pharmacy of the generic for a brand name prescription, or vice versa. The issue which merits comment is that the instructions for the administration of EpiPen, a product distributed by Mylan Pharmaceuticals, is different than the instructions for the administration of either the Adrenaclick or the "generic" automatic epinephrine injector. There is presently no generic autoinjector which employs the same administration technique as the EpiPen.

Thus, you may have trained your patient for the administration of one type of injector, and the pharmacy may provide another type on which the patient has not been trained. During the stress of an anaphylactic reaction, this may be confusing to a patient and could result in the delay or perhaps an error in the administration of the drug.

You can view each type of injector and the instructions for its administration at each of the respective websites: www.adrenaclick.com; www.epipen.com; dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=16934

Monday, May 10, 2010

Oprah the Greek!

Went to a Greek restaurant with the family yesterday for a combined Graduation and Mother's Day celebration. The boys loved the saginaki!

Son #2 kept yelling, "Fire, fire!" (oh, dear.)

Son #1 asked: "Daddy, why do you keep shouting 'Oprah!'?"

Monday, May 3, 2010

Donate Your Expired Epinephrine Autoinjectors to a Good Cause!

Have an expired epinephrine autoinjector and don't know how to dispose of it properly? Here's an opportunity to donate your expired medication to a good cause!

AllergySense is collecting expired epinephrine autoinjectors for use as training devices at hospitals and clinics in the U.S. and Canada. As a thank you - for each autoinjector you donate, you'll be entered in a drawing for some nice prizes!

Here's the link: http://www.allergysense.com/promo_epi.php

5 Year Old Teaches Mom to Look at the Silver Lining of Road Construction

Anyone who hails from Chicago knows that we have two seasons: winter and construction. Now that construction season is upon us, it is often difficult to stay in a good mood while commuting.

When construction delays forced me to take a circuitous route home last week, bypassing the highway and winding through all sorts of local roads we had never seen before, I was starting to get frustrated. I mean, how is it that every highway needs to be upgraded every spring? I just want to get on the highway and fly home, you know? Kids are in the car, we're hungry and tired, and I could feel my blood starting to boil as we hit yet another red light.

We finally pulled into the garage, and my 5 year old says, "Mommy, I really liked the new way you took us home today- it was very creative!"

God bless preschool teachers. God bless 'em.

Sunday, May 2, 2010

Tylenol, Motrin, Zyrtec, Benadryl Recalled Due to Quality Control Issues

Especially important during this active allergy season- Please see the following link for a list of lot numbers affected in the McNeil recall (affecting Tylenol, Motrin, Zyrtec & Benadryl).

http://www.mcneilproductrecall.com/page.jhtml?id=/include/new_recall.inc

Tuesday, April 27, 2010

Does Your Food--Allergic Child Qualify for a 504 Plan?

A parent of 2 food-allergic kiddo's shared an interesting tidbit with me the other day, of which I was not previously aware.

If your child has a history of anaphylaxis to a food allergen, he/she may be a candidate for a 504 plan, which creates a specific plan outlining the accommodations that may be needed in the school setting to ensure that the student with a disability (in this case, severe food allergy) is not excluded from the full educational resources available to other children due to his/her disability.

From the Department of Education website: Section 504 is a federal law designed to protect the rights of individuals with disabilities in programs and activities that receive Federal financial assistance from the U.S. Department of Education (ED). Section 504 provides: "No otherwise qualified individual with a disability in the United States . . . shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance . . . ."

Many parents of food-allergic children already meet informally with teachers and school administrators to discuss their child's food allergy, and how best to ensure safety in the learning environment. For the most part, especially for children with milder food allergies, this is sufficient.

However, for those children with a history of anaphylaxis to commonly encountered foods (especially those for which the risk of cross-contamination is high, and which cannot be easily excluded from the school environment), parental anxiety about proper precautions and procedures in the event of a reaction is understandably higher. Even when the relationship with school staff is cooperative and non-adversarial, having a detailed 504 plan in place can be beneficial for all involved, as it puts into writing a legal document which details appropriate educational measures for all individuals involved in the affected child's education. This document can provide guidance regarding everything from bus transportation issues to the provision of a "peanut-free" computer keyboard.

Obviously, creating a 504 plan is an involved process, and is not appropriate for every food-allergic child. But, if after discussion with your child's physician, you determine that your child needs the accommodations provided by a 504 plan, it can be helpful to approach the school with some of the "homework" already completed. As a parent, you are an integral member of the 504 plan team.

To that end, I've discovered an excellent resource created by a mother of a child with severe food allergy, based on research of 504 plans compiled from around the country. This is an outline of a 504 plan which addresses many of the issues facing food-allergic children in the school setting. It is, of course, not intended to replace medical advice, nor does the author claim that is is fully comprehensive. However, it is a formidable effort, and is likely to be very useful to you as you work with your school to ensure that your severely food-allergic child has a safe and healthy learning environment. Here's the link (on the allergysupport.org website): http://allergysupport.org/index.php?option=com_content&task=view&id=16&Itemid=1

Saturday, April 24, 2010

Thursday, April 22, 2010

Warnings About Volcano-Related Respiratory Problems May Have Been Premature

Eyjafjallajokull (ay-yah-FYAH-lah-yer-kuhl). Say that five times fast!

No matter how you pronounce it, this volcano has been in the news and in water-cooler conversations around the world. It has affected travelers, governments, and reportedly, even a rhinoceros who got stuck en route!

On Friday, the World Health Organization issued a warning for patients in Europe with asthma and other respiratory problems, claiming that the ash cloud released by the volcano could be "very dangerous" for them due to the abrasive and corrosive nature of volcanic dust particles.

However, they have since toned down this warning. The tiny particles of volcanic ash which are most likely to cause these issues are still very high up in the atmosphere- too high to cause significant problems for individuals on the ground (except in the immediate vicinity of the volcano). A low-pressure weather system expected over Iceland later this week may push the ash cloud towards the Arctic and prompt rain which may further "wash out" the ash. With any luck, the fine particles of volcanic ash capable of causing severe respiratory issues will never make it to the ground in highly populated areas.

In the meantime, it is important to keep in mind that volcanic ash particles are probably less toxic to our lungs than the small particles from traffic pollution and HVAC systems. So, in honor of Earth day... less fretting about what Mother Nature has done to us, and more fretting about what we have done to Mother Earth!

Thursday, April 8, 2010

Should Smoking in Passenger Vehicles be Banned?

The dangers of environmental tobacco smoke (ETS) have been well-documented. Environmental tobacco smoke has been associated with increased risk for not only asthma and ear infections, but also with meningitis and sudden infant death syndrome. Young children are particularly susceptible to these ill-effects. The risk is not limited to second-hand smoke, however. Third-hand smoking occurs when an individual is exposed to an environment in which someone has been, but is not currently, smoking.

Quoting from the Pediatrics article "Beliefs About the Health Effects of 'Thirdhand' Smoke and Home Smoking Bans" by Jonathan P. Winickoff, MD, MPH et al: "Research has documented the association between smoking in the home and persistently high levels of tobacco toxins well beyond the period of active smoking. These toxins take the form of particulate matter deposited in a layer onto every surface within the home; in loose household dust; and as volatile toxic compounds that 'gas' into the air over days, weeks, and months."

Knowing this, the Royal College of Physicians in the United Kingdom has called for a smoking ban in vehicles. The goal is to protect children, who are unable to advocate for themselves when riding in cars in which adults choose to smoke. I couldn't agree more! As parents and physicians, we have a responsibility to advocate for the health of all children, who don't have a say in whether they are exposed to the damaging effects of ETS. They are completely dependent upon the decisions we make, and permit others to make.

Without an outright ban on smoking, we cannot legislate what happens within the home. However, there are municipalities within the U.S. that have proposed classifying smoking in a vehicle carrying minors as a secondary offense, meaning that although a police officer cannot stop you for smoking, they can cite you for smoking if you are pulled over for another reason. It's a start, but this only addresses the risks of second-hand, and not third-hand smoke. (Anyone who's stepped into a taxi where the cabbie had been recently smoking knows where I'm coming from.)

Perhaps I am in the minority, but I view ETS as a child-endangerment issue. Given the documented risks of third-hand smoke and the exquisite susceptibility of young children to it, why should we tolerate anything less than a ban on smoking in vehicles altogether? Of course, there are those who argue that such a ban would be an affront to personal liberty.

My argument: why should your "right" to smoke trump your child's right to breathe clean air?

What do you think? In the United States, could a ban on smoking in vehicles ever be enforecable?

Wednesday, March 31, 2010

Food Challenges- What Are They, and Why is it So Hard to Get One?

With the awareness of food allergies increasing, there is expanded interest in the various methods of diagnosing food allergy. Of course, the skin test vs. blood test debate is ongoing. (I have more trust in the skin test, in case you're wondering.) There are also plenty of proponents of what I call "weird science". These are unproven methods that might make someone feel like they're getting an answer (and are certainly enriching the practitioner), but do very little to diagnose actual food hypersensitivity and, more often than not, lead to unnecessarily restrictive diets.

However, there's decidedly less discussion about what is considered the most definitive way to diagnose food allergy- the oral food challenge. A food challenge is a test that involves giving a patient incrementally larger doses of a specific food by mouth over a period of time, all the while monitoring the patient for signs and symptoms of an allergic reaction. Because the risk of an acute allergic reaction occurring during an oral food challenge exists, the test should be administered by trained medical professionals in a setting where emergency treatment can be immediately provided in the event of a reaction.

There are two main types of food challenge: blind and open. The type of challenge chosen for testing depends on what you are trying to determine.

In a single-blind challenge, the patient does not know which food he/she is being given to eat during the test. In addition to the food being tested, a dummy food is also offered, and the flavors and smells of both items are masked. This decreases the possibility of a patient reacting to the tested food on the basis of his/her belief that the food will not be tolerated, rather than due to a physical hypersensitivity. This is the test I might choose when I have a patient who is convinced that he/she cannot tolerate a particular food, but all the testing is negative. Although I might encourage the patient to resume eating this food, he/she will most likely be reluctant unless I can prove that it can be eaten without a reaction.

In a double-blind challenge, even the physician is not aware of which food is which until after the testing is complete. This method is used mainly in research studies, to reduce the risk of bias on the part of the individual recording the results. It is considered the "gold standard" in food allergy testing.

In an open challenge, the physician and patient are both aware which food is being tested. A placebo, or dummy food, is not required. Although this makes the test much simpler than a blinded placebo-controlled challenge, it does introduce a risk of bias. An example of how I use this test is when I suspect that a child may have outgrown a food allergy, but due to the severity of the initial reaction, I do not want to take the risk of reintroducing the food outside of medical supervision.

Food challenges can offer valuable diagnostic information when wading through the confusing world of food allergy, but they are underutilized. In fact, in some areas, it is difficult to find an allergist who is able to offer food challenges in the office setting. You may be forced to travel hours away to the nearest academic allergy center for food challenge testing.

Why? The truth is this- in the United States, the majority of health insurance companies will not reimburse the allergist for food challenges. The time spent (usually 2 to 4 hours) of measuring food doses, administering the doses, and monitoring the patient is generally bundled into the reimbursement for a 25-40 minute visit. Unfortunately, even though they would like to offer this testing method, most community allergists cannot afford to tie up a patient room and a nurse for this extent of time without reimbursement. This leaves many patients in the position of either finding an academic center, or continuing to avoid the suspected food allergen.

However, this may be changing. The American Academy of Allergy, Asthma & Immunology's committee responsible for food allergy is spear-heading an initiative to update the practice parameters for the diagnosis and management of food allergy. With the development of more defined protocols for food challenges in the office setting, it is possible that insurance companies may be convinced of the importance of food challenges, and the current barriers to the accessibility of food challenges in the community setting may be overcome.

Friday, March 19, 2010

Our Children Are Watching... the Way We Encourage Them to Behave!

Just went a local restaurant to pick up lunch. As I exited my car, I was shocked to see a mother shielding her ~4 year old son with the car door while he urinated in the parking lot- in the spot directly in front of the restaurant entrance!

I'm sorry, but this is inexcusable. You're not camping in the woods, you standing in front of at least fifty people behind glass walls. In a restaurant that has a bathroom, for goodness sakes! If your child cannot control his bladder, I understand- all children toilet train at their own pace. Sometimes, especially while you're learning, "I gotta go" means, "I gotta go NOW".

But parental actions dramatically impact what our children learn to accept as appropriate behavior.

People knock country music sometimes. but there are some lessons to be learned...
I was listening to a Dixie Chicks album in the car yesterday, and was struck by the following lyrics: "Our children are watching us, they put their trust in us, they're gonna be like us."

If you giggle while allowing your child to void in the entrance of a place of business, instead of picking him up and racing to the washroom that is no more than 30 feet away, you teach your children that it is acceptable to disrespect other people and their property.

Shame on you. And don't come crying to me when your kid gets picked up by the cops for vandalism in 11 years. You only have yourself to blame.

Wednesday, March 17, 2010

Son #1 Labels Son #2 a Trouble-Maker

Those who know my children personally know that Son #1 is cautious and thoughtful, and Son #2 is impulsive and and fearless. So, the following conversation seems especially intuitive.

Son #1: Mommy, I'm going on a trip to Mexico.

Me: Ooh... mommy wants to come!

Son #1: No, you can't come. It's a kids trip!


Me: Will you be taking your brother along?

Son #1: No- he can't come either. He's just going to run around all over Mexico and cause problems.

Sunday, March 14, 2010

Can We Go Overboard in Our Efforts to Protect Food Allergic Children?

Warning: This post will be controversial.

I have seen too many instances of terrified parents falsely believing that being in the same room as a peanut is going to kill their child. I have heard too much about 10 year old children being kept home from birthday parties, families being kicked off planes for requesting that peanuts not be served to anyone on board, of people demanding that high schools be peanut-free. I feel that something needs to be said.

The bottom line is this: there comes a time when we need to sit down and come to terms with the actual risk posed by inhalant exposure of peanut allergen vs. the perceived risk.

I do not need a double-blind placebo-controlled trial to tell me that the perceived risk of anaphylaxis to inhaled peanut protein far, and I mean FAR, outweighs the actual risk.

The majority of parents whose children have experienced food-related anaphylaxis are understandably traumatized by the event, and would go to the ends of the earth to prevent a repeat reaction. I get this. I personally know the nightmare of being doubled over in pain, covered in hives, and feeling my inside of my throat swell to the point that I had difficulty speaking. I am the mother of two allergic children myself, and was pleased when my son's daycare informed me they were peanut-free. To my mind, makes sense to exclude peanuts from a facility full of little kids with poor impulse control.

But I am saddened by the number of parents who wrongly have been made to feel as though the world is not safe for their children. Anaphylaxis sucks. But the vast majority of children with food allergy, even those who experience anaphylaxis with ingestion, are able to live safely in close proximity to their food triggers. Peanut protein is undetectable in the air after study subjects have consumed peanut butter. A study by Dr. Scott Sicherer (a highly esteemed clinician-researcher in the field of food allergy) evaluated 30 highly peanut-allergic children by having them sniff peanut butter for 10 minutes- none of the children reacted. This might be different with peanut flour, which could potentially trigger symptoms at points of contact: eyes, nose, lungs. However, this would be with close proximity, and is exceedingly unlikely to trigger the cardiovascular collapse associated with full-blown anaphylaxis.

So, why are so many parents telling teachers, school administrators, restauranteurs & airlines the following: "Don't you get it? My child could DIE!"

The answer is simple. Because they believe it.

At some point, a medical professional did an allergy test, gave the parents a lecture on the dangers of hidden peanut exposure, advised strict peanut avoidance, and trained the family in the proper use of autoinjectable epinephrine. None of these these are necessarily wrong.

The bad part is what's missing from the conversation. Where is the discussion about the actual risks of having peanut products in the home or school, the utility of peanut-free tables, of going out to a restaurant, of flying on a plane? What about the risk of eating those pesky "processed in a facility that also processes peanuts/tree nuts" items? This is where we, as a medical community, have let food-allergic children and their families down.

All too often, it seems easier and safer for the doctor to say- "Avoid peanuts at all costs. Here's an EpiPen- keep it close, and don't hesitate to call 911." Why unnecessarily risk a severe reaction, right? Seems logical enough. But it doesn't make things easier. It makes things harder. It FREAKS parents out.

The above statement, translated into parentese, is this: "Remember how your kid looked after eating that peanut butter cookie- all red and swollen and puking? If you're not careful- it'll happen again- might even be worse! Better be ready!" You think you're being cautious- but at what cost to your patient's quality of life? No wonder the parents are losing hair and gaining wrinkles over sleep-overs and school lunches and class trips to the state capitol! No wonder we have a new generation of children so ardently protected from any chance peanut encounter, however minute, that they've come to see the outside world as a danger zone!

This is counter to what we should be trying to accomplish as medical professionals. What is needed is a more nuanced, individualized discussion of risk, tailored to each peanut-allergic child. Parents need to know what to protect their children from, to be sure. They need excellent training in the indications and use of emergency medicine. But they also need to know which situations are relatively safe, even if it goes counter to the popularly held conceptions. This is where counseling from an allergist can be especially helpful.

It breaks my heart when I see parents who have not been adequately educated about the real risk involved with non-ingested peanut exposure, and have therefore been worried about scenarios that pose little to no risk to their children. As physicians, the onus is on us to do better by these families. All it takes it a little time, thoughtfulness, and a willingness to break free from a cookie-cutter approach to treating food allergy.

Thursday, March 4, 2010

Healthy Diet During Pregnancy Decreases Risk of Eczema and Wheeze in Baby

A Japanese study published in the European Journal of Allergy and Clinical Immunology (link: http://www3.interscience.wiley.com/journal/123251237/abstract?CRETRY=1&SRETRY=0) shows what many of us in the allergy world have suspected for a long time- mom's prenatal diet does have an impact of the risk of atopic manifestations in offspring at 16-24 months of age.

The study evaulated over 700 Japanese mother-child pairs. A diet-history questionnaire evaluated maternal consumption of fruits, vegetables, and antioxidants during pregnancy (at week 17). Atopic symptoms were evaluated based on criteria from the International Study of Asthma and Allergies in Childhood (at aged 16-24 months).

The study found that higher maternal intake of green and yellow vegetables, citrus fruit, and β-carotene during pregnancy was significantly associated with a reduced risk of eczema, but not wheeze, in the offspring. Maternal vitamin E consumption during pregnancy was significantly inversely related to the risk of infantile wheeze.

The authors concluded that maternal diet may reduce the risk of certain atopic manifestations in the offspring.

Although the results of this study are exciting, I do have a few concerns:

1) Self-reporting of diet history does introduce a risk of recall bias. Even in a scientific study, I fear that subjects are more likely to report a healthier than actual diet, the same way that we all tend to exaggerate to our physicians our actual rates of compliance with medication. So, if we're not actually having the patients write down what they are eating while they eat it (with a food diary, for example), are we really getting an accurate dietary history?

2) Because the study was done in a relatively homogeneous Japanese population, it doesn't account for genetic differences between different groups. We can't be certain that these results would be replicated in a genetically heterogeneous U.S. population.

These concerns notwithstanding, I still believe that this an important study, because it reminds us that what we put into our bodies has implications beyond our waistlines.

Future directions? I'd love to see a similar study done in a genetically diverse population, with a full dietary diary throughout the 9 months pf pregnancy. I'd also like to see this study done in multigravid women, so we can see if having a first child with atopy impacts the ability of diet to modify risk in a subsequent child.

As a mother of two allergic children, one with both eczema and wheezing, I'd be curious to know if my dietary choices played any role in my children's health. Full disclosure: Pregnancy #1- craved cottage cheese, yogurt, and produce. Pregnancy #2- craved cheeseburgers.

Guess who's itchy and wheezy?

Friday, February 26, 2010

How Social Media Can Help Doctors Stay Up-to-Date

Physicians, like many other professionals, have continuing education requirements. We are exposed to the newest research and advances while in training, but after we pass our board exams and enter practice, the onus is on us to maintain our knowledge to current standards. Without regular reading and attendance at medical conferences, you can easily get left behind as medicine advances.

I am currently attending the Annual Meeting of the American Academy of Allergy, Asthma & Immunology in New Orleans. It is always a wonderful meeting, full of new information to bring home to my patients. I will be periodically tweeting medical information that I believe may be of interest to my readers: http://twitter.com/allergistmommy

Other colleagues will be doing the same- Matthew Bowdish, M.D. is an allergist who has shared information from past allergy conferences, and will be tweeting at http://twitter.com/matthewbowdish (His tweets from the Western Allergy Society meeting were great, and I'm sure those from AAAAI will be just as informative!)

Ves Dimov, M.D. is an allergy fellow and prolific tweeter, whose updates educate both physicians and patients on the science of allergy: http://twitter.com/allergy

Amazing how technology helps us share information so widely and quickly!

In a seminar earlier today, I shared with colleagues how I believe that using social media tools has made me a better physician. Because I have access to so much information, I read more, and learn more, than I could without these connections. Because I hear first-hand what patients/parents care about, I know what to spend time discussing during visits, and what to write about. So thanks, Twitter, Facebook, Blogger! You're an integral part of this physician's continuing medical education!

Wednesday, February 24, 2010

The Allergist Mommy Confessions

Confession #1: I am still co-sleeping with Son #2. Why is an 18 month old in charge of my bed? I blame absence of any set routine. Because I parent my kids with the help of their grandmothers during the week while DH is out-of-town for work, the boys have 3 households, and 3 separate beds each. While this has fostered a great deal of flexibility and adaptability in my sons, it has also made it difficult to establish bedtime consistency. Hence, Son #2 wedges himself quite comfortably between DH and me in the middle of the night (even on weekends, when he easily could be in his crib). This is also why the odds of a Child #3 coming along any time soon are remarkably slim.

Confession #2: I no longer enjoy nursing, and am desperately trying to wean. I feel guilty admitting this, because I am such an ardent proponent of breastfeeding. However, partly due to Confession #1, and partly due to my own inability to suffer my child's noctural complaints, I have enabled Son #2 in his quest to remain eternally latched. He should have been sleeping through the night long ago, and it's really hard to blame this one on anyone but myself. As my husband reminds me every time I complain about this, I am too soft.

Confession #3: I really want a mommy-cation. I want to sleep through the night. I want to eat at a restaurant that has cloth napkins. I want to take a 30 minute shower. I want to get my nails done and actually let them dry fully before leaving the salon.

Confession #4: I'm skipping town. Hopping on a plane to the Big Easy (OK, fine- it's a medical conference, but that's as close as the Allergist Mommy is going to get to a real vacation right now). Leaving the kids with their loving father and grandparents for a few nights. Maybe, magically, miraculously, Son#2 will be sleeping all night in his own bed when I return. Or maybe not. Whatever- at least my nails will look good.

Monday, February 22, 2010

2010-11 Influenza Vaccine Will Include H1N1 Virus

The Health Organization Committee that determines the composition of the yearly influenza vaccine met last week, and has decided to include H1N1 in the 2010-11 vaccine.

It is recommended that the following viruses be used for influenza vaccines in the 2010-
2011 influenza season (northern hemisphere):
– an A/California/7/2009 (H1N1)-like virus;
– an A/Perth/16/2009 (H3N2)-like virus;#
– a B/Brisbane/60/2008-like virus.

For the full report, please go to: http://www.who.int/csr/disease/influenza/201002_Recommendation.pdf

This was anticipated, but there was a chance that the H1N1 would still be separated into an additional injection, so I am pleased that my patients will only need a single dose of vaccine to get coverage for both seasonal and H1N1 influenza this coming year. Interestingly, the strain of H1N1 is the same as in the 2009-10 H1N1 vaccine- so it may actually serve as a booster dose for patients who received the vaccine this past season.

Friday, February 19, 2010

The Doctor Will See You... Sooner Than You Thought? Why Asthma Patients Need Frequent Follow-Up.

At the end of every patient visit, I let my patients know when I would like to see them again. For some patients, the visits are infrequent- once a year for a well-controlled patient with nasal allergies. However, for asthmatics, I recommend more frequent visits.

Lately, I've begun noticing that my chronic asthma patients occasionally look at me sideways when I tell them that I expect to follow-up with them every 3-4 months to document asthma control and adjust medications. There have been a few disgruntled phone calls after a patient learns that only 3 months worth of refills have been submitted to the pharmacy, instead of the standard 6-12 month supply. It has occurred to me that my patients are not alone in their confusion as to why their physician can not bear to be apart from them for more than 12 weeks at a time, so let me explain myself:

1. I am not secretly in love with you.
2. I am not trying to get paid for shooting the breeze with you quarterly.
3. I am not in cahoots with big pharma, or trying out new drugs on you. (If there's a new drug, I'll try it out on myself first, thank you very much.)

The real reason, albeit dull, is an important one. CONTROL.

No, not my inane need to control every aspect of your life (although my hubby and kids might tell you otherwise).

I'm on an endless search for asthma control. It is unacceptable to me to have my patients walking around puffing on their rescue inhalers (>2x/week) when what they really need is a more optimal dose of controller medicine. It is equally unacceptable to have my patients walking around symptom-free on higher-dose controller medicine, when a lower amount of medication might adequately control their disease.

So, how do I decide how often is often enough, when it comes to asthma follow-up?

Inhaled corticosteroids, when taken regularly as prescribed, generally take around 2 weeks to begin exerting their beneficial effects, but take around 6 weeks to reach maximal efficacy. So, after changing a patient's asthma controller medicine dose or regimen, I will wait at least 6 weeks before deciding if the new dose is working adequately. If it is working well, I will continue the dose for at least 3 months before attempting to decrease the dose, per asthma guidelines published in 2007 by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. But, I always attempt to decrease, as long as the patient has done well for the past 3 months. Asthma severity is fluid, and changes over time. Just because a patient required a certain dose in January 2005, doesn't mean that they should be on the same dose in August of 2010. It is my responsibility as an asthma specialist to keep pushing the dose of medication as low as tolerated.

To find a dose that works and just keep it there for years on end without trying to limit cumulative medication dosage is just laziness, in my opinion.

In light of the recent FDA recommendations regarding long-acting beta agonist medications in asthma, it seems even more important to keep pushing these doses down. Read more: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm200923.htm

So when your doctor asks to see you sooner that you anticipated, don't worry that you're the object of an inappropriate crush- she may actually have your best health in mind.

Wednesday, February 10, 2010

Chasing Rainbows- Or, How Even Crappy Days Have Silver Linings

Son #1 woke up three times overnight and ended up in Grandma's bed after he decided that me marching him back to his own room was no longer acceptable. (Grandma's are softies.)

Son #2 was actually sleeping soundly for the first time in weeks, until the earthquake woke us up. Earthquake? Yes, earthquake. (Thank goodness our cities are built on a thick layer of bedrock, and that our municipalities enforce building codes.)

I woke up to a foot of snow covering my car, and my windshield wipers were frozen to my windshield. Yipee.

So, the thought of trudging to work on a day when the majority of patients will choose to stay home was less than enticing.

However, as I was driving along, the wheels of all the cars in front of me on the highway aerosolized the slush on the road. It's a strikingly clear and sunny day, and when the sunlight hit the airborne slush droplets, it had the magical effect of creating small rainbows between me and my fellow commuters. From slushy mess to beatiful refraction- if that's not making lemonade from lemons, I don't know what is.

Sunny day, will probably have plenty of time to finish my stack of paperwork today, chased rainbows this morning... things could be worse. :)

Tuesday, February 9, 2010

Happy Birthday to the Allergist Mommy Blog!

Time flies- it's been a whole year since the first Allergist Mommy blog post!

In that time, I've enjoyed sharing my perspective on the latest developments in pediatric allergy. It's nice to have an audience other than my husband for my musings. I haven't asked, but I think he also appreciates that I have redirected my educational efforts away from him. :)

In the past year, you've learned how (against the odds) Son #1 outgrew his peanut allergy. You've read about Son #2's eczema and developing asthma. You've seen how underneath the cool exterior, physicians are parents too. We worry about our kids the same way our patient's parents do. And we make the same mistakes that everyone does.

That said, I hope I've also shed some light on the fact that while we certainly don't have all the answers, physicians can help shed some light on the mystery that is modern medicine, and be valuable guides to help parents and children navigate the challenges of allergies and asthma.

Thanks for reading- here's to another great year ahead!

Wednesday, February 3, 2010

Dry Winter Air Means Itchy Flaky Cranky Kids- Here's What You Can Do!

It's that time of year- the heat is on indoors, and the humidity in our homes takes a nosedive. Kids (especially those with a history of eczema) start getting itchy, scaly, cracked skin. Ouch! We all want to minimize the amount of medication we apply to our children's bodies, so try these these quick tips first:

1. lukewarm baths/showers, no greater than 10 minutes
2. pat (don't rub) dry with a towel that is free of fabric softener
3. immediately apply an emollient - a ceramide-containing cream all over the body in the AM (Cera/ve, Mimyx, Atopiclair are all good choices), and don't skimp on the petroleum jelly at bedtime (who cares of they're a little slippery?)
4. keep the ambient humidity in your home between 40-50%
5. turn down the heat!

For most cases of dry winter skin, the above is enough to keep a bad eczema flare at bay. However, if your child's skin does flare up, don't be afraid to use the topical anti-inflammatory ointments (they work better than creams or lotions) aggressively for a short period of time. As the condition of the skin improves, you'll be able to back off on the frequency of application.

Below is the text of the dry skin care regimen I suggest for my patients:


Dry Skin / Eczema Care Instructions

Cleansing:

Bathe/shower with warm water (never hot!) for no longer than 10 minutes 1-2 times daily. Apply soap to the following areas only: folds of neck, underarms, groin, buttocks, palms, and soles.

The following cleansers are mild enough for daily use:
  • Aveeno Skin Relief Fragrance Free Body Wash
  • Basis Sensitive Skin Bar
  • Cetaphil Gentle Cleansing Bar
  • Dove Sensitive Skin Beauty Body Wash
  • Dove Sensitive Skin Unscented Beauty Bar
  • Vanicream Cleansing Bar

Moisturizing:

After bathing, pat (don’t rub) with a towel until the skin is mostly dry. Apply generous amount of moisturizer/emollient to skin immediately after drying, and rub until no longer visible. Avoid most lotions, which contain mostly water, and are not effective at locking moisture into the skin. The simplest and least expensive emollient is simply petroleum jelly. Other effective OTC options include: Cera/ve cream, Vanicream, Eucerin cream, Aquaphor, and Aveeno Cream.

Topical Medications:

Once moisturizer/emollient is absorbed into skin, apply topical anti-inflammatory medication to affected areas only. See instructions below:

Acute flare of eczema: TBD by physician
Resolving eczema patches: TBD by physician
Maintenance for areas prone to flares: TBD by physician


Laundry:

Cotton clothing is best for sensitive skin. Use dye-free, fragrance-free detergent, such as ALL Free and Clear. Use hot water and a second rinse cycle to ensure that all detergent is washed out of your clothing. Avoid fabric softener, especially dryer sheets.

Monday, February 1, 2010

My Valentine's Day Party Saga- Or, Why it Never Pays to Think Ahead

I was so proud of myself. I had a little extra time on my hands (don't ask me where it came from, because I can't imagine I'll ever find it again), so I decided I would take a trip to the store and buy all the supplies I needed to make cute peanut/treenut-free Valentine's Day goodie bags for Son #1's preschool class.

I dutifully purchased stickers, little plastic baggies, pencils, and individually wrapped/labelled candies for distribution to the little cuties.

I sat and patiently assembled all the bags for him and his 13 classmates, and even made an extra couple of bags, just in case.

Last night, I read the newsletter from his classroom: "If your child will be bringing Valentines in for our party on the 12th, please make sure to bring for everyone, so we don't have any hurt feelings." Excellent point- I couldn't agree more. (hence the extra few bags!)

The newsletter continued: "We have 22 students." WHAT??!?! 22?! Ahem- where did these extra 8 children magically come from? Were you running an enrollment special in January?

Sheesh. Serves me right for pretending to be super-mom. I'm done with thinking ahead- I'm going back to being procrasti-mom, thank you very much. And, apparently, I'm also headed back to the store...

Thursday, January 28, 2010

Allergy Blood Testing- My Thoughts on Why it is Overused

A recent article in the Wall Street Journal (Is Your Kid Truly Allergic? Tests Add to Food Confusion) recently highlighted the inherent problems with over-calling food allergy in children on the basis of serum IgE testing. I was impressed with the article, and encourage parents of allergic children to read it: http://tinyurl.com/yb5fw5s

This is an issue that most allergists run into on a fairly frequent basis- a parent walks into the office with bloodwork ordered by another physician. Tests returned as "positive" for multiple foods, so for the past 3 months, parents have restricted all these foods (generally there's always something that's a pain in the butt to eliminate, like soy or wheat). Now we have a child who is still as symptomatic as ever, and cranky to boot.

When I tell the parents that their child in all likelihood is not allergic to all of the eliminated foods, the reactions are a mixture of relief and annoyance: "That's great news, but why did we just spend 3 months of our lives wasting a good portion of our paychecks in the gluten/wheat-free aisle at Whole Foods?"

The answer: Because the blood test was ordered without a full understanding of how to interpret the results. The presence of IgE to a specific food does not always translate into clinical allergy.

It is possible to become sensitized to a food, but tolerate it without issue. In these cases, it can actually be counter-productive to eliminate this food, because continuing to eat it in small amounts may be maintaining a state of immune tolerance.

There are multiple nuances in the diagnosis and management of food allergy that simply cannot be delineated by a blood test.

So, why are these blood tests ordered so frequently? The reasons are numerous:
  1. Physicians want to help their patients by finding the source of a problem. We're detectives by nature. Because the vast majority of primary care physicians do not have the capability to offer skin testing (more accurate than blood testing) in their offices, blood testing seemingly offers a simple way to provide the same service to their patients.
  2. There is a misperception among both physicians and the lay public that allergy skin testing is a painful, traumatic process. Physicians and parents feel that they are sparing the child an invasive procedure by choosing a blood test instead. This is inaccurate- allergy skin testing is needleless and bloodless. In the case of a pediatric panel, the testing takes only seconds to apply, and 20 minutes to get results. In contrast, a blood draw requires temporarily restraining the young child while the phlebotomist uses a needle to access a vein (more painful than the superficial scratch from the plastic skin testing device), and then waiting for 1-2 weeks until the test results are delivered to the ordering physician.
  3. There is the inaccurate assumption that blood testing is more economical that skin testing. This is certainly wrong. The average cost for an individual Phadia Immunocap blood test is $100. In contrast, the average allergy skin test is $10 per item. Some argue that the cost of the blood-based food panels are less than ordering the same tests individually- however, there is generally not value in ordering a panel test which includes foods that the child obviously tolerates- it is a complete waste of resources. In my office, I do not skin test a child to a food that they tolerate without issue. Even when you factor in the cost of the allergist's office visit, skin testing offers a better value, with less wastage of health care resources.
That said, I still believe that specific serum IgE testing is a valuable resource, when used and interpreted correctly.

The scenarios in which I use blood allergy testing:
  • A child has such extensive eczema that there is not sufficient clear skin on which to apply the test.
  • The history of reaction was so immediate and severe (example- life-threatening anaphylaxis from minimal peanut exposure) that it is not prudent to risk the small risk of a systemic reaction from the skin test if the allergy can be confirmed by blood test instead.
  • For whatever reason, a child is not able to discontinue antihistamines prior to skin testing.
As medicine continues to advance, there will be even more ways to diagnose allergy. I welcome this progress openly- but with the following caveat: all tests, no matter how advanced, need to be ordered judiciously and interpreted in the context a patient's individual history. We should embrace technology and the information it provides, but in the process, we cannot allow ourselves to abandon thoughtful restraint. The moment this happens, the best interest of the patient is sacrificed.

Tuesday, January 19, 2010

The Legacy We Leave Our Children: What Will Your Gift Be?

Short little post to get me back into blogging after a small hiatus:

I've been thinking a lot about the legacy that we leave for our children.

For some, the legacy they leave is material in nature: a substantial inheritance to start them on their way, a business to provide them a livelihood, a home in which to raise their own families...

For others, it is memories of wonderful times together: family vacations, heartfelt conversations, carefully preserved photographs and videos...

I hope to leave both of these for my sons, but the more I think about it, the more I want my legacy to be a way of thinking about themselves and the world around them. Anyone who knows me knows that my children don't really resemble me- they are miniatures of their father (I was simply the vessel). So, since the only thing they seem to have inherited from me is a predisposition for allergies and asthma, I'm hoping to instill in them my life philosophy.

So, I decided to sum up into a single statement the kind of men I want my boys to grow up to be, and make that statement a guiding principle in how I raise them. What do I want for my children? Of course, I want them to be successful , happy, prosperous... but I also want them to be men who lead by example, to be generous to others, gracious in their daily lives and thankful for their blessings. How to sum that up in a way that a young child can understand?

Here's what I came up with: "Always strive for greatness, but never at the expense of your goodness."

I'm off to nurture some future world leaders: wish me luck!