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:

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!