Babies Going Nuts

This week’s guest columnist is Dr. Trey Halliburton, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

Peanuts are great.  From Snickers candy bars to PB &J sandwiches, they’re tasty and healthy.  But as those with peanut allergies know, sometimes they cause a range of troubles, from itchy rashes to life threatening throat swelling and shock.  For years doctors have cautioned parents from administering peanut products to infants to avoid “sensitization,” where your immune system becomes responsive to an allergen.  However, there’s new evidence that maybe we’ve had it wrong.

I recently saw an 8 year-old girl in clinic who has a severe peanut allergy, and needed a refill of her Epipen.  The Epipen is a spring-loaded injector for when she might accidentally ingest a peanut product.  Then the nearest adult (parent, teacher, babysitter) would stick the pen on her thigh, push the button, and inject epinephrine, a fast-acting allergy antidote. During the visit I thought, “What a stress for her parents!”  Peanuts are in a vast array of food products.  The food labels spell this out, but who reads every label, particularly 8 year-olds?  A friend offers to share the wrong granola bar…

Food allergic reactions, including to peanuts, have been increasing in the population.  But now there’s a way to prevent such allergies for the coming generation.  In 2015 researchers concluded the LEAP Trial (“Learning Early About Peanut” allergy, not standardized testing!). LEAP examined infants ages 4-11 months at risk for allergy development (those with eczema or known food allergies), giving half the infants doses of peanut.  The other half got none.  Results: infants given peanut early had an 81% less risk of developing peanut allergy.  A follow-up study of these kids, LEAP-On, showed that the benefits persisted 12 months later.

Based on these studies, the American Academy of Allergy, Asthma, and Immunology recommends that infants 4 months and up be allowed to experience the wonders of this ground nut. If your infant is high-risk for food allergies however (having severe eczema or already known food allergic reaction), the Academy recommends your child be tested first, and have peanut product introduced in an allergist’s office under controlled conditions.

In the spirit of the LEAP trial, Dr. Hamilton conducted his own peanut experiment, on his feisty little poodle Milou.  Rest assured, no animals were harmed during this study.  In fact, the American Kennel Club states that peanut butter is good for dogs, as long as it doesn’t contain the artificial sweetner Xylitol.  He smeared peanut butter (non-chunky, to avoid choking hazard) on Milou’s palate, and proved his hypothesis: Milou licked and licked and licked his snout, for a recorded 47 seconds, amusing Dr. Hamilton no end.

Which raises the question: how to introduce peanut to an infant, as recommended by the LEAP Trial?  In the study, early peanut exposure in infants’ diets greatly reduces the chance of developing peanut allergy.  Certainly don’t give your baby whole peanuts, a choking risk.  Straight peanut butter isn’t safe either, as infants may choke on its sticky thickness as well.

Best is to dissolve a small amount of peanut butter, about 2 teaspoons, in cereal or formula.  Alternately, 2 teaspoons of peanut flour or powder can be mixed in yogurt or applesauce. Give the first spoonful, then wait several minutes to make sure baby doesn’t have a reaction.  No rash- chow on!  Continue feeding peanut product three times per week.

Again, like we said above, there’s babies who require a medical evaluation before starting peanut in their diet.  Kids at moderate or high risk for allergies need to see a doctor first. These are infants with moderate to severe eczema, or have already had allergic reactions to other foods.  Needless to say, don’t make peanuts the first food you introduce.  Start with the usual hypoallergenic foods, like fortified oat, barley, or multigrain cereals, followed by pureed fruits, vegetables, and grains.

High risk babies can certainly benefit from peanut introduction, but they should be tested to see that they don’t already have peanut allergy.  Then they should have it started under controlled conditions.  This means in an allergist’s office, with careful dosing, and allergy antidotes at hand.  So it may seem scary, but as the LEAP trial showed, early peanut exposure may prevent your child from developing a life-threatening allergy down the road.  Mr. George Washington Carver would be proud.

Scary Nuts

This week’s guest columnists are Drs. Crystal Davis and Danielle Fuselier, Family Practice residents at the University Hospital and Clinics here in Lafayette.

She was hungry after softball practice, and took the snack bar her friend offered.  It looked like a bar she had eaten before, so she didn’t think twice.  A few minutes later, though, her throat began to feel scratchy and tight.  She got scared and called her father.  When he arrived, he saw she was pale, had a swollen face, and was breathing hard.  He gave her benadryl and called 911.  Later, the girl told us that when she looked at the snack bar package again, she saw it contained cashews.  She had an allergy to tree nuts.

Severe allergic reactions can be very frightening for parents, and kids!  Everyone knows a horror story of allergies that end tragically.  Knowing the proper steps to take can save your child’s life.  First, its important to identify the symptoms.  These include hives, itching, and flushing or pallor.  More severe symptoms include swelling of the lips and tongue, shortness of breath, wheezing, vomiting, and worsening lethargy.

We call severe allergic reactions anaphylaxis- when the allergy affects two or more organ systems (cardiovascular system, respiratory system, skin, GI tract, etc).  Anaphylaxis can be deadly and requires quick action.  If your child has an epipen, use it!  Then call 911.  Studies show that many parents, and even doctors, don’t give epinephrine often enough.  Don’t be afraid to use it- it doesn’t hurt kids to give (except for the shot sting itself), and can be lifesaving.  There are videos and dummy epipens for training, so parents and patients can practice for when it’s needed.

Your job’s not over yet.  Take your child to the ER for further evaluation.  Best to call 911- paramedics carry epinephrine, steroids, benadryl, and other important anti-allergy medicines. Then at the hospital, your child will be observed in the ER and maybe admitted overnight.  Even after initial treatment, the body continues to release inflammatory cells and chemicals to attack the substance it recognizes as foreign.  Thus kids need monitoring and may require further medication.

Our girl above, who had nut allergies and ate a cashew-containing snack bar, had low blood pressure, shortness of breath, and was lethargic and pale when the paramedics arrived.  They gave her an epinephrine shot, steroids, and IV fluids.  She still looked sick when the medics brought her in- pale and fatigued.  But she gave us a weak smile and insisted she felt better!  We admitted her to the ICU, and she recovered.

When kids have severe allergic reactions, or lesser but still bothersome symptoms, it’s important to find the culprit.  There’s no single way to identify allergens.  Some types are best identified with skin tests, like inhaled allergens.  Blood tests are better to identify food allergies, or causes of eczema.

When we say “skin tests,” there’s different kinds of that.  One is the prick test, where drops of fluid with allergens are put on the back, and then pricked into the skin with a  needle.  If the child is allergic, the skin swells and reddens around the prick, like a mosquito bite.  Up to 40 different allergens can be tested at once this way, depending on the allergist’s suspicions, the size of the child’s back, and what the kid will tolerate!

Other skin tests are “intradermal,” where allergen is injected within layers of the skin.  In cases of possible anaphylaxis, like our girl with the tree nut allergy, “challenge” allergy testing like this may not be safe- no one wants anaphylaxis in the office!  Blood testing is safer.

The point of allergy testing is to find out what to avoid.- bee stings, spring pollen, kiwi.  Avoidance can be used as as an allergy test itself, particularly for foods.  Say a kid has a chronic allergy like eczema.  You start the “elimination diet,” where you subtract suspected foods from the child’s diet, one food per week.  If in one of those weeks the eczema suddenly improves- voila, you have the culprit!

Testing can help you choose appropriate treatment: avoidance, medicines for when your kid can’t avoid the air he breathes, allergy shots, or epipens.  For the potentially severe reactions, as we said above, don’t be afraid to use that epipen!  It could save a life gone nuts.

Rashes- The Home Triage

This week’s guest columnist is Dr. Justin Pratt, a Family Practice resident at the University Hospital and Clinics here in Lafayette. 

The nurse’s note read “rash.”  When I walked into the exam room, the mother’s eyes were wide with fear.  ”Doc, over the past 2 days he’s been having a reaction to the antibiotic he got earlier this week.  I gave Benadryl this morning and the rash is still there!  Is he going to be okay?”  Meanwhile, the patient, an 8 year-old boy, was lying in bed laughing at cartoons on TV. The rash certainly wasn’t bothering him much, unlike his mother!

Rashes can be distressing for parents of infants and children. They can appear out of nowhere, cover a large part of the body, and look awful.  The good news is that most rashes are not life-threatening and don’t need immediate attention. Some are caused by direct irritation of the skin, some indirectly like with allergies, and some by infections from viruses, bacteria, or fungus.

In the case of the boy I saw that Saturday night, his rash wasn’t a sign of anything bad, though it certainly looked weird.  It consisted of flat, paisley-shaped red blotches all over his body.  It didn’t hurt, didn’t itch, and he didn’t feel too bad. This rash, called erythema multiforme, turned out to be due not to the antibiotic,but from an infection called mycoplasma, a.k.a. “walking pneumonia.”  We changed his antibiotic to cover that infection, and off he went.

Every year there are about 12 million visits for rashes and other skin concerns.  68% of these are with the patient’s own doctor, leaving 32% to walk-in clinics and Emergency Departments.  How do you know if your kid can wait to see their pediatrician, or needs immediate attention?

First, don’t panic at the site of a rash, no matter how much of your child it covers.  Rashes are like fevers- the height of the fever and the amount of rash don’t correlate with severity. It’s more about how your child is acting with the rash.  If she’s calm, drinking easily, breathing comfortably, and awake and with it, then it’s not an emergency. Give benadryl for the itch, call your doctor for reassurance, and chill out.

This advice about how to respond to your kid’s rash, brings up an experience I had in my last year of medical school.  It wasn’t about a pediatric patient- it was ME!  I woke one morning after an itchy night.  I turned to my wife to ask if she had used a new laundry detergent on our sheets, and was met with a look of shock: “Justin, ARE YOU OK!?!” Besides being a little itchy, I felt fine.  ”Look in the mirror!  I think you need to go to the hospital now!”

I was covered with a rash from head to waist, my face beet red.  A little startling to see, but then I remembered my training.  When did it start?  During the night I guess.  Was I breathing okay?  Yes.  Were my throat, tongue, or lips swollen?  No.  Was it getting worse? Didn’t seem so.  Did I feel ill or have fever?  No. There, no emergency honey.

Was the rash raised and itchy?  Yes- thus probably allergic.  Was there peeling, crusting, pain, or weeping?  No- therefore probably not an infection.  Were there tiny red freckles that didn’t blanch when pressed on?  No- again not a serious infection.  What was different in the past few days?  Soaps, detergents, food?  Wait, I’d been stung by a hornet yesterday! The rash I had was urticaria, commonly called hives, a delayed reaction to the sting. When I saw my allergist later that day, she prescribed steroids, an antihistamine, and in two days I was better.

When deciding whether your child’s rash can wait for the pediatrician, or needs to be seen immediately, remember the important questions:  Does he appear ill (looking past that awful rash!).  Is there lip, tongue, or throat swelling?  Is she not breathing comfortably? Are there tiny red freckles that don’t blanch when pressed?  If yes, proceed to the nearest Emergency Department.

If no to these questions, relax!  Give benadryl, tylenol, or ibuprofen for itching, fever, or other discomfort.  Call your pediatrician if you need further guidance.  Like fevers, rashes are generally not emergencies.  Take a deep breath, take two benadryl, and call me in the morning. 

Was Rudolph The Red Nosed Reindeer Allergic?

When my son got his first ear infection at 8 weeks old, I might have known.  Soon after he began having continual congestion.  He spent much of his childhood with itchy eyes and nose.  Many pictures from that time show him smiling away with a red nose like Rudolph.  He lived on Zyrtec and Flovent in the winter months in order to keep the itching and coughing down and to help him sleep and not be miserable during the day.  Teenage years came and thank god he outgrew that stuff.  Now his biggest medical complaint is a sore pitching arm.

Head allergies are common in kids, though they are sometimes hard to diagnose.  Cold viruses and sinus infections give kids a lot of the same symptoms- runny nose, cough, itching eyes and noses.  Allergies tend to give kids symptoms a lot longer, but young ones in daycares or schools can have long lasting symptoms too because they catch cold virus after cold virus, one right after the other, so it looks like one continous illness.  Chronic asthma can sometimes act like allergies, with continous coughing and chest congestion that doesn’t always wheeze. 

So how do you tell the difference between continuous colds, allergies, or mild chronic asthma?  Besides the itchy head, does your child get his symptoms with change in seasons?  Is there a history of allergies in mom or dad or other relatives?  Do obvious allergic triggers like animals or dust seem to make the child sneeze and itch?  If it seems like the kid has allergies, one way to make the diagnosis is to try an anti-allergy medicine.  Drugs like Claritin (Loratidine) or Zyrtec (Cetirizine) are pretty effective and very safe, so safe that they can be bought over-the-counter.  If the child gets better in a day or two and stays better on the drug, allergies may be the cause.  Some allergies are hard to diagnose, or hard to treat effectively, in which case the child might need to see the allergist.

Your pediatrician or family practitioner can usually diagnose allergies without an allergist’s help.  If the child has lots of eye and nose itching and is always congested, if there is a family history of allergy, that may be enough.  The doctor will often ask for the parent’s help with figuring out what is causing the allergic reaction- dust, dogs, seasonal pollens in the air, mold?  What seems to make their child sneeze and twitch?  Sometimes parents are asked to keep a journal of when their child has symptoms and where they are at the time.  Your doctor can also order blood tests which can give clues to allergy being the problem and what is causing the allergy. 

If your doctor has trouble figuring out if allergies are truly the cause of the child’s misery, or if standard treatments aren’t working, that is when the child is referred to an allergist.  The allergist can perform more accurate tests to see if the child is allergic, and to what.  Once the diagnosis is confirmed, the allergist then often goes back to the basics for treatment- avoiding the thing the kid is allergic to.

Avoidance is the mainstay of allergy treatment.  If dust is the cause, and it often is, then the allergist can talk to the family about dust control in the bedroom and the rest of the house.  If it is cockroaches, another common allergy trigger, they can address that.  If medicines are needed, the allergist can help the family figure out what medicine or combination of medicines would be best.  Finally, if a child has an allergy that is really hard to avoid and treat, the allergist can design a “immunotherapy” program to help the child’s body be less sensitive to the allergen.  These are the”allergy shots.”  Immunotherapy is safe and effective for the right patient, and can make a big difference in the quality of the kid’s life.

So if you think your child has allergies, talk to your doctor.  Pay attention to what seems to make your child cough and sneeze and rub his nose and eyes.  Itchy faces can be miserable, take it from my son.