Early Peanut Introduction

Recent data from Israel showed a much lower incidence of Israeli children developing peanut allergy than here in the US. Further research revealed their infants were fed peanut products much earlier in life. Studies now confirm when peanut products are ingested by 6 months of age, these children are much less prone to develop peanut allergies. Patients with egg allergies and severe eczema are high risk for peanut allergy. These children should have peanut skin tests and/or a blood test(Immunocap RAST) to determine if they are allergic. If their test are negative, peanuts should be introduced between 4-6 months of age. Mild to moderate eczema patients should have peanuts introduced by 6 months after a few solids(cereals/fruits and vegetables) have been tolerated. We recommend using Bamba which is a peanut containing puff. Some practices use peanut butter mixed with milk(breast or formula) or hot water. We do not recommend direct peanut butter or actual peanuts because of obvious choking potential. Avoid peanut introduction to patients who are sick.
With the above knowledge we can hopefully look forward to reversing the surging trend towards increase peanut allergies in young children especially over the past 2 decades.
More to come…. JR

NUCALA THERAPY

Nucala (mepolizumab) is a new drug used as an anti-Interleukin 5(IL-5) therapy for severe persistent asthma. It targets eosinophils which are major inflammatory cells in our bodies contributing to asthma and asthma flareups.

Nucala is approved for 12 years of age and above. It is not indicated for relief of bronchospasm during an asthma exacerbation. It is also not indicated for other eosinophilic diseases such as Allergic Rhinitis, Nasal Polyps, Gastroesophageal diseases, Hypereosinophilia, etc.

Patients must meet certain criteria to have this drug prior approved by their insurance. Documentation of multiple asthma flares despite compliance with a maintenance high dose inhaled corticosteroid as well as adjunct therapy including oral/systemic steroid bursts must be reported. Pre-therapy CBC/Differential labs must show a total eosinophilic count of >150.

The approved dose of Nucala is 100mg subcutaneously every 4 weeks. It is given in our office under supervision of our staff. Patients are observed for 1 hour after their first injection and 30 minutes after each subsequent injection. Beneficial clinical responses with decreased asthma flares, use of rescue inhalers, ER/Hospital visits and Prednisone bursts should be noted within a few months. However, some studies suggest 6-12 month trials before noted benefit is seen.

Common side effects include local site reactions with redness, itching and swelling. Headaches, back pain, fatigue and itchy(non site ) reactions have been less commonly noted. Rare systemic reactions have also been reported. All patients are given and trained on use of either Epipen, Auvi-Q or Adrenaclick which should be carried for 24 hours after each injection.

Whether patients are candidates for Nucala(mepolizumab), Cinqair(Reslizumab) or Xolair(Omalizumab) should be discussed with Dr Rockoff.

Eosinophilic Esophagitis(EOE)

Eosinophilic Esophagitis(EOE) is a condition where eosinophils (allergic/inflammatory cells) appear in the esophagus of patients. These cells are normally found in the eyes and nose especially in patients with allergies, in the lungs in patients with asthma, on the skin in patients with atopic dermatitis(eczema) and in the gastrointestinal tract from the stomach down to the lower intestines. These cell can also appear in patient that are healthy without any atopic disease. Eosinophils are not normal when found in the esophagus. The etiology(cause) of EOE is currently unknown.

EOE will occasionally run in families and can present in pediatrics as well as adults. Children will often experience recurrent nausea and vomiting, abdominal pains and feeding problems especially refusing to eat solid foods. Adolescents and adults usually present with a history of dysphagia(trouble swallowing) especially solid foods. They will also report food getting stuck, heartburn as well as abdominal or chest pains.

This condition can be diagnosed by Gastroenterologist(GI specialist) after endoscopy where biopsies of esophageal inflamed tissue reveal eosinophils.

Treatment involves a very strict diet and medications. EOE patients should avoid 4 common foods: eggs/milk/soy and gluten(barley/oats/rye and wheat). There are some reports that show that peanuts/tree nuts and shellfish may also promote eosinophils in certain patients. An initial diet avoiding all these foods can be very challenging, but lead to significant improvement in patient’s symptoms. A repeat endoscopy should reveal decreasing eosinophils if patient’s comply with this diet. Nuts and shellfish may be added back into the diet slowly after several months of improvement if the re-introduction does not result in increasing symptoms and/or increasing eosinophils on repeat biopsies.

Medications include proton pump inhibitors(PIP’s) such as: Prilosec (Omeprazole), Prevacid (Lansoprazole), Nexium( Esomeprazole), Aciphex( Rabeprazole), Dexilant (Dexlansoprazole), Protonix (pantoprazole) and Zegerid(Omeprazole/sodium bicarbonate). PPI’s are usually given to patients with gastroesophageal reflux qd(daily), however in EOE these meds are started bid(2x/day). Inhaled corticosteroids are also used. Flovent 220 and more recently budesonide are also swallowed bid, not inhaled. These meds provide topical anti-inflammatory effects.

Complications include anemia,weight loss and fatigue from poor caloric content as well as gastrointestinal strictures just to name a few. The differential diagnoses includes true food allergies, food protein-induced enterocolitis syndrome(FPIES),celiac disease and many other GI diagnoses. Your primary care, allergist and gastroenterologist should all work together with these patients and their families to provide a better outcome.

Differential Diagnosis for Hoarseness

Common acute causes of hoarseness include: voice abuse (especially after cheering for your favorite team) and as part of a viral infection (laryngitis). Both of these cases will resolve within a few days or weeks. Chronic hoarseness may be caused by the following:

#1. Chronic voice abuse (children or adults who abuse their vocal cords).
#2. Recurrent sinusitis with thick purulent post nasal drip.
#3. Gastroesophageal reflux (GERD) where gastric acid irritates the vocal cords.
#4. Anatomic: most lesions are benign(nodules/cysts/polyps), malignancies are rare.
#5. Inhaled corticosteroid to treat asthma may cause vocal cord myopathy(weakness).
#6. Trauma: from neck injury or post intubation during surgery(vc paralysis).

A good medical history will help decipher which of the above etiologies may be the cause. Flexible Fiberoptic Rhinoscopy can be performed in our office to determine whether further work ups are necessary. An otolaryngologist (ENT) evaluation and potential voice therapy may be indicated.

Sublingual Immunotherapy (SLIT)

Sublingual (under the tongue) immunotherapy has recently been approved by the FDA for grass and ragweed.

Grastek tablets from Merck and Oralair tablets from Greer are both grass tablets which may be given to grass allergic patients(documented by + skin or blood tests). Grastek is for patients 5-65yo and Oralair is for 10-65yo. This treatment plan should be started ~3 months prior to grass season(Feb/March) and taken daily till the end of grass season(mid-July). The 1st dose will be administered in our office by placing the tablet under the tongue. After 1 minute, patients may swallow and food/liquids can be consumed after 10 minutes. Patients are observed in our office for 30 minutes. Common side effects include mild swelling and itching under the tongue, palate and throat or itchy ears. These symptoms resolve usually within 10 minutes. More severe reactions include: flushing, tightness or difficulty swallowing/breathing, dizziness,GI cramping, hives and feeling faint. For any of these symptoms patients will be appropriately treated and SLIT will be discontinued.

Ragwitek tablets have also been approved by Merck for Ragweed allergic patients from 18-65 yo. This tablet should be started in May and continued till the 1st frost(~mid-October). Similar treatment plans and side effect profile stated above apply.

If you or your children are interested in SLIT please feel free to discuss this with our medical staff.

Baked egg diet instructions developed at the Jaffe Food Allergy Institute.

Instructions for introducing baked egg at home – after the physician-supervised OFC (oral food challenge) and when approved by your doctor.

When your child has passed the baked egg challenge, he or she will be able to eat extensively baked products with egg as an ingredient. Should your child develop an allergic reaction to the food that contains baked eggs, please record the offending food, amount eaten, preparation technique and symptoms. Please contact our office at your earliest convenience to review the reaction.

Your child may now eat the following:

  • Store-bought baked products with egg/egg ingredients listed as the third ingredient or further down the list of ingredients.
  • Home-baked products that have no more than one third of a baked egg per serving. For example, a recipe that has 2 eggs/batch of a recipe that yields 6 servings.
  • Remember to check store-bought products and ingredients on the basis of your child’s food allergies to avoid a reaction to other allergens.
  • All baked products must be baked throughout and not wet or soggy in the middle.

Your child should continue to avoid unbaked egg and egg-based foods such as the following:

  • Baked products with egg listed as the first or second ingredient.
  • Caesar salad dressing.
  • Custard.
  • Eggs in any form, such as hard boiled, soft boiled, scrambled or poached.
  • Egg noodles.
  • French toast and pancakes.
  • Homemade waffles.
  • Frosting containing egg.
  • Ice cream.
  • Mayonannaise.
  • Quiche.

Baked milk diet instructions developed at the Jaffe Food Allergy Institute

Instructions for introducing baked milk at home – after the physician-supervised OFC (oral food challenge) and when approved by your doctor:

When your child has passed the baked milk challenge, he or she will be able to eat extensively baked products with CM (cooked milk) as an ingredient.  Should your child develop an allergic reaction to the food that contains baked milk, please record the offending food, amount eaten, preparation technique, and symptoms. Contact our office at your earliest convenience to review the reaction.

Your child may now eat the following:

  • Store-bought baked products with CM/CM ingredient listed as the third ingredient or further down the list of ingredients.
  • Home-baked products that have no more than one-sixth cup of CM per baked milk serving. For example, a recipe that has 1 cup CM per batch of a recipe that yields 6 servings.
  • Remember to check store-bought products and ingredients on the basis of your child’s food allergies to avoid a reaction to other allergens.
  • All baked products must be baked throughout and not wet or soggy in the middle.

Your child should continue to avoid unbaked milk and CM-based foods such as the following:

  • Baked products with CM listed as the first or second ingredient.
  • Product that may have a CM ingredient that has not been baked, such as a CM ingredient containing frosting on a cookie or cupcake, or a cheese flavoring on a cracker that may not have been baked (e.g. flavorings may be applied topically after the product is baked).
  • Milk chocolate chips that will melt during baking but not bake. Please continue to use CM-free chocolate chips.
  • Regular milk or dairy in any form including whole, low-fat, nonfat, or skim CM, lactose-free products, dry milk powder, yogurt, sour cream, butter, hard and soft cheeses, ice cream, sherbet, butter, etc.
  • Frosting with a CM ingredient.
  • French toast and pancakes.
  • Homemade waffles.
  • Cooked milk products that are not baked, such as pudding.

Passive smoke: How does it affect allergies and asthma?

Cigarette smoking is considered the single most preventable cause of death and illness in the United States. Over 400,000 deaths per year are attributable to smoking. Despite this, approximately 20- 25% of adults and adolescents in this country currently smoke.

People who smoke affect themselves (active exposure) as well as people they come in contact with (passive exposure). Environmental tobacco smoke is a combination of mainstream smoke which is inhaled by the smoker, and sidestream smoke that comes from the burning end of a cigarette. Cigarette smoke contains over 7000 chemicals including nicotine, tar, formaldehyde, cyanide, arsenic, carbon monoxide, methane and benzene. 69 of these chemicals are known carcinogens. Secondhand smoke contains twice as much tar and nicotine than smoke inhaled through cigarette filters. The Journal of the American Medical Association in 1996 concluded that more than 40% of children in the United States, age 2 months to 11 years, live in homes with at least one smoker. In 2006 the United States Surgeon General reported that nonsmokers have a 20-30 percent greater chance of developing lung cancer if they are exposed to secondhand smoke at home or work.

Children exposed to second-hand smoke have a statistically significant higher incidence of otitis media (ear infections), tonsillitis, sinusitis, bronchitis, pneumonia and asthma exacerbations than children not exposed. Infants of maternal smokers are three times more likely to die from sudden infant death syndrome (SIDS). Smoking during pregnancy has resulted in documented spontaneous abortions, premature deliveries, lower birth weights and subsequent decreased lung function, with a higher risk for developing asthma during childhood.

A proposed mechanism for smoke-induced disease involves greater production of an allergy antibody known as IgE, which promotes allergies, asthma and increased hyper-responsiveness in the airways. More recently, cigarette smoke has been recognized as a major irritant to mucosal surfaces which adversely affects ciliary function. The cilia line our upper and lower respiratory tracts and are responsible for moving mucus. After active or passive smoke exposure, our cilia become dysfunctional, thus promoting disease. What most people do not realize is that during smoke exposure, the smell of smoke from hair, clothing or the smoker’s breath will affect the cilia.

The New York States Smoker’s Quitline reports that smoking decreases a person’s life expectancy by 13-14 years. The sooner a smoker quits the better chance the lungs have to heal. Nicotine is one of the most addictive chemicals known. Therefore, smoking cessation may be difficult. Many, “Stop Smoking Programs” are available but are only effective when a true commitment to STOP has been undertaken.

Smokers need to consider the effects of continued smoking on their own bodies as well as all people they come in contact with. If this isn’t a good enough reason to quit, consider the cost. At $10.00 per pack (in Western New York as of 2013), a one pack-per-day smoker will spend approximately $3650 a year for cigarettes. Additional other costs include higher health and life insurance premiums as well as health care costs associated with tobacco-related diseases. By contrast it costs the tobacco companies 5 cents to produce a pack of cigarettes.

For help to quit smoking contact the New York State Smoker’s Quitline at 1-866-NY-QUITS  (1-866-697-8487) or their website www.nysmokefree.com.