2018-19 TOW #29: Food allergy

Next week’s topic is on food allergies, a hot topic with the recently evolving literature and recommendations.

Materials for next week:

A few take-home points:

  1. What’s the epidemiology? As many as 1 in 13 children is thought to have a food allergy. Along with other allergies, the rate of rise of food allergies has been rapid. While well-meaning, the recommendation to delay introduction of foods probably led to an increase in allergy development as children were sensitized through exposure, such as through the skin. Generally, the most common allergens in childhood include egg, milk, peanut, tree nuts, wheat, soy, fish, shellfish,and sesame.
  2. How do we prevent food allergies? We’ve had a recent dramatic change in practice in solid food introduction: we are now recommending solids foods between 4-6 months to “teach the body” during the window of time when less reaction occurs. We should recommend introducing a variety of foods, including foods containing peanuts, eggs, and tree nuts soon after children start solids. Mixing a bit of water into peanut butter to make it soupy is one way to expose infants to peanut butter (more recipes/options in the appendices here). For eggs, baking them into foods denatures the proteins so may be the best initial exposure for babies with a higher food allergy risk based on family history. Also egg yolks are less allergenic than egg whites. Breastfeeding for at least 4 months and when new foods are introduced is associated with decreased risk of atopy, though doesn’t necessarily prevent food allergies.
  3. How do we diagnose food allergies? Symptom reaction to the food: usually these are Type-1 IgE-mediated hypersensitivity reactions that happen within minutes of ingestion: including skin (most common), oral or nasal mucosa, GI, or respiratory reactions, or a combination of these in full anaphylaxis. Typically symptoms resolve within 4-12 hours. There are also Type-4 cell-mediated hypersensitivity reactions to food, such as milk protein allergy, that cause mostly GI symptoms. Some children avoid foods due to symptoms, so pay attention to these behaviors. Once a reaction has occurred, testing may help evaluate the allergy but are not fully diagnostic. A skin-prick test for food is recommended but it’s not 100% specific, with high false positive rate. Serum specific IgE testing is useful for patients who cannot discontinue antihistamine therapy or for those with extensive skin disease or dermatographism. An oral food challenge is considered the gold standard and may be part of making the diagnosis when it’s in question.
  4. How do we manage food allergies? Strict avoidance of the allergenic food is the primary approach. Egg and milk may be tolerated in cooked forms, with exposure helping build tolerance to other forms of the foods. Treatments for allergies are evolving and it’s exciting to see emergence of more success with new immunotherapies.
  5. How do we treat reactions and prevent death from anaphylaxis? Food-induced anaphylaxis is a “rapidly progressive, multiorgan allergic reaction that can result in death.” Recognition and quick response is essential to save lives. Anaphylaxis symptoms may be uniphasic, biphasic, or protracted. In all cases, most important is rapid treatment with IM epinephrine. Repeated epinephrine dosing should be used when symptoms progress or response is not optimal. All patients with any moderate to severe IgE-mediated reactions to foods should have self-administered IM epinephrine available. Mild skin-only reactions may be treated with diphenhydramine.

2018-19 TOW #20: Tobacco Exposure and Cessation

This week’s topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up next week on Thursday November 15th. The American Cancer Society designates the 3rd Thursday of November (the Thursday before Thanksgiving) each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking cessation.

Materials for next week:

 

Take-home points:

  1. How many children are exposed to secondhand smoke? How does teen smoking relate to adult smoking? More than half of US children have secondhand smoke exposure (based on biological samples of population data). Approximately 90% of adults who smoke began smoking prior to age 19 (which is why tobacco companies target ads to youth…) Each day, an estimated 4400 American teenagers try their first cigarette. 80% of youth who smoke will continue to smoke into adulthood.
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with non-respiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What’s the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective.  Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. All states have quitlines with counselors who are trained specifically to help smokers quit. The quitline number is meant to be remembered: 800-QUIT-NOW (800-784-8669). There’s also an online chat via the National Cancer Institute.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. “Is your child around anyone who smokes?” is a neutral way to open up the conversation. If the parent is smoking I often follow-up with “How are you feeling about smoking?” as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don’t forget about using 1-10 scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) This is a great stat to highlight: Getting help through medications and counseling doubles or even triples the chance of successfully quitting. 
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes, especially among teenagers.

TOW #43: Seasonal allergies

May is designated National Asthma and Allergy Awareness Month. The pollen currently covering my car is definitely one indication it’s spring and allergy season! Indeed, many among us are suffering from the season’s blooms.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  1. How many people are affected by allergic rhinitis? Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
  2. What is the clinical definition or AR? Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” AR is a hypersensitivity reaction to allergens due to IgE. Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks. It’s often tricky to evaluate relative to viral-induced symptoms, given there is so much frequency of both, but with AR, itching of nose and eyes is more prominent, rhinorrhea is clear.
  3. What do we see on physical exam? Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease in children who chronically push their palms upward under their noses (to wipe mucus)-(and they really happen – last year my daughter developed one of these!)
  4. What’s the appropriate work-up? You may decide to do skin testing to evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is preferred to blood testing, but is not 100% specific and requires clinical correlation with symptoms/triggers.
  5. How do we manage AR? Treatment options are allergen avoidance, pharmacotherapy, and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids, which is approved for kids >2. Next best are non-sedating antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists. Sometimes people develop tolerance to one group, so switching drugs can help. Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.

TOW #19: Asthma diagnosis and management

This week our REACH pathway R2s shared some asthma management tips and tricks for morning report and featured R2 Bryan Fate’s new hit song “IHELP You”! As one of our most common childhood conditions, asthma diagnosis and outcomes highlight the effects of social determinants of health and the resulting health disparities that unfortunately exist. Our residents reminded us how we can recognize and address social needs through screening, referral and use of support systems. The IHELP mnemonic is used to screen for Income, Housing, Education, Legal/Literacy and Personal safety needs that affect overall health, including asthma. We want to provide effective care for children of all backgrounds and to recognize and address the powerful influence of social factors on health. Let’s keep this in mind as we discuss asthma.

A BIG thank you to Dr. Cathy Pew our intrepid gen peds team leader at Neighborcare – Meridian who tackled being lead author for our local outpatient asthma management guidelines and to the wise Dr. Jeff Wright, emeritus faculty, who initially designed the algorithms to accompany them.

Materials:

Asthma Diagnosis and Management take-home points:

  1. Epidemiology: Asthma rates are increasing every year in the US. Asthma affects 1-2 out of 10 children in the US and rates are even higher among black and Hispanic children. From 2001 through 2009 asthma rates rose the most among black children, almost a 50% increase.
  2. Asthma diagnosis and management is based on age, severity, and level of control. “Severity” is the intrinsic intensity of the disease process, which is based on impairment and risk. Severity is classified as “intermittent” or as “persistent” with mild, moderate, or severe levels. “Control” refers to the degree to which manifestations of asthma are minimized and the goals of therapy are met. This is classified as “well controlled,” “not well controlled”, or “very poorly controlled.” To help make this diagnostic process easier, please refer to our UW Division of General Pediatrics outpatient clinical guidelines for asthma which are based on the 2007 NHLBI guidelines and include flow diagrams for 0-4 yo, 5-11 yo and 12 and older (as above).
  3. We use a step-wise treatment to help manage asthma. The National Asthma Control Initiative outlines 6 priority messages for clinicians to help control asthma:
  4. To reduce environmental exposures for children, there are a number of resources we can use. Key resources locally include the American Lung Association home health assessment program and the King County asthma program, both of which have home visiting programs that we can refer families to that will help identify environmental exposures. The Medical-Legal Partnership is also helpful to access the legal system to ensure environmental triggers are minimized in rental properties where children live.
  5. Be sure to review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options. For clinics using EPIC, there is a great smartset for asthma that Dr. Sheryl Morelli helped champion based on the outpt guidelines.

Thanks for all you do to care for our community’s children and address their needs at many levels.

TOW #29: Food allergy

Next week’s topic is on food allergies, a hot topic with regard to the evolving literature and recommendations.

Materials for next week:

A few take-home points:

  1. Epidemiology: As many as 1 in 13 children is thought to have a food allergy. Along with other allergies, the rate of rise of food allergies has been rapid. While well-meaning, the recommendation to delay introduction of foods probably led to an increase in allergy development as children were sensitized through exposure, such as through the skin. Generally, the most common allergens in childhood include egg, milk, peanut, tree nuts, wheat, soy, fish, shellfish,and sesame.
  2. How do we prevent food allergies? This is perhaps the most exciting and dramatic change in practice in terms of solid food introduction. We are now recommending introduction of solids foods between 4-6 months with a variety of foods fairly quickly, including foods containing peanuts, eggs, and tree nuts. Mixing a bit of water into peanut butter to make it soupy is one way to expose infants to peanut butter (more recipes/options in the appendices here). Especially for eggs, baking them into foods denatures the proteins so may be the best initial exposure for babies with a higher food allergy risk based on family history of atopy/allergy. Also egg yolks are less allergenic than egg whites, so could be offered first. Breastfeeding for at least 4 months and breastfeeding at the time when new foods and cow’s milk protein are introduced is associated with decreased risk of allergy.
  3. How do we diagnose food allergies? Symptom reaction to the food: usually these are Type-1 IgE-mediated hypersensitivity reactions that happen within minutes of ingestion: including skin (most common), oral or nasal mucosal, GI, or respiratory reactions, or a combination of these in full anaphylaxis. Typically symptoms resolve within 4-12 hours. There are also Type-4 cell-mediated hypersensitivity reactions to food, such as milk protein allergy, that cause mostly GI symptoms. Some children may avoid a food due to symptoms they experience, and we should also pay attention to these behaviors. Once a reaction has occurred, testing options may help to better evaluate the allergy but are not fully diagnostic. A skin-prick test for food allergy is recommended but it's not 100% specific, as there is a high false positive rate. Serum specific IgE testing is useful for patients who cannot discontinue antihistamine therapy or for those with extensive skin disease or dermatographism. An oral food challenge is considered the gold standard and may be part of making the diagnosis when it's in question.
  4. How do we manage food allergies? Strict avoidance of the allergenic food is the primary approach. The exception is for some foods, especially egg and milk, which may be tolerated in cooked forms, with exposure helping build tolerance to other forms of the foods.
  5. How do we treat reactions and prevent death from anaphylaxis? Food-induced anaphylaxis is a "rapidly progressive, multiorgan allergic reaction that can result in death." Recognition and quick response is essential for appropriate management to save lives. The symptoms may be uniphasic, biphasic, or protracted. In all cases, most important is rapid treatment with IM epinephrine. Repeated epinephrine dosing should be used when symptoms progress or response is not optimal. All patients with any moderate to severe IgE-mediated reactions to foods should have self-administered IM epinephrine available. Mild skin-only reactions may be treated with diphenhydramine.

TOW #21: Tobacco exposure

GASO Banner 2016

This week's topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up on Thursday November 17th. The American Cancer Society designates the 3rd Thursday of November each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking.

Materials for next week:

Take-homes points:

  1. How many children are exposed to secondhand smoke? More than half of US children have secondhand smoke exposure (based on biological samples of population data).
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with nonrespiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What's the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. "Is your child around anyone who smokes?" is a neutral way to open up the conversation. If the parent is smoking I often follow-up with "How are you feeling about smoking?" as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don't forget about using scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) Using pharmacologic treatment doubles the chance that a smoker will quit.
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes.

TOW #19: Acute asthma

It's the time of year when our clinics and the ED are starting to see more kids with acute asthma exacerbations, so it's an opportune time to review the guidelines and resources to address these. The REACH pathway residents provided super helpful updates to this topic this week for morning report, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research. This week's teaching materials:

Take-home points for acute asthma management:

  1. Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
  2. Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
  3. Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
  4. Education is critical: as we know, education about asthma is so important to families' understanding and implementation of treatment. It's important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency.
  5. Provide follow-up: it's important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also critical. Refer to these great resources for home health assessments through the American Lung Association.

TOW #37: Allergic rhinitis

‘Tis the season for stuffy noses – increasingly the allergic kind now, so a good time to review allergic rhinitis.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  • Epidemiology: Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
  • Clinical definition: Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks.
  • Differential: Top concerns include acute viral rhinitis, sinusitis, allergic rhinitis, nasal polyps, adenoidal hypertrophy, and foreign body.
  • Physical exam: Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease seen across the bridge of the nose in children who chronically push their palms upward under their noses (to wipe mucus).
  • Work-up: usually nothing is needed. Skin testing may help evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is better than blood testing, but still has false positives and requires clinical correlation with symptoms/triggers.
  • Management: Treatment options for AR are allergen avoidance, pharmacotherapy and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids -approved for kids >2. Next best are antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists (equally good as antihistamines). Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.

Enjoy the beautiful blooms – hopefully without too much sneezing!