Leickly Stories

This morning after finishing the Sunday paper, I browsed through one of my recent pediatric journals Contemporary Pediatrics Volume 26 . I was attracted to the ‘Your Voice’ article by Dr. Amar Dave of Ottawa, Ill titled above, the sad loss of the patient history. I applaud  Dr. Dave for the comments. The issue so adroitly pointed out the knack of physicians to depend on some sort of test especially when making a simple diagnosis.

The context is the always fascinating ‘Puzzler’ cases that are submitted by the readers. The case appeared in the September issue of the journal. The letter points out that the case is a “blatant example of what is happening to medical education”. The basic elements of our encounters with patients are the history of the illness and the physical examination. Dr. Dave points out that these skills are disappearing and are replaced by tests, radiographic studies, and more tests. Sometimes the tests are performed prior to taking a history and doing an examination. In this case, a thorough history and physical examination may have revealed the diagnosis. Tests sometimes beget more tests and this may not always be necessary and may be costly.

I see this way too often in the practice of allergy. Allergy tests are done prior to visiting with the physician, they are done as panels, and they are sometime performed in the operating room. Sometimes no relevant history is taken and the tests are used to make the diagnosis and treatment plan. In some situations this may work, however I have seen children who were denied foods that they enjoyed (and needed), families who were told to make drastic changes in their lives, animals that were sent elsewhere, and a significant amount of money spent not only for the test but also for special diets and gizmos to alter the environment. This  is not fair nor is it the proper way to do an allergy evaluation!

An allergist/clinical immunologist spends a significant amount of time deciding if the complaints fit a template or pattern of allergic disorders by taking that detailed history and doing an appropriate physical examination. The relevant allergens are then selected for testing. What is ‘relevant’? What I mean by relevant is that they are items that the child is exposed to and with that exposure there will be a reliable set of symptoms. Cause and effect relationships need to be established. For example, if milk is taken everyday and with the drinking of milk there are no symptoms of allergy, then the test should not have been done (given this history) and if the results were positive, then they are irrelevant. The value of the test results is only as good as the story or history that supports it.

Remember, the tests make no child allergic. The test only means that antibody is made or has been made. The allergic child has a set of symptoms consistent with allergy with positive tests to relevant allergens. I go more into this topic in the What is Allergy and Testing pages on this site.

Thank you Dr. Dave for lamenting the possibility of lose of an important part of medical training.

Every now and then I will bring in what I call ‘pet peeves’. These are for me everyday experiences that I have developed a humble opinion about and when the mood strikes I will elaborate on my perspective (properly plugged as pet peeve perspectives, perhaps?). So here goes – Pet Peeve Number 1- where to go for allergy care?

There are a number of health care specialists who offer allergy evaluations and allergy directed care. I have seen over the past week three new children who have had evaluations for allergy by someone who offers ‘allergy’ care and they were not allergists. In one instance a type of allergy test was done in the operating room. In one child, intradermal tests for foods were done ( a technique that is replete with false positive results) and most concerning was one child who was tested for foods, found to have a few positive responses, and was given a set of instructions that may have caused a problem. As I reviewed the previous allergy test records with the family I noted that the instructions were “3 days of total avoidance followed by 1 day of exposure to as much as could be eaten of the positive food”.

In the world of IgE-mediated, type-one hypersensitivity food ‘allergy’ reactions (see pages on What is an Allergy and Allergy Tests) the current recommendation is full and strict avoidance of the offending food. There is an evolving science that is helping with prevention and with treatment of some food allergies, but we are not there just yet. I have never come across a program that involves days of avoidance followed by overindulgence, nor could I find anything in the literature regarding this. This could be a very dangerous recommendation especially for a child who may have a systemic response such as hives or allergic shock.

The presenting problem was recurrent ear infections. Now here is where philosophies come into play. The track record even in the best designed study is that at a maximum 1/3 of children with recurrent ear infections may have allergy as a contributor. Between the lines, the allergens were inhalants and the 1/3 of children affected was the one study with the highest fraction. Many of the studies on this connection had fewer children triggered by allergy. In regards to foods, the reports from double-blinded placebo-controlled food challenges (this being the best way to prove a reaction) have shown that foods are a rare cause of isolated respiratory tract symptoms. What was also observed was the fact that if a food was involved, the families suspected it before the evaluation. Again the answer was in the medical history.

Who offers allergy care- well anyone can offer and perform some type of test for allergy. Therein lies the problem. Be ware of what and who is out there. Get the best for your investment of time, money, and safety. The American Academy of Allergy, Asthma, and Immunology (AAAAI) has a issued a position statement about questionable tests and testing procedures for allergy.  The bottom line on these evaluations is that it is not money well spent!

We have primary caretakers, allergists, and otolaryngologists (ENT) tauting expertise in allergy.

Let me describe an allergist- This is an individual who has primary training in either pediatrics or internal medicine. The individual then has done a 2-3 year training program in allergy/immunology and is then eligible to sit for their specialty boards. Allergy/Clinical Immunology is a conjoint board, one of the few that credentials trained individuals to see both children and adults within the context of their specialty. The graduate of the fellowship training program has the opportunity to sit for their specialty boards and they become a board certified allergist-clinical immunologist. They could then join one of two national groups that help set the standards of allergy care, the American College of Allergy, Asthma, and Immunology (ACAAI) and the American Academy of Allergy, Asthma, and Immunology (AAAAI). Through a tenure of membership in these organizations and in their primary specialty, the allergist may become for example a fellow of the American Academy of Pediatrics (AAP) and a fellow of the AAAAI.

Resolves for my pet peeve number 1.

1. Ask about credentials- What is the primary specialty- pediatrics, internal medicine, family practice, or ent surgery?

2. Where was the allergy training – a fellowship, part of surgical training, a course?

3. Is the practitioner boarded in the specialty of allergy? Are they board eligible in the specialty of allergy?

4. Are they a member of a peer group- ACAAI or AAAAI?

5. This one is very biased- although the allergist/immunologist has training in each world I would suggest the pediatric-trained allergist for the children. From my experience at a wonderful children’s hospital- you just have to know about kids and be kid-oriented to be more effective in what we do.

FEL

How about this as pet peeve #2 in my allergy practice? I will share my thoughts and practice guidelines regarding the old adage is “the child too young to test for allergy”. I have heard this countless times from concerned parents. There may be some truth to this, but it depends on the situation. Oh, by the way this pertains to any type of allergy test. Let me elaborate.

First off, allergy takes time to develop. There has to be exposure to cause sensitization. Sensitization involves stimulating the immune system to make that allergy antibody called IgE. That antibody then circulates through the body and binds to cells in the gut, skin, respiratory tract, and cardiovascular system. So we need time, a genetically prone child (thank you mom and dad only please), and exposure.

Secondly the nature of the allergen is important to consider. We get a daily dose of food so food allergy has a chance of developing early in life. Inhalants such as animal dander, insect parts, mold spores, and pollen take longer. We then also need to consider the allergen of concern.

We can see food reactions beginning about 2-3 months of age and usually presenting as a form of eczema (dry, itchy, scaly skin) called ‘atopic dermatitis’. In our pediatric allergy clinic at Riley we can and do test infants with eczema looking to see if a food is a possible stimulant for the condition. We skin prick test for egg white, milk, wheat, soy, peanut, and fish (these foods account for more than 90% of food allergy in children) and provide the family with the results of the skin tests (they take only 15 minutes) and a game plan prior to leaving the office. Here the point is that food allergy can be seen in the very young and we can effectively test. So with the proper condition, that being a skin problem, allergy testing can be done and can be very helpful in the very young. Respiratory tract allergy however is a different story.

Respiratory tract illnesses- asthma, rhinitis, otitis media, and recurrent sinusitis can be due to inhalant allergy. Keep in mind that there are other things to also consider such as day care exposure, irritant responses, and possible structural problems.  Inhalants act differently. The first point to be made is that the child has to be God’s earth for at least one year before inhalant allergy can appear. Furthermore, it may take two but for the most part three outdoor seasons for the child to become sensitive to the pollens of trees, grasses, and weeds. This is obviously dependent upon where you live. In Florida, California, and Hawaii for example, the pollen season tends to be all year round. But here in Indiana the pollen seasons are limited to shorter durations. For indoor allergens such as insect parts, danders of dogs and cats. and mold, it takes at least a year for the exposure, sensitization, and symptom sequence to start. Testing an infant to inhalants/pollens would not reveal clinically relevant sensitivities.

So is the child too young to allergy test? I use these general guidelines-

• Food allergy– early infancy and onward
• Indoor inhalants– needs to be at least one year old to be of value
• Pollens– usually three years old and beyond
• Too young to test for allergy? Yes/No:  it truly depends upon what you are testing for.

FEL