Immunology

A significant dissatisfier for both clinician and patient is that inhaled corticosteroids, commonly underutilized and potentially lifesaving medications, are almost never (if ever) covered at the lowest tier by insurance companies. We would select a first-tier medication if there were one that we could substitute for an ICS; but frequently there isn’t, so we can’t.

Because of this, patients may be financially motivated to simply stop the medication – especially if they perceive that they are on the lowest doses and believe the medication perhaps is not needed at all. Clinicians, meanwhile, are doing the balancing act of moving patients to the lowest doses in order to avoid side effects while maintaining optimal disease control.

So, what are the risks when patients stop using inhaled corticosteroids?

Dr. Matthew A. Rank of the Mayo Clinic, Rochester, Minn., and his colleagues recently published a systematic review of the literature to answer this question (J. Allergy Clin. Immunol. 2013;131:724-9). In this review, randomized, controlled clinical trials in which the study intervention was continuing or stopping low-dose ICSs were included. Studies had to have 4 or more weeks of a run-in with stable doses of ICSs to ensure a minimum period of asthma stability. Seven studies met inclusion criteria. Two studies were exclusively in children, and one was exclusively in adults.

Asthma exacerbations were more likely among patients who stopped ICSs, compared with those who did not (relative risk, 2.35; 95% CI: 1.88-2.92). The risk for an asthma exacerbation in the next 6 months on low-dose ICSs was 16% if patients continued taking the medications, and 38% if they stopped. For every five patients who stopped ICSs, one patient would be expected to have an asthma exacerbation in the next 6 months – which could have been prevented if steroids had been continued. The mean decrease in forced expiratory volume in 1 second associated with discontinued ICSs use was 130 mL.

Most patients can step down with ICSs if they are on long-acting beta-agonists. Expert panels have suggested that patients should be controlled for 3 months before stepping down therapy. Findings from this study further suggest that patients who discontinue low-dose ICSs are at an increased risk of asthma exacerbation.

We need to help our patients understand the risk of stopping low-dose ICSs and encourage them, as much as they are able, to stay on them.

Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no relevant financial conflicts. The opinions expressed are those of the author.

This column, "What Matters," appears regularly in Internal Medicine News.

A significant dissatisfier for both clinician and patient is that inhaled corticosteroids, commonly underutilized and potentially lifesaving medications, are almost never (if ever) covered at the lowest tier by insurance companies. We would select a first-tier medication if there were one that we could substitute for an ICS; but frequently there isn’t, so we can’t.

Because of this, patients may be financially motivated to simply stop the medication – especially if they perceive that they are on the lowest doses and believe the medication perhaps is not needed at all. Clinicians, meanwhile, are doing the balancing act of moving patients to the lowest doses in order to avoid side effects while maintaining optimal disease control.

So, what are the risks when patients stop using inhaled corticosteroids?

Dr. Matthew A. Rank of the Mayo Clinic, Rochester, Minn., and his colleagues recently published a systematic review of the literature to answer this question (J. Allergy Clin. Immunol. 2013;131:724-9). In this review, randomized, controlled clinical trials in which the study intervention was continuing or stopping low-dose ICSs were included. Studies had to have 4 or more weeks of a run-in with stable doses of ICSs to ensure a minimum period of asthma stability. Seven studies met inclusion criteria. Two studies were exclusively in children, and one was exclusively in adults.

Asthma exacerbations were more likely among patients who stopped ICSs, compared with those who did not (relative risk, 2.35; 95% CI: 1.88-2.92). The risk for an asthma exacerbation in the next 6 months on low-dose ICSs was 16% if patients continued taking the medications, and 38% if they stopped. For every five patients who stopped ICSs, one patient would be expected to have an asthma exacerbation in the next 6 months – which could have been prevented if steroids had been continued. The mean decrease in forced expiratory volume in 1 second associated with discontinued ICSs use was 130 mL.

Most patients can step down with ICSs if they are on long-acting beta-agonists. Expert panels have suggested that patients should be controlled for 3 months before stepping down therapy. Findings from this study further suggest that patients who discontinue low-dose ICSs are at an increased risk of asthma exacerbation.

We need to help our patients understand the risk of stopping low-dose ICSs and encourage them, as much as they are able, to stay on them.

Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no relevant financial conflicts. The opinions expressed are those of the author.

This column, "What Matters," appears regularly in Internal Medicine News.

A significant dissatisfier for both clinician and patient is that inhaled corticosteroids, commonly underutilized and potentially lifesaving medications, are almost never (if ever) covered at the lowest tier by insurance companies. We would select a first-tier medication if there were one that we could substitute for an ICS; but frequently there isn’t, so we can’t.

Because of this, patients may be financially motivated to simply stop the medication – especially if they perceive that they are on the lowest doses and believe the medication perhaps is not needed at all. Clinicians, meanwhile, are doing the balancing act of moving patients to the lowest doses in order to avoid side effects while maintaining optimal disease control.

So, what are the risks when patients stop using inhaled corticosteroids?

Dr. Matthew A. Rank of the Mayo Clinic, Rochester, Minn., and his colleagues recently published a systematic review of the literature to answer this question (J. Allergy Clin. Immunol. 2013;131:724-9). In this review, randomized, controlled clinical trials in which the study intervention was continuing or stopping low-dose ICSs were included. Studies had to have 4 or more weeks of a run-in with stable doses of ICSs to ensure a minimum period of asthma stability. Seven studies met inclusion criteria. Two studies were exclusively in children, and one was exclusively in adults.

Asthma exacerbations were more likely among patients who stopped ICSs, compared with those who did not (relative risk, 2.35; 95% CI: 1.88-2.92). The risk for an asthma exacerbation in the next 6 months on low-dose ICSs was 16% if patients continued taking the medications, and 38% if they stopped. For every five patients who stopped ICSs, one patient would be expected to have an asthma exacerbation in the next 6 months – which could have been prevented if steroids had been continued. The mean decrease in forced expiratory volume in 1 second associated with discontinued ICSs use was 130 mL.

Most patients can step down with ICSs if they are on long-acting beta-agonists. Expert panels have suggested that patients should be controlled for 3 months before stepping down therapy. Findings from this study further suggest that patients who discontinue low-dose ICSs are at an increased risk of asthma exacerbation.

We need to help our patients understand the risk of stopping low-dose ICSs and encourage them, as much as they are able, to stay on them.

Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no relevant financial conflicts. The opinions expressed are those of the author.

This column, "What Matters," appears regularly in Internal Medicine News.

Don’t base diagnosis of exercise-induced bronchoconstriction on symptoms alone – but do have patients use inhaled short-acting beta-agonists and do warm-ups before exercise, according to new clinical practice guidelines issued May 1 by the American Thoracic Society.

The guidelines define exercise-induced bronchoconstriction (EIB) as "acute airway narrowing that occurs as a result of exercise."

Considering the high prevalence of EIB, which also affects people without asthma, "evidence-based guidelines for its management are of critical importance," said Dr. Jonathan Parsons, the lead author and chair of the committee that drafted the guidelines, in a statement.

The recommendations "synthesize the latest clinical evidence and will help guide the management of EIB in patients with or without asthma, and in athletes at all levels of competition," added Dr. Parsons, associate professor of internal medicine and associate director of the Ohio State University Asthma Center, Columbus.

The EIB guidelines cover pathogenesis, environmental triggers, diagnosis, treatment, and screening (Am. J. Resp. Crit. Care Med. 2013;187 [doi:10.1164/rccm.201303-0437ST]). Also included is a section on exercise, asthma, and doping – with reminders about which EIB drugs are banned in competitive sports (most beta-agonists) and which are allowed (short-acting inhaled albuterol and inhaled steroids).

Although the guidelines can apply both to adolescents and adults, they cannot be applied reliably to young children, Dr. Parsons noted in an interview.

EIB prevalence among people with asthma is not known, but the estimated prevalence among people who have not been diagnosed with asthma is as high as 20%, according to the ATS. EIB is more prevalent among athletes, affecting 30%-70% of Olympic and elite athletes. Environmental factors likely play a role, such as pollutants emitted from ice surfacing machines in indoor ice rinks, high trichloramine levels in the air of indoor pools, and cold, dry air.

An EIB diagnosis should not be based on symptoms, which are variable, nonspecific, and have poor predictive value. Instead, diagnosis should be made based on changes in lung function provoked by exercise, using serial lung function measurements after a specific exercise or a hyperpnea challenge. Assessing the effects of exercise on forced expiratory volume in 1 second (FEV₁) is preferred.

The guidelines grade EIB as mild, moderate, or severe, depending on the percent fall in FEV₁ from baseline. They also offer information on alternatives to exercise testing.

The authors rate pharmacologic and nonpharmacologic therapies based on the quality of the supportive evidence. Their first recommendation – administration of an inhaled short-acting beta-agonist (SABA) before exercise – earns a "strong" recommendation based on "high-quality" evidence. Patients typically take SABAs 15 minutes before exercise.

Because of the potential for serious side effects, the authors recommend against daily use of an inhaled long-acting beta-agonist (LABA) for EIB – a strong recommendation based on moderate-quality evidence.

For patients who use an inhaled SABA but continue to have symptoms or need to use the inhaled SABA "daily or more frequently," treatment options before exercise include a daily inhaled corticosteroid (ICS), a daily leukotriene-receptor antagonist, or a mast-cell–stabilizing agent.

"We generally add a daily inhaled ICS or a daily leukotriene-receptor antagonist first, with the choice between these agents made on a case-by-case basis depending upon patient preferences," the guideline authors note. Mast-cell–stabilizing agents and inhaled anticholinergic drugs "play a secondary role," they added. There is also a role for antihistamines in patient with continued symptoms despite treatment, but not for patients without allergies.

Nonpharmacologic measures include interval or combination warm-up exercises before planned exercise, which the guidelines recommend "for all patients" with EIB – a strong recommendation, based on moderate quality evidence. The guidelines cite evidence showing a lower reduction in FEV₁ after exercise among people with EIB who engaged in "interval, low-intensity continuous; high-intensity continuous; or combination warm-up" before they exercised.

Another nonpharmacologic recommendation is use of a mask or another device that warms and humidifies the air when patients exercise in a cold climate.

While there is not much evidence supporting dietary modifications, patients interested in this approach can try a low-salt diet, or take fish oil or vitamin C supplements. However, the use of lycopene is not supported, based on the available evidence.

"Our overall recommendations regarding therapy leave a lot of options for the individual patient, which should be discussed with the patient’s physician and tried and evaluated on an ongoing basis," the authors concluded.

The mainstay of treatment "remains maintaining good control of underlying asthma (if present) and preventing or treating symptoms of EIB with SABAs."

The EIB practice guidelines were supported by the ATS and approved by the ATS board of directors. Dr. Parsons’ disclosures include having received lecture fees from AstraZeneca, GlaxoSmithKline, Merck, and Schering Plough. All but one of the other authors disclosed financial relations with a wide range of pharmaceutical companies.

[email protected]

Don’t base diagnosis of exercise-induced bronchoconstriction on symptoms alone – but do have patients use inhaled short-acting beta-agonists and do warm-ups before exercise, according to new clinical practice guidelines issued May 1 by the American Thoracic Society.

The guidelines define exercise-induced bronchoconstriction (EIB) as "acute airway narrowing that occurs as a result of exercise."

Considering the high prevalence of EIB, which also affects people without asthma, "evidence-based guidelines for its management are of critical importance," said Dr. Jonathan Parsons, the lead author and chair of the committee that drafted the guidelines, in a statement.

The recommendations "synthesize the latest clinical evidence and will help guide the management of EIB in patients with or without asthma, and in athletes at all levels of competition," added Dr. Parsons, associate professor of internal medicine and associate director of the Ohio State University Asthma Center, Columbus.

The EIB guidelines cover pathogenesis, environmental triggers, diagnosis, treatment, and screening (Am. J. Resp. Crit. Care Med. 2013;187 [doi:10.1164/rccm.201303-0437ST]). Also included is a section on exercise, asthma, and doping – with reminders about which EIB drugs are banned in competitive sports (most beta-agonists) and which are allowed (short-acting inhaled albuterol and inhaled steroids).

Although the guidelines can apply both to adolescents and adults, they cannot be applied reliably to young children, Dr. Parsons noted in an interview.

EIB prevalence among people with asthma is not known, but the estimated prevalence among people who have not been diagnosed with asthma is as high as 20%, according to the ATS. EIB is more prevalent among athletes, affecting 30%-70% of Olympic and elite athletes. Environmental factors likely play a role, such as pollutants emitted from ice surfacing machines in indoor ice rinks, high trichloramine levels in the air of indoor pools, and cold, dry air.

An EIB diagnosis should not be based on symptoms, which are variable, nonspecific, and have poor predictive value. Instead, diagnosis should be made based on changes in lung function provoked by exercise, using serial lung function measurements after a specific exercise or a hyperpnea challenge. Assessing the effects of exercise on forced expiratory volume in 1 second (FEV₁) is preferred.

The guidelines grade EIB as mild, moderate, or severe, depending on the percent fall in FEV₁ from baseline. They also offer information on alternatives to exercise testing.

The authors rate pharmacologic and nonpharmacologic therapies based on the quality of the supportive evidence. Their first recommendation – administration of an inhaled short-acting beta-agonist (SABA) before exercise – earns a "strong" recommendation based on "high-quality" evidence. Patients typically take SABAs 15 minutes before exercise.

Because of the potential for serious side effects, the authors recommend against daily use of an inhaled long-acting beta-agonist (LABA) for EIB – a strong recommendation based on moderate-quality evidence.

For patients who use an inhaled SABA but continue to have symptoms or need to use the inhaled SABA "daily or more frequently," treatment options before exercise include a daily inhaled corticosteroid (ICS), a daily leukotriene-receptor antagonist, or a mast-cell–stabilizing agent.

"We generally add a daily inhaled ICS or a daily leukotriene-receptor antagonist first, with the choice between these agents made on a case-by-case basis depending upon patient preferences," the guideline authors note. Mast-cell–stabilizing agents and inhaled anticholinergic drugs "play a secondary role," they added. There is also a role for antihistamines in patient with continued symptoms despite treatment, but not for patients without allergies.

Nonpharmacologic measures include interval or combination warm-up exercises before planned exercise, which the guidelines recommend "for all patients" with EIB – a strong recommendation, based on moderate quality evidence. The guidelines cite evidence showing a lower reduction in FEV₁ after exercise among people with EIB who engaged in "interval, low-intensity continuous; high-intensity continuous; or combination warm-up" before they exercised.

Another nonpharmacologic recommendation is use of a mask or another device that warms and humidifies the air when patients exercise in a cold climate.

While there is not much evidence supporting dietary modifications, patients interested in this approach can try a low-salt diet, or take fish oil or vitamin C supplements. However, the use of lycopene is not supported, based on the available evidence.

"Our overall recommendations regarding therapy leave a lot of options for the individual patient, which should be discussed with the patient’s physician and tried and evaluated on an ongoing basis," the authors concluded.

The mainstay of treatment "remains maintaining good control of underlying asthma (if present) and preventing or treating symptoms of EIB with SABAs."

The EIB practice guidelines were supported by the ATS and approved by the ATS board of directors. Dr. Parsons’ disclosures include having received lecture fees from AstraZeneca, GlaxoSmithKline, Merck, and Schering Plough. All but one of the other authors disclosed financial relations with a wide range of pharmaceutical companies.

[email protected]

Don’t base diagnosis of exercise-induced bronchoconstriction on symptoms alone – but do have patients use inhaled short-acting beta-agonists and do warm-ups before exercise, according to new clinical practice guidelines issued May 1 by the American Thoracic Society.

The guidelines define exercise-induced bronchoconstriction (EIB) as "acute airway narrowing that occurs as a result of exercise."

Considering the high prevalence of EIB, which also affects people without asthma, "evidence-based guidelines for its management are of critical importance," said Dr. Jonathan Parsons, the lead author and chair of the committee that drafted the guidelines, in a statement.

The recommendations "synthesize the latest clinical evidence and will help guide the management of EIB in patients with or without asthma, and in athletes at all levels of competition," added Dr. Parsons, associate professor of internal medicine and associate director of the Ohio State University Asthma Center, Columbus.

The EIB guidelines cover pathogenesis, environmental triggers, diagnosis, treatment, and screening (Am. J. Resp. Crit. Care Med. 2013;187 [doi:10.1164/rccm.201303-0437ST]). Also included is a section on exercise, asthma, and doping – with reminders about which EIB drugs are banned in competitive sports (most beta-agonists) and which are allowed (short-acting inhaled albuterol and inhaled steroids).

Although the guidelines can apply both to adolescents and adults, they cannot be applied reliably to young children, Dr. Parsons noted in an interview.

EIB prevalence among people with asthma is not known, but the estimated prevalence among people who have not been diagnosed with asthma is as high as 20%, according to the ATS. EIB is more prevalent among athletes, affecting 30%-70% of Olympic and elite athletes. Environmental factors likely play a role, such as pollutants emitted from ice surfacing machines in indoor ice rinks, high trichloramine levels in the air of indoor pools, and cold, dry air.

An EIB diagnosis should not be based on symptoms, which are variable, nonspecific, and have poor predictive value. Instead, diagnosis should be made based on changes in lung function provoked by exercise, using serial lung function measurements after a specific exercise or a hyperpnea challenge. Assessing the effects of exercise on forced expiratory volume in 1 second (FEV₁) is preferred.

The guidelines grade EIB as mild, moderate, or severe, depending on the percent fall in FEV₁ from baseline. They also offer information on alternatives to exercise testing.

The authors rate pharmacologic and nonpharmacologic therapies based on the quality of the supportive evidence. Their first recommendation – administration of an inhaled short-acting beta-agonist (SABA) before exercise – earns a "strong" recommendation based on "high-quality" evidence. Patients typically take SABAs 15 minutes before exercise.

Because of the potential for serious side effects, the authors recommend against daily use of an inhaled long-acting beta-agonist (LABA) for EIB – a strong recommendation based on moderate-quality evidence.

For patients who use an inhaled SABA but continue to have symptoms or need to use the inhaled SABA "daily or more frequently," treatment options before exercise include a daily inhaled corticosteroid (ICS), a daily leukotriene-receptor antagonist, or a mast-cell–stabilizing agent.

"We generally add a daily inhaled ICS or a daily leukotriene-receptor antagonist first, with the choice between these agents made on a case-by-case basis depending upon patient preferences," the guideline authors note. Mast-cell–stabilizing agents and inhaled anticholinergic drugs "play a secondary role," they added. There is also a role for antihistamines in patient with continued symptoms despite treatment, but not for patients without allergies.

Nonpharmacologic measures include interval or combination warm-up exercises before planned exercise, which the guidelines recommend "for all patients" with EIB – a strong recommendation, based on moderate quality evidence. The guidelines cite evidence showing a lower reduction in FEV₁ after exercise among people with EIB who engaged in "interval, low-intensity continuous; high-intensity continuous; or combination warm-up" before they exercised.

Another nonpharmacologic recommendation is use of a mask or another device that warms and humidifies the air when patients exercise in a cold climate.

While there is not much evidence supporting dietary modifications, patients interested in this approach can try a low-salt diet, or take fish oil or vitamin C supplements. However, the use of lycopene is not supported, based on the available evidence.

"Our overall recommendations regarding therapy leave a lot of options for the individual patient, which should be discussed with the patient’s physician and tried and evaluated on an ongoing basis," the authors concluded.

The mainstay of treatment "remains maintaining good control of underlying asthma (if present) and preventing or treating symptoms of EIB with SABAs."

The EIB practice guidelines were supported by the ATS and approved by the ATS board of directors. Dr. Parsons’ disclosures include having received lecture fees from AstraZeneca, GlaxoSmithKline, Merck, and Schering Plough. All but one of the other authors disclosed financial relations with a wide range of pharmaceutical companies.

[email protected]

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

[email protected]

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

[email protected]

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

[email protected]

SAN ANTONIO – Oral and sublingual immunotherapy strategies aren’t yet ready for prime time, but they continue to show promise for inducing tolerance in children with food allergies.

Oral immunotherapy

Preliminary findings from a study of low-dose oral immunotherapy (OIT) for peanut allergy, for example, suggest this approach is an effective early-intervention strategy, Dr. Brian Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In a randomized, controlled trial involving 49 peanut-sensitized children aged 9-36 months, both low- and high-dose immunotherapy resulted in a significant reduction in both peanut-specific IgE (psIgE) and skin prick test values after a median of 19 treatments, said Dr. Vickery, who is a pediatric allergist and immunologist at the University of North Carolina at Chapel Hill.

The degree of change was similar in those treated with low-dose and high-dose oral immunotherapy. The low dose slope coefficient for psIgE was -2.53 for the low dose group, compared with –1.63 for the high-dose group; and the low dose slope coefficient for the skin prick test was –0.007, compared with –0.009 for the high-dose group, he said.

Of eight subjects who met the criteria for tolerance evaluation as of the time of Dr. Vickery’s presentation, seven had successfully achieved tolerance and now eat peanut ad lib, he noted.

Study subjects were enrolled within 6 months of their index reaction or demonstration of psIgE greater than 5 kUA/L. After randomization to the low- or high-dose treatment group, they underwent serial analysis of immune responses. After at least 1 year of maintenance oral immunotherapy, clinical tolerance was assessed using a double-blinded placebo-controlled oral food challenge based on predefined clinical and immunologic benchmarks.

The findings are preliminary but suggest that early-intervention peanut oral immunotherapy is a feasible strategy. In addition, low-dose oral immunotherapy – using a 10-fold lower dose of peanut protein (the equivalent of about 1 vs. 10 peanuts comprised the maintenance doses in the low- and high-dose groups, respectively) may be sufficiently immunomodulatory in young children with newly diagnosed peanut allergy, Dr. Vickery said during a press briefing at the meeting.

Furthermore, the findings suggest that such an approach is technically possible in that young children can be recruited and treated in this manner, he noted.

Dr. Robert A. Wood, who is chief of the division of allergy and immunology at Hopkins Children’s Center at Johns Hopkins University, Baltimore, and who also presented oral immunotherapy data, noted during the press briefing that the approach used in this study "is sort of seizing on the opportunity that maybe kids early in life, when their allergy is less established, may be more amenable to treatment."

Peanut allergy that manifests in early childhood typically intensifies over 5-10 years, he explained.

The findings, however, are very preliminary.

"In order for us to really understand the impact of these two doses, we will need to assess all of the endpoints in all of the subjects who are currently enrolled, and then unblind the study at the end of it, and do an assessment to really understand whether low or high dose therapy was effective," Dr. Vickery said.

Sublingual immunotherapy

Sublingual immunotherapy (SLIT) is another promising intervention for food allergic children, according to findings from a study presented by Dr. A. Wesley Burks, who is chair of pediatrics at the University of North Carolina at Chapel Hill and physician in chief of N.C. Children’s Hospital, also in Chapel Hill.

Interim data from that study of 44 patients showed that after 36 months of dosing, peanut SLIT–induced clinical tolerance with concurrent changes in skin testing and peanut-specific immunoglobulin levels.

Of 11 patients who completed 36 months of dosing, 6 passed a peanut oral food challenge to 5,000 mg of peanut protein. The remaining five patients ingested a median of 3,750 mg of peanut protein. After SLIT discontinuation for 1 month, five of six passed an identical oral food challenge, suggesting clinical tolerance.

Children in this study were aged 2-11 years. All received open-label peanut SLIT with a daily maintenance dose of 2 mg of peanut protein, Dr. Burks said.

The findings do not say anything about long-term efficacy of SLIT, but they do show that tolerance can be induced, at least in the short term, Dr. Burks said.

Predictors of tolerance induction

Another study presented by Dr. Burks shed some light on factors associated with induction of tolerance, namely basophil hyporesponsiveness and a low peanut IgE:IgG4 ratio.

In that study of 12 patients who received SLIT and 27 who received OIT, 5 (41.7%) and 18 (66.7%), respectively, developed tolerance following immunotherapy. In the SLIT subjects, basophil responses were significantly lower among those who developed tolerance than among those who did not. This was true for each of the 4 log-fold dilutions of peanut antigen used in the assay, Dr. Burks said.

The vast majority of tolerant subjects (91.3%) had a peanut-IgE:IgG4 ratio below 0.92, compared with only 20% of nontolerant subjects.

All subjects underwent double-blind placebo-controlled food challenges to assess desensitization while they were on daily immunotherapy, and those passing the challenge ceased daily therapy and avoided all peanut products for 4 weeks. At 4 weeks, a second food challenge was administered.

The findings suggest that basophil suppression and the balance of antigen-specific IgE and IgG4 may be important in the development of tolerance following peanut immunotherapy, Dr. Burks said.

Long-term immunotherapy outcomes

One missing piece of the immunotherapy puzzle are data on long-term outcomes, as most studies report only 1-2 year outcomes. Another study presented by Dr. Wood, however, takes a step toward filling the gap – with underwhelming results.

The small study looked at long-term outcomes following milk oral immunotherapy in children, and showed that at 4.5 year follow-up, only about 25% of 32 patients were tolerating at least one serving of milk daily and 25% were consuming only trace amounts or were on strict avoidance mainly because of reactions. About 40% of patients were having frequent reactions to milk, 20% had required epinephrine for reactions, and 30% had experienced systemic reactions.

The patients were treated in two studies during 2006 and 2007 with a dose escalation to 500 mg of milk protein over about 8 weeks, followed by 3 months of maintenance dosing. Dietary milk was introduced in amounts ranging from 500 to 4,000 mg daily based on the results of a double-blind placebo-controlled food challenge.

Of note, one subject who passed a 16-g challenge without symptoms went on to become reactive again and now consumes only minimal milk, Dr. Wood said

In fact, one of the surprising things in this study was that some of the more dramatic failures long-term were in children who had achieved success in the initial studies.

These were children who "looked like absolute successes" at the end of the study, because there were tolerating large amounts of milk, he said.

"We really thought – and we hesitate to use the word "cure" – that they were about as close to cured as we could really imagine. And now, 3-5 years later, they are having anaphylactic reactions and are back on strict milk avoidance," he said.

As a result, the excitement following the initial studies has waned somewhat.

"We had a very high degree of optimism. I’m not saying we lost that optimism, but it is certainly tempered a bit by looking at where these kids now stand 3-5 years out," he said, concluding that more research with respect to long-term outcomes of food oral immunotherapy is needed, including investigation of whether longer treatment would improve outcomes, and whether certain factors can predict response and failure.

"The most important message is that this sort of adds another caveat about why we need more research before we can bring this out to our patient population. A message that I think all of us who are doing this research have come to agree upon is that we need long-term follow-up and that letting these kids go at the end of the study is not the end of the story."

Taken together, the findings of these studies underscore a need for more research regarding SLIT vs. OIT, higher vs. lower dosing, and treatment duration, as well as long-term follow-up, the investigators agreed.

"The message is that what we are doing so far is very encouraging, but it’s not the final answer. Where we need to be to bring this out to the general public is several steps beyond where we are now," Dr. Wood said.

The investigators reported having no disclosures.

SAN ANTONIO – Oral and sublingual immunotherapy strategies aren’t yet ready for prime time, but they continue to show promise for inducing tolerance in children with food allergies.

Oral immunotherapy

Preliminary findings from a study of low-dose oral immunotherapy (OIT) for peanut allergy, for example, suggest this approach is an effective early-intervention strategy, Dr. Brian Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In a randomized, controlled trial involving 49 peanut-sensitized children aged 9-36 months, both low- and high-dose immunotherapy resulted in a significant reduction in both peanut-specific IgE (psIgE) and skin prick test values after a median of 19 treatments, said Dr. Vickery, who is a pediatric allergist and immunologist at the University of North Carolina at Chapel Hill.

The degree of change was similar in those treated with low-dose and high-dose oral immunotherapy. The low dose slope coefficient for psIgE was -2.53 for the low dose group, compared with –1.63 for the high-dose group; and the low dose slope coefficient for the skin prick test was –0.007, compared with –0.009 for the high-dose group, he said.

Of eight subjects who met the criteria for tolerance evaluation as of the time of Dr. Vickery’s presentation, seven had successfully achieved tolerance and now eat peanut ad lib, he noted.

Study subjects were enrolled within 6 months of their index reaction or demonstration of psIgE greater than 5 kUA/L. After randomization to the low- or high-dose treatment group, they underwent serial analysis of immune responses. After at least 1 year of maintenance oral immunotherapy, clinical tolerance was assessed using a double-blinded placebo-controlled oral food challenge based on predefined clinical and immunologic benchmarks.

The findings are preliminary but suggest that early-intervention peanut oral immunotherapy is a feasible strategy. In addition, low-dose oral immunotherapy – using a 10-fold lower dose of peanut protein (the equivalent of about 1 vs. 10 peanuts comprised the maintenance doses in the low- and high-dose groups, respectively) may be sufficiently immunomodulatory in young children with newly diagnosed peanut allergy, Dr. Vickery said during a press briefing at the meeting.

Furthermore, the findings suggest that such an approach is technically possible in that young children can be recruited and treated in this manner, he noted.

Dr. Robert A. Wood, who is chief of the division of allergy and immunology at Hopkins Children’s Center at Johns Hopkins University, Baltimore, and who also presented oral immunotherapy data, noted during the press briefing that the approach used in this study "is sort of seizing on the opportunity that maybe kids early in life, when their allergy is less established, may be more amenable to treatment."

Peanut allergy that manifests in early childhood typically intensifies over 5-10 years, he explained.

The findings, however, are very preliminary.

"In order for us to really understand the impact of these two doses, we will need to assess all of the endpoints in all of the subjects who are currently enrolled, and then unblind the study at the end of it, and do an assessment to really understand whether low or high dose therapy was effective," Dr. Vickery said.

Sublingual immunotherapy

Sublingual immunotherapy (SLIT) is another promising intervention for food allergic children, according to findings from a study presented by Dr. A. Wesley Burks, who is chair of pediatrics at the University of North Carolina at Chapel Hill and physician in chief of N.C. Children’s Hospital, also in Chapel Hill.

Interim data from that study of 44 patients showed that after 36 months of dosing, peanut SLIT–induced clinical tolerance with concurrent changes in skin testing and peanut-specific immunoglobulin levels.

Of 11 patients who completed 36 months of dosing, 6 passed a peanut oral food challenge to 5,000 mg of peanut protein. The remaining five patients ingested a median of 3,750 mg of peanut protein. After SLIT discontinuation for 1 month, five of six passed an identical oral food challenge, suggesting clinical tolerance.

Children in this study were aged 2-11 years. All received open-label peanut SLIT with a daily maintenance dose of 2 mg of peanut protein, Dr. Burks said.

The findings do not say anything about long-term efficacy of SLIT, but they do show that tolerance can be induced, at least in the short term, Dr. Burks said.

Predictors of tolerance induction

Another study presented by Dr. Burks shed some light on factors associated with induction of tolerance, namely basophil hyporesponsiveness and a low peanut IgE:IgG4 ratio.

In that study of 12 patients who received SLIT and 27 who received OIT, 5 (41.7%) and 18 (66.7%), respectively, developed tolerance following immunotherapy. In the SLIT subjects, basophil responses were significantly lower among those who developed tolerance than among those who did not. This was true for each of the 4 log-fold dilutions of peanut antigen used in the assay, Dr. Burks said.

The vast majority of tolerant subjects (91.3%) had a peanut-IgE:IgG4 ratio below 0.92, compared with only 20% of nontolerant subjects.

All subjects underwent double-blind placebo-controlled food challenges to assess desensitization while they were on daily immunotherapy, and those passing the challenge ceased daily therapy and avoided all peanut products for 4 weeks. At 4 weeks, a second food challenge was administered.

The findings suggest that basophil suppression and the balance of antigen-specific IgE and IgG4 may be important in the development of tolerance following peanut immunotherapy, Dr. Burks said.

Long-term immunotherapy outcomes

One missing piece of the immunotherapy puzzle are data on long-term outcomes, as most studies report only 1-2 year outcomes. Another study presented by Dr. Wood, however, takes a step toward filling the gap – with underwhelming results.

The small study looked at long-term outcomes following milk oral immunotherapy in children, and showed that at 4.5 year follow-up, only about 25% of 32 patients were tolerating at least one serving of milk daily and 25% were consuming only trace amounts or were on strict avoidance mainly because of reactions. About 40% of patients were having frequent reactions to milk, 20% had required epinephrine for reactions, and 30% had experienced systemic reactions.

The patients were treated in two studies during 2006 and 2007 with a dose escalation to 500 mg of milk protein over about 8 weeks, followed by 3 months of maintenance dosing. Dietary milk was introduced in amounts ranging from 500 to 4,000 mg daily based on the results of a double-blind placebo-controlled food challenge.

Of note, one subject who passed a 16-g challenge without symptoms went on to become reactive again and now consumes only minimal milk, Dr. Wood said

In fact, one of the surprising things in this study was that some of the more dramatic failures long-term were in children who had achieved success in the initial studies.

These were children who "looked like absolute successes" at the end of the study, because there were tolerating large amounts of milk, he said.

"We really thought – and we hesitate to use the word "cure" – that they were about as close to cured as we could really imagine. And now, 3-5 years later, they are having anaphylactic reactions and are back on strict milk avoidance," he said.

As a result, the excitement following the initial studies has waned somewhat.

"We had a very high degree of optimism. I’m not saying we lost that optimism, but it is certainly tempered a bit by looking at where these kids now stand 3-5 years out," he said, concluding that more research with respect to long-term outcomes of food oral immunotherapy is needed, including investigation of whether longer treatment would improve outcomes, and whether certain factors can predict response and failure.

"The most important message is that this sort of adds another caveat about why we need more research before we can bring this out to our patient population. A message that I think all of us who are doing this research have come to agree upon is that we need long-term follow-up and that letting these kids go at the end of the study is not the end of the story."

Taken together, the findings of these studies underscore a need for more research regarding SLIT vs. OIT, higher vs. lower dosing, and treatment duration, as well as long-term follow-up, the investigators agreed.

"The message is that what we are doing so far is very encouraging, but it’s not the final answer. Where we need to be to bring this out to the general public is several steps beyond where we are now," Dr. Wood said.

The investigators reported having no disclosures.

SAN ANTONIO – Oral and sublingual immunotherapy strategies aren’t yet ready for prime time, but they continue to show promise for inducing tolerance in children with food allergies.

Oral immunotherapy

Preliminary findings from a study of low-dose oral immunotherapy (OIT) for peanut allergy, for example, suggest this approach is an effective early-intervention strategy, Dr. Brian Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In a randomized, controlled trial involving 49 peanut-sensitized children aged 9-36 months, both low- and high-dose immunotherapy resulted in a significant reduction in both peanut-specific IgE (psIgE) and skin prick test values after a median of 19 treatments, said Dr. Vickery, who is a pediatric allergist and immunologist at the University of North Carolina at Chapel Hill.

The degree of change was similar in those treated with low-dose and high-dose oral immunotherapy. The low dose slope coefficient for psIgE was -2.53 for the low dose group, compared with –1.63 for the high-dose group; and the low dose slope coefficient for the skin prick test was –0.007, compared with –0.009 for the high-dose group, he said.

Of eight subjects who met the criteria for tolerance evaluation as of the time of Dr. Vickery’s presentation, seven had successfully achieved tolerance and now eat peanut ad lib, he noted.

Study subjects were enrolled within 6 months of their index reaction or demonstration of psIgE greater than 5 kUA/L. After randomization to the low- or high-dose treatment group, they underwent serial analysis of immune responses. After at least 1 year of maintenance oral immunotherapy, clinical tolerance was assessed using a double-blinded placebo-controlled oral food challenge based on predefined clinical and immunologic benchmarks.

The findings are preliminary but suggest that early-intervention peanut oral immunotherapy is a feasible strategy. In addition, low-dose oral immunotherapy – using a 10-fold lower dose of peanut protein (the equivalent of about 1 vs. 10 peanuts comprised the maintenance doses in the low- and high-dose groups, respectively) may be sufficiently immunomodulatory in young children with newly diagnosed peanut allergy, Dr. Vickery said during a press briefing at the meeting.

Furthermore, the findings suggest that such an approach is technically possible in that young children can be recruited and treated in this manner, he noted.

Dr. Robert A. Wood, who is chief of the division of allergy and immunology at Hopkins Children’s Center at Johns Hopkins University, Baltimore, and who also presented oral immunotherapy data, noted during the press briefing that the approach used in this study "is sort of seizing on the opportunity that maybe kids early in life, when their allergy is less established, may be more amenable to treatment."

Peanut allergy that manifests in early childhood typically intensifies over 5-10 years, he explained.

The findings, however, are very preliminary.

"In order for us to really understand the impact of these two doses, we will need to assess all of the endpoints in all of the subjects who are currently enrolled, and then unblind the study at the end of it, and do an assessment to really understand whether low or high dose therapy was effective," Dr. Vickery said.

Sublingual immunotherapy

Sublingual immunotherapy (SLIT) is another promising intervention for food allergic children, according to findings from a study presented by Dr. A. Wesley Burks, who is chair of pediatrics at the University of North Carolina at Chapel Hill and physician in chief of N.C. Children’s Hospital, also in Chapel Hill.

Interim data from that study of 44 patients showed that after 36 months of dosing, peanut SLIT–induced clinical tolerance with concurrent changes in skin testing and peanut-specific immunoglobulin levels.

Of 11 patients who completed 36 months of dosing, 6 passed a peanut oral food challenge to 5,000 mg of peanut protein. The remaining five patients ingested a median of 3,750 mg of peanut protein. After SLIT discontinuation for 1 month, five of six passed an identical oral food challenge, suggesting clinical tolerance.

Children in this study were aged 2-11 years. All received open-label peanut SLIT with a daily maintenance dose of 2 mg of peanut protein, Dr. Burks said.

The findings do not say anything about long-term efficacy of SLIT, but they do show that tolerance can be induced, at least in the short term, Dr. Burks said.

Predictors of tolerance induction

Another study presented by Dr. Burks shed some light on factors associated with induction of tolerance, namely basophil hyporesponsiveness and a low peanut IgE:IgG4 ratio.

In that study of 12 patients who received SLIT and 27 who received OIT, 5 (41.7%) and 18 (66.7%), respectively, developed tolerance following immunotherapy. In the SLIT subjects, basophil responses were significantly lower among those who developed tolerance than among those who did not. This was true for each of the 4 log-fold dilutions of peanut antigen used in the assay, Dr. Burks said.

The vast majority of tolerant subjects (91.3%) had a peanut-IgE:IgG4 ratio below 0.92, compared with only 20% of nontolerant subjects.

All subjects underwent double-blind placebo-controlled food challenges to assess desensitization while they were on daily immunotherapy, and those passing the challenge ceased daily therapy and avoided all peanut products for 4 weeks. At 4 weeks, a second food challenge was administered.

The findings suggest that basophil suppression and the balance of antigen-specific IgE and IgG4 may be important in the development of tolerance following peanut immunotherapy, Dr. Burks said.

Long-term immunotherapy outcomes

One missing piece of the immunotherapy puzzle are data on long-term outcomes, as most studies report only 1-2 year outcomes. Another study presented by Dr. Wood, however, takes a step toward filling the gap – with underwhelming results.

The small study looked at long-term outcomes following milk oral immunotherapy in children, and showed that at 4.5 year follow-up, only about 25% of 32 patients were tolerating at least one serving of milk daily and 25% were consuming only trace amounts or were on strict avoidance mainly because of reactions. About 40% of patients were having frequent reactions to milk, 20% had required epinephrine for reactions, and 30% had experienced systemic reactions.

The patients were treated in two studies during 2006 and 2007 with a dose escalation to 500 mg of milk protein over about 8 weeks, followed by 3 months of maintenance dosing. Dietary milk was introduced in amounts ranging from 500 to 4,000 mg daily based on the results of a double-blind placebo-controlled food challenge.

Of note, one subject who passed a 16-g challenge without symptoms went on to become reactive again and now consumes only minimal milk, Dr. Wood said

In fact, one of the surprising things in this study was that some of the more dramatic failures long-term were in children who had achieved success in the initial studies.

These were children who "looked like absolute successes" at the end of the study, because there were tolerating large amounts of milk, he said.

"We really thought – and we hesitate to use the word "cure" – that they were about as close to cured as we could really imagine. And now, 3-5 years later, they are having anaphylactic reactions and are back on strict milk avoidance," he said.

As a result, the excitement following the initial studies has waned somewhat.

"We had a very high degree of optimism. I’m not saying we lost that optimism, but it is certainly tempered a bit by looking at where these kids now stand 3-5 years out," he said, concluding that more research with respect to long-term outcomes of food oral immunotherapy is needed, including investigation of whether longer treatment would improve outcomes, and whether certain factors can predict response and failure.

"The most important message is that this sort of adds another caveat about why we need more research before we can bring this out to our patient population. A message that I think all of us who are doing this research have come to agree upon is that we need long-term follow-up and that letting these kids go at the end of the study is not the end of the story."

Taken together, the findings of these studies underscore a need for more research regarding SLIT vs. OIT, higher vs. lower dosing, and treatment duration, as well as long-term follow-up, the investigators agreed.

"The message is that what we are doing so far is very encouraging, but it’s not the final answer. Where we need to be to bring this out to the general public is several steps beyond where we are now," Dr. Wood said.

The investigators reported having no disclosures.

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]

SAN ANTONIO – Overweight and obese children in need of epinephrine for anaphylaxis should be injected in the calf or in the lower thigh, rather than upper half of the thigh, to ensure intramuscular administration, according to findings from an ultrasound study of 93 children.

Ultrasound measurement demonstrated that the distance from skin surface to muscle depth was greater than auto-injector needle length at one quarter of the distance down the thigh in 82% of obese children vs. 25% of nonobese children. At three-quarters of the way down the thigh, this was the case in only 17% of obese children and 2% of nonobese children, Dr. Peter Arkwright reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

At a point midway down the calf, the skin surface to muscle depth was less than the length of the auto-injector needle in all of the children, said Dr. Arkwright of the University of Manchester (England).

Intramuscular injection, rather than subcutaneous injection, is imperative for effective delivery of epinephrine, he said, noting that this study was undertaken because of growing concerns that increasing obesity among children could make existing auto-injectors inadequate for providing intramuscular delivery in a significant proportion of patients.

Children included in the study were patients from regional pediatric allergy clinics. All were measured for height, weight, and body mass index, and all underwent ultrasound measurement at set distances down the thigh and leg. Higher weight, BMI, and waist circumference – but not age or gender – were associated with skin surface to muscle depth greater than auto-injector needle length, he noted.

"Based on our study, injecting epinephrine into the lower rather than upper thigh would be advised in overweight or obese children," he said, adding that caregivers of children at risk of anaphylaxis should be advised about the importance of administering epinephrine into the muscle in the most effective way.

For overweight and obese children, this involves injecting into the lower half of the thigh, and for very obese children it involves injecting at the middle of the calf, he said.

Dr. Arkwright reported having no disclosures.

SAN ANTONIO – Overweight and obese children in need of epinephrine for anaphylaxis should be injected in the calf or in the lower thigh, rather than upper half of the thigh, to ensure intramuscular administration, according to findings from an ultrasound study of 93 children.

Ultrasound measurement demonstrated that the distance from skin surface to muscle depth was greater than auto-injector needle length at one quarter of the distance down the thigh in 82% of obese children vs. 25% of nonobese children. At three-quarters of the way down the thigh, this was the case in only 17% of obese children and 2% of nonobese children, Dr. Peter Arkwright reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

At a point midway down the calf, the skin surface to muscle depth was less than the length of the auto-injector needle in all of the children, said Dr. Arkwright of the University of Manchester (England).

Intramuscular injection, rather than subcutaneous injection, is imperative for effective delivery of epinephrine, he said, noting that this study was undertaken because of growing concerns that increasing obesity among children could make existing auto-injectors inadequate for providing intramuscular delivery in a significant proportion of patients.

Children included in the study were patients from regional pediatric allergy clinics. All were measured for height, weight, and body mass index, and all underwent ultrasound measurement at set distances down the thigh and leg. Higher weight, BMI, and waist circumference – but not age or gender – were associated with skin surface to muscle depth greater than auto-injector needle length, he noted.

"Based on our study, injecting epinephrine into the lower rather than upper thigh would be advised in overweight or obese children," he said, adding that caregivers of children at risk of anaphylaxis should be advised about the importance of administering epinephrine into the muscle in the most effective way.

For overweight and obese children, this involves injecting into the lower half of the thigh, and for very obese children it involves injecting at the middle of the calf, he said.

Dr. Arkwright reported having no disclosures.

SAN ANTONIO – Overweight and obese children in need of epinephrine for anaphylaxis should be injected in the calf or in the lower thigh, rather than upper half of the thigh, to ensure intramuscular administration, according to findings from an ultrasound study of 93 children.

Ultrasound measurement demonstrated that the distance from skin surface to muscle depth was greater than auto-injector needle length at one quarter of the distance down the thigh in 82% of obese children vs. 25% of nonobese children. At three-quarters of the way down the thigh, this was the case in only 17% of obese children and 2% of nonobese children, Dr. Peter Arkwright reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

At a point midway down the calf, the skin surface to muscle depth was less than the length of the auto-injector needle in all of the children, said Dr. Arkwright of the University of Manchester (England).

Intramuscular injection, rather than subcutaneous injection, is imperative for effective delivery of epinephrine, he said, noting that this study was undertaken because of growing concerns that increasing obesity among children could make existing auto-injectors inadequate for providing intramuscular delivery in a significant proportion of patients.

Children included in the study were patients from regional pediatric allergy clinics. All were measured for height, weight, and body mass index, and all underwent ultrasound measurement at set distances down the thigh and leg. Higher weight, BMI, and waist circumference – but not age or gender – were associated with skin surface to muscle depth greater than auto-injector needle length, he noted.

"Based on our study, injecting epinephrine into the lower rather than upper thigh would be advised in overweight or obese children," he said, adding that caregivers of children at risk of anaphylaxis should be advised about the importance of administering epinephrine into the muscle in the most effective way.

For overweight and obese children, this involves injecting into the lower half of the thigh, and for very obese children it involves injecting at the middle of the calf, he said.

Dr. Arkwright reported having no disclosures.

SAN ANTONIO – More of the children who present to the pediatric emergency department with asthma exacerbation received recommended care when the staff had instituted a nurse-initiated, evidence-based, standardized order set, according to Dr. Moira E. Breslin.

Specifically, the percentage of patients receiving at least one dose of ipratropium bromide improved from 55.4% before implementation of the order set to 90.9% after implementation. Compliance with the recommendation of the National Asthma Guidelines that patients receive three consecutive nebulized treatments of ipratropium bromide increased from 13.5% to 40.9%, Dr. Breslin of Duke University Medical Center, Durham, N.C., reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The median time to delivery of rescue medication also improved from 21 minutes to 14 minutes for first inhaled bronchodilator administration, and from 41 minutes to 19 minutes for delivery of systemic corticosteroids.

All differences were statistically significant.

The findings are based on a review of charts for 193 patients treated in the pediatric emergency department for status asthmaticus before implementation of the evidence-based standardized order set, or EBSOS, (between Feb. 23, 2009, and Feb. 22, 2012), and for 22 patients treated after implementation (between Feb. 23, 2012, and July 31, 2012).

The EBSOS for the treatment of pediatric asthma used in this study was developed and incorporated into the emergency department electronic ordering system because personnel were not consistently following national asthma treatment guidelines, according to a separate 2010 emergency department records review.

That review showed that 24% of patients admitted for status asthmaticus had not received the recommended ipratropium bromide treatment, and that only 14% of those who did receive ipratropium bromide received the recommended three consecutive doses.

Implementation of the EBSOS involved the use of an algorithm based on a validated Modified Pulmonary Index Score that allowed for triage nurse initiation of the EBSOS. The EBSOS called for continuous pulse oximetry, supplemental oxygen as needed, evaluation by a respiratory therapist, nebulized albuterol administration at 5 mg every 20 minutes for three treatments, administration of nebulized ipratropium bromide at 0.5 mg every 20 minutes for three treatments, and administration of one dose of oral prednisolone at 2 mg/kg up to a maximum of 60 mg.

"Implementation of an EBSOS improved compliance to national asthma guidelines, as evidenced by a higher proportion of pediatric emergency department patients in status asthmaticus receiving ipratropium bromide, as well as shortened time to delivery of inhaled bronchodilators and systemic steroids," Dr. Breslin concluded, noting that future analysis of this review will focus on patient-centered outcomes.

Dr. Breslin reported having no relevant financial disclosures

SAN ANTONIO – More of the children who present to the pediatric emergency department with asthma exacerbation received recommended care when the staff had instituted a nurse-initiated, evidence-based, standardized order set, according to Dr. Moira E. Breslin.

Specifically, the percentage of patients receiving at least one dose of ipratropium bromide improved from 55.4% before implementation of the order set to 90.9% after implementation. Compliance with the recommendation of the National Asthma Guidelines that patients receive three consecutive nebulized treatments of ipratropium bromide increased from 13.5% to 40.9%, Dr. Breslin of Duke University Medical Center, Durham, N.C., reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The median time to delivery of rescue medication also improved from 21 minutes to 14 minutes for first inhaled bronchodilator administration, and from 41 minutes to 19 minutes for delivery of systemic corticosteroids.

All differences were statistically significant.

The findings are based on a review of charts for 193 patients treated in the pediatric emergency department for status asthmaticus before implementation of the evidence-based standardized order set, or EBSOS, (between Feb. 23, 2009, and Feb. 22, 2012), and for 22 patients treated after implementation (between Feb. 23, 2012, and July 31, 2012).

The EBSOS for the treatment of pediatric asthma used in this study was developed and incorporated into the emergency department electronic ordering system because personnel were not consistently following national asthma treatment guidelines, according to a separate 2010 emergency department records review.

That review showed that 24% of patients admitted for status asthmaticus had not received the recommended ipratropium bromide treatment, and that only 14% of those who did receive ipratropium bromide received the recommended three consecutive doses.

Implementation of the EBSOS involved the use of an algorithm based on a validated Modified Pulmonary Index Score that allowed for triage nurse initiation of the EBSOS. The EBSOS called for continuous pulse oximetry, supplemental oxygen as needed, evaluation by a respiratory therapist, nebulized albuterol administration at 5 mg every 20 minutes for three treatments, administration of nebulized ipratropium bromide at 0.5 mg every 20 minutes for three treatments, and administration of one dose of oral prednisolone at 2 mg/kg up to a maximum of 60 mg.

"Implementation of an EBSOS improved compliance to national asthma guidelines, as evidenced by a higher proportion of pediatric emergency department patients in status asthmaticus receiving ipratropium bromide, as well as shortened time to delivery of inhaled bronchodilators and systemic steroids," Dr. Breslin concluded, noting that future analysis of this review will focus on patient-centered outcomes.

Dr. Breslin reported having no relevant financial disclosures

SAN ANTONIO – More of the children who present to the pediatric emergency department with asthma exacerbation received recommended care when the staff had instituted a nurse-initiated, evidence-based, standardized order set, according to Dr. Moira E. Breslin.

Specifically, the percentage of patients receiving at least one dose of ipratropium bromide improved from 55.4% before implementation of the order set to 90.9% after implementation. Compliance with the recommendation of the National Asthma Guidelines that patients receive three consecutive nebulized treatments of ipratropium bromide increased from 13.5% to 40.9%, Dr. Breslin of Duke University Medical Center, Durham, N.C., reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The median time to delivery of rescue medication also improved from 21 minutes to 14 minutes for first inhaled bronchodilator administration, and from 41 minutes to 19 minutes for delivery of systemic corticosteroids.

All differences were statistically significant.

The findings are based on a review of charts for 193 patients treated in the pediatric emergency department for status asthmaticus before implementation of the evidence-based standardized order set, or EBSOS, (between Feb. 23, 2009, and Feb. 22, 2012), and for 22 patients treated after implementation (between Feb. 23, 2012, and July 31, 2012).

The EBSOS for the treatment of pediatric asthma used in this study was developed and incorporated into the emergency department electronic ordering system because personnel were not consistently following national asthma treatment guidelines, according to a separate 2010 emergency department records review.

That review showed that 24% of patients admitted for status asthmaticus had not received the recommended ipratropium bromide treatment, and that only 14% of those who did receive ipratropium bromide received the recommended three consecutive doses.

Implementation of the EBSOS involved the use of an algorithm based on a validated Modified Pulmonary Index Score that allowed for triage nurse initiation of the EBSOS. The EBSOS called for continuous pulse oximetry, supplemental oxygen as needed, evaluation by a respiratory therapist, nebulized albuterol administration at 5 mg every 20 minutes for three treatments, administration of nebulized ipratropium bromide at 0.5 mg every 20 minutes for three treatments, and administration of one dose of oral prednisolone at 2 mg/kg up to a maximum of 60 mg.

"Implementation of an EBSOS improved compliance to national asthma guidelines, as evidenced by a higher proportion of pediatric emergency department patients in status asthmaticus receiving ipratropium bromide, as well as shortened time to delivery of inhaled bronchodilators and systemic steroids," Dr. Breslin concluded, noting that future analysis of this review will focus on patient-centered outcomes.

Dr. Breslin reported having no relevant financial disclosures

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SAN ANTONIO – Dietary restrictions prescribed for children with food allergies may lead to growth impairment, according to findings from a review of medical records for 245 food-allergic pediatric patients.

The risk of growth impairment was greatest for children whose dietary restrictions required elimination of more than two foods and/or elimination of cow’s milk, Dr. Brian P. Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

After age 2 years, the food-allergic children had lower mean percentiles for weight (67.5 vs. 72.5) and a lower body mass index (57.6 vs.68.0), than did 4,584 healthy age-matched controls.

Furthermore, the 52 patients with more than two food allergies (and thus more than two food restrictions), compared with 193 patients with one or two food allergies, had significantly lower mean percentiles for height (62.2 vs. 74.8) and weight (55.3 vs. 69.2). The 66 patients with milk allergy, compared with those with other food allergies, had lower mean percentiles for weight (54.5 vs. 70.6) and BMI (48.9 vs. 58.8), according to Dr. Vickery of the University of North Carolina at Chapel Hill.

Milk-allergic children younger than 2 years of age were particularly vulnerable to growth restriction, he said during a press briefing at the meeting.

The food-allergic children in this study, who were aged 1 month to 11 years and who presented to a University of North Carolina outpatient clinic between 2007 and 2011, also were compared with 205 "disease controls," consisting of children with either cystic fibrosis or celiac disease, two conditions that are associated with impaired growth. When children passed their second birthday, the effect of food allergy on growth was very similar to the effect of celiac disease on growth, Dr. Vickery said.

The findings of this study confirm those from a smaller study, conducted more than a decade ago, that also showed that milk allergy and multiple food allergies were associated with growth impairment.

That study is "the most commonly cited previous study to address the growth of food-allergic children in the United States," Dr. Vickery noted.

"The prevalence [of food allergy] has increased over the past 10 years, so we wanted to take another look in a bigger population to kind of reassess the impact of elimination diets on growth," he said.

The current findings demonstrate that a food allergy–associated elimination diet can place children at risk of impaired growth, compared with their healthy peers, regardless of whether they are under age 2 years, or are 2-11 years old, and that after age 2, the effect of food allergy on growth is very similar to that of chronic diseases known to affect growth, he said.

"While awareness of food allergy is increasing along with the prevalence of the disease, it is important to draw attention to the important consequences of elimination diets. We feel that providers should counsel patients and caregivers about the growth-related risks of the elimination diets that are used to treat food allergy, and ensure that families are excluding only the foods that are medically required or otherwise culturally indicated, that nutritional assessment and/or supplementation is provided as needed, and that subspecialty consultation is arranged, especially for children at highest risk," he said.

Dr. Vickery reported having no relevant financial disclosures.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SAN ANTONIO – Dietary restrictions prescribed for children with food allergies may lead to growth impairment, according to findings from a review of medical records for 245 food-allergic pediatric patients.

The risk of growth impairment was greatest for children whose dietary restrictions required elimination of more than two foods and/or elimination of cow’s milk, Dr. Brian P. Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

After age 2 years, the food-allergic children had lower mean percentiles for weight (67.5 vs. 72.5) and a lower body mass index (57.6 vs.68.0), than did 4,584 healthy age-matched controls.

Furthermore, the 52 patients with more than two food allergies (and thus more than two food restrictions), compared with 193 patients with one or two food allergies, had significantly lower mean percentiles for height (62.2 vs. 74.8) and weight (55.3 vs. 69.2). The 66 patients with milk allergy, compared with those with other food allergies, had lower mean percentiles for weight (54.5 vs. 70.6) and BMI (48.9 vs. 58.8), according to Dr. Vickery of the University of North Carolina at Chapel Hill.

Milk-allergic children younger than 2 years of age were particularly vulnerable to growth restriction, he said during a press briefing at the meeting.

The food-allergic children in this study, who were aged 1 month to 11 years and who presented to a University of North Carolina outpatient clinic between 2007 and 2011, also were compared with 205 "disease controls," consisting of children with either cystic fibrosis or celiac disease, two conditions that are associated with impaired growth. When children passed their second birthday, the effect of food allergy on growth was very similar to the effect of celiac disease on growth, Dr. Vickery said.

The findings of this study confirm those from a smaller study, conducted more than a decade ago, that also showed that milk allergy and multiple food allergies were associated with growth impairment.

That study is "the most commonly cited previous study to address the growth of food-allergic children in the United States," Dr. Vickery noted.

"The prevalence [of food allergy] has increased over the past 10 years, so we wanted to take another look in a bigger population to kind of reassess the impact of elimination diets on growth," he said.

The current findings demonstrate that a food allergy–associated elimination diet can place children at risk of impaired growth, compared with their healthy peers, regardless of whether they are under age 2 years, or are 2-11 years old, and that after age 2, the effect of food allergy on growth is very similar to that of chronic diseases known to affect growth, he said.

"While awareness of food allergy is increasing along with the prevalence of the disease, it is important to draw attention to the important consequences of elimination diets. We feel that providers should counsel patients and caregivers about the growth-related risks of the elimination diets that are used to treat food allergy, and ensure that families are excluding only the foods that are medically required or otherwise culturally indicated, that nutritional assessment and/or supplementation is provided as needed, and that subspecialty consultation is arranged, especially for children at highest risk," he said.

Dr. Vickery reported having no relevant financial disclosures.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SAN ANTONIO – Dietary restrictions prescribed for children with food allergies may lead to growth impairment, according to findings from a review of medical records for 245 food-allergic pediatric patients.

The risk of growth impairment was greatest for children whose dietary restrictions required elimination of more than two foods and/or elimination of cow’s milk, Dr. Brian P. Vickery reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

After age 2 years, the food-allergic children had lower mean percentiles for weight (67.5 vs. 72.5) and a lower body mass index (57.6 vs.68.0), than did 4,584 healthy age-matched controls.

Furthermore, the 52 patients with more than two food allergies (and thus more than two food restrictions), compared with 193 patients with one or two food allergies, had significantly lower mean percentiles for height (62.2 vs. 74.8) and weight (55.3 vs. 69.2). The 66 patients with milk allergy, compared with those with other food allergies, had lower mean percentiles for weight (54.5 vs. 70.6) and BMI (48.9 vs. 58.8), according to Dr. Vickery of the University of North Carolina at Chapel Hill.

Milk-allergic children younger than 2 years of age were particularly vulnerable to growth restriction, he said during a press briefing at the meeting.

The food-allergic children in this study, who were aged 1 month to 11 years and who presented to a University of North Carolina outpatient clinic between 2007 and 2011, also were compared with 205 "disease controls," consisting of children with either cystic fibrosis or celiac disease, two conditions that are associated with impaired growth. When children passed their second birthday, the effect of food allergy on growth was very similar to the effect of celiac disease on growth, Dr. Vickery said.

The findings of this study confirm those from a smaller study, conducted more than a decade ago, that also showed that milk allergy and multiple food allergies were associated with growth impairment.

That study is "the most commonly cited previous study to address the growth of food-allergic children in the United States," Dr. Vickery noted.

"The prevalence [of food allergy] has increased over the past 10 years, so we wanted to take another look in a bigger population to kind of reassess the impact of elimination diets on growth," he said.

The current findings demonstrate that a food allergy–associated elimination diet can place children at risk of impaired growth, compared with their healthy peers, regardless of whether they are under age 2 years, or are 2-11 years old, and that after age 2, the effect of food allergy on growth is very similar to that of chronic diseases known to affect growth, he said.

"While awareness of food allergy is increasing along with the prevalence of the disease, it is important to draw attention to the important consequences of elimination diets. We feel that providers should counsel patients and caregivers about the growth-related risks of the elimination diets that are used to treat food allergy, and ensure that families are excluding only the foods that are medically required or otherwise culturally indicated, that nutritional assessment and/or supplementation is provided as needed, and that subspecialty consultation is arranged, especially for children at highest risk," he said.

Dr. Vickery reported having no relevant financial disclosures.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

[email protected]