Asthma Allergies Children: a parent's guide

CHAPTER 1

Introduction to Allergy

IF YOU ARE THE PARENT OF AN ALLERGIC CHILD, YOU VERY LIKELY suffer from allergies yourself. You know the misery allergies can bring, on a scale from annoying itching of skin and eyes at one end, to debilitating sneezing fits in the middle, to life-threatening asthma attacks or anaphylactic shock at the other. You know how allergies can be misdiagnosed. You know about drowsiness induced by some antihistamines, and the inconvenience of carrying nebulizers and inhalers. You know how the joy of childhood can be diminished by eternal vigilance about foods, activities, and environments.

We know about them, too. We are both board-certified pediatric allergists. For some sixty years between the two of us, we have been treating children like yours, and from what we have seen, the prognosis for allergy treatment is troubling.

For one thing, allergies seem to be becoming more common.

Part of this is due to changes in the way we live. We live in homes that are sealed to trap heat in the winter and cool conditioned air in the summer. We have wall-to-wall carpeting and throw rugs on our floors. But this comfortable and energy-conscious approach creates an environment in which dust mites thrive. Energy efficiency means that there is less fresh air from outside being exchanged with stale air indoors, which means that dust builds up inside. Carpeting may be comfortable to walk on, insulating, and attractive, but stuff that settles in it is fodder for dust mites, and their waste is highly allergenic.

In a sense, allergy is a price we have paid for progress. Part of the body’s defenses, the immune system, evolved to help us fight off parasites when our ancestors had very little ability to influence either their environment or their diet. Now that we do have such power, that mechanism has gone haywire. The first great impetus for the development of allergies may have been the invention of shoes, which kept worms or other parasites from entering our feet and thereby put parts of the immune system out of work.

Frank T. Vertosick, Jr., author of a book called The Genius Within: Discovering the Intelligence of Every Living Thing, advances the theory that the brain is not the only part of the body that can learn from experience. He writes, “The immune system must learn and recall billions, perhaps trillions, of different molecular patterns. Our lives depend on its ability to make instant discriminations between friend and foe, not an easy task.” While our specialty is Allergy and Immunology, we will reserve judgment on whether this constitutes “intelligence” or not. However, we never cease to wonder at the resourcefulness of the immune system, not only its resiliency in combating disease, but also its potential for mischief when it goes awry.

Because of modern sanitation, climate control, and immunization, many of the original problems the immune system evolved to combat no longer exist routinely in advanced industrial countries like ours. However, the defenses are still within us. Like soldiers demobilized at the end of a war, they need time to adjust after the fighting stops, but in the case of immunity that has evolved over eons, the adjustment hasn’t begun. Idle hands make the devil’s work. These are defenses in search of an enemy, and they spend their time attacking all kinds of things—molds, pollens, chemicals used in the construction of our homes—and in the process of attacking those irritants, they throw off toxins that make us sick.

There’s a saying that what children need in their homes to keep allergies from developing is a pound of dirt, as would be the case on a farm. That theory recently gained support in a study published in the New England Journal of Medicine (Sept. 19, 2002) saying that infants raised in homes with two or more cats and dogs developed allergies at roughly half the rate as children in pet-free homes. Moreover, they were less allergic not just to dogs and cats but to pollens and other common allergens as well. Other studies have supported those findings, but others have not, and we remain equivocal, as we were in 2002.

The newest wrinkle is experimentation with hookworms, which are common in regions where people defecate in outdoor latrines and come into contact with their waste by walking barefoot in the designated areas. Epidemiologists have established that where hookworms are prevalent, allergies and asthma are unknown, possibly because they keep an antibody called IgE busy doing something constructive instead of attacking harmless proteins, which is the basis of allergic disease. You will read more about this in these pages.

While we would like to see natural processes harnessed to fight allergy, however, this throwback science is not proven, whereas the incidence of pernicious anemia and other conditions associated with hookworm are quite well known. Research is ongoing, particularly at the University of Nottingham in England.

Still, it is legitimate to ask, if progress is causing all that trouble, if our environment is too antiseptic, is worth it? Or should we just move into mud huts with no indoor toilets?

We’ll leave that to philosophers. In the meantime, we have the obligation to try to keep ahead of our bodies’ own defenses. Science allows us to give it a try. And what the science says is that the jury is still out on exposing children to cats and dogs to try to protect them against allergies, as the authors of the study were among the first to point out. After all, the data cited in the study were contrary to long-established wisdom and practice on the subject. It may well be a statistical anomaly. The results must be repeatable. So, much to the consternation of animal-loving new parents in families with a history of allergy, we must advise that they not run out to the animal shelter and stock up on new pets.

Why Treatment May Be Getting Worse

The science is good, and it’s getting better. As the understanding of allergy grows, so does the effectiveness of drugs to treat various conditions, as well as environmental adjustments to minimize attacks. Still, treatment may be getting worse.

And it’s not for want of effort. Many general practitioners and family practitioners are doing more to treat allergy than their counterparts did when we began practice decades ago. Indeed, a generation ago, most GPs (general practitioners) and pediatricians didn’t even acknowledge allergy as something to be taken very seriously. One of your authors—Dr. Ehrlich—is the son of a late and much respected pediatrician who rarely referred any of his patients to allergists, even when his own son became one. Instead, children and their parents were given antihistamines and counseled to put up with sneezing. Skin conditions were treated with all-purpose ointments and creams. Bad asthma attacks were controlled with systemic cortisone, which would affect the whole body, not just the lungs. Prolonged cortisone use had substantial long-term side effects.

Today, we know what works to keep asthma under control, but doctors don’t always do it. In 1990 and 1991 the National Institutes of Health (NIH) convened experts under the leadership of Albert Sheffer, MD, from Harvard Medical School to produce guidelines for the treatment of this growing threat to public health. However, as the Journal of Asthma has pointed out, more than a decade later, these treatment guidelines are not followed in 50 percent of cases, although as the most recent NIH data show, treatment has never been safer or more effective. (The American Academy of Allergy, Asthma & Immunology has position statements on treatments currently deemed effective at www.aaaai.org.)

The largest and most comprehensive study of the quality of children’s health care in the U.S. reached disquieting conclusions, as reported in the New England Journal of Medicine (Oct. 11, 2007). While children received the appropriate treatment for acute conditions like colds 92 percent of the time, children with asthma got the appropriate care just 46 percent of the time—exactly half as frequently. This means that more often than not, they were deprived of appropriate care. Inadequately treated asthmatic children are more likely to fail at school, more likely to lose out on sports and other activities, more likely to miss out on the fun and challenges of childhood, and more likely to be less productive as adults.

While part of the needlessly high incidence of asthma is the fault of doctors, there’s also blame to be found in the behavior of patients, and patients’ parents. The parents have misgivings about a diagnosis of asthma, so their doctor will treat their child for “bronchitis” instead. They don’t want their child to take corticosteroids because they confuse them with the drugs that athletes take. They don’t want to pay $20 out of pocket for a peak flow meter because their insurance won’t pay for it. They want fast-acting relief drugs, not controller drugs that must be taken even when they don’t have symptoms. These treatments are all part of the NIH guidelines, yet they are commonly overlooked. Some 70 percent of asthma patients never refill their control medication, which is one reason we have 2 million emergencies due to asthma.

Referrals to Allergists—Still Dwindling

Despite all we know about effective treatment, referrals to allergists are dwindling. Part of the trouble is that allergy is still not taken seriously even at some of the best teaching hospitals....