This time of year is interview time for residency applicants for the pediatrics and medicine/pediatrics training programs. We have many outstanding applicants from our region as well as other parts of the nation. We have six pediatric and four medicine/pediatric positions and are looking forward to an outstanding group of new recruits. Approximately 20% of our graduates go on for further subspecialty training whereas the majority goes into practice in this region.
Since our last newsletter, Stacey Knobler, MD, pediatric neurologist, has joined KUMC. She comes to us from St. Christopher’s Hospital in Philadelphia. She has a special interest in neuromuscular disease. She joins Dr. Lillian Pardo in the pediatric neurology division. Their office number is (913) 588-6371.
The Annual Spring Symposium will be held on Friday, May 9, 2003 in Wahl East. The KAAP dinner and presentation, featuring Louis Cooper, MD, FAAP, will be held the preceding evening, May 8, 2003. Dr. Cooper will also speak on Friday at the Symposium. More detailed information will follow shortly.
Professor and Chair
Chief, Pediatric Asthma, Allergy, Immunology
Clinical Associate Professor of Pediatrics
Questions about peanut allergy have become common and a recent increase in interest is seen in numerous publications. Peanut allergy and/or tree nut allergy occurs in 1.1 million Americans with onset typically under 14 months of age. Despite similar quantity of peanut intake peanut allergy remains rare in China, which might be a genetic difference or might be due to lack of use of high dry-roasting temperatures in China.
Strict avoidance remains the best treatment because attempts at desensitization do not have an acceptable risk-benefit ratio. Patients with previous anaphylaxis to peanut or nut and who suspect that they have been exposed should proceed to the nearest medical facility for observation. Delay in treatment significantly increases the risk of a fatal outcome.
Patients should be instructed in the use of an Epipen® or Epipen JR® (epinephrine 1:1000, 0.3 and 0.15cc respectively) or other epinephrine delivery device and carry a rapidly-absorbed H1 antihistamine such as Benadryl®.
Epipen Use:
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Patients and their families should become familiar with these epinephrine delivery devices before an emergency arises. They should be instructed to avoid touching the ends of the Epipen as a significant number of persons each year report to emergency rooms with the injector needle imbedded in a finger bone. These people mistakenly think the needle emerges from the end of the injector where the cap is removed when, in fact, it emerges from the other end.
When anaphylaxis occurs, patients should receive emergency medical care,
including intramuscular epinephrine. Intramuscular epinephrine has faster
and more complete absorption than subcutaneous injection. Treatment should
include H1 and H2 antihistamines and corticosteroids, administered acutely
and continued for 72 hours. Inhaled beta agonists may be given where needed.
Severe anaphylaxis patients should be observed for at least four hours
for the onset of biphasic reaction. Ninety percent of biphasic reactions
start within four hours and biphasic reactions occur in up to one-third
of patients with severe anaphylaxis. In a biphasic reaction the patient
seems to be recovering from the initial reaction when they develop sudden-onset
severe bronchospasm. Biphasic reactions may occur despite corticosteroid
treatment.
Patients should be referred for skin testing two to three weeks after a reaction.
Testing via prick skin test is preferred. Testing for patients with suspected
peanut allergy is done to peanut and to tree nut (walnut, pecan, hazelnut)
as 25% may have allergy to both. This allergy was once thought to be lifelong.
However, recent studies suggest that children be retested annually to identify
the 20% who will lose their sensitivity.
The practice of strict peanut avoidance needs to include reading labels, avoiding unlabeled foods, and avoiding foods that might be contaminated with trace amounts of peanut such as oriental foods, buffets, and chocolate.
Until this issue can be further studied there is limited data that mothers with a history of atopy should consider peanut avoidance during pregnancy, lactation and the child’s first three years of life. Children who have milk or egg allergy have a 30% chance of developing other food allergies and should consider avoiding peanuts or delaying peanut introduction for the first three years of life. Young children with peanut allergy should also avoid tree nuts since 25% develop tree nut allergy.
Oral epinephrine may be an easier emergency treatment for these patients
in the future and a recent abstract reported it was as effective as intramuscular
injection. It is currently under further study for use in anaphylaxis.
Therapy with anti-IgE may be useful in severe peanut allergy where peanut
avoidance is not successful. Engineered recombinant peanut proteins may
be used for immunotherapy to decrease the risk:benefit ratio. Work is being
done to genetically alter peanuts to remove the major antigens. Finally,
we need to identify the reason that peanut allergy is not seen with the
same frequency in other populations.
For more information, or to discuss referrals, contact Nancy Y. Olson, MD at
(913) 588-2238 or at the Pediatric Rheumatology Office (913) 588-6325.
Treatment of atopic dermatitis remains a pediatric challenge but recent advances are offering improvement. Atopic dermatitis continues to affect 7 to 21% of children and is often caused by food allergy. If patients appear sensitive to more than one major or two minor foods double-blind food challenge should still be undertaken. Therapy until now has included: avoiding foods where appropriate, antihistamines to decrease itching and scratching, moisturizing after bathing, treatment of secondary infection, dust mite avoidance where indicated, and topical corticosteroids. Unfortunately, due to the extent and chronicity of the disease, use of topical corticosteroids may be associated with hypopigmentation and hypothalamic-pituitary-adrenal axis suppression.
As in many chronic conditions friends and family may pressure patients to try alternative medicines. A recent review of two alternative medicines found neither aloe vera gel nor tea tree oil were effective in atopic dermatitis.
In atopic dermatitis there is a risk of developing a secondary allergic disease, such as allergic asthma or rhinitis. Preventing this secondary allergic disease may be possible in atopic dermatitis treatment. In a long term study of atopic dermatitis, in which patients were treated with cetirizine (Zyrtec) vs placebo, there was a 50% decrease in development of allergic asthma. This was likely due to inhibition of the late phase response in the cetirizine group. Significant inhibition of the late-phase response appears to be unique to the antihistamine cetirizine.
Perhaps the most exciting development in the treatment of atopic dermatitis is the introduction of two new topical immunosuppressants: tacrolimus (Protopic .03% for children and .1% for adults and adolescents) and pimecrolimus (Elidel 1%). Both are approved for use in children age two and up. These immunosuppressives block local production of inflammatory cytokines by T cells and release of mediators by mast cells and basophils. Pimecrolimus has been shown to have negligible blood levels despite application on up to 92% of body surface area in pediatric patients. These agents produce significant improvement without corticosteroid side effects. Side effects with tacrolimus and pimecroimus appear minimal with some patients experiencing a transient minor burning sensation.
The future includes further study of the genetics of atopic dermatitis and identification of new anti-inflammatory agents.
For more information or to ask about referrals contact Nancy Olson, MD at KU (913) 588-2238 or at the Overland Park Satellite Office (913) 649-3335.
Division Chief, Pediatric Asthma, Allergy, Immunology
Clinical Associate Professor of Pediatrics
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The University of Kansas Medical Center