Abstracts
Adults
Adult Respiratory Symptoms
Evaluated the relationship between home dampness and adult respiratory symptoms from questionnaires returned by parents of 3,344 children living in the Netherlands. The response rate was 73%.
Home dampness was characterized by damp stains or mold growth on indoor surfaces, and was reported in 23.6% and 15.0% of the studied population respectively. Of the homes, 25.4% had dampness and/or mold.
Information about respiratory symptoms was collected for the mothers and fathers of a population of 6 to 12-year-old children.
Symptoms included: cough, phlegm, wheezing, asthma and allergy to pollen or house dust. Cough and phlegm in both men and women were found to be strongly associated with living in a damp home.
There were weaker associations for wheezing and asthma, and there was little association for a damp home and pollen or house dust allergy.
Current smoking was strongly associated with cough, phlegm and wheeze in both men and women. Smoking was inversely associated with allergy to pollen or house dust.
The association between home dampness and respiratory symptoms that had been previously reported in children applied to adults.
The suggested mechanisms include exposure to contaminants produced by fungi or house dust mites, but there is a possibility of some undetermined exposure.
"Damp Housing and Adult Respiratory Symptoms", Brunekreef, B., Allergy, 1992;47:498-502.
Avoidance
Allergy Avoidance and Infancy
This study tried to find out if avoidance of food and inhaled allergens in infancy protects against the development of allergic disorders in high risk infants.
Infants (#120) with a family history of atopy and high cord-blood concentrations of IgE were placed randomly in either a prophylactic group (N=58), consisting of lactating mothers avoiding foods such as milk, eggs, fish and nuts, and avoided feeding their infants these foods, as well as soya, wheat and oranges, up to the age of 12 months. The infants' bedrooms and living rooms were treated with acaricidal powder and foam every 3 months, and concentrations of dust mites were evaluated by enzyme-linked immunosorbent assay.
In the control group (N=62) the diets of mothers and infants were unrestricted. There was no acaricidal treatment.
A pediatric allergist evaluated the infants for allergic disorders at 10 and 12 months.
At 12 months, allergic disorders had developed in 25 (40%) control infants and 8 (13%) of the prophylactic groupThe prevalence at 12 months of asthma and eczema was also significantly greater in the control group. Parental smoking was a significant risk factor for total allergy at 12 months. The authors feel reduced exposure of infants to allergens in food, and in house dust, lowered the frequency of allergic disorders in the first years of life. Passive smoking is an independent risk factor for atopy.
"Effect of Allergen Avoidance on the Development of Allergic Disorders in Infancy", Arshad, Syed H., et al, The Lancet, June 20, 1992;339(8808):1493-1497.
Caseins
The allergic potential of alpha-caseins from bovine, ovine, and goat's milk sharing more than 85% identical amino acids was compared.
Caseins were purified by anion-exchange chromatography and used for a specific IgE and IgG ELISA with diluted human sera. Sera were from 17 children with immediate-type allergy to cow's milk, from 59 children with atopy but without food allergy, and from 27 healthy children without atopy disease.
The sera of cow's milk-allergic children showed a significantly higher IgE and IgG binding to alpha-caseins from all three species than the sera of the other groups. All groups showed an increased antibody binding to bovine alpha-casein compared to the sheep and goat proteins, but the differences were significant only in the groups of atopic children and of healthy controls. Furthermore, inhibition of the IgE binding to bovine alpha-casein with alpha-casein from cow, goat, and sheep revealed that the alpha-casein from these species are highly cross-reactive; on the basis of the small differences in their primary structure.
The milk of goat and sheep harbor an allergic potential and is not suitable for milk-allergic patients.
Spuergin P et al., Allergenicity of alpha-caseins from cow, sheep, and goat. Allergy, 1997 Mar, 52:3, 293-8.
Cow's Milk
Cow's milk (1)
This study investigated the nutritional status and adequacy of the diet for children with cow's milk allergy (CMA).
Thirteen (72%) of the children with CMA used a formula based on soy or casein hydrolysate. The amounts of these formulas consumed by the allergic children were smaller (371 ml vs 559 ml) than the amount of milk and milk products consumed by the healthy children. There was no difference in energy intake between the groups. Protein intake by the allergic children was lower (39 g versus 48 g) and fat intake higher (47 g versus 39 g) than that of the healthy children.
The mean intakes of energy and zinc in both groups, and the intake of iron in the healthy children, were below the RDAs. The diet in the allergic children was supplemented with calcium and in 11 children with vitamins A and D. Fourteen healthy children had vitamin A and D supplement. The height-for-age was lower in the children with CMA as compared to healthy children. Serum biochemical measurements were within the reference range in the allergic children, and no nutritional problems were found.
For the eliminated foods children with CMA substituted nutritionally corresponding food items which resulted in adequate mean intakes of nutrients. Specific formulas contributed substantially to the nutrient intake. Children with CMA need intensive nutritional counselling and regular monitoring of growth.
Tiainen JM et al., Diet and nutritional status in children with cow's milk allergy. Eur J Clin Nutr, 1995 Aug, 49:8, 605-12.
Cows milk (2)
Community based studies suggest reported reactions to cow's milk are very common in the first 12 months of life but many of them may not be reproduced on challenge. Recent laboratory based studies have identified three groups of infants with cow milk allergy (CMA) who demonstrate different symptom and laboratory profiles.
The first, an IgE-sensitized group, shows features of immediate cutaneous eruptions and anaphylaxis.
The second, a non-IgE sensitized group, develops gastrointestinal symptoms within hours of ingesting moderate amounts of cow milk.
Whereas the third group of patients shows symptoms of gastrointestinal disturbance with or without bronchitic and/or eczematous symptoms after ingesting cow milk over several hours or days.
The late reacting non-IgE sensitized CMA patients demonstrate elevated T-cell reactivity in vitro to milk proteins. Hospital based studies, which are likely to reflect the more severe end of the spectrum of CMA, suggest adverse clinical reactions which persist longer may be associated with intolerance to a wide range of foods. Children with persistent CMA frequently develop eczema, asthma and rhinitis. Because of these complexities children with CMA should remain under the long term care of a medical practitioner, familiar with the management of these problems.
Medical practitioners responsible for the care of children with suspected CMA must be prepared to conduct cow milk challenges in a safe environment with facilities for resuscitation available. The notion that infants with suspected CMA should be referred to nutritionists and health workers for implementation of empirically devised low allergen diet programs without the diagnosis of CMA, being firmly established should be rejected.
Hill DJ & Hosking CS: The cow milk allergy complex: overlapping disease profiles in infancy. Eur J Clin Nutr, 1995 Sep, 49 Suppl 1:, S1-12.
Rhinitis
Allergic Rhinitis and Inflammatory Mediators
Though histamine is the principal mediator of immediate allergic reactions, others include mast cells, leukotriene C4, and prostaglandin D2.
There is an increase as well in neuropeptides and bradykinin.
Mast cells in vitro release tumor necrosis factor-alpha, interleukins, and granulocyte-macrophage colony stimulating factor.
Since all these mediators help produce the rhinorrhea and congestion, antihistamines alone cannot control the symptoms.
The use of antihistamines in conjunction with topical steroids can inhibit the generation, release, and activity of most of these inflammatory substances.
"Mediators of Allergic Rhinitis", White, Martha V., MD and Kaliner, Michael A., MD, Journal of Allergy and Clinical Immunology, October 1992;90(4)/Part II:699-704.
Shiners
Allergic Shiners/Dark Circles
Physicians noting dark circles under the eyes associated with allergies are called "allergic shiners". This may be due to food, inhalant allergies, or allergies to common substances.
Some people may be allergic to mold in their mattresses. One way to find out if foods are a problem is to have the patient eat foods they very seldom eat for 4 days.
Dark circles in African-American patients may also be due to asymptomatic anemia. Treating the anemia along with encouragement of 8 hours of sleep helps resolve these symptoms.
"Dark Circles: Allergic Shiners", Peacock, Lamar, MD et al, Cortlandt Forum, April 1992; 112: 50-17.
Testing
Allergy Testing and Clinical Practice
This article reviews general principles of allergy testing and notes the goal of allergy testing is to document the involvement of IgE-mediated degranulation of mast cells and basophils in causing or worsening a disease and to identify the allergen involved. Unjustified manipulation of one's environment may inappropriately disrupt the lives of patients.
Therapeutic recommendations must be based on accurate information that has appropriate predictive value. The author notes "no test by itself can replace rational thinking and clinical acumen of a physician actually dealing with the patient." There are 5 principles of allergy testing: 1. Some clinical symptoms are likely to be caused by allergies, while many are not. 2. Allergy testing with materials not shown to be allergenic are unlikely to produce clinically useful information. 3. Degranulation of mast cells and basophils may be caused by mechanisms other than those that are IgE-dependent. 4.
Tests that document the presence of IgE antibodies do not necessarily predict these antibodies are involved in clinical illness. 5. Allergy testing using agents unlikely to cause IgE mediated symptoms are unlikely to produce positive results.
There are 2 types of testing: provocation testing and skin testing. Oral challenge is the gold-standard for documenting food allergy in a double-blind, placebo-controlled challenge, and a manual for the use of double-blind, placebo-controlled challenges in office procedure has been published. Inhalation challenge testing can be useful in documenting respiratory response to allergenic exposure. There are 2 major techniques for skin testing, epidermal or epicutaneous.
Epicutaneous testing is both safer than intradermal testing and causes less sensitivity than intradermal testing.
Serial testing of the allergen is clinically useful in testing allergy to insect venoms or drugs, because of the risk of anaphylaxis in these situations.
Threshold dilution testing to identify the lowest dilution that produces a positive skin reaction (the end point) and determination of dose-responsive curves of skin testing reactions for allergens are useful for allergen standardization and clinical research. The Wrinkle method of immunotherapy has not been validated.
There are variables in allergy skin testing which include quality of extract, how it has been stored, its dilution, site of testing, spacing of testing and the appropriate technique. Patient medication and age may also affect the data. Serum IgE levels have a good correlation between cord levels and the risk of developing atopic disease later.
Elevated levels are associated with allergy, whereas normal levels are not. Patients who have normal IgE levels can have clinical symptoms and demonstrable allergen-specific IgE. IgE-specific antibodies, utilizing the allergosorbent tests, are not quite as sensitive as allergy to skin tests.
The clinical usefulness of IgG specific antibody measurements is limited to monitoring individuals receiving immunotherapy. Other potential uses of IgG and IgG subclass assays have not been validated. Antigen-induced histamine release from basophils in samples of washed leukocytes or heparinized whole blood correlates reasonably well with other allergy tests. There is no clear consensus as to what percent of histamine release constitutes a positive test. There are a number of tests of proven value which include the lymphocytes, phenotypes and transformation, leukocytotoxicity testing, measurements of circulating immune complexes and measurements of serum complement.
"Allergy Testing and Clinical Practice", Smith, TF. Annals of Allergy, April 1992; 68: 293-301.
Alternative Allergy Testing
This is a critical review, by the Royal College of Physicians Committee on Clinical Immunology and Allergy, regarding the leukocytoxicity test, hair analysis, vega testing, applied kinesiology, and auriculo-cardiac reflex method. The leukocytotoxicity test involves mixing the white blood cells of the patient with a food extract while looking for evidence of damage. This technique results in a high number of false positives and negative reactions. The author notes heavy metal poisoning is well recognized and documented in forensic science, and hair analysis can indicate recent exposure to metals. The relationship of heavy metals to allergic symptoms is speculative. Dowsing by swinging a pendulum over the hair sample for allergy has no validation as well. The vega machine measures electroconductivity with a Wheatstone bridge circuit. This is connected to an electrode placed on acupuncture points or held in the patient's hand.
The circuit is completed by a metallic honeycomb into which different solutions are placed for allergy testing. The machine is calibrated by placing poison in a glass vial in the honeycomb. Substances which give a similar reading as a poison are considered potential allergens. It is believed the offending substances omit radiation. This technique is not proven and has no valid controlled trials. Applied kinesiology believes allergens cause muscles to weaken temporarily. Samples of food are placed under the tongue or in a glass jar in the hand, and muscle tone is tested by asking the patient to push his or her free arm against the examiner. Again, published data is lacking and one study resulted in failure in a double-blind trial. The auriculo-cardiac reflex method for diagnosing allergy occurs by applying foods and other suspected substances wrapped in filter paper over the skin of the forearm.
The tester rests the tip of the thumb over the radial artery of the wrist so the wrist pulse is just out of reach beyond the tip of the thumb. Bright light is shown on the earlobe or through the back of the hand. It is stated when the filter contains an allergen, the pulse gets stronger for 12 or more beats in response to light. There is no scientific validation for this test.
"Other Diagnostic Tests Used by Practitioners of Alternative Allergy", Clinical and Experimental Allergy, October, 1992;22(3):32-33.
Treatment
Assessment, Prevention and Treatment in Children
Treatment of childhood allergies during fetal development, infancy and toddlers can prevent more disruptive symptoms occurring later on in life. Allergies may aggravate physical, emotional, behavioral and learning problems in children.
Other problems include reflux, sleep disturbance, skin problems, repeated infections, leg aches, intestinal complaints, personality changes and unusual fatigue. A simple history can reveal food sensitivities, mold or pollen problems. Milk sensitivity frequently causes constipation. Young children with milk sensitivity may make unusual clucking sounds in their throat. Looking for the "Jekyll and Hyde" personality is a sign of allergies. The allergic face includes wrinkling of the nose, red earlobes, circles and puffiness under the eyes and "wiggling" legs. Food elimination is a mode of assessment. Highly allergic foods such as wheat, corn and luncheon meats are excluded. Many times children crave the foods they are sensitive to.
Elevated pulses can be a sign of allergy and can be lowered after treatment. Dr. Doris Rapp, a pediatric allergist, made these comments at the American Academy of Family Physicians annual meeting. She utilizes the provocation/neutralization technique in her office.
"Treating Allergies Early Can Reduce Later Toll", Family Practice News, November 15-30, 1990;20.
Alternative Allergy Treatments
Enzyme potentiated desensitization (EPD) involves mixing an allergen with beta-glucuronidase and applying it to the skin in very low doses. This has been claimed to be effective for hay fever and identifying food allergens in ulcerative colitis. The authors feel EPD claims of benefit have not been substantiated. Claims that acupuncture is effective in the treatment of allergy in general, and asthma in particular, are not based on results of well controlled trials, but have shown a small and temporary improvement in some studies in wheeziness. Homeopathy, which operates on the law of similars, is a concept of "like cures like". The authors note one carefully conducted double-blind study found the solution of grass pollen diluted to the point where no molecules remained (1 in 1060) was significantly more active than placebo in controlling hay fever.
No attempts have been made to compare homeopathic drugs to conventional anti-allergy drugs.
There is no adequate evidence of any beneficial results from homeopathy in the treatment of allergic disorders. It is noted hypnosis can affect physical reactivity to the skin, bronchi, and the gut, though its treatment in allergy remains debatable. The authors encourage further research on the use of hypnosis or self-hypnosis, especially in syndromes such as asthma. Ionization machines omit a negative charge which attracts airborne allergens and pollutants, and therefore these allergens fall to the ground in a cluster. There is a need for proper trials to validate the claims of ionization benefiting hay fever and asthma. In general, most herbal therapies in the treatment of allergies have produced no convincing evidence they work. One exception is traditional Chinese medicinal plants used in the treatment of atopic eczema in childhood. One carefully designed, double-blind, placebo-controlled trial showed substantial benefit. This treatment needs further evaluation.
"Other Treatments Used by Practitioners of Alternative Allergy", Clinical and Experimental Allergy, October, 1992;22(3):34-35.
Levels of Phospholipids
Levels of Phospholipids
This study suggests an association between fatty acid composition in maternal serum and the appearance of allergic disease in their children during the first six years of life. In studying the composition of serum phospholipids in 26 nonallergic and 32 allergic mothers at the time of delivery, an inverse relationship was found between levels of linoleic acid and its metabolic product arachidonic acid in the non-allergic, but not in the allergic mothers. In comparing the fatty acid levels in maternal and umbilical cord serum, a significant correlation was seen between linoleic acid levels in the serum of non-allergic mothers and their infants. Maternal dihomo-gamma-linolenic acid levels correlated with cord serum levels of arachidonic acid, C22:4 and with docosahexaenoic acid (DHA). There was no relationship seen when comparing fatty acid levels in allergic mothers and their infants. In mothers of children who did not develop any allergic manifestations during the first six years of life, arachidonic acid levels correlated with C22:4 and eicosapentaenoic acid (C20:5omega-3).
Yu, G. and Bjorksten, B.: Serum Levels of Phospholipid Fatty Acids in Mothers and Their Babies in Relation to Allergic Disease, European Journal of Pediatrics, 1998;157:298-303.
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