House CallFeb/Mar 2012 Issue

Pediatric Allergies Q & A - Flu Vaccine, Celiac Disease and EE, and More!

Pediatric specialists answer your questions about allergies and sensitivities

Flu Vaccine

My doctor recently told me that I didn’t need to worry about my egg-allergic son having a reaction to the flu vaccine. In the past, she said that my child had to be tested by an allergist beforehand and, if deemed safe, the vaccine would be given in split doses. Why is it safe now?

Dr. Jain The American Council for Immunization Practices (ACIP) recently changed its recommendations for influenza vaccination of egg-allergic individuals. The change was based on several large studies that demonstrated the flu vaccine is safe for patients with egg allergy, even those with a history of severe reactions. Some mild reactions were reported, including worsening of eczema, but no participants in the studies had severe reactions to the vaccine.

Many allergists, including myself, have historically skin-tested patients with a history of severe reactions to egg. But in these studies, even patients with a positive skin test did not have a reaction when administered the vaccine. Why? The levels of egg protein in the vaccine are not felt to be high enough to cause reactions in egg-allergic individuals.

I now recommend that patients with a history of severe allergy to egg get their flu vaccine in their allergist’s office, just in case there’s a reaction. Those with no history of severe egg allergy can receive their vaccine from their primary care doctor. Either way, patients should wait for at least 30 minutes after vaccination to make sure that a reaction does not occur.

Allergy, Asthma, Eczema

I’ve been told that a gene has been identified that demonstrates that food allergies are hereditary. Is that true?

Dr. Leo Over the past five years, scientists have localized a mutation in the filaggrin gene that points to its role in the development and severity of asthma and peanut allergy, as well as skin disorders like eczema.

The filaggrin protein influences development of the epithelial cell layer, an important scaffolding of cells that makes up the inner structure of the surfaces in our bodies. This may explain why the surface and internal workings of the skin, lungs and gut are affected by mutations in this gene. Since the basis of food allergy and other allergic conditions involves inappropriate protein absorption by the skin, intestines or mucous membranes, these defects in filaggrin may explain the development of many allergic diseases, including food allergies.

Children with eczema and certain filaggrin mutations can have a three to five times higher risk for peanut allergy. Other studies of filaggrin mutations have shown that it can be hereditary and passed from parent to child, suggesting that food allergies and other allergic diseases can be hereditary.

Although research is in the very early stages, scientists and physicians hope that targeting this gene with new therapies may lead to treatments for eczema, asthma and food allergy.

Celiac Disease and EE

I’ve had celiac disease for many years. Recently, my nephew was diagnosed with eosinophilic esophagitis. I have concerns he might be gluten intolerant. Could he have both diseases?

Dr. Leo In the past, having either celiac disease or eosinophilic esophagitis (EE) was considered rare and having both diseases together was unheard of. But in recent years, the medical literature has noted an increased incidence of both celiac disease and allergic conditions, such as EE, and more clinicians are reporting patients with both disorders.

Celiac disease and EE are two distinct clinical entities but there are some similarities in symptoms (stomach pain, reflux or nausea can occur in both) and in treatment (significant dietary change is required in both). Celiac disease is associated with biological markers such as anti-gliadin and anti-endomysial antibodies. These types of markers have yet to be discovered with eosinophilic esophagitis.

People with both conditions should work with a specialist physician who is attentive to dietary issues since celiac disease requires a gluten-free diet and eosinophilic esophagitis may involve dietary manipulation and topical steroid medication. Both diseases may need endoscopic procedures to follow progress. Physicians who treat children should carefully monitor growth parameters, as well as be alert to the psychosocial ramifications of living with both conditions.

Camel’s Milk

My child is allergic to cow’s milk. The allergist says goat’s milk isn’t an option. Is there another type of animal milk that won’t cause an allergic reaction?

Dr. Jain An allergy to cow’s milk can often mean an allergy to goat’s milk and mare’s milk. The proteins that most people are allergic to in these milks are very similar, making them cross-reactive.

Camel’s milk may be an alternative. A recent study demonstrated that 80 percent of people allergic to cow’s milk were able to drink camel’s milk without problems. Skin testing for camel’s milk accurately identified those who could safely drink the milk.

Camel’s milk is not widely sold in the United States. However, there appears to be growing commercial interest in making it more available in pasteurized form.

Nuts to Peanuts

My first child has several food allergies, including a severe peanut allergy. I want to prevent these issues with my next child. Should I avoid peanuts when I’m pregnant?

Dr. Jain A recent study published in the Journal of Allergy and Clinical Immunology addressed this important question. In the study, mothers of young infants and children with either an egg or milk allergy were asked about their dietary practices during pregnancy. The infants were followed to determine if they would go on to develop a peanut allergy. There was a strong correlation between the moms who ate peanuts during pregnancy and the development of peanut allergy in their infants.

Based on these findings, I advise against eating peanuts during pregnancy if you already have a child with food allergies. Whether this same approach should be taken for other allergenic foods, like milk or eggs, remains to be determined.

Neal Jain, MD, is an allergist and immunologist with San Tan Allergy and Asthma in Phoenix, Arizona.
Harvey L. Leo, MD, is a pediatric allergist with Allergy and Immunology Associates of Ann Arbor and an assistant research scientist with the Center for Managing Chronic Disease at the University of Michigan.

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