Medicine Mondays: Food Allergies in an Adult

Hi Everyone,

Welcome back to Medicine Mondays.

Each Monday I'll post the questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

Here is a topic that we have been discussing for the past week on an older post Food Allergies in the School.


Food Allergies in an Adult


Dr. Cason -

Just a question - what could cause sudden almond allergy in an adult?- G

G-

I can't say I know for sure. Is it a sudden systemic reaction like hives or swelling, anaphylaxis to almonds or just contact dermatitis? - Dr. Cason

Dr. Cason -

The almond allergy only started a few years ago - now I can't even tolerate trace amounts of almond. The reaction is nausea, sweating, extreme abdominal pain (once so bad I was on the bathroom floor for an hour or so - I couldn't move). I was fine with almond until this started, also I can't tolerate coffee any more either - just makes me feel extremely nauseous!- G

G-

Sounds like you have a true allergy to almonds. Unless it was with something else that you are reacting to.

You can test the blood to see if you have an increase in IgE level to almonds. But the gold standard to see if you have an allergy to food is what happens when you eat it. You know that it makes you sick so you have your answer. I would probably still go and have them evaluate it though because it is unusual that you would acquire this as an adult.- Dr. Cason

Dr. Cason-

It was definitely almonds - I had my first reaction after eating some whole ones - just to be sure I tried it again, but only ate one. It definitely pays to ask - we went to a huge dinner last night, before dessert was served I asked if either contained almonds (I've never done that before) one was sticky date pudding, the other was a chocolate cake/mousse type thing - the waitress checked with the chef - both had almonds - I would never had guessed looking at them. p.s. Is there anything you can have, say like anti-histamine to help with a reaction?

G-

Great that you asked! It's amazing the cross contamination that is present. One can never be too sure. Yes, you can take Benadryl (an Antihistamine) to help counter the effects that histamine has on the body. Medscape.com explains it nicely. (I added the emphasis)

All antihistamines are reversible, competitive antagonists at histaminic (H₁) receptors. They act by inhibiting binding of circulating histamine to its receptor site, but do not prevent histamine release. Administration of an antihistamine results in inhibition of respiratory, vascular, and gastrointestinal smooth muscle constriction, a decrease in histamine-activated secretions from salivary and lacrimal glands, and anti-inflammatory effects. Antihistamines also decrease capillary permeability, which reduces the wheal and flare response to an allergen, as well as diminishes itching.

If you truly have vomiting, facial swelling, tongue swelling, difficulty breathing and a drop in your blood pressure then what you are experiencing is anaphylactic shock. You need to carry 2 Epi Pens around with you. Benadryl is good if the symptoms are pretty mild- hives, itching- but for a life threatening reaction you want Epi! - Dr. Cason

Medicine Mondays- ADHD and Poor Weight Gain and Breast Feeding Frequency and Babies

Hi Everyone,

Welcome back to Medicine Mondays.

As suggested by the title, each Monday I'll post the questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

We had a couple of questions this week.

Here's the first:

ADHD and Poor Weight Gain

Question- Dr Cason,

I have a 5 year old boy that has ADHD and has been on Focalin XR 15mg. The meds aren't strong enough but they are scared to up his meds more because he is 35 lbs....

You can read the whole post here: ADHD and Poor Weight Gain

Nursing Frequency and Babies

This next question I just found buried in my comments. It comes from a friend of mine. She posted it on my other blog DrCason.org where I showcase my life as a Pediatrician and pretend to be a Photographer!

Question: Hello Mommies,

Just wondering at 8-9 months old how often everyone nursed? I am getting varying opinions from friends, between 4-8 times a day. We are eating solid foods 3 times a day and nursing 4 times a day. I have a chart for food qty at this age but I can’t find a good nursing chart. Just wondering?- JH

Answer:

Dear JH,

I haven't found a specific nursing chart per se and as a physician I don't refer to them. I usually look at how the babies are growing and thriving. You have to remember that some babies are snackers and love to nibble and nosh their way through the day.

Some babies though prefer to be off and crawling around much like a busy 8 or 9 month old. Who has time to eat when there is so much of the world yet to be explored!

Look at your child. Don't worry about the number of times she eats. (Though 4 sounds good to me) She may be a very efficient nurser and gets a lot when she does nurse. Just ask yourself, Is she growing? Is she happy?

If she is tugging and punching at your breast when you are nursing then you know your supply is decreasing. Just make sure you eat and drink and keep nursing and it'll increase. Also see your pediatrician and look at her growth. At about this age babies will plateau a little because they are too bust exploring. It's normal and I usually don't worry about it.

Hope this all helped! See you all next week-

Sheila Cason MD

ADHD and Poor Weight Gain

Dr Cason,

I have a 5 year old boy that has ADHD and has been on Focalin XR 15mg. The meds aren't strong enough but they are scared to up his meds more because he is 35 lbs. They want me to put him in a day treatment program. Do have any tips for me to get him to eat and to listen to me because I'm starting to get really depressed about things.

- SM

Dear SM,

Unfortunately loss of appetite is the side effect of stimulant medication that can't really be avoided. Consider a holiday from the medication on weekends to get his appetite back or give a dose just after breakfast. You could also try to increase the caloric count of his foods so that he'll get more calories in a smaller amount. Such as milk shakes, grilled cheese sandwiches, peanut butter on crackers. Also you can have his doctor prescribe Pediasure- a nutritional supplement. It's available over the counter but some insurances will pay for it if it's considered medical treatment.

Try your best not to get into power struggles over his food and lack of interest in eating. You'll only lose and in the end drive him further away from eating. A thin but otherwise healthy child is ok. Be sure your pediatrician is comfortable with this.

Also I encourage you to look into the day treatment program. I've seen great success with some kids whose behavior was able to be managed with certain "Behavior Modifications" such as positive feedback and specific rewards for specific behavior.

Finally- it sounds like you still have some concerns that need addressing. 5 years old is young to be on medication but not completely unheard of. There may be some other issues that can be addressed. Also make sure your child's psychiatrist is willing to work with varying doses of stimulant medication. The idea is to keep going up incrementally as long as the ADHD behavior is still present and the side effects are not too unpleasant or risky.

I hope this helps. Don't despair, your pediatrician can find some local resources that will help you connect with some support groups. It's often very helpful to meet other parents who have gone through what you are going through!

Sheila Cason MD

Medicine Mondays- The Importance of School Physicals

Hi welcome back to Medicine Mondays-

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

This week I don't have a question but rather an article about the importance of School physicals! Has your child had theirs yet??

The Importance of School Physicals

Well it’s that time of year again, school is back under way and if you haven’t got your child’s annual physical yet, make sure you put it at the top of your list of things to do.

You may think that because you take your child in frequently for that never ending cold that he’s getting enough of the doctor’s time but that’s not so. A 10-15 minute sick visit isn’t enough time to talk about your child’s short stature or the fact that he’s just went up two pant sizes. Before you go for your appointment, make sure you record any medicine they are taking, make a list of issues you’d like to discuss and bring your immunization record. At the visit the doctor will review a few key points. I’ve outlined those below.

General Health and Well-Being

One of the first things the doctor will do is screen your child by checking their height, weight, blood pressure and temperature. We’ll also place a PPD to screen for tuberculosis, check a CBC to screen for anemia and do a urinalysis to screen for infection and protein. We’ll test their hearing and vision as well as discuss their appetite and sleep habits. In addition to this we’ll also address how your child is getting along with everyone. Are they contributing to the family? Are there chores that are being accomplished? Are they receiving an allowance and finally has there been any notice of depression or mental health issues.

Review of Illnesses

A thorough head to toe physical exam is completed next. We’ll discuss any acute illnesses your child may be having such as a cold or virus. If the current illness is complex or your child is running a fever, then we’ll treat the illness and often may ask to reschedule the well visit and/or delay immunizations. Once the acute illnesses are addressed we’ll move on to discuss any chronic medical issues. This is an important time to review conditions that your child may not be resolving. Most parents can’t even begin to talk about the importance of chores or potty training if their child is having recurrent urinary tract infections. This is also the ideal time to review sub-specialist recommendations and make any changes to the treatment plan as deemed necessary.

Height and Weight Analysis

After the acute and chronic illness, the pediatrician will then review the general height and weight of your child. We’ll look to see that they are growing appropriately- at least an average of 5 cm per year. We don’t analyze the height and weight at any one time but rather we look at the trends over a course of many visits. Looking at it this way we can easily see if there are sudden spikes in the curve or if they are reaching a plateau. We’ll also look at whether your child is proportional in relation to their height and weight. A child in the 50th percentile for their height should have a relatively similar percentage for their weight. Like most things in health, we look for balance. Most everyone will receive counseling regarding healthy eating. With obesity being a growing epidemic it is never too late to talk about limiting juice and fast food consumption. If your child already has a weight issue then we may analyze it further with labs tests to screen for diabetes, liver disease and thyroid issues.

A Private Talk

If your child is older than twelve then we’ll ask to talk with them alone to address risky behavior. The teen talk is critical to ensure a teenager’s well being. The American Academy of Pediatrics in 2005 estimated that almost 50% of teenagers had engaged in sexual intercourse already and nearly 50% also had tried cigarettes smoking. Taking the time to discuss these private issues is important to ensuring their safety. All answers are confidential. Though if a child wants to hurt themselves or another person then we are required to report it. If I hear something else concerning, then I encourage the child to talk with the parents with or without me. These questions include but are not limited to:

• Do you have a boy friend or girlfriend?
• Have you engaged in any sexual activity
  
• Do you smoke or drink?
• Do you do any other recreational drugs?
• How is school?
• Do you feel safe at home?
• Are there questions you’d like to ask?

School Issues
Next we’ll move on to review your child’s school performance. We’ll discuss grades, motivation, concentration and homework. We’ll ask how the previous year went and how the relationship with the teacher and classmates were. We’ll discuss any issues that the teachers may have had concerns with. As a child gets older and the school work becomes more difficult a child may have difficulty keeping up. They may suddenly develop behavior problems that hadn’t been present otherwise. Further testing may be needed to search for Attention Deficit Disorder or other learning disabilities.

Safety Review

One of the most important discussions we’ll have is a review of safety. This includes protecting children from head injuries, falls, and drowning. In particular we’ll review car safety and the proper ages to be restrained in the car. The American Academy of Pediatrics reports that motor vehicle injuries are the most common type of fatal injuries among children and the leading cause of death among children younger than 18 years of age.

Sports Readiness

If your child is involved in any sports then we’ll often address aspects specific to that sport. We address any past history that may be relevant including asthma, heart disease and orthopedic issues. Most importantly we’ll ask of any family history of sudden death in a person less than 50 years of age. This could indicate an inherited disease that puts your child at an increased risk.

Immunization Update

As the visit concludes we’ll review any vaccines that need to be given. By the time a child finishes high school they should have received all their shots and will only need Tdap every 5-10 years. Use the following guide to determine whether your child is up to date. This is just a guideline as some offices use a different vaccination schedule. Also make sure you review your insurance coverage; Meningococcal and HPV are not covered by all plans. Rotavirus is not on this list, though it is recommended by the AAP and given by some clinics.

• At Birth- Hepatitis B#11 Month- Hepatitis B#2
• 2 months- DTaP # 1, IPV #1, Hib#1, Prevnar#1
• 4 months- DTaP # 2, IPV #2, Hib#2, Prevnar#2
• 6 Months- DTaP #3, Hib #3, Prevnar#3
• 9 Months- IPV
• 12 months- MMR#1 and Varicella#1, Hep A #1
• 15 Months-DTaP #3, Prevnar #4 and Hib#4
• 18 Months-Hep A#2
• 4 Years: MMR #2, Varicella #2, IPV#4, DtaP #5
• 11 Years: Tdap, Meningococcal, HPVl#1 and 6 months later HPV #2

As you can see there are a lot of issues that could be discussed. Often it’s not possible to cover everything in one visit but with regular scheduled care during the year which includes sick visits and phone calls, we can come close to addressing it all. As the school year is about to begin you’ll find it gets harder to get an appointment.

Call today to get that ball rolling with your child’s pediatrician.

Don’t miss this valuable annual opportunity to review your child’s health

Statistic source: http://www.aap.org/advocacy/washing/Statistics.pdf

Potty Training Regression

Dear Dr. Cason - Do most kids regress with potty training after going for months?

My son tells us that he doesn’t have to go pee when he clearly does. Is this a power struggle?

- Anonymous

Dear Anonymous,

There are some reasons for potty training regression such as such as a bladder infection or life stressors. But when he says that he doesn't need to go, it's quite possible that your son really doesn't feel that he needs to go.

Remember that the bladder is a muscle and will accommodate to increasing urine by first spasming and then when it is ignored, the bladder will relax. Do this too often though and the bladder doesn't truly sense that it's full until the urethral sphincter spasms and then it almost too late. They then can be found holding themselves and running at breakneck speed to the restroom. All the while you are puzzled looking at them and exclaiming, "But you just said you didn't have to go!"

The way you help little kids to retrain their bladder is to have them do "timed voids" every two hours. Just take them whether they feel like they have to go or not. Gradually the bladder retrains itself.

If there appears to be any other persistent problems then take your child to their pediatrician they may need to rule out out other reasons for regression.

Imaginary Friends and Children

Is there someone new at your house lately? It can be disturbing to find that your child's new friend isn't one you can see. But don't worry this is a normal part of a child development particularly around the age of 3 and 4. In fact there is some research out there that speculates that those children with imaginary friends are more creative and imaginative.

This can be a delightful peak into your child's imagination. And it's more common than you think.
When I asked my readers at DrCason.org if they had any experience with imaginary friends this is what they said.

As for imaginary friends, yes, they have been around a lot lately. My son, now 3.5 years old, tells me, “My friends are here” and “We are having a sleepover.” They have slept over almost every day for the past few weeks! I even call their imaginary moms to see if they can come over to play or have them come pick up the kids if they are not behaving. (At the request of my son, of course!). I think it is great and I tell them they need to behave and play nice. I treat his imaginary friends like I would if his real friends are over. I don’t want him to think there is something wrong with having imaginary friends.

I had an imaginary friend as a child. Humpty Dumpty and his family (he had a sister, mother, and father) lived in my bathroom, although Humpty would come out and play with me in the rest of the house, too. My mom made me a handmade Humpty Dumpty doll and I remember going into the bathroom and telling him I couldn’t play with him after that.

My daughter had an imaginary friend named Dubbie Dubbie and Dubbie. To this day we aren’t sure if Dubbie was one person or three. We also don’t know what Dubbie looked like. He or They hung around for about a month, then was never spoken of again. She was 2 at the time. Now she’s four and gives me a dirty look when I bring him/them up.

Strangely enough, my child started playing with an imaginary friend just today! We were at my parent’s house for dinner and she was in the bathroom playing with “X-”. I said, “But I’m X-.” and she said, “No, this is X-. (pointing at no one) She lives in the bathroom, she’s my best friend!”

As for imaginary friends, My eldest created two imaginary friends for herself. Claire Bonnet and Lucy. They would only come to play when she was sick and or in hospital. Lucy came with her for each and every operation and test and Claire bonnet was always there afterward to pick up the pieces. She was the only one to have the imaginary friends though. It was really interesting to watch. Especially as she was one of twins, so she always had company.

I have a 14 year old who had an imaginary friend for quite a long time, a few years, as I recall. She called her imaginary friend Sam. I never knew whether Sam was a boy or a girl.

My 10 year old son had an imaginary friend when he was young also. I think his name was Henry or something but I don’t remember and wasn’t around very long.

Pretty cute huh? In fact it makes me wish my child has one so I could see in their world a little!

• Listen carefully to what your child says to his imaginary friend. You might be able to identify some of the stressors that your child is coping with.
  
• Don't let the "friend" get away with breaking the rules. Just tell your child that rules are the same for "Princess Amy" as with anyone else.
• Try not to be overly inquisitive about their friend. If they mention it then great- ask a few questions. But let your child's friend be their friend not yours.
• Talk with your pediatrician if you notice that the "friend" is interfering with your child from interacting or developing his own "real" friends.