Allergies vs. a URI

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Summary from Allergy Health Online (Division of HealthCentersOnline. [Great site with video enhancement -- jgk]

Colds, infections, flu and allergies all involve the immune system – the body’s mechanismAllergies occur when the immune system mistakes a harmless substance as being dangerous and attacks. for resisting disease and infection. The immune system produces antibodies to eliminate foreign substances.

In the case of a cold, infection or flu, the foreign bodies are harmful bacteria or viruses. The immune system attacks these invaders, which have the potential to harm the body.

In the case of allergies, the body mistakes a harmless substance, such as pollen or dust, for a dangerous invader. It then launches an attack that leads to the symptoms commonly associated with allergies.

Because these processes are so similar, the symptoms people experience with allergies often mimic those of a cold or infection. These include sneezing, nasal congestion and watery eyes.

Cold and flu symptoms generally resolve in a few days, once the body has successfully fought and conquered the invading organism. Since allergens are already harmless, allergy symptoms will continue for as long as the person is in contact with that substance.

In rare cases, allergies can cause a severe allergic reaction (anaphylactic shock) that may result in hospitalization or even death. Therefore, it is important for people to consult a physician to determine the specific allergy triggers to which they are sensitive. Avoiding these triggers is the best defense for people with allergies.

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Most penicillin allergies are not forever; in fact, the number of people who had an allergic reaction after taking penicillin and then had another reaction after taking the antibiotic again was far fewer than expected--previously, 60% and now under 2%. In other words, past smaller studies concluded that about 60% of such persons would have been allergic. Now, U. of Penna. researchers reviewed 3.4 million electronic medical records for people in Great Britain who were prescribed penicillin from 1987 to 2001 and found the number of second allergic responses to be less than 2%.

Dr. Brian L. Strom, et al. Journal of Allergy & Clinical Immunology, April, 2004.

Early Exposure to Dogs and Cats and Later Allergies

Context Childhood asthma is strongly associated with allergic sensitization. Studies have suggested that animal exposure during infancy reduces subsequent allergic sensitization.

Objective To evaluate the relationship between dog and cat exposure in the first year of life and allergic sensitization at 6 to 7 years of age.

Design, Setting, and Subjects Prospective birth cohort study of healthy, full-term infants enrolled in a health maintenance organization in suburban Detroit, Mich, who were born between April 15, 1987, and August 31, 1989, and followed up yearly to a mean age of 6.7 years. Of 835 children initially in the study at birth, 474 (57%) completed follow-up evaluations at age 6 to 7 years.

Main Outcome Measures Atopy, defined as any skin prick test positivity to 6 common aeroallergens (dust mites [Dermatophagoides farinae, D pteronyssinus], dog, cat, short ragweed [Ambrosia artemisiifolia], and blue grass [Poa pratensis]); seroatopy, defined as any positive allergen-specific IgE test result for the same 6 allergens or for Alternaria species.

Results The prevalence of any skin prick test positivity (atopy) at age 6 to 7 years was 33.6% with no dog or cat exposure in the first year of life, 34.3% with exposure to 1 dog or cat, and 15.4% with exposure to 2 or more dogs or cats (P = .005). The prevalence of any positive allergen-specific IgE test result (seroatopy) was 38.5% with no dog or cat exposure, 41.2% with exposure to 1 dog or cat, and 17.9% with exposure to 2 or more dogs or cats (P = .003). After adjustment for cord serum IgE concentration, sex, older siblings, parental smoking, parental asthma, bedroom dust mite allergen levels at 2 years, and current dog and cat ownership, exposure to 2 or more dogs or cats in the first year of life was associated with a significantly lower risk of atopy (adjusted odds ratio, 0.23; 95% confidence interval, 0.09-0.60) and seroatopy (adjusted odds ratio, 0.33; 95% confidence interval, 0.13-0.83).

Conclusion Exposure to 2 or more dogs or cats in the first year of life may reduce subsequent risk of allergic sensitization to multiple allergens during childhood.

Ownby DR, Cole Johnson C, Peterson EL. Exposure to Dogs and Cats in the First Year of Life and Risk of Allergic Sensitization at 6 to 7 Years of Age. JAMA. 2002;288:963-972

Allergic Rhinitis

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Nasal corticosteroids.Anti-inflammatory nasal sprays are the most effective medical treatment for allergic rhinitis. They help turn off the immune reaction in the nasal passages and provide sustained relief. Nasal corticosteroids can irritate the nasal membranes, but they don’t have the troubling side effects associated with oral, injected, or inhaled steroids, such as bone loss and weight gain.

Antileukotrienes. These oral drugs block the effects of leukotrienes, chemicals that cause inflammation. They’re an alternative to antihistamines.

Mast cell stabilizers. These drugs reduce swelling and secretions by interfering with the release of certain chemicals from mast cells (see “Anatomy of allergic rhinitis,” above). They’re very safe but not as effective as nasal corticosteroids.

Immunotherapy. Better known as allergy shots, immunotherapy involves injecting an allergen under the skin in small and increasing doses every week for several months, then monthly for three to five years. The object is to accustom the immune system to the substance so that it doesn’t provoke an allergic attack. Immunotherapy can markedly reduce the need for medication, and it also cuts the risk that allergic rhinitis will progress to asthma. The drug omalizumab (Xolair) represents a different approach to immunotherapy, dubbed anti-IgE. It is FDA-approved only for asthma but has shown promise in preventing allergic rhinitis.

Selected resources

• American Academy of Allergy, Asthma, and Immunology
• 800-822-2762 (toll free)
• National Institute of Allergies and Infectious Diseases 301-496-5717
• From: "What to do when allergic rhinitis is in bloom" What to Do about Allergies; A Special Health Report from Harvard Health Publications. Harvard Women's Health Watch Volume 12 - Number 08 - April 2005

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Six Agents are Currently Available to Tx Allergic Rhinitis:

• beclomethasone dipropionate, flunisolide (Nasalide, Elan)
• triamcinolone acetonide, budesonide (Rhinocort, AstraZeneca)
• fluticasone propionate (Flonase, GlaxoSmithKline)
• mometasone furoate (Nasonex, Schering)

Intranasal Corticosteroid Products

Drug	Products	Pediatric Age Approval
beclomethasone dipropionate	Beconase aerosol; beconase AQ spray; Vancenase Pockethaler aerosol; Vancenase aerosol; Vancenase AQ DS (double strength)	>6 years
flunisolide	Nasalide spray; Nasarel spray	>6 years
triamcinolone acetonide	Nasacort; Nasacort AQ	>6 years
budesonide	Rhinocort Aqua spray; Rhinocort aerosol	>6 years
fluticasone	Flonase spray	>4 years
mometasone furoate	Nasonex spray	>3 years

Source: Edward A. Bell, PharmD, BCPS

Studies that have evaluated the intranasal steroids, generally have been short and have included subjects with moderately severe symptoms. Little differences among the agents have been found and the available intranasal steroids are, therefore, and/or emperically, considered to be equally effective. Regardless, intranasal steroids are most effective if used prior to allergen exposure.

Relationship between systemic corticosteroid exposure and growth velocity

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BACKGROUND:: Use of high-dose oral corticosteroids (CSs) can reduce growth velocity (GV) in children, whereas use of low-dose topical CSs has either no effect or transient effects on short-term growth and no effect on final adult height Despite the large body of literature on this topic, some fundamental questions remain concerning the relationship between CS exposure and growth effects.

OBJECTIVES:: The aims of this study were to determine the relationship between CS exposure and GV in children receiving CS therapy for asthma or rhinitis, and to examine whether there is likely to be a link between GV and cortisol suppression.

METHODS:: Data from 32 published studies of the effect on growth of inhaled, intranasal, and oral CSs, includingdelivery by dry powder inhaler, metered-dose inhaler, and aqueous nasal spray, were consolidated by expressing CS exposure in cortisol equivalents using a physiologically based pharmacokinetic/pharmacodynamic approach. The relationship between change in GV and CS exposure in cortisol equivalents was described using a nonlinear sigmoid maximum-effect (E(max)) model with the following parameters: E(max) = -5.9 cm/y; steady-state unbound AUC for 50% reduction in GV, in cortisol equivalents = 20,000 ng-h/L; Hill constant= 1.2; and change in GV at zero systemic exposure = 0.06 cm/y. Validation was achieved by comparing the model's predictions with data from 5 studies that were not included in the model development The model was also used to predict the potential of various CS regimens to reduce GV

RESULTS:: Exploratory data analysis established that change in GV was highly correlated with exposure in cortisol equivalents (P < 0.001). CSs with high systemic bioavailability by the intranasal route were predicted to have short-term growth effects exceeding the clinical equivalence limit for change in GV (+/-0.8 cm/y), whereas those with lower bioavailability were predicted to produce systemic exposures below the threshold for significant effects on GV The findings were similar for inhaled CSs and for regimens combining delivery by the intranasal and inhaled routes. In descending order, the model predicted the following ranking of the potential of the various intranasal, inhaled, and oral regimens to reduce GV, expressed as fractions or multiples of the pediatric dose (in mug/d): oral prednisolone 5000 mug/d, 0.14; inhaled beclomethasone dipropionate metered-dose inhaler 400 mug/d, 0.54; inhaled budesonide dry powder inhaler 400 mug/d, 0.66; intranasal triamcinolone acetonide aqueous nasal spray 220 mug/d, 0.74; inhaled triamcinolone acetonide metered-dose inhaler 400 mug/d, 0.75; intranasal beclomethasone dipropionate aqueous nasal spray 336 pg/d, 0.89; inhaled mometasone furoate dry powder inhaler 200 mug/d, 2.4; intranasal budesonide aqueous nasal spray 128 mug/d, 2.5; inhaled fluticasone propionate dry powder inhaler 200 mug/d, 2.6; intranasal mometasone furoate aqueous nasal spray 100 mug/d, 120; and intranasal fluticasone propionate aqueous nasal spray 100 pg/d, 150. Values >1 are predictive of no significant effect on GV The model predicted that a 10% to 15% reduction in plasma cortisol concentration should be detectable at the lower equivalence limit for growth reduction (-0.8 cm/y). The validation procedure showed that the model was capable of predicting the results of the 5 comparative growth studies not included in model development with a correlation coefficient of 0.98.

CONCLUSIONS:: Growth effects appear to be nonlinearly related to CS exposure; therefore, no-effect exposure should be possible for CSs with low systemic exposure. Growth inhibition appears unlikely to occur in the absence of detectable reductions in cortisol concentrations.

Daley-Yates PT, Richards DH. "Relationship between systemic corticosteroid exposure and growth velocity: development and validation of a pharmacokinetic/pharmacodynamic model." Clin Ther. 2004 Nov;26(11):1905-19. PMID: 15639702 [PubMed - in process]

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The Potential for Growth Supression From Intranasal Corticosteroids

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The most valuable data ... are long-term studies where final adult height is determined. Unfortunately, these studies do not exist. However, studies evaluating long-term treatment with orally inhaled corticosteroids have been published. Two hundred and eleven children with asthma were followed (mean treatment duration of 9.2 years) until final height was attained (Agertoft). Of these, 142 children were treated with a mean daily budesonide dose of 412 &micro;g, and were compared with controls and healthy siblings. While some reduction in growth velocity occurred early on in the first year in patients receiving budesonide, targeted adult heights were obtained.

Another study evaluated the effects of budesonide (400 &micro;g/day) as compared with nedocromil or placebo in more than 1,000 children (5-12 years of age) for four to six years (Childhood Asthma Management Program Research Group). Final adult heights were estimated, and it was found that children treated with budesonide grew 1.1 cm less than the placebo group (p < 0.05). This reduction, however, mostly occurred in the first year of treatment. Growth rates by the end of treatment did not differ, and projected final adult heights were similar among all treatment groups.

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Bell EA. Intranasal corticosteroids for allergic rhinitis; Six intranasal steroids in different products and strengths are available for allergic rhinitis. Pharmacology Consult May 2002

About 3/4ths of seasonal allergic rhinitis symptoms is caused by ragweed whose pollens are most frequent in the eastern and central parts of North America growing luxuriantly, for example, in grain fields and construction areas.

Reference: Swanson's Family Practice Review - A Problem Oriented Approach, Fourth Edition, Alfred F. Tallia, Dennis A. Cardone, David F. Howarth, Kenneth H. Ibsen, 2001.

1. AAFA or the Asthma and Allergy Foundation of America--for those who suffer from asthma and allergies.
2. eMedicine.com affords excellent and Free CME on Asthma

Angioneurotic Edema

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The clinical picture can vary widely from one patient to another, and even among members of the same family. ANE presents as follows:

1. Subcutaneous or submucosal, white, soft, non-pruritic edema that occurs episodically and lasts 3-5 days, often with an area of predilection for each patient. These edemas do not respond to treatment with corticosteroids or antihistamines.

   The triggering events are: any trauma, even minor, stress, certain times of the female hormonal cycle.

2. Episodes of abdominal pain mimicking a surgical emergency (intense pain, contracture, occlusion ...)

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Bouillet-Claveyrolas L.; Angioneurotic edema.

Orphanet encyclopedia, April 2001

ORPHANET is a database dedicated to information on rare diseases and orphan drugs. Its access is free of charge.

Allergic Conjunctivitis with Chemosis

• In mild cases: artificial tears (eg, Refresh) 4-8 times a day
• In moderate cases: vasoconstrictor and antihistamine drops (eg, naphazoline with pheniramine) 4 times a day
• In severe cases: topical steroid (eg, fluorometholone) 4 times a day for 1-2 weeks

Reference: Rhee DJ, Pyfer MF, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Wolters Kluwer Company; 1999.

Allergic rhinitis

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extract, modified

Early diagnosis and treatment of allergic rhinitis are crucial in those with uncontrolled asthma.

Allergic rhinitis, a common chronic illness, affects patients' quality of life and has astounding direct and indirect medical costs.

The allergic inflammatory response results in the release of various chemical mediators that produce the clinical manifestations.

The symptoms of allergic rhinitis include nasal congestion, itchy nose, sneezing, rhinorrhea, watery eyes, chronic cough, dry throat, and facial pain from sinusitis.

Findings on examination are boggy, pale or bluish nasal mucosa and watery discharge. Repeated rubbing of the nose causes a dorsal nasal crease (ie, allergic salute).

Allergic rhinitis is usually diagnosed on the basis of clinical features, but it may be confirmed by means of allergy tests or in vitro blood tests.

Treatment with intranasal corticosteroids (eg, Nasacort, Flonase, Rhinocort, Nasonex) is the most effective therapy for allergic rhinitis. These drugs are recommended for all stages of allergic rhinitis, including moderate-to-severe persistent rhinitis, for which these medications are considered the most appropriate therapy. Nasal corticosteroids effectively treat most allergic rhinitis symptoms, including sneezing, rhinorrhea, itching, and nasal congestion.

Published studies have shown that nasal steroids are superior to nonsedating histamines, leukotriene receptor antagonists, and the combination of the two.

All brands of nasal steroids are equally effective and safe; major differences are related to their taste, smell, ease of use, technique of application, and spray volume. These attributes, along with the patient's preferences, determine compliance and long-term outcomes. A recent placebo-controlled study demonstrated no significant difference in efficacy between budesonide and fluticasone; however, patients treated with budesonide had greater improvement in quality of life.

Therefore, treatment with nasal steroids is the most effective therapy for allergic rhinitis and plays an important role in the management of comorbidities such as asthma, rhinitis, and nasal polyposis.

References

* Bousquet J, Van Cauwenberge P, Khaltaev N; Aria Workshop Group; World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5 suppl):S147-S334.
* Ciprandi G, Canonica WG, Grosclaude M, et al. Effects of budesonide and fluticasone propionate in a placebo-controlled study on symptoms and quality of life in seasonal allergic rhinitis. Allergy. 2002;57:586-591. Abstract.
* Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998;81(5Pt2):478-518.
* Kaliner MA. Patient preferences and satisfaction with prescribed nasal steroids for allergic rhinitis. Allergy Astma Proc. 2001;22(6 suppl):S11-S15.
* Yanez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systemic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89:479-484. Abstract.

eMedicine by Sat Sharma, MD, posted Sept. 27, 2003

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Intranasal steroid sprays in the treatment of rhinitis: is one better than another?

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Abstract
The treatment of allergic rhinitis has been revolutionized by the introduction of topical nasal steroids, which are one of the commonest prescriptions from otolaryngology departments. With so many different sprays available on the market, the literature was reviewed for the efficacy, side-effect profile and relative cost of each product and the following conclusions made:

1. A meta-analysis of randomized controlled trials comparing the efficacy of intranasal corticosteroids and oral antihistamines in the treatment of allergic rhinitis showed a clear benefit in favour of intranasal steroids in relieving nasal symptoms.
2. There is no clear evidence to support the suggestion that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis.
3. All the sprays have a similar side-effect profile; the commonest being epistaxis with a reported incidence between 17 and 23 per cent. In all the clinical trials, the placebo spray had an appreciable rate of epistaxis of between 10 to 15 per cent.
4. Fluticasone causes a reduction in endogenous cortisol secretion but no significant adrenal suppression was seen with triamcinolone, beclomethasone, budesonide or mometasone.
5. There is little evidence that skeletal growth is restricted by the administration of topical nasal steroid sprays.
6. There is considerable variation in the daily cost of each spray. Beclomethasone, dexamethasone and budesonide are significantly cheaper than fluticasone, mometasone or triamcinolone.

Waddell AN, Patel SK, Toma AG, Maw AR. "Intranasal steroid sprays in the treatment of rhinitis: is one better than another?" J Laryngol Otol. 2003 Nov;117(11):843-5.

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Are all Once-Daily Intranasal Corticosteroids the Same in Allergic Rhinitis?

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Abstract

Objective: The purpose of this review is to describe the similarities and differences among the 4 aqueous once-daily intranasal corticosteroids (INS) for the treatment of allergic rhinitis (AR). INS are the recommended first-line therapy for all patients with AR that is greater than mild intermittent in severity.
Data Source/Study Selection: Data were obtained from MEDLINE searches of all English-language articles published from January 1966 to January 2005 with the following search terms: allergic rhinitis and intranasal corticosteroid, nasal steroid, budesonide aqueous nasal spray, fluticasone propionate nasal spray, mometasone furoate nasal spray, or triamcinolone acetonide nasal spray. Also selected for review were data from published abstracts from recent scientific meetings.

Data Extraction: Data comparing efficacy, safety, patient preferences, and cost-effectiveness of any of the 4 available aqueous once-daily INS were extracted from the studies and are summarized.

Conclusion: All 4 aqueous once-daily INS available in the United States for the treatment of AR are similar with regard to efficacy and safety at the recommended starting dose. However, differences in patient preference, cost, and safety of use during pregnancy may contribute to primary care physicians' selection of an INS therapy for their patients.

	BANS vs FPNS	TANS vs FPNS	TANS vs MFNS
Overall comfort	BANS[64]	NSD	TANS[63;65]
Less rundown into nose/throat	BANS[64]	TANS[63]	TANS[63]
Less runout from nostrils	BANS[64]	---	---
Less irritation	---	NSD	TANS[63;65]
Milder odor	BANS[64]	TANS[62;63;65]	TANS[63;65]
Preferred odor	---	TANS[62;63;65]	TANS[63;65]
Milder taste	BANS[64]	TANS[63;65]	TANS[63;65]
Preferred taste	---	TANS[62]	TANS[63;65]
Preferred feel of spray in nose/throat	BANS[64]	TANS[63;65]	TANS[63;65]
Preferred force of spray	BANS[64]	---	---
Less aftertaste	BANS[64]	TANS[63;65]	TANS[65]

NSD = no significant difference; --- = not studied; BANS = budesonide aqueous nasal spray (e.g., Rhinocort Aqua Nasal Spray - AstraZeneca LP); FPNS = fluticasone propionate nasal spray (e.g., Flonase Nasal Spray - GlaxoSmithKline); TANS = triamcinolone acetonide aqueous nasal spray (e.g., Nasacort AQ Nasal Spray - Sanofi-Aventis); MFNS = mometasone furoate nasal spray (e.g., Nasonex Nasal Spray - Schering)

Table 3 (partial). Economic Comparison of Intranasal Corticosteroid Therapy for Allergic Rhinitis

Mean cost of INS per day based on the mean prescribed daily dosage[68]	BANS	FPNS	MFNS	TANS
	$1.54	$1.88	$1.80	$1.97

Yawn B. "Comparison of Once-Daily Intranasal Corticosteroids for the Treatment of Allergic Rhinitis: Are They All the Same?" Medscape General Medicine. February 19, 2006 {Posted 01/25/2006]

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Topical nasal steroids in otitis media with effusion and/or adenoidal hypertrophy

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OBJECTIVES: Topical steroid treatment can be a powerful alternative to surgery in controlling adenoid hypertrophy and otitis media with effusion (OME).

METHODS: A prospective, controlled, randomized, clinical study in an academic tertiary care center. A total of 122 children (3-15-year-old) on the waiting list for an adenoidectomy and/or ventilation tube placement were enrolled into the study and control groups. The study group (67 patients with adenoid hypertrophy, 34 of them with otitis media with effusion) received intranasal mometasone furoate monohydrate 100 mcg/day, and the control group (55 patients with adenoid hypertrophy, 29 of them with otitis media with effusion) was followed up without any treatment. All patients were evaluated at 0 and 6 weeks. The assessment of each patient included history, a symptom questionnaire, a skin prick test, a tympanogram, if possible a pure tone audiogram, and otoscopic and endoscopic examinations. The size of adenoid tissue was graded as a percentage according to obliteration of the choanae. The adenoid/choana ratio (A/C) was recorded for each patient. Symptoms were scored as 0 (absent), 1 (intermittent/periodic), or 2 (continuous). The data were analyzed with the "Statistical Package for the Social Sciences" (SPSS 9.0) using the appropriate nonparametric tests for nominal and ordinal data.


RESULTS: Resolution of otitis media with effusion in the study group (42.2%) was significantly higher than that in the control group (14.5%) (p<0.001). Forty-five patients (67.2%) with adenoid hypertrophy in the study group showed a significant decrease in adenoid size according to the endoscopic evaluation compared to the control group (p<0.001). A significant improvement in obstructive symptoms was seen in the study group (p<0.001). The endoscopically measured adenoid/choana ratio and degree of obstructive symptoms showed a significant correlation (r=0.838 p<0.001, r=0.879 p<0.001, r=0.838 p<0.001, r=0.879 p<0.001). The adenoid/choana ratio improved significantly in atopic patients in the study group (p<0.05), whereas in atopic patients in the control group there was no change (p=0.221).


CONCLUSION: Nasal mometasone furoate monohydrate treatment can significantly reduce adenoid hypertrophy and eliminate obstructive symptoms. It is a useful alternative to surgery, at least in the short term, for otitis media with effusion.

Cengel S, Akyol MU. "The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy." Int J Pediatr Otorhinolaryngol. 2006 Apr;70(4):639-45. Epub 2005 Sep 16.

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Can nutritional strategies prevent allergic disease? Discussion about infants

There's an increase in allergic diseases and, generally, a progression of atopic disease in genetically predisposed children, worldwide. The following discussion reviewed key factors that are associated with risk of developing allergic disease, and the evidence for a role of diet in preventing allergic disease in young children.

• The prevalence of allergic disease is increasing in all countries
• It is greatest among African-American children in the U.S.
• Food allergy affects 6% to 8% of young children, with cow's milk protein the single most common food allergen, although the prevalence of some other food allergies, such as peanuts, is increasing.
• Asthma, the most common chronic disease of childhood, affects more than 6 million children.
• The prevalence of atopic dermatitis also continues to rise, and half of the approximately 17% of U.S. schoolchildren with atopic dermatitis will develop asthma and allergic rhinitis.

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Breastfeeding for at least the first 3 months of life confers a significant protective effect against allergic disease, but what of those infants who are unable to be breastfed? The 2003 German Infant Nutritional Intervention Study demonstrated that the cumulative incidence of atopic dermatitis was greater at 36 months of age among those children receiving intact cow's milk formula and partially hydrolyzed whey formulas than those children who received extensively hydrolyzed whey or casein formulas.

Modified for presentation here
Eggleston P, Boguniewicz M, Kerner JA (Speakers, 2006 Pediatric Academic Societies' Annual Meeting. Sunday. April 30, 2006 San Francisco, CA),"Can nutritional strategies prevent allergic disease in infants not breastfed?" Reproduced in Contemporary Pediatrics Dateline, May 1, 2006

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Nonallergic (Vasomotor) v. Allergic Rhinitis/Rhinorrhea

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BACKGROUND: Chronic rhinitis, a prevalent primary care disorder associated with significant comorbidities, is often incorrectly diagnosed. As a result, inappropriate treatment leads to higher health care costs and poor clinical outcomes.

OBJECTIVE: To verify whether responses to specific questions may help in the diagnosis of nonallergic vasomotor rhinitis (NAVMR).

METHODS: A questionnaire listing allergic and nonallergic triggers was blindly distributed to 100 random new patients with chronic rhinitis in an allergist's office. Questionnaire and physician diagnoses were compared. Allergic triggers included cat, dog, feathers, other furry animals, and symptoms during the spring, summer, and fall seasons. Nonallergic triggers included temperature changes, diesel and car exhaust, tobacco smoke, perfumes and fragrances, incense, cleaning products, newsprint, hairspray, and alcoholic beverages, spicy foods, or eating.

RESULTS: The construct validity and internal consistency indicated that the questionnaire was a good tool for diagnosing NAVMR. Multivariate analysis revealed that the absence of outdoor symptoms in the spring (odds ratio [OR], 7.76; 95% confidence interval [CI], 1.18-51.22; P = .03), no parental history of allergy (OR, 5.16; 95% CI, 1.05-25.20; P = .04), no symptoms around cats (OR, 3.82; 95% CI, 0.59-24.83; P = .16), the presence of symptoms around perfumes and fragrances (OR, 4.875; 95% CI, 1.05-22.60; P = .04), and age at symptom onset (OR, 1.08; 95% CI, 1.02-1.14; P = .008) were predictive of NAVMR.

CONCLUSIONS: Specific questionnaire responses may help primary care physicians accurately diagnose NAVMR. Questions asked of patients by physicians to diagnose allergic rhinitis do not correlate well with physician diagnosis.

Brandt D, Bernstein JA. "Questionnaire Evaluation and Risk Factor Identification for Nonallergic Vasomotor Rhinitis." Ann Allergy Asthma Immunol. 2006;96:526-532

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Food Allergy in Infants and Young Children

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Incidence

Food allergy is an immunologically mediated adverse reaction that develops after the ingestion of an offending food or food ingredient. It is different from the more general term “food intolerance,” which also encompasses reactions that are not mediated by the immune system.1 Around 15%–20% of infants and young children are suspected of having adverse reactions to foods according to their parents2,3 but only 2.2% to 6% of them demonstrate documented food allergy.4 Cow’s milk allergy (CMA) is the most common food allergy in the first year of life, affecting 2.2% to 2.8% of infants.4-7 Other common food allergies in young children are to egg, soy, and peanut; allergy to wheat, tree nuts, fish, and shellfish are also observed, as the child gets exposed to these allergens.1,2,5,8

8. Strobel S. Dietary manipulation and induction of tolerance. J Pediatr. 1992;121:S74-S79.

Children with IgE-mediated CMA that have persistent symptoms were shown to have higher SPT sensitivity and serum IgE to cow’s milk at the beginning of the disease and at subsequent time points, as compared with those whose disease remitted earlier. However, it is noteworthy that a high proportion of children with IgE-mediated cow's milk allergy (CMA) will still have positive serum IgE to cow’s milk at the time they develop tolerance to cow’s milk in their diet.44 For this reason, carefully conducted food challenges are usually necessary to assess development of tolerance.

Scalabrin DMF. (Mead Johnson Nutritionals, Evansville, IN; enfamilresourcecenter@enfamil.com

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Common (Mild) Nasal and Sinus Symptoms--Nasal Congestion; Post-nasal Drip

Caveat:

For nasal irrigation, use a commercial irrigation solution or make your own with 1/4 tsp. Kosher Salt and 8 oz warm tap water to which is added 1/4 tsp of Baking Soda. Use an 8 oz. squeeze bottle of sorts or a Neti Pot from which 4 oz is instilled in each nostril - Watch this Youtube video, "Spring cleaning ... for your nose" to learn how to keep the salt water from coming out of your mouth and for further information.

Reference:
Pynnonen MA, Mukerji SS, Kim HM, Adams ME, Terrell JE. "Nasal saline for chronic sinonasal symptoms." Arch Otolaryngol Head Neck Surg 2007;133 (11):1115-1120. [PubMed abstract]