I had the chance to moderate a course given by the American Academy of Pediatrics (AAP) last weekend. For many years I had the role as a speaker for these programs. These are great opportunities for primary caretakers, pediatricians and nurse practitioners to hear some very practical approaches to common problems in pediatrics.
Providence, Rhode Island was the host city for this Practical Pediatrics offering. In early April Providence does not have a lot going on. The weather was wet and cold. This kept us indoors. The seafood and Italian food were great! I also recommend the IMAX 3-D movie Aliens vs. Monsters. Despite the inclement weather, I did learn a few new things and learned to appreciate many other aspect of care for our children.
Dr. Martin T. Stein, Professor of Pediatrics at the University of California, San Diego shared a few thoughts on pediatrics in general. He presented things that made me stop and wonder about the incredible job that is done by healthcare providers that look after our children. Did you know that for well child care the recommendation is for 31 visits? Back in the day (okay, 1974) only 14 well child care visits were the standard. I am sure this increase is due to the need for guidance, safety, development, and prevention. It makes our pediatricians busier. I also learned that our children benefit from a level of primary care above what is offered in other countries. The United States is the only country where board certified pediatricians provide that essential well child care. I have always held our pediatricians in high esteem. I learned a few things that have increased my respect for them and for what they do.
I learned a few more things about allergy and had a few of my standard issues emphasized by Dr. William T. Boleman, who is the Chief of Allergy at the Keesler Medical Center (USAF) in Biloxi, Mississippi. I learned that controversies in allergy are not at all unique to Indiana. Mississippi seems to be affected by theories, practices, and therapies done under the name of allergy, but clearly without a shred of evidence that allergy accounts for the problem. Dr. Boleman talked about sugar, wheat, yeast, chemical, electromagnetic radiation, hormones, and voodoo allergy testing including IgG antibodies to foods. One of his messages was to be sure that the story matches a condition in which allergy may be a cause. History taking remains an essential part of any allergy evaluation.
I have always enjoyed listening to the dermatologists. Their lectures are replete with pictures and practical information on a wide variety of things that can affect our skin. Dr. Miriam Weinstein from Toronto Sick Children’s hospital shared her opinion on a condition that is often seen by both the allergist and the dermatologist. That condition is atopic dermatitis, a form of eczema that has associations with allergy. I was surprised and concerned after the talk on evidence-based therapy of atopic dermatitis. She had pulled references from the dermatology literature. The evidence-based review is a critical summary of good and bad studies. One of my courses in the public health program actually taught us how to critique one of these reviews. It is quite an art to go over a vast literature looking for answers to specific questions and making sure that the methods used to get that answer were without any flaws.
The things that I learned and what I thought would be very helpful for the children I see with atopic dermatitis in my allergy practice include the emphasis that it is not just one thing such as a food that will trigger a flare of itchy, dry, flaky skin. There are many different reasons for the condition to flare and sometimes it just happens. When we discover something like a food that could trigger that is great because there is one less thing to worry about.
We also need to keep the skin as moist as possible. Moisturizing the skin can be considered front or first line therapy. These children need to be so slicked-up that they just slide through your fingers.
Using the topical steroid ointments once a day may be just as effective as using them twice a day and using them a few times during the week even when the skin is clear may help keep the skin from flaring.
I now emphasize that the use of the anti-histamines is not so much for the itch component of the skin, but for sedation. A significant amount of scratching of the skin occurs during the night. Helping with sleep by taking advantage of the sedative aspects of antihistamines makes a difference. Choices here would be agents like Benadryl or preferably Atarax (Hydroxyzine).
Skin infection needs to be controlled. The scratching and breakdown of the skin leads to infection. The infected skin then causes further scratching and misery.
Also, contrary to what an allergist would like to believe, being allergic to house dust mites and consequent house dust avoidance techniques may not make any difference in controlling flares.
Food allergy may not be the cause of many of the flares. Unfortunately these children have many positive skin tests and the track record is that the positive predictive value of the food test is about 50%. So when the allergy test for food is positive, there is a 50/50 chance that it is relevant and that exposure to that food causes a flare of the skin. Of all the foods that have been associated with flaring, egg is the most common.
It is important to keep learning new things, new perspectives, and be open to changes that may be of benefit to our patients. Hopefully a few of these tidbits may help.
Fred Leickly
Leickly Stories 