Seeking the best care for allergy

Every now and then I will bring in what I call ‘pet peeves’. These are for me everyday experiences that I have developed a humble opinion about and when the mood strikes I will elaborate on my perspective (properly plugged as pet peeve perspectives, perhaps?). So here goes – Pet Peeve Number 1- where to go for allergy care?

There are a number of health care specialists who offer allergy evaluations and allergy directed care. I have seen over the past week three new children who have had evaluations for allergy by someone who offers ‘allergy’ care and they were not allergists. In one instance a type of allergy test was done in the operating room. In one child, intradermal tests for foods were done ( a technique that is replete with false positive results) and most concerning was one child who was tested for foods, found to have a few positive responses, and was given a set of instructions that may have caused a problem. As I reviewed the previous allergy test records with the family I noted that the instructions were “3 days of total avoidance followed by 1 day of exposure to as much as could be eaten of the positive food”.

In the world of IgE-mediated, type-one hypersensitivity food ‘allergy’ reactions (see pages on What is an Allergy and Allergy Tests) the current recommendation is full and strict avoidance of the offending food. There is an evolving science that is helping with prevention and with treatment of some food allergies, but we are not there just yet. I have never come across a program that involves days of avoidance followed by overindulgence, nor could I find anything in the literature regarding this. This could be a very dangerous recommendation especially for a child who may have a systemic response such as hives or allergic shock.

The presenting problem was recurrent ear infections. Now here is where philosophies come into play. The track record even in the best designed study is that at a maximum 1/3 of children with recurrent ear infections may have allergy as a contributor. Between the lines, the allergens were inhalants and the 1/3 of children affected was the one study with the highest fraction. Many of the studies on this connection had fewer children triggered by allergy. In regards to foods, the reports from double-blinded placebo-controlled food challenges (this being the best way to prove a reaction) have shown that foods are a rare cause of isolated respiratory tract symptoms. What was also observed was the fact that if a food was involved, the families suspected it before the evaluation. Again the answer was in the medical history.

Who offers allergy care- well anyone can offer and perform some type of test for allergy. Therein lies the problem. Be ware of what and who is out there. Get the best for your investment of time, money, and safety. The American Academy of Allergy, Asthma, and Immunology (AAAAI) has a issued a position statement about questionable tests and testing procedures for allergy.  The bottom line on these evaluations is that it is not money well spent!

We have primary caretakers, allergists, and otolaryngologists (ENT) tauting expertise in allergy.

Let me describe an allergist- This is an individual who has primary training in either pediatrics or internal medicine. The individual then has done a 2-3 year training program in allergy/immunology and is then eligible to sit for their specialty boards. Allergy/Clinical Immunology is a conjoint board, one of the few that credentials trained individuals to see both children and adults within the context of their specialty. The graduate of the fellowship training program has the opportunity to sit for their specialty boards and they become a board certified allergist-clinical immunologist. They could then join one of two national groups that help set the standards of allergy care, the American College of Allergy, Asthma, and Immunology (ACAAI) and the American Academy of Allergy, Asthma, and Immunology (AAAAI). Through a tenure of membership in these organizations and in their primary specialty, the allergist may become for example a fellow of the American Academy of Pediatrics (AAP) and a fellow of the AAAAI.

Resolves for my pet peeve number 1.

1. Ask about credentials- What is the primary specialty- pediatrics, internal medicine, family practice, or ent surgery?

2. Where was the allergy training – a fellowship, part of surgical training, a course?

3. Is the practitioner boarded in the specialty of allergy? Are they board eligible in the specialty of allergy?

4. Are they a member of a peer group- ACAAI or AAAAI?

5. This one is very biased- although the allergist/immunologist has training in each world I would suggest the pediatric-trained allergist for the children. From my experience at a wonderful children’s hospital- you just have to know about kids and be kid-oriented to be more effective in what we do.

FEL

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