Your Child's Asthma and Allergies -- Stanley Goldstein, MD -- 8/13/03
By Stanley Goldstein
Allergies and asthma can be a potent pair. In fact, most asthma attacks are triggered by allergies. We looked at the connection between allergies and asthma and answered questions about treatments and prevention when pediatric allergy expert Stanley Goldstein, MD, was our guest.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Member question: I have a 2-year-old daughter that has allergies. She is currently taking Zyrtec and Singulair chewables once daily. My question is if this combo of meds doesn't work could she possibly have to start taking shots? She has seasonal food and antibiotic allergies.
Goldstein: The reason that someone would go to allergy injections is based upon:
If Singulair and Zyrtec are not working, one can add, even in a young child, an intranasal corticosteroid. If there's a poor response to all the medications, then it would seem she would benefit most from allergy medications.
Member question: My son was just diagnosed with eczema at 15 weeks of age. The dermatologist says that he is now prone to allergies and asthma. Do you agree with this theory? Is there anything we can do now to prevent this?
Goldstein: Having eczema early in life is usually a sign of an allergic medical background. So the dermatologist's statement is true. Children who develop eczema early in life have a higher chance of developing asthma and allergies. It does not mean that your child will develop asthma and nasal allergies, but your child has a definite higher chance of that happening than a child without eczema.
Member question: What meds treat both asthma and allergies?
Goldstein: Asthma and allergies are created by exposure to allergens that create inflammation in the nose and lungs. The only class of medication that affects both the upper and lower airways is called the antileukotrienes. The most commonly used medication used in this class is Singulair. Singulair is approved for the treatment of both nasal allergies and asthma. There is no other class of medications that has the same approval.
Member question: My 3-year-old son is asthmatic and we have not determined exactly what triggers it or when he will have an attack. At this time, he is only taking medicine on a seasonal basis or when he has a need (right before the onset of attack and not at the time of attack). I am constantly monitoring his environment and activities. His father would like to enroll him in swimming lessons but I do not support this until he is a little older and stronger. My son was born with meconium aspiration. I cannot find any information to support my stance. I have spoken to older asthma suffers and parents of asthmatic kids who also cannot find information but know first-hand that their asthma is and has been often triggered by swimming. Do you have any information on swimming, swimming pools, etc., regarding asthma sufferers?
Goldstein: Yes, a lot of information. Number one, any young child or anyone with asthma should not be restricted from any physical activity, and that includes swimming. Out of any sporting activity that potentially induces asthma symptoms, swimming is the activity that has the least chance of that happening. So I would actually encourage, and asthma specialists actively encourage, children to be involved in physical activity.
If you are concerned about the chlorine in the pool or the chlorine smell in the environment of the pool it's best to swim outdoors where the concentration is not as great, or to pre-treat your child with albuterol, which will enable him to even swim indoors.
Member question: My 12-year-old daughter is a track runner and has been diagnosed with exercise-induced asthma. She has tried every asthma medication under the sun (Advair, Flonase, etc.). She complains that at times when she cannot breathe her body "shuts down," that her legs begin to hurt even though she hasn't run that far. Are there other medications or anything else she can do?
Goldstein: The first question that you have to ask yourself as the parent is does your child who does not respond to all the asthma medications you mentioned, in that it does not prevent her from having symptoms when running or doing exercise, truly have asthma? I would suggest that your child has a exercise challenge lung function study, where they would do a lung function before exercise and after, to get an objective assessment of whether your child does or does not have exercise-induced asthma.
Member question: If asthma is caused by allergies do you suggest screening kids with these symptoms? A simple blood test has become available called ImmunoCAP, which tests for the most common allergens in children. This is not the old RAST test but newer technology. How do you feel about this test?
Goldstein: Being that asthma is caused by allergies, it's important for any person with persistent asthma to be aware of what those allergens may be. There are several ways of testing for allergies. ImmunoCAP is one of these methods. Prick allergy and RAST are other methods. The ImmunoCAP is a screening blood test for allergies and is not as sensitive as prick allergy skin test and/or RAST. Because the ImmunoCAP may miss some allergens because of the lower sensitivity, I would suggest continuing to use the allergy prick skin test and/or RAST.
Member question: My 6-year-old has been treated for allergies for about four years now. We have just had the skin tests done and all came up negative. We are waiting for the results from the blood tests. How often do the blood tests result in positive, when skin was negative? Is there an asthma test?
Goldstein: The prick allergy skin tests are more sensitive than the blood test and the blood test is more specific than the skin test. However, it is rare to have a positive blood test where the allergy skin tests were negative. So it truly sounds that even though your child has been characterized as having allergy symptoms, that your child is truly not allergic. This is not uncommon. There is something known as nonallergic rhinitis, which means having what appears to be typical allergy symptoms, but no specific allergen that can be determined that is causing the symptoms.
As far as an asthma test, the weight test for asthma is by doing a lung function test. A lung function test is done with a device called a spironometer. Most hospitals have a spironometer and specialists, and some general physicians would have a spironometer. It's an easy test. One exhales into a tube attached to a computer, the computer measures different values of the air that's exhaled, those values are compared to normal values, and based upon the results one can determine whether that person does or does not have asthma.
Member question: My child has had asthma and allergies since early childhood, and has been solely on beta 2-agonists such as Ventolin to ease his symptoms up until now. Recently our doctor suggested we try a combo drug that might better control his symptoms. He referred my child to try either Symbicort or Advair and find out which one worked best. I was wondering if you would be able to lend your opinion on these two drugs and the advantages each might have over using solely a corticosteroid or beta 20agonist, and also how they might stack up against each other. Thanks!
Goldstein: The appropriate way of controlling asthma is controlling the airway inflammations. A medication such as a beta-agonist is only a bronchodilator and does not treat airway inflammation. Therefore anyone who has persistent asthma should be treated with an anti-inflammatory medication, such as inhaled corticosteroids.
Symbacort and Advair are similar medications, in that they both contain a long-acting bronchodilator and an inhaled corticosteroid. Even though these individual medications are different, they work very similarly, in that there really is no major difference with either one. They are both very effective treatments for asthma.
In the United States Symbacort is not available, therefore we primarily use Advair. But with the evidence of airway inflammation, patients with asthma should not be using beta-agonists on any routine basis.
Member question: My 14-year-old son came down with respiratory problems last September and was ultimately diagnosed with severe asthma. He has been in and out of the hospital because every time he is taken off of steroids his condition deteriorates very suddenly. His IGE levels have been anywhere from 1,800 to 900. During this time our doctors have conducted numerous allergy tests (which all have come back negative except for milk, which we took him off of completely).
We are to the point now where our doctors want to send my son to a hospital in Denver for evaluation, which we are in the process of setting up. Is there a possibility that a person could be allergic to medication such as Advair, Prednisone, albuterol, Xopinex, Singular, or any other asthma-related medication?
Goldstein: Your child's symptoms and history are not typical of 99% of people with asthma. There is no one who truly is allergic to the asthma medications you stated. I would agree with your doctors in the necessity of sending your child to the specialty asthma center in Denver for evaluation, because of the atypical history and symptoms that your child has.
Member question: When my daughter's allergies flair up, asthma always kicks in. Is there any kind of medicine for allergies that I can't give her? Can the breathing machine always be given once she's on allergy medication?
Goldstein: There are no allergy medications that cannot be given when your child is having asthma symptoms. It's important in your child to control the allergy symptoms and by doing that you achieve better asthma control. Controlling the allergy symptoms can be done in several different ways that should be discussed with your physician.
Member question: In winter my daughter used to have colds and she had to take Flovent, two puffs in the morning and two puffs in the night and sometimes albuterol through the nebulizer every four to six hours, but now the weather has changed and I see that she is fine without the medication. She does not need the Flovent or the albuterol so I just wanted to know if I should stop giving her Flovent and how do I do that? Do I stop at once or do I go slowly, like give it to her once in the morning and then skip the night dose and then slowly stop the morning dose also? Please let me also know what do I do when winter starts again?
Goldstein: Often children with asthma get worse during the fall and winter and do best during the spring and summer. Therefore, it's often that we will stop asthma medications in these children during the summer months. One can simply stop Flovent and one does not need to taper the medication. If your child has a history of her asthma becoming worse during the fall, then it would make sense to restart the Flovent sometime in September when school begins.
Member question: What age is it safe for a child to have an allergy test done?
Goldstein: Allergy tests can be done at any age, even during infancy. It's an absolutely safe form of testing for allergies.
Member question: My grandson was recently diagnosed with asthma in 2002 and has had a deep, continuous cough that gets worse with increased activity such as running or playing a lot and he will go into a coughing spasm. He is presently taking Advair, Allegra 30 mg, Becovent chewable tab, and we have to use the nebulizer when the coughing gets frequent with almost no letup.
He has been checked for allergies at the allergy and asthma clinic, and they have gone through numerous meds without success. He had a T&A last year, which has reduced the frequency of URIs and helped resolve a horrible sinus infection he had to contend with. Most of the time he looks overly tired and is cranky and acts tired especially during the mornings until about 9 a.m.-11 a.m. then he's a roadrunner with black eyes. Got rid of the majority of his stuffed animal collection and we keep the windows closed and use the ceiling fans and air conditioner but he doesn't seem to get better at home, school, outside, etc.
Goldstein: In your grandchild, who continues to cough despite all the asthma medications, one has to consider other possibilities besides asthma causing the cough. One should make sure your grandchild's lung function is normal before looking for other causes.
You mentioned that your grandchild was diagnosed as having sinusitis. Sinusitis is the most common associated condition that results in a continuous cough, despite good asthma control. I would suggest that they evaluate your grandchild for sinusitis, despite not having overt sinus symptoms.
Member question: My daughter, 18, has had asthma all her life. She used to use albuterol but now she cannot. They tell us that she has had an adverse reaction to it and it actually makes her lung functions drop. As a replacement for her rescue inhaler she is using Xopenex. Do you know when it will become an MDI? Also, she cannot use Foradil or Serevent due to her adverse reactions to albuterol.
She is being seen at National Jewish in Denver and they have done multiple double blind studies and have found that she cannot take them. Are there any other long-acting bronchodilators that she might be able to use? She uses her Xopenex an awful lot now as it is. She's on meds for asthma, allergies, and gastric reflux.
Goldstein: Interesting. Xopenex is a medication that is actually albuterol, but it's what's known as an isomer of albuterol. It is therefore difficult to understand why albuterol itself would cause an adverse reaction, whereas Xopenex would not. The Xopenex MDI is presently under investigation by Sepracor. Their main office is based in the Boston, Massachusetts area. If Xopenex is the only bronchodilator your child can use, I would suggest calling Sepracor to see if your child can be involved in any of their research programs.
There are no other long-acting bronchodilators besides Foradil or Serevent. Serevent, as a metered dose inhaler (MDI) is no longer available; however, Seravent as a dry powder inhaler in a device called Diskus is available.
Member question: We know that Xopenex is the left-sided isomer of albuterol. Could it be something that was changed that causes her to have a reaction?
Goldstein: There is some data that the R isomer potentially makes asthma worse, and that's why your child responds well to Xopenex and not to the regular albuterol.
Member question: I have been diagnosed with allergies and now with asthma. I have heard that a milder climate could help me control the attacks I get as well as the allergy symptoms. I currently am in Texas. Could you please tell me if this is true about a milder climate?
Goldstein: Coming from New York, I think Texas is a milder climate; however, wherever one would move, even if you characterize that as milder, the allergies and asthma will follow you. There really is no reason to make a major lifestyle change by moving to try to avoid the allergy and asthma symptoms.
Member question: I was recently diagnosed with asthma after moving from an arid/semi-arid region to the east coast and high humidity. The higher the humidity is the worse my attacks are. Why?
Goldstein: Humidity may lend to more molds in the environment, and also dust mites, which are the most common allergen, will breed better in a damp environment. Therefore, high humid areas will have more dust mites, which can contribute to increasing allergy and asthma symptoms.
Member question: I have a history of allergies and asthma and am currently on Pulmocort (via the nebulizer), Qvar, and 48 mgs of Medrol daily. I am wondering if all of these medications will cause problems in either bearing children or if it will affect their growth and the like. I have been on an ICS since I was 8 and oral steroids for two years. Thank you in advance!
Goldstein: The greatest concern about your medications is the high dose and continuous need for all steroids. There is a new medication called Xolair, recently approved for asthma that may be of benefit to you. This, however, has to be evaluated by your physician. The inhaled steroids should not cause you any long-term side effects.
Member question: I have a 4-year-old who has asthma and takes allergy injections once a week. He is allergic to everything. He is already a picky eater and he is allergic to wheat, baker's yeast, corn, tomato, cow's milk, and egg. Do you know a diet or a web site where I can get a diet without these things in it? The few things he would eat he can't eat now.
Goldstein: The best source for anyone with food allergies, as far as diet, as far as ingredients and avoiding different food allergens, is the Food Allergy and Anaphylaxis Network, known as FAAN, in Fairfax, Virginia. Their phone number is 800-929-4040. Their web site is www.foodallergy.org.
Moderator: Dr. Goldstein, before we wrap up for today, do you have any final comments for us?
Goldstein: The most important information that you need to aware of with respect to asthma and allergies is that:
Moderator: Thanks to Stanley Goldstein, MD, for sharing his expertise with us.
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