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Exercise Induced Anaphylaxis:  What To Know?

by Dr. Inderpal Randhawa, M.D.

Screenshot_2015-10-02-13-19-01 (2)Anaphylaxis from all causes impacts over 3 million Americans annually.  The most common cause of anaphylaxis involves the most common food triggers- milk, egg, wheat, soy, tree nuts, peanut, fish and shellfish.  Other triggers include medications, contrast dye, non-steroid anti-inflammatory drugs (NSAIDs), and other causes.  A very rare but interesting form of anaphylaxis is termed exercise induced anaphylaxis.

Exercise induced anaphylaxis has been described for decades.  It involves a patient eating foods like wheat or celery and typically one hour after ingestion with moderate exercise resulting in anaphylaxis symptoms.  The symptoms can be as mild as fatigue, red skin, lightheadedness, and throat tightening.  Symptoms can progress to life threatening anaphylaxis.  The causal relationship of the reaction is unclear.  The reaction is likely related to histamine release from mast cells and basophils primed by the food allergen exposure.

When should a parent be concerned about exercise induced anaphylaxis?  If a child, especially a teenager, notices a reduction in exercise tolerance after a new food exposure, it is worth a discussion with your primary care doctor.  It may be appropriate to perform food allergy testing and an exercise cardiopulmonary challenge to make the diagnosis.

An important note for OIT patients:  the reason most clinicians recommend a rest period after food dosing is due to the risk of a similar reaction described above.

 

 

 

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Running Track with Exercise Induced Anaphylaxis: One Doctor Turns a Passionate Goal into a Reality

by DeeDee Riley

Screenshot_2015-10-02-13-30-12 (2)Kayla was in first grade when she first started running track. She was seven and loved to run. Her little legs moved so fast, and she was in the youngest age group. Her cheeks would flush and become spotty after each time she ran. There were times she complained of stomach cramps. Anyone who runs knows that a great run usually consists of stomach cramps and vomiting when you are getting conditioned. I thought this was what was happening – her body was conditioning and she was having physical symptoms.

In between her first and second grade years, Kayla began having struggles with her medical issues. She put on weight from the medications and we had a few challenges. When it came time to run track, I assumed her nausea, flushed cheeks, and weakness were due to lack of conditioning. I thought she just needed to push through and eventually her body would follow suit.  I had no idea that these symptoms she was experiencing were life threatening and a warning sign that anaphylaxis was fast approaching.

During one of Kayla’s visits with Dr. Randhawa, her symptoms were brought up. I thought maybe he would be able to help us condition her in a way that was more comfortable, given all of her other medical conditions. What he said shocked me, “I think she may have exercise induced anaphylaxis, and we need to test her.”

I can remember thinking, “Anaphylaxis caused by exercise. How is that possible?”

Dr. Randhawa challenged her system with an exercise test. Only 2 minutes into the test, her heart rate raised and her blood pressure dropped and separated. The test was immediately stopped. What Dr. Randhawa had suspected was quickly demonstrated during the exercise test – Kayla has E.I.A. (Exercise Induced Anaphylaxis). She was told she could not run. Kayla was devastated.

Dr. Randhawa is unique in the manner with which he handles his patients. He recognized Kayla’s devastation and put a plan together to get her back on the track. We experimented with two different medications – midodrin and cortef. Kayla was also told she no longer could eat wheat or celery – as both of these foods enhance E.I.A.  With time, everything became balanced enough for her to begin running again.Screenshot_2015-10-02-13-04-12 (2)

Kayla wore a heart rate monitor while she ran, I had a blood pressure cuff with me at all times, and her EpiPens were always within a few feet of her. The coaches and parents on her school track team were incredible. It was this village of people who allowed her to run. They were taught about her symptoms and trained on what to do if they arose. Kayla was taught to constantly check her heart rate monitor and maintain a certain reading.

As her mom, it is terrifying placing my child in a situation where anaphylaxis can occur. Knowing that running stimulates an anaphylactic reaction, and I am allowing the situation is challenging. Dr. Randhawa provided numerous resources to help us learn and understand this condition. Yes, it is life-threatening.  However, when E.I.A. is treated correctly, monitored safely, and challenged in a controlled setting prior to team runs, it is a condition that can be managed. Though extremely rare in children, and lacking in protocol for them, Dr. Randhawa knew what to do and how to keep her running. Instead of crushing her spirit and keeping her off of the track, Dr. Randhawa found a way for Kayla to continue doing what she enjoyed.

Kayla is now twelve. What felt like a long journey, began six years ago, half of her lifetime. E.I.A is a scary, life-threatening diagnosis. However, with the right physician and plan in place, exercise does not have to be stopped, just modified with safety precautions. We are so thankful that Kayla can continue doing what she loves!

 

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Living with Cystic Fibrosis and 3 Active Children

by Janice Perkins

Janice and familyI am a 37 year old female with Cystic Fibrosis. I have 2 sons (conceived naturally) and a stepdaughter that we raise full time. I am a patient of Dr. Randhawa and I want to share my success since having him as my doctor.

I have seen hundreds of doctors in my lifetime and not one has ever made such an impact as Dr. Randhawa. I was very ill under the care of another CF doctor and was hospitalized. Luckily, my doctor was on vacation and that’s when I met Dr. Randhawa. The moment I met him, I knew he had to be my doctor. He drew out pictures of lungs, listed what factors were affecting my health, set realistic goals for me, and taught me exercises and breathing techniques to clear my lungs of mucus. These are things no other doctor had ever done.

With Dr. Randhawa’s five board certifications, he is able to treat multiple aspects of Cystic Fibrosis. He has treated my immune system with certain medications that only his knowledge could make possible. He goes out of his way for his patients, making sure they have what they need to be well. He knows that one size does not fit all. Dr. Randhawa sees the potential in his patients and expects them to put forth the effort to maintain their health.

Normally visits with previous doctors consisted of looking at lung function numbers and weight, making a guess on what might work for me and then sending me on my way hoping I would still be alive to see them the next visit. One doctor advised me not to have children because I could not be the mother I wanted to be with Cystic Fibrosis and that I would not be able to see my children grow up. Now dealing with CF and having 3 very busy children is definitely a challenge. But with Dr. Randhawa’s passion, knowledge, honesty, and motivation, I am able to be less ill than most CF patients and focus my attention on raising my family.

I have included some helpful hints that have made a difference for myself and raising a family.

Staying Active! I can’t stress enough what exercise does for your lungs and body. I know exercise is the last thing a person with CF wants to do when they do not feel well. A slow walk or some stretching can make a huge difference. Having a family to take care of forces me to get out of bed and get moving.

Eating Well. Most people with CF are told to consume many more calories per day than a person without CF. I try to eat as healthy as possible, consuming smoothies with spinach, berries, coconut water, & hemp oil. I try to cook healthy meals daily and always have a healthy snack on me.

Positive Thinking. The power of positive thinking can have a dynamic effect on your health. I have always maintained a positive outlook while remaining realistic. I do not think about “what if”. I am focused on my future with my family, CF is irrelevant to my thinking. I do not let CF define me. I keep a notebook of my future goals and refer to it often.

Probiotics. These make a huge difference for me. Since we are frequently on antibiotics, it makes a difference to take a probiotic.

Today the life expectancy of a person with CF is 41 years of age (quoted from the Cystic Fibrosis Foundation website). I know that I will surpass that age and that I have many, many more years ahead of me under Dr. Randhawa’s care. Please trust there are people that understand Cystic Fibrosis and will risk anything to make a difference. TPIRC will do great things for the Cystic Fibrosis community and Dr. Randhawa is the hope that we have been waiting for.

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Back to School with CFBack to School with CF – A Parent’s Advice

When our son, Beckett, was diagnosed with Cystic Fibrosis 12 days after birth our world turned upside down.  We cried, we prayed, we yelled, we begged, we researched like crazy…but most importantly we rose up.  Much of what causes fear in life is the unknown.  Cystic Fibrosis couldn’t have been more foreign to us; we came from healthy families and had another son gliding through his toddler years.  We decided to face this disease head on and fight the fight by not letting CF define our family, but rather Beckett defining CF.

Trust me, I realize the anxiety that comes with being a parent of a child with CF; every cough, runny nose, throat clearing can set you off and make you jump to horrifying conclusions.  But let’s put the anxiety aside for a minute.  Be an advocate for your child.  Be confident that you are doing all that needs to be done on a daily basis.  Our crazy-skateboarding-soccer playing-jog-a-thon winning 6 year old boy doesn’t know a day without treatment but he also doesn’t know any different.

We trust in our healthcare provider, team and stick to our routine.  When you do this, your child will be as strong as possible and ready to fight what needs to be fought with proper care.  I’m not saying it’s easy; there will be battles, long days, bronchoscopies, doctor visits, more treatments… but what I am saying is to be confident in those things you can control.  Don’t settle for a life attached to a machine.  We all know this disease can rear a mind of its own at times, but there is also much of Cystic Fibrosis we can have more control over than you might realize.  Cliché I know, but knowledge is power.  Become a student of this disease rather than just a parent of a patient.

Going back to school causes a whole bunch of emotions that CF parents deal with.  Granted, I have them too.  But, I also feel they have dissipated with my experience and knowledge.  And, after 2 years of preschool – let’s face it…we are both ready for Kindergarten!

A few little tricks I have found successful are:

– Saline Spray… give a little spray up each nostril right before you give your last minute hugs and the old lunchbox hand off.  Ask your child’s teacher to do the same right after lunch (usually half way through the day).  Keeping the sinus moist and full of Saline makes bacteria difficult to manifest.

– Can’t say enough about Pocket-Sized Sanitizers.  They are a must.  Even though sanitizer is my third arm, it’s more important to have thorough hand washing with warm water and soap for 30 seconds (we usually sing the ABCs but considering he told me recently that’s a “baby” song… I’m in search of another catchy jam – if you got one post it here)!

– Sinus Rinses!!  …it really is the best way to wipe those sticky, gooby, dirty germs out after a day of finger painting, sandbox throwing and most likely nose picking (you can’t control everything!!).  Since most kids with CF have sinus challenges, I suggest buying in bulk.  Another tip: instead of 1 packet, try using 2 to create a more concentrated saline needed for most CFers.

– Pocket Sized Disposable Pill Bags. These puppies are awesome.  We get ours at CVS but you can get them anywhere (including AmazonSmile).  Considering I don’t always trust that others are washing their hands as thoroughly as I might have (wink wink), this is the best way to skip that added stressor.  They simply open up the bag and use it to directly take the enzymes.  No touching; no worries.  I can pack a week’s worth of snack and lunch labeled baggies in less than 2 minutes.  You can either drop off with the nurse or teacher depending on your school’s regulations.  Some allow the child to just put it in their lunch box daily.  And oh yes, remember to have a few extras stashed with the school nurse, teacher, lunch lady, janitor… you get the point.

– Neosporin.  What doesn’t this magic do?  It’s wonderful at preventing and fighting infection.  I use a little dab on the end of a Q-tip and wipe the inside of each nostril.  I do this a few times a week (more often if I know of an event, bus ride, field trip, flight, etc.) to help combat things I don’t like living in his sinuses.

– Confidence is vital!  I don’t know about you, but when I am confident in something it silences fear.  There is an amazing book called Who I Am.  I have been reading Beckett this book for 3 years.  He LOVES it.  So much so that he brings it with him the first day of school.  He asks the teacher to read it to the class – I have also prompted the teacher this will be happening…  It makes him feel comfortable (and I think kinda cool) that a book is about him.  It clears up questions young kids might have when he is taking enzymes or nose spray or even when he wore a mask on their Farm Field trip last year.  Proven as much, not one kid said anything to him.  It was just what Beckett does, no big deal.  Check it out, read it, get it: http://issuu.com/brentrg/docs/pulmozyme_story_book

In closing, I think the best thing to remember when going back to school is this: The child is excited.  The first day of school is like winning the lottery to them!  They aren’t thinking of all the extras CF is hurling their way.  They probably don’t even know you have most likely met with their teachers, PE instructors, principal, teacher’s aides, or even that you are reading this entry… They just know they have a really cool new lunch box and a parent that loves them dearly.  Be excited for them, too!  I promise, you’ll make it – and they will thank you for it!

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Back to School on Oral Immunotherapy:  Prevention is Key!

by Dr. Inderpal Randhawa, M.D.

Food Allergy FullSizeRender

After treating nearly 600 patients with oral immunotherapy for nearly a decade, I am often asked what worries me the most.  From a parent’s standpoint, I would imagine the anticipated response will be a severe anaphylactic reaction during a visit updose/challenge or a severe reaction at home.  However, I believe in security during OIT.  Hence, the hospital based therapy and food challenges.  Similarly, the dosing protocols which limit the risk of a significant reaction to under 1 percent.  So what worries me the most with OIT?  The month of September.

September is back to school month.  After a predictable summer, the children on OIT now return to a bastion of bacteria, viruses, pollutants and more.  This is fodder for the immune system to react to.  It is most common, in my experience, to see a surge of mild reactions during home based therapy in September.  My advice is the same every year.  Prevent what you can and notify your physician prior to any OIT dosing if you see any signs of infection or increased inflammation.

The most common illnesses in September include:

  • Viruses (simple to complex colds)
  • Wheezing/Bronchitis
  • Sinusitis
  • Pharyngitis (strep throat)
  • Otitis media (ear infections)
  • Skin infections (pustules)
  • Gastroenteritis (diarrhea/vomiting)
  • Conjunctivitis (eye/eyelid infection)

What can you do to prevent a difficult September for your child?

  1. Lots of handwashing
  2. Use a safe nasal washing system after school daily
  3. Talk to the school teacher about sanitizers, wipes, and handwashing for all children
  4. Enforce the sick child policy (so sick children are sent home)
  5. Obtain a lung function test prior to school starting to ensure maximum lung function
  6. Monitor and limit activity on high pollution days
  7. Ensure your child’s technique for inhalers and nasal sprays is correct
  8. Avoid unnecessary visits to high risk areas (busy grocery stores, daycares, etc.)
  9. Apply the wash and change routine to all children and adults in the home. Many studies show the most common carrier of viral and bacterial pathogens are adults and older children.  The first thing to do when you get home?  Change clothes and wash down (hands, arms, neck, and face) with soap and water.
  10. Ensure a healthy classroom (refer to the American Lung Association healthy classroom checklist).

As always, if your child is ill during OIT, notify your doctor immediately PRIOR to dosing. 

Hopefully this September will be a smooth transition for all OIT patients.  Stay healthy!

 
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