ALLERGY RELIEF DRUGS
Allegra	Flonase
Zyrtec	Nasacort
	Nasonex

Allergy

1) What to look for to suspect allergies

2) Allergy treatment

3) Foods

1) What to look for to suspect allergies

Contributors:

1.1 What to look for - food allergies

Food allergies range from very mild to life-threatening. The mildest symptoms are vague itchiness in the mouth and throat. Other mild to moderate symptoms:

• general itchiness
• hives or rash, sometimes all over body
• runny/itchy nose and eyes
• recurrent earaches
• nausea and vomiting
• diarrhea

Some foods can cause a life-threatening anaphylactic reaction. The mouth, throat, and bronchial tubes swell enough to impede breathing. The person may wheeze or faint. Often there are generalized hives and/or swollen face. This is an emergency!! As anyone would, call your doctor or 911! For breathing trouble or loss of consciousness, call 911 immediately. See also the sections on insect stings and anaphylatic reactions.

One severe allergic reaction to food puts you at risk for more. Discuss with your doctor what to do for repeat reactions.

Common food allergens:

• peanuts: This is often life-threatening. Call a doctor for ANY reactions to peanut products! (Peanuts can be a hidden ingredient in a number of foods.)
• soy: again can be a hidden ingredient in a number of foods.
• fish and/or shellfish: in some people, these reactions can be severe, ranging from extreme nausea to breathing difficulties. Watch carefully and call 911 for any breathing problems.
• berries
• peppers
• milk proteins: (less common than you'd think - most people are intolerant not allergic).
• wheat (and gluten), as well as some other grains (corn, rye)
• eggs
• many reactions have unknown cause!

Interestingly, some common food proteins are similar enough to ragweed to cause reactions in sensitive people. These include bananas and melons.

Allergic reactions may progress from mild to severe, so keep track of any reactions.

Food allergies may be amount-sensitive. That is, you don't feel the reaction until you've ingested a certain amount; however, severe reactions may occur with ANY tiny amount of allergen. This is especially true of peanut allergies.

1.2 Inhalants

The most common inhaled allergen is dust! More precisely, dust mites and their wastes (every house has them, no matter how clean). Other:

• mold
• pollen (ie. hayfever)
• animal dander (especially cats)
• chemicals
• perfumes

• CLEAR runny nose and sneezing
• itchy or stuffed nose
• itchy, runny eyes
• lethargy
• asthma

1. pollen counts are highest
2. you've been sleeping for hours in a room filled with dust and/or mold

1.3 Asthma

On asthma: Not all people with asthma have allergies. Roughly 5% of the population lives with asthma.

A generally accepted definition of asthma is that it is a disease that is charaterized by increased responsiveness of the trachea (windpipe) and bronchi (main airway) to sometype of trigger that causes widespread narrowing of the airways that changes in severity either as a result of treatment, or spontaneously.

Acute asthma is what we generally refer to as an asthma attack. The bronchial tubes suddenly narrow, and the person is acutely short of breath, and (sometimes) wheezes. An acute attack may require medical stabalization in a hospital setting; unless special equipment, medication, and help is available in the home.

Chronic asthma produces symptoms on a frequent basis, in some cases almost constantly. It is characterized by frequent symptoms, ranging from very mild symptoms to full-blown acute attacks. Chronic asthma generally requires daily medication, and may require the use of oral steroids, in addition to other medications.

On doctors: Allergists are not the only physicians who treat asthma. Pulmonologists are also medically specialized physicians who treat many people who have asthma.

Not all asthma is triggered by allergies. Not all allergies cause or develop into asthma.

One main asthma trigger in children is illness. Typically a child has his first attack 1-2 days after the onset of a respiratory illness. Symptoms:

• wheezing (no wheeze may mean WORSE asthma, sometimes)
• elevated breathing rate: (normal under 25 breaths per minute, over 40 is cause for calling doctor. Test your child's normal rate when well, so you can tell when breathing is elevated. Remember: These numbers are just ballpark!
• coughing, especially early morning
• longer expiration than inspiration
• retraction

Asthma and reflux often co-occur, although it's not known what the relationship is.

Attacks may build over days (as with illness-induced) or hit within seconds. Generally, the more triggers present, the worse the attack.

In little kids, asthma is often misdiagnosed. Many little kids with recurrent bronchial illness really have asthma. Of particular note is "cough variant" asthma, in which the main symptom is coughing, especially early morning. My allergist's rule is "If ventolin [an asthma medication] helps, it's asthma," no matter what it's called.

1.4 Rashes, hives, and eczema

Allergies can show themselves through various skin reactions. The main reactions are rashes (small bumps or larger red patches), hives (also called urticaria; itchy, red raised patches on the skin), or eczema (also called atopic dermatitis; an itchy, weeping rash). These symptoms can have various causes. Most often it is allergies, but some people get hives from heat, cold or sun exposure.

Contact allergies/dermatitis is defined as a skin rash caused by direct contact with a substance to which the skin is sensitive. Symptoms include a red rash, swelling, and itching. In more severe cases, blisters can form. Many substances can cause allergic contact dermatitis: poison ivy and other plants (such as tomato plants), wool, perfumes and dyes (in soaps, detergents, lotions, etc.), metals (in jewelry, hair clips, etc.), locally applied medicinal ointments such as antibiotic creams, and latex (often used in latex gloves). These can occur at any age and can appear at any time. It can take years for a sensitivity to a particular substance to develop, so "I've used this for years" isn't a reason to exclude anything from the possible allergen list. Symptoms may appear as soon as 7 to 10 days from first contact. Once a sensitivity develops, however, the reaction can occur in 24-48 hours.

Treatment of contact dermatitis generally consists of avoiding the allergen. To determine whether or not something is the cause, patch tests (a small amount of the substance applied to the skin, then covered and left for 24 hours) can often show whether or not that substance causes the reaction.

Other allergies can cause rashes, too. Some find that citrus fruits cause small raised bumps when ingested.

Eczema is often caused by a food allergy, though there may be other causes. Cow's milk is a particularly common allergen for those with eczema. Avoiding allergens provides long-term relief, while short-term relief can be had by using moisturizers on the skin and taking antihistamines. Some find that using all cotton clothing and bedding makes a difference.

Hives can be caused by a number of factors, not just allergies. Hives occur suddenly and may end suddenly, though there are chronic cases where hives are present for a month or more. Other causes of hives are sun exposure, heat and cold. Again, avoidance is the primary treatment.

1.5 Insect stings

Various insects can cause allergic reactions. Wasps, honey bees, hornets, yellow jackets and ants are the insects most likely to cause strong allergic reactions. Some biting insects (mosquitoes, flies, lice, kissing bugs and fleas) can cause allergies as well because they inject saliva to thin the blood when they bite. Finally, some caterpillars are covered with hairs that contain a substance irritating to human skin and this can sometimes cause allergic reactions.

In general there are three kinds of reactions to insect stings. The first kind, normal reactions, involve pain, redness, swelling, itching, and warmth at the site of the sting. The second kind, toxic reactions, are the result of multiple stings. Five hundred stings within a short time are considered likely to kill because of the quantity of venom involved. As few as ten stings within a short time can cause serious illness. Symptoms of toxic reactions include muscle cramps, headache, fever, and drowsiness.

Allergic reactions are the third type. They may involve some of the same symptoms as toxic reactions, but may be triggered by a single sting or a minute amount of venom. Any non-local reaction to a single sting should be considered allergic until proven otherwise.

Allergic reactions may be local or systemic. An allergic reaction is considered local if it involves only the stung limb, regardless of the amount of swelling. A slight systemic reaction may involve hives and itching on areas of the body distant from the sting site as well as feelings of anxiety and being run down. A moderate systemic reaction may include any of the above plus at least two of edema (swelling), sneezing, chest constriction, abdominal pain, dizziness, and nausea. A severe systemic reaction has the symptoms already described plus at least two of difficulty in swallowing, labored breathing, hoarseness, thickened speech, weakness, confusion, and feelings of impending disaster.

The most serious symptoms are the closing of airways and shock (anaphylaxis) since they can be fatal if not treated quickly and effectively. Allergic reactions may begin within ten to twenty minutes after the sting or they may be delayed. Usually, the sooner the reaction starts, the more severe it will be.

1.6 Children vs. adults - differences

Allergies can show themselves in a number of ways - runny noses, ear infections, digestive disorders, irritability, hyper- and hypo- activity, and such. Adults are often more sensitive to "not feeling right" than children are, so look for indicators such as changes in behavior or chronic/repeated sickness the corelates to exposure to various substances (foods, air-borne particles, chemicals, etc.). Recurrent stomach aches, never-ending ear infections, or changes in bowel habits may indicate that an allergy is present. In infants, colic, formula intolerance, frequent spitting up, and low-grade fevers can be signs of allergies. Note that allergic reactions will not occur on first exposure to the allergen; they require that initial "priming." Some may occur on second exposure, while others may take repeated exposure to develop.

For infants, breastmilk is the safest food, in terms of allergies. Some children are allergic to or intolerant of cow's milk, soy formulas, and such. The best advice is to experiment until you find what works for your child. (Some mothers report that the mother's consumption of cow's milk will cause a reaction in a breastfed child; this has been confirmed by medical experts, so you may need to check this if your child is breastfed. References to this and other infant issues are given at the end of section 8. )

When a child is born, the intestinal track is not fully developed. Some foods may cause a reaction in babies that will be outgrown as the child matures. The safest course is to introduce new foods one at a time over an extended period (say, one food per week) and see if the child has an allergic reaction. Postponing the introduction of common allergens (wheat, cow's milk, corn, eggs) and favoring the introduction of almost-always-safe foods (rice, apples, bananas) is one sensible approach.

For older children, allergies can have any of the symptoms above. If a child is extremely reluctant to eat a particular food, there may be an allergy problem that shows up as a stomach ache (common in milk intolerance) or other non-visible way. On the other hand, while most children will avoid foods which make them really sick, some may NOT make the connections when the allergy is mild. So parents need to listen to the child and use common sense and detective abilities to help determine the problem.

Children may outgrow some allergies, or at least become less sensitive to some allergens. Parents may want to retry foods after a long period. NOTE: if the allergy is a severe one, do NOT retest the food on your own! Do this only under the supervision of your doctor! For less severe allergies, you can first test the allergen by rubbing a bit on the child's wrist (inside) and see if a skin reaction occurs. If no reaction occurs, let the child try a very small amount of the food. Again, if no reaction occurs, let the child try a slightly larger amount. The child may never be able to eat a lot of the food but may be able to tolerate small amounts after a "rest" period away from the allergen.

1.7 Views of allergies

There are a number of views about allergies. Most doctors agree that not all allergies are "all or none"; you may be able to tolerate a certain amount of an allergen without reacting. Once you exceed a certain amount, your body reacts. NOTE: this is not true of all allergens, especially peanuts and shellfish, which may cause quick, life threatening reactions. For some allergens, any amount is too much!

Your doctor may use various metaphors when discussing allergies. Most have to do with some threshold amount of allergens that a person can tolerate. Once this amount is exceeded, allergic symptoms appear. ( One common term is "glass of resistance" - once the glass is full, you react). The amount of allergens tolerated can depend on a number of things: stress levels, the particular allergen, the combination of allergens, illness, etc. As time goes on, an allergy sufferer can determine just how much, if any, of what is ok. For food allergies, some recommend a rotation diet in which various foods are eaten in rotation so that no one food is ever eaten more than once in a three-to-five day period. (The food juggling gets very complicated, but some find that the rotation diet helps them. The best thing to do is read about it [see references section] and decide for yourself.)

2) Allergy treatment

2.1 Doctors: see an allergist!

For both asthma and allergies, a doctor in general practice may not recognize allergies. Some doctors do recognize and treat allergies while others do not. An allergist (sometimes listed as "Allergies and Immunology") specializes in this particular area and are up-to-date (we hope!) on treatments. As with any doctor, it is good to get recommendations from your doctor, friends, or professional orgnizations. If you are not comfortable with one allergist, try another. For children, there are allergists who specialize in pediatric allergies or advertise that they treat children. Though any allergist can treat adults or children, it sometimes helps to have one who definitely *likes* children and respects the differences between adults and children.

ASTHMA: Pediatricians seem reluctant to use the term asthma. This bugs my allergist (and me), because he feels it precludes proper treatment sometimes. If you see any asthma symptoms and are poo-pooed by the pediatrician, see an allergist! This seems most often the case with an allergic kid who coughs every morning. I've heard MANY stories of pediatricians who, at most, tell parents to use an antihistamine (worse, cold medicine; worst, don't worry). Then the child ends up in acute distress in the hospital!

Allergists are most up to date on asthma treatment, which really matters. Allergists can often pinpoint particular allergens to avoid, from testing or only history! Allergists will tell you which environmental changes to make.

2.2 Tests

Blood tests can be done to look for elevated white blood cell counts, level of particular antibodies, or for reactions with allergen extracts. Blood tests are not 100% reliable and, to get good results, must be done by highly trained lab technicians. Some doctors use these tests, while others prefer not to. The patient will need to have blood drawn for this, which may be a drawback for testing children.

"Scratch" test involves scratching the skin, then dropping liquid allergen on the scratch. It's done on the arm or (for very small children) the back. It seems to hurt a little, but may be scary to little ones. [Ed. - it doesn't hurt much; it's just annoying.] Each slate has up to 6 tests, plus positive (histamine) and negative controls. Bumps/weals for a reaction appear immediately or several minutes later. The patient must remain in the office in case of severe reaction (rare).

A positive reaction is reliable, but a negative reaction may not be; that is, you may be allergic but not react. Skin tests are more reliable for airborne allergies than for foods.

Elimination diets are the only guaranteed way to determine food allergies. The patient goes on a *very* restricted diet, composed only of foods that rarely cause allergy problems. A new food is added each week. If the patient does not have any allergic symptoms to the new food during that week, then it is not considered an allergen. A new food can be added the next week. If the patient has a reaction to the food, the food is considered an allergen and removed from the diet. The patient then goes back to the previous diet until all symptoms are gone for three days; then a new food can be added.

This is a very slow way to build up much of a varied diet, but it is certain. In adding foods, you must be careful that it is only one food that is being added. This means no processed foods (may have additives), no pre-packaged foods (may have additives), no seasonings (except salt), etc. This can be very difficult to follow if you eat out for any meals. Generally safe, non-allergenic foods usually include apricots, peaches, pears, beets, sweet potato, rice, distilled or spring water, cane sugar, salt, tapioca, olive oil, lamb and chicken. (Not very exciting..) Your doctor may give a different list, based on your personal situation. It is fairly easy to put a young baby on an elimination diet, but it gets harder as the child gets older. For very young children, this should only be done under a doctor's supervision (unless the child is exclusively breastfed) to insure a balanced diet.

If the original allergic reaction was moderate or worse, you must challenge test when adding a suspected new food. That is, you start with a pea-sized piece. If no reaction, on day 2 try a 3-pea-sized piece. No reaction, day 3 try a 9-pea-sized piece. Discuss this with your doctor. ALWAYS get instructions beforehand (and medicine, if necessary) on what to do for a severe reaction. If the original reaction was severe, your doctor will want to do this at his office or at the hospital.

2.3 Medications

OTC antihistamines - most are sedating but may overexcite kids or cause hallucinations (in me, some do). For example, benadryl, brompheniramine. Benadryl is the drug of choice for an acute allergic attack because it is effective within 20 minutes, reaches maximum effectiveness at an hour, and wears off in 6 hours.

OTC decongestants - only help stuffy nose. May excite.

Other antihistamines such as seldane (12 hour) and hismanol (24 hour) - for adults only! May or may not work. May have severe side effects - talk to your doctor. Some, such as Guaifed, are available in dosages for children; your doctor will have to decide whether these are appropriate.

Sodium cromolyn (nasalcrom nosespray for allergies, intal by nebulizer or in- haler for asthma). Prevents mast cells from reacting, preventing allergic reactions. Takes at least a week for enough to build up in body, so needs to be taken regularly as preventative. Not useful for current symptoms. No known side effects. Won't work for some people.

Steroid nasal sprays [beconase, rhinocort] also prevent and reduce inflammation, but need several days of use before they are fully effective. They must be used daily in order to remain effective. Great preventative! Often works better than nasalcrom in adults.

Antihistamine eyedrops (optcon-a, vasocon-a) - immediate relief for 8 hours. Works, but stings.

Bronchodilators [Ventolin, Bricanyl] - to open bronchial tubes for immediate relief from attack. Nebulizer most effective in acute attacks, then turbuhaler [not yet available in the US], then metred-dose inahlers and dischalers/rotohalers. Oral preparations [syrups, tablets] are least effective, requiring higher dosages to achieve the same effect as mDIs, and having generally significant side effects [because of the oral route]. These can makes kids hyper, grumpy; they make me shake. Great for occasional use. Most often used to treat acture asthma flare-ups, although some asthmatics must take them daily in addition to other medications. If you need to use bronchodilators more than twice a week , discuss with your doctor the use of an anti-inflammatory medication or other appropriate medication (Ex. intal, steroid, or theophyline).

Epipen/AnaKit (epinephrine autoinjector) - an autoinjection (shot) most commonly given for anaphylactic reactions. Carry this with you at all times if you've ever had this severe a reaction!

Nebulizer vs. inhaler (puffer, MDI) for intal and ventolin: Some individuals have poor reactions to [including having asthma attacks triggered by] the propellants in MDIs and cannot use them. Also, most children can't manage them until age 5, though some can manage at a younger age (some as early as 3). Children should use them with a spacer.

The nebulizer is a machine which drives air through liquid medication to make mist for a patient to breathe. Treatment takes 10-20 minutes. This is the most effective delivery system. Adults use a mouthpiece. Kids use a mask; if they refuse, you can blow the mist at them by mouthpiece.

Other alternatives to MDIs include rothalers and dischalers, which are powder inhalers, and a turbuhaler [not yet available in the USA], which is a breath-activated inhaler containing a very fine powder form of the drug. Turbuhalers contain ONLY the pure drug; there are no propellants, preservatives or other compounds present. Turbuhalers are more effective than MDIs, and some Paediatric ERs have switched to using Turbuhalers in the place of mask treatments for non-severe attacks. Turbuhalers should be available in the US within the next year; both inhaled corticosteroids and bronchodilators are available in turbuhaler form [e.g. Bricanyl and Pulmicort].

2.4 Desensitization (injections)

One treatment for inhalant allergies is desensitization. This is not available for food allergies.

In desentization treatment, the patient is injected with small, dilute extracts of the inhalant allergens. The dosage is gradually built up, until the body is less sensitive to the allergen. This is a slow process, involving months to years for a complete treatment, though there is benefit even after a few months for many. Initially, the patient receives two shots per week. This is reduced to one shot a week, then one every other week over time. The initial treatment, however, involves visits to the doctor (or a medical place that will do the injections) rather regularly. The actual time to get the injection is about 20 minutes - the injection is quick, but the patient is usually asked to wait in the office for about 20 minutes to see if a reaction develops. These reactions occur in a small percentage of patients but they need to be treated promptly.

Desentization can also be used for insect sting allergies. Your doctor will know whether this is an appropriate treatment in your particular case.

2.5 Avoidance and environmental changes

For most allergies and asthma, the best treatment is to avoid the allergen. This is easier for foods and more difficult for inhalant allergens.

For food allergies, a number of books have been written with recipes and advice. The list of resources below give some ideas. Altering the diet to exclude certain foods can be easy if the food is relatively uncommon or is easy to spot. For example, shellfish, melons, citrus, and bell peppers are usually easy to spot and avoid. Foods like eggs, wheat, corn, peanuts and milk are harder to spot as they may be hidden ingredients in a number of foods. Many recipes are available that are easy, tasty, and avoid the allergen. Although some change in diet is inevitable, it is not a death sentence; most people do not have to cut out social events or change their lives radically.

For inhalant allergies, avoidance requires more work. For seasonal allergens (pollens), try to stay indoors as much as possible and avoid going out during peak pollen times ( usually early mornings). Filter masks are available to prevent breathing in allergens if you must be out. For year-round and household allergens (mold, dust, dander), the best approach is minimizing places for the stuff to gather. Patients are usually advised to remove curtains, carpets, and unnecessary clutter. If anything is left :-), make sure it is easily washable and wash it frequently. Vacuum often; once a day is recommended by some. Make sure allergy-prone people (especially asthma sufferers) are out of the house before any painting, waxing, or other heavy-duty fume- producing activity occurs. Air filtering systems are available for individual rooms and as whole-house systems. (See resources section). Furry pets are a big source of dander, so it is best not to have pets or, next best, keep them outside. Absolutely keep pets out of bedrooms at all times. Tobacco smoke is irritating to many allergic people, so this should also be eliminated or kept outside.

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Cleaning the Home Environment:

Invest in an electrostatic filter (plastic frame $27.00, metal frame $60.00 up to $100.00) if you have a heating system that accepts changeable filters. It saves on the throwaway filters, trips to the doctor, allergy medications and misery for several months a year. But you MUST wash it out once a month to clean the pollen and keep your pump working at top efficiency.

It may pay to have your air circulation ducts professionally cleaned, to get out old dirt, pollen, pet dander. Use the phone book, call heating/cooling specialists for recommendations. This may be especially useful if you are moving into a used house.

If you take prescription allergy medications like Seldane (.92 each pill) take that when you need to be awake, but take a cheaper, over the counter medicine at night (if it has the effect of making you drowsy, not irritable). Suggested by my pharmacist.

Suggested by my doctor: During the allergy season buy one bottle of nasal saline spray and then make the refill solution yourself. By spraying the nasal passages, you rinse out the irritating pollens. This can cut down on the need for medication and overall discomfort. But you must remember to do it after every time you go outside. The refill is just one teaspoon of salt into 1-2 ounces of water, stirred until dissolved.

If you have forced air vents, put cheesecloth or air conditioner filter in each one. Keeps dirt from the vents and air system from entering the house.

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Health Insurance:

If a Health Insurance provider with whom you have a prescription payment plan excludes a medication, challenge them. I have done this 3 times and each time won (over $200.00) for some time on the phone using their 800 number. On two occasions the data entry person just hit the wrong key. On the other my pharmacist spoke with them and proved that my four year old could not take the over the counter equivalent they said he should be getting. (Wrong dosage for his size, not chewable). Just remember to stay calm and polite and have all the facts and policy numbers at hand when you call.

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Sources for Products of Interest

Provide free (with orders?) pamphlets on Cat Dander, House Dust/Mites, Understanding Vacuum Cleaners Vacuum Exhaust and Allergen Containment, Mold Spore Allergy. Products include: special mattress/pillow covers, blankets (Vellux), room cleaners (filter room air), face masks, vacuum filters (don't let the dust/dirt back out of vacuum), high filtration vacuum cleaner bags, Miele canister Vacuum cleaner, filters for A/C, and central heating systems, Allergy Control Solution (neutralizes dust mite and their feces, a primary allergen for many people).

I have used their vacuum filters, Allergy Control Solution and mask. All very good and extremely helpful.

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Information on Food Allergies

Non-profit organization that puts out a newsletter ($18.00US 6 issues/year) on food allergies, that covers allergy-related subjects such as eczema, allergen-free recipes, drug updates, news updates, a dietician's column. They also sell a number of reasonably priced booklets and cards to help you cope with schools, information on anaphylaxis (potentially lethal allergic reactions), how to read food labels so as to avoid allergens (ex. soy products go by many names in packaging). Sample newsletter and information sent on request.

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Sources of Food Products for Special Diets, Allergen Free (or Substitute) Products

You can call them for their free Allergy packet of information. They manufacture and sell baking mixes, ready-made baked items, recipes (sorted by 45 dietary criteria) and specialize in products for those on gluten-free, wheat-free, egg-free, corn-free, soy-free, milk-free or low protein diets. The order form groups products by what they DON'T have (ex. wheat, eggs) and tells you the ingredients for each item. Sold by single package or by the case. Some of their products can be found in good health food stores. But if you want to buy it in bulk and save a decent amount of money, try one package from either a store or the manufacturer to see if you like it, and then place a bulk order with Ener-G. They also sell products for people with renal failure and malabsorption syndrome (Celiac-Sprue).

2.6 Children vs. adults - TBD

3) Foods

3.1 Overview

Allergies are an immune system reaction to substances that don't harm most people. This can include pollens, dust, foods, cosmetics, and such. The body produces antibodies to neutralize the foreign substance, which triggers the release of histamine, which produces what we see as allergies or asthma. Treatment can work on any part of the process: avoiding the allergen, reducing the production of histamines, etc. Allergies should be taken seriously; most allergic reactions are merely annoying but some can be life threatening.

A number of people find that the most likely food to cause a problem is one that you eat the most frequently. In fact, some people report that they have an almost addictive craving for that food.The craving may be more intense if you have had the food in the past day or so. The more of it you have, the more intense the craving becomes. This can be a clue as to the foods to suspect in your initial search for allergens. Common foods to think about are milk (and milk products), wheat (and wheat products), corn (and corn products), and eggs. These are common foods in Western diets to which many people are allergic.

3.2 Adverse Reactions to Milk

When the term allergy was coined, it referred to a broad category of adverse reactions to substances. Today, allergy specifically refers to an immunologic interaction between an allergen and an antibody. Other adverse reactions are now typically referred to as intolerances. Extreme food allergy leading to anaphylaxis or asthma requires special treatment; otherwise, for both intolerances and "true allergy", the only real solution is avoidance (with a couple exceptions). This section of the FAQ deals specifically with milk sensitivity, whether lactose intolerance or milk allergy.

Lactose Intolerance

Lactose intolerance is the inability to digest lactose, found in animal milk (including human milk, which, in fact, has about twice has much lactose as cow's milk). An enzyme called lactase is required to digest lactose. When this enzyme is missing, the following symptoms may occur: abdominal cramps, diarrhea, gas, a feeling of bloatedness. Symptoms may occur within an hour, or up to several days later. The intensity of symptoms varies widely.

Diagnosis

Lactose intolerance can be self-diagnosed by eliminating milk and dairy products from your diet for two weeks, then reintroducing milk (a glass or two), and seeing what happens. Your doctor can administer a couple of tests to confirm lactose intolerance (basically involves drinking a sweet drink containing a lot of lactose on an empty stomach and monitoring blood levels of glucose - no rise in glucose means the lactose is not being absorbed; the other involves checking breath levels of hydrogen).

Treatment

If you are diagnosed with lactose intolerance, you have a variety of options. Lactase is available by prescription (Lactaid), and can be added to milk (drops) or taken with food containing dairy products (tablets). Some people may have adverse reactions to this medication, however (in tablet form - the reaction is believed to be allergic. Drops seem to be ok.). Lactose reduced milk and cheeses are available in some areas. Aged cheeses, yogurt and sour cream may be tolerable (most of the lactose has already been converted). You can find your level of lactose tolerance by either cutting out dairy products entirely and slowing working them back into your diet, or you can slowly eliminate them until you stop having difficulties. Tables indicating lactose content for milk and milk products are available (see Zukin below).

Some believe that lactose intolerance is, in fact, the human (and mammalian) norm, rather than an aberration, citing in support statistics that indicate most of the world's population is lactose intolerant (Europeans and those of European descent being the exceptions), and the tendency to lactose intolerance with increased age.

Milk Allergy

Milk allergy, on the other hand, involves an allergic reaction to one or more of the proteins in milk (casein, lactalbumin, lactoglobulins). An allergic reaction to milk may include: eczema, rash, mucous buildup, wheezing, asthma, rhinitis, pneumonia, anaphylaxis. The type and severity of symptoms varies widely. Because a true milk allergy may involve mast cells in the mouth and throat, it is possible to have an allergic reaction to milk or milk products before they are digested. It is possible to be both lactose intolerant AND allergic to milk.

Diagnosis

The bad news is, diagnostic tests for milk allergy — for food allergy in general — are hit or miss. One source I have claims that a negative is accurate, but false positives are common. Another states that the extracts used in allergy tests tend to lose potency quickly so you might test negative on a test and STILL be allergic. Elimination diets are the best test you have available to you. If you suspect milk allergy, eliminate milk and milk products for two or more weeks, and see what happens. If you can convince your physician to conduct a double-blind test on you, you may be able to confirm the diagnosis.

Treatment

The worse news is, no cure is available — avoidance, and symptom control via antihistamines, etc. are the best you can do. (For now, at least, this is true of all food allergy, at least according to the conservative medical community — but research is ongoing. I have a reference to a study by the National Jewish Center for Immunology and Respiratory Medicine in Denver which claims successful desensitization to peanuts in people who had a life history of allergic reaction to them. There's a dim hope, at least.)

[The National Jewish Medical and Research Center in Denver has prepared a report about successful desensitization to peanuts in patients with a life history of allergic reaction to them.

The address for that group is:

Nutritional Implications of a Dairy-Free Diet

That enough? No? The primary source of calcium for most Americans is milk or milk derived. If you discover you are unable to consume milk or milk products — whether because of lactose intolerance or milk allergy — you should seriously consider calcium supplementation. Unfortunately, you may discover (as many do) that these, too, cause intestinal distress (read: pain). If so, experiment with different types of calcium (calcium citrate was the least distressing of all the ones I tried). If you discover none of them work well, you may want to cut down your meat consumption; some studies suggest that too high levels of dietary iron may be a more important factor in osteoporosis than lack of dietary calcium (mechanism speculative - this also implies not supplementing iron unless you have an actual deficiency. Talk to your doctor about all supplementation, of course). You may also need to supplement vitamin D.

You may need/want to check with a dietician or nutritionist about your or your child's diet. One suggestion is choose a calcium supplement with a 2:1 ratio of calcium and magnesium. S. Rogers, Tired or Toxic?, considers this ratio VERY IMPORTANT. Other nutritionists have also backed this ratio.

Where to Find Help

If you are lactose intolerant or allergic to milk and choose to stay on a no-dairy diet, there are cookbooks out there to help you. The most readily available seems to be:

• The Milk-Free Kitchen: Living Well without Dairy Products by Beth Kidder (1991, ISBN: 0-8050-1836-0)
• Dairy-Free Cookbook by Jane Zukin
• Raising Your Child Without Milk by Jane Zukin

While Ms. Kidder devotes some pages to discussion of allergy, intolerance, and eating out, Ms. Zukin's commentary extends to 70 pages, and is very informative. Many of the recipes included call for "milk substitute" - but, to be fair, you're also told where to find rice and soy milk, among other things. The two cookbooks are complementary.

Vegan cookbooks can also be very useful, if you can find one. If you have Usenet access (and it seems likely, if you're reading this!), you might consider hanging out on rec.food.veg or rec.food.veg.cooking a fair number of vegan recipes are posted. Also, vegetarians typically have some good advice on coping with a non-standard diet. (See the essays AARS essays and guides page, especially AARS cooking, food, and nutrition page and The Recipes Folder on the Web.) There is now a mailing list for people following a milk/casein/lactose-free diet.

Both Zukin and Kidder emphasize that eating out — whether at restaurants or at the homes of friends or relatives — can be difficult, and provide information and suggestions to help you cope. They also emphasize the need to read the labels on everything you buy or eat — milk derivatives are found in the most unexpected places (e.g. the batter on fried chicken), masquerading under bizarre names (e.g. sodium caseinate). While the lactose intolerant may be able to cope, the results for the milk allergic can be severe.

So while you may not have any difficulty digesting milk, if someone asks you whether a food item contains milk or milk products and you are not certain, please, please, please answer honestly. Some people react very strongly to very small exposures. This is not a preference. When a person declines to eat a certain dish on the grounds of allergy, don't waste your time or their patience with arguments about how good it is, or how little (insert allergen here) is contained within. They know their problems best; it is no insult to you.

3.3 Gluten (wheat) and grain allergies

Allergies to grain products can be hard to pin down. Grain products are ubiquitous. Most allergic reactions are quite mild, but some can be quite severe. Usually the symptoms are a runny nose, red eyes, and such, but grain allergies can also cause digestive troubles.

A common allergy is to gluten, a mixture of proteins found in wheat and other grains (rye, oats, barley etc.). Gluten is the portion of flour that gives a porous, spongy texture to bread. It is also used as a base in cosmetic powders and creams. Reactions range from runny nose and itchy eyes to upset stomach to severe gas. In children (and adults!), personality changes can be a symptom - inability to concentrate, irritableness, crankiness, difficulties with mental alertness and memory. Some research indicates there may be a connection between attention deficit disorders and undiagnosed gluten allergies.

Gluten allergies can also cause dermatitis herpetiformis (D.H.), a chronic benign, skin disorder characterized by an intense burning and itching rash. A new unscratched lesion is red, raised, and usually less than 1 cm in diameter with a tiny blister at the center. However, if scratched, crusting appears on the surface. The "burning" or "stinging" sensation is different from a "regular" itch, and can often occur 8-12 hours before a lesion appears. The most common areas are the elbows, knees, back of the neck and scalp, upper back, and the buttocks. Facial and hair-line lesions are not uncommon; the inside of the mouth is rarely affected. The rash has symmetric distribution. Medications are available to treat the problem, but elimination of gluten is a long-term answer.

Severe reactions to wheat occur in the condition known as Celiac-Sprue [note: this may not be a true allergy, but I will include it here.] For people with this condition, the intestine reacts strongly to gluten products. The small cilia on the intestinal wall gradually flatten, reducing the ability of the intestines to absorb nutrients. This is a serious condition leading to malnutrition. The treatment consists of avoiding wheat and gluten in any form. In Western cultures, this can be VERY difficult. Remember that other grains such as rye and oats can cause problems, since they contain small amounts of gluten. It is unknown whether a child will outgrow this condition, but the current safe opinion is that gluten must be avoided for life. More information is available from several support organizations. (See resources list for a mailing list.)

It can be difficult to avoid gluten in processed foods. It's used as a starch, binder, bulking agent, formulation aid, stabilizer, shaper, thickener, emulsific filler and as a glaze. Some foods labeled "wheat free" may still contain gluten. Even things like lip gloss, make-up, shampoo and hand cream can contain gluten.

It is possible to have good food without eating a wheat based diet. You will have to investigate the various options and see which suits your situation best. A number of cuisines are not based on wheat and provide alternatives around which to center your diet. Chinese, Indian, and other Asian countries often center the diet around rice. Some Eastern European countries use other grains such as millet, barley and buckwheat.

A number of substitutes for wheat in baking are available. If you can tolerate some gluten, rye and oats can be used. These do not make a baked product exactly like wheat, but do make an acceptable one. For gluten free baked products, a mixture of rice flour, potato starch flour, and tapioca flour can be used. (Recipes given below.)

Any baking done without wheat will take practice; you have to learn a whole new way of doing it. The products are not exactly like wheat products but are tasty and satisfying. Most are as easy to make as the wheat version (after a few initial failures while learning). For many cookies and cakes, the results are very good. For breads, the results are better termed satisfactory but still quite good in their own way.

Corn is another potential allergen, distinct from gluten allergies. As with wheat, corn products are found in any number of products. Corn starch is used as a thickener for many foods, as a base for cosmetics, and to prevent sticking. Corn sugar is used as an ingredient in many sodas, bottled fruit drinks, baking mixes, and such. It is also used in the glue for envelopes and stamps, in cosmetics, as a pill coating, in processed foods, and spice mixes. Symptoms range from skin rashes, runny nose and itchy eyes, to asthma.

3.4 Allergy Cookbooks

3.5 Unknown food allergies

Some food allergies are very hard to pin down. An elimination diet (described above) is the only sure-fire way to determine the specific cause. Some items to consider when trying to track allergies down are:

• wheat
• milk
• seafoods
• peanuts
• eggs
• corn (includes corn syrup and corn starch)
• citrus fruits
• yeast
• molds (includes cheeses, etc)
• mint
• tomatoes
• green peppers

• preservatives
• food colors
• additives

Remember that almost anything can be a potential allergen to somebody.

A number of other illnesses can be related to the diet or the environment. Various claims have been made about yeast, sugar, and other foods as causes of various illnesses. This has not been accepted by some physicians, but the ideas can be kept in mind if untreatable, chronic symptoms occur. Some air borne compounds affect some people more than others. Again, this can be kept in mind if untreatable, chronic symptoms occur. DISCLAIMER: Any treatment should be under the direction of a physician!

3.6 anaphylactic reactions - when to call 911 immediately

Anaphylactic reactions are general, dramatic reactions that can result in collapse and possibly death. It is caused by a sudden release of histamines and other chemicals that overwhelm the body. The onset is usually quite rapid and symptoms occur within minutes. Death can potentially occur immediately or within two hours.

The first sign may be swelling and redness of the skin or may be a non-visible internal reaction such as swelling of the airway, a drop in blood pressure, shock, or nausea. The allergic person may also have a feeling of great anxiety.

Immediate action is needed. Persons who know they are prone to these reactions (allergies to peanuts, shellfish, and insect stings can be of this type), should consult with their doctor about a small emergency kit to carry with them. For this type of reaction, call for medical help immediately. Minutes are vital.

Standard treatments used to control the reaction are epinephrine, oxygen, and intravenous fluids. Antihistamines and corticosteroids can also be used. The person needs to be under medical supervision until the reaction is under control.