Allergy Doc, Allergy DadArticle from Ener-G Foods

Allergy Doc, Allergy Dad

Alicia Woodward, Living Without (Fall 2006)

This physicians takes food allergies personally
If pediatric allergist Harvey L. Leo, MD, were to describe a philosophy behind his medical practice, it might be that he tries to walk a mile in his patients’ shoes. For Leo of Ann Arbor, Michigan, understanding a patient’s experience is a part of medical treatment.
Leo’s attitude may have started years ago when he served as a physician at a diabetes summer camp, directing the care of 150 children. He and his wife Anne, a school teacher, actually lived with the kids, eating with tem and sleeping alongside them. The experience was an eye-opener.
“I’d been a doctor for a while but I hadn’t really understood what it was like to live with a child with Type I diabetes, the worry parents have every waking moment. Is he eating the right thing? Why doesn’t she eat? Is he getting enough medicine?”, says Leo, 34. “Until then, it hadn’t dawned on me – or my wife – that this was hard. This never goes away.”
He took the lesson with him into his private medical practice at Allergy and Immunology Associates of Ann Arbor. To that end, he tasted all the medicines he now prescribes (“No wonder kids don’t like that one. It tastes lousy!”) and has undergone every medical procedure with which he treats a child (“I tell kids and their families how they feel so they know what to expect.”).
Even at home, Leo, an amateur cook, experiments with new allergy recipes in the family kitchen, baking up egg-free and milk-free items and trying out the gluten-free diet.
“What’s it like to not eat this food every single day? Maybe it’s a lot harder than you think but maybe not. I wanted to find out so I could talk about it with my families,” he says. “So I tell people, look, it’s doable.”

Make It Personal
About two years ago, Leo noticed a stubborn rash on his 2-month-old daughter, Miriam. His wife had used a little mineral oil during a baby massage, causing irritation on the baby’s skin that had blossomed into a persistent red, flaky patch. Examining Miriam with an allergist’s eye, Leo had a sinking suspicion. He called in two friends, both doctors, to check it out.
“As a pediatrician and an allergist, I had a felling – but as a father, I just didn’t want to wish one of these rashes on my kid,” Leo says. “We all looked at my daughter’s rash and we all said, yeah, that’s the rash.”
He ran a panel of blood and skin test on the baby. Results pointed to a food allergy: Miriam was allergic to peanuts.
“It was devastating news,” Leo says. “Every day I tell families that their children have food allergies or eczema or some combination thereof that their child can’t eat this or their child will die if they come across that, etc. I had the same sort of discussion in my head about my own child.”
According to the Food Allergy Initiative, the majority of food-allergic children under five (almost 85 percent of these kids, says Leo) has allergies to only a handful of substances – peanuts, milk, wheat, egg, tree nuts, shellfish, fish and soy. An allergy to peanuts is one of the most common – and often the most serious – because it can lead to anaphylaxis, a potentially fatal IgE antibody-triggered reaction. Symptoms of a peanut reaction, which can occur immediately or over a period of up to two hours, can range from hives, rashes, runny nose to gastrointestinal distress (vomiting, diarrhea, nausea), swelling of the mouth, tongue airways (causing wheezing and obstructed breathing) and shock as blood pressure drops. Some people are so sensitive that just the smell of peanuts in the air or second-hand contact (e.g., kissing someone who has just eaten peanut butter) can prompt a response.
“Reaction can be mild, like a rash, to life threatening – or nothing at all,” says Leo. “In many cases, a child will not outgrow it.”
Leo says the odds are better for milk and egg allergies.
“Assuming it’s diagnosed in infancy, under a year of age, a child has about an 80 percent chance of outgrowing a milk or egg allergy by the time he’s 4 or 5 years old. That’s why you’ll hear parents say that their baby was sick, throwing up, crying every time he ate milk but got better at five,” he says. “Peanut and tree nut allergy are almost the reverse of that. Depending on whose data you look at, just 10 to 20 percent of kids diagnosed early in life will outgrow it by age four or five.”
By analyzing blood work, considering a child’s history and ultimately performing an oral challenge, doctors can potentially “tease out” the children who might be the lucky ones.
“Peanut allergy is specific to each child. But the science has gotten much better in the past few years that there sare some indications we can track kids. If we identify them early and do the right thing, we may be able to do something to help them outgrow it,” Leo says.
He urges parents to check with their child’s pediatrician and then work closely with a “a reputable doctor specializes in childhood food allergy.”

On the Rise
The incident of peanut allergy has spiked over the past decade, with the number of U.S. children diagnosed under age five doubling between 1997 and 2002. The allergy affects 0.6 percent of the population, according to the National Institutes of Health.
“It’s not just peanut but all food allergies in general, as well as diseases like celiac disease and diabetes, are becoming more prevalent,” says Leo. He feels the rise is “generally plateauing off” but admits to being frustrated by the increase. “Right now, roughly 3 to 5 percent of this country’s kids under five have a milk or egg allergy. Of course, we have all these academic discussions as to why.”
Theories abound. Peanuts introduced to children too early? Babies sensitized by drinking soy formulas? Environmental considerations like pesticides, herbicides, pollution? Too much processed food? Vaccinations? And then there’s the hygiene theory.
“The hygiene theory is this general idea that our young children’s immune systems are no longer being challenged as they were meant to be – living on a farm, living next to the goats, running around dirt all day, that sort of thing – and that the immune system, which is programmed to fight parasites, worms, bad bacteria, disease, gets bored,” Leo says. “In the non-industrialized world, people are having babies in fields, in dirt huts, in not-so-clean environments, while here we’re so sanitized. For all our cleanliness, for all the baby wipes you’ve ever bought, all the scrubbing, the cleaning with antibacterial soap, all the vaccinations, and the antibiotics your kids get at the fist sight of this and that, the immune system doesn’t really know what to do. And so it freaks out against the first challenge it sees, which is food. India, China and South America don’t have the food allergies issues we do. Mind you, their kids are dying of typhus and other old-fashioned diseases but they’re not dying of peanut allergy.”

So what’s a parent to do?
“I’m not advocating you to pick up some cow dung and expose your child,” says Leo, with a laugh. “The hygiene theory is fine but it has nothing to do with what’s happening to your kid today. It’s just as observation of our lifestyle. When it comes to my child or your child, it’s all a crap shoot as to who will develop a food allergy. Look at studies of identical twins. Both can get a food allergy but sometimes one will get it and the other won’t. We don’t know why. It’s as much genetics as it is environment.”

A Family Affair
The standard treatment for food allergy is avoidance of the allergen. For Leo, it’s a family affair and his patients’ parents are expected to be proactive. After their child is diagnosed with a food allergy, he gives parents “marching orders,” including required reading as homework.
“This is a very different lifestyle. The day parents hear that diagnosis is the day their lives change forever,” says Leo. “A passive parent has to become active one. They’re going to read labels and pay attention like they didn’t have to before. They’re going to have to learn. I expect parents to return in two weeks with questions. If they don’t have questions, I confront them. It means they haven’t done the reading.”
After that, he sees a child at least once a year so that he can prepare families for what to expect as the child grows.
“I’m not treating a child just when he’s diagnosed; I’m trying to incorporate a plan of how to treat that 6th grader, that teenager,” Leo says. “Kindergarten, first grade, middle school, these are challenging transition times for all kids – but food-allergic kids carry extra burdens. How do you deal with hot lunches? Field Trips? School buses? Parental anxiety comes when nobody tells them what to expect or what to do.”

School Days
Leo holds an academic position at the University of Michigan School of Public Health. He shares his medical expertise with Ann Arbor’s school district where he tracks the incidence of food allergies. Unlike other non-communicable diseases, food allergies affect the entire community.
“Whether or not your child has health issues, this is a disease that influences how you raise your child. When a parent informs a teacher that a child is peanut allergic and could die if he comes across a peanut, all the school dynamics change,” he says.
Leo also mediates with parents when tensions rise, as they often do surrounding this issue.
“For decades, kids have come to school with peanut butter and jelly sandwiches in their lunch bags. Now nobody can bring it into the classroom. What about the kids who will only eat peanut butter and jelly?” Leo says. “Once parent has the right to feed her child the way she wants. Another parent has the right to protect her food-allergic child. Who’s right and who’s wrong? This is a challenging discussion for the community.”
Peanut and tree nut parents are often the most vocal and many Ann arbor schools have accommodated these allergies, Leo says. But what happens when children who have egg, milk, wheat, or soy allergies, conditions that are just as dangerous, come into a school?
“The parent of an egg-allergic or milk-allergic child asks for the same school-wide accommodations and some peanut parents call it unreasonable. As a father, I have a bias for the peanut allergy. As a doctor, I have a bias for all those kids with other food allergies who get lost in the fray. So whose child is more important?” Leo asks.
The problem is addressed logistically (for example, limit snacks to fresh fruits and veggies, have allergic kids eat separately with someone observing, etc.) but more importantly, there’s an appeal to higher values.
“We all want our children to grow up to be good citizens. We want them to learn to accept others of different races, religions, backgrounds, health conditions. The food allergy issue is the perfect way to help kids – and their parents – do this. Our kids learn by our example,” Leo says. “We really do have to work together to find common ground so that our kids are safe.”

Risky Business
At two years of age, Miriam’s diet is still under parental control. Leo generally lets Anne call the shots at home because, he says, “I’m her father. I can’t be objective about these things.”
Thus far, Miriam as been reaction free. “I’ve never has the nightmare of my child having anaphylaxis,” he says…but he worries. “at night, I often think about what might happen if I slip up one day because it’s chaotic, I’m rushing out the door, both kids are crying, I’m in a hurry and I forget the Epi-pen. I’m sure all parents worry about this stuff.”
Miriam’s new brother, Andrew, 10 months old, is allergy free – so far.
“We have one child who has food allergy and another who doesn’t. How do you bridge the gap?” muses Leo. “My advice to families is, don’t allow it in the house.” But what if it were milk or egg instead of peanut? Do you make the whole house egg-free or do you make an exception for one child? “My wife and I have had this discussion and we haven’t crossed that bridge yet. My patients’ parents split – some do and some don’t. Bottom line? Any exposure is a risk.”
Another risk is adolescence.
“If you look at the fatality rate across the country for peanut and tree-nut allergic kids, it’s not the complaint 4 or 6 year olds who are dying from the disease. It’s primarily teenagers, doing typical risk-taking behavior, like not carrying an Epi-pen and not taking precautions,” Leo says.
“We need to pay attention to these kids. They need to have good self-esteem. The more we deal with them early on to make them feel normal, to make them accept their health issue for what it is and help them feel good about it, the less likely they’ll be 14 year olds who are mad that they have this disease, who can’t’ deal with it and who don’t make good choices,” Leo says.
That’s why he normalizes the disease every day in his medical practice, in the community – and at home.
“Anne and I take reasonable precautions. We don’t have peanuts or nuts in the house and we check whenever we go over to somebody else’s home, but you would never know my daughter has a peanut allergy,” Leo says. “We don’t make a big deal about it because I want her to feel normal. I want her to have that. I don’t ever want her to feel that her allergy hinders her.”
This parental attitude, common among families of allergic children, is also Leo’s professional goal.
“As a pediatrician, my job is to help kids be healthy and safe and if they don’t outgrown their allergy, to help them come to grips wit living with it,” he says. “My message for kids is this: Do not define yourself by your allergy. You run and play, you’re smart, you go to school, you have a good time, you have friends, you’re happy. And by the way, you have a food allergy. So what? Everyone has something – and yours just happens to be this.”

Reprinted with permission from Living Without Magazine, www.livingwithout.com

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