Category: Allergies and asthma

Furry pets are among the most common and potent causes of allergy symptoms. However, fur usually is not the only animal allergen. Even shorthaired, “non-shedding” animals leave a trail of dander and saliva.

Cats are commonly more allergenic than dogs. Although certain breeds of dogs are said to be less allergenic than others, studies don’t support the claim. Comparisons of dogs also show wide differences in levels of allergen-creation between individual dogs of the same breed. Reptiles, fish, and amphibians are not generally causes of allergy.

Making Adjustments

For families with a member allergic to an animal that are deeply attached to their animals, the notion of finding another home for a pet is hard to accept. Many prefer to keep the animal and battle on against allergy symptoms. If you can’t part with your pet, at least keep it out of your allergic child’s bedroom, and sweep, dust, and vacuum frequently.

Another solution may be to keep your cat or dog permanently outdoors with adequate shelter. Weekly bathing in tepid water has also been shown to lower a pet’s potential allergens, including animals that never venture out of doors, but doing this regularly and consistently is often not realistic. Long after an animal has left the family home, animal allergens can persist due to hair and dander left behind.

A household pet may be unjustly blamed for causing allergy symptoms. Don’t automatically banish Fido to the doghouse unless your child’s been tested and the results suggest that your child has an animal allergy.

Occasionally, symptoms that seem to be caused by an animal may be, in fact, due to other allergies, such as to pollen or mold. What happens is that Fido and Felix explore outdoors, then come back into the house with a load of pollen granules and mold spores in their coats. Every time the hay fever sufferer pats the pets, he stirs up an invisible cloud of allergens that triggers symptoms.

Before You Consider a New Pet…It is unwise to bring home a furry pet if you have a strong family history of allergies and, consequently, a high risk that infants and young children in your home could develop allergies. Better to wait a few years and, then, if there are no signs of trouble and your child’s allergy tests are clear, you may want to look into pet ownership. Try to expose your child to the pet a few times before bringing the pet home, just to see if there are any allergic symptoms that would indicate this is not the right move for your child.

Tips for Handling Pet Allergies

More than 70 percent of U.S. households have a dog or cat, according to the American College of Allergy, Asthma, and Immunology (ACAAI). People with allergies should be cautious in deciding what type of pet they can safely bring into their home. The ACAAI offers the following advice:

Pet exposure may cause sneezing and wheezing. An estimated 10 percent of the population may be allergic to animals, and 20 to 30 percent of individuals with asthma have pet allergies.

The best types of pets for an allergic patient are pets that don’t have hair or fur, shed dander, or produce excrement that creates allergic problems. Tropical fish are ideal, but very large aquariums could add to the humidity in a room, which could result in an increase of molds and house dust mites. Other hypoallergenic pets include reptiles and turtles, but be aware that turtles can spread salmonella, a highly contagious bacterial disease.

If the family is unwilling to remove the pet, it should at least be kept out of the patient’s bedroom and, if possible, outdoors. Allergic individuals should not pet, hug, or kiss their pets because of the allergens on the animal’s fur or saliva.

​Indoor pets should be restricted to as few rooms in the home as possible.Isolating the pet to one room, however, will not entirely limit the allergens to that room. Air currents from forced-air heating and air-conditioning will spread the allergens throughout the house. Homes with forced-air heating and/or air-conditioning may be fitted with a central air cleaner. This may remove significant amounts of pet allergens from the home. The air cleaner should be used at least four hours per day. The use of heating and air-conditioning filters and HEPA (High Efficiency Particulate Arresting) filters as well as vacuuming carpets, cleaning walls and washing the pet with water are all ways of reducing exposure to the pet allergen.

When it comes to diagnosing pet allergies, most are pretty obvious — symptoms occur soon after exposure. But sometimes the allergy is subtler. Skin tests or special allergy blood tests can be done, if necessary, to confirm a suspicion of an animal allergy. One way to confirm a pet’s significance as an allergen, is to remove the pet from the home for several weeks and do a thorough cleaning to remove the residual hair and dander. It is important to keep in mind that it can take weeks of thorough cleaning to remove all the animal hair and dander before a change in the allergic patient is noted.

Allergy shots (immunotherapy) may be needed for cat or dog allergies, particularly when the animal cannot be avoided. They are typically given for at least three years and may decrease symptoms of asthma and allergy. They are not recommended as routine treatment for pet allergy in children, though. Avoidance and pet elimination are the preferred approach.

You may have been given an asthma action plan for your child after a doctor’s office visit, a trip to the emergency department, or after your child was hospitalized. Ideally, everyone with asthma should have one.

An asthma action plan is designed to help families manage a child’s asthma. The goal is to prevent asthma emergencies by preventing and controlling flare-ups.

Because asthma affects people differently, asthma action plans are personalized for your child. While every asthma action plan looks a little bit different, they all include the same major parts.

Create an asthma action plan for your childDownload this ​asthma action plan ​so you and your pediatrician can personalize it for your child. Save and print it for your records. Be sure to share it with your child’s school and anyone else who cares for your child.​​​

Generally, asthma action plans include a list of the medications taken, early warning signs for asthma symptoms, and instructions on when to use the medicines and call your health care provider. ​

​The asthma action ​plan format

• Your child’s asthma action plan will be divided into a traffic light format:
  • Green means go! This is your child’s everyday plan.
  • Yellow means proceed with caution – this is for when your child isn’t feeling quite right. Still follow everything in the green zone, but add on other options.
  • Red zone means danger! This is urgent, when your child needs medications quickly and fast medical attention to prevent symptoms from getting even worse.
• Contact information: Every Asthma Action Plan should have information about your child, including name and family contact information. It should also have the name and phone number for the doctor who takes care of your child’s asthma, whether it’s your pediatrician or a lung doctor.
• Peak Flow: Depending on your child’s age, there may be a number written on the top of your asthma action plan. This number measures how hard your child can breathe out when feeling healthy on a peak flow machine. It is a good way to see if your child’s breathing effort is normal.

The zones

• Green Zone: Every Day
  • The green zone represents what you should do when your child is feeling completely normal. This is what to do when your child is breathing comfortably, sleeping through the night, not having any coughing or wheezing, and can play just like other kids. It means your child’s peak flow range is normal.
  • Your child’s daily controller medication will be listed here, along with how much to take and when to take it. This is the medication that your child should take every day. Examples include inhaled steroids or anti-allergy medication.
  • Some children have exercise-induced asthma, or asthma symptoms that flare up when they exercise or play actively. For children with this issue, medicine they need to take before exercise will also be listed in the Green Zone.
• Yellow Zone: First signs of illness
  • This yellow zone is for when your child may be starting to get sick and is at risk of having an asthma flare. Symptoms include: cough or cold symptoms, some wheezing, having a known trigger for a flare (like change in weather), coughing at night, or having a tight chest or belly pain (little kids have a hard time knowing if they are having belly pain or chest pain). The peak flow range listed will be less than normal.
  • Your child will need to take all of their Green Zone medication PLUS the medication listed in the Yellow zone. The Asthma Action Plan will include how much of the medicine to take and how often.
  • Your asthma action plan will also list when to call your child’s doctor if the symptoms are not improving or getting worse.
• Red Zone: This is urgent!

• This red zone is for when your child is sick and their asthma flare is dangerous: medicine is not helping, you notice your child is breathing hard and/or fast, you can see your child’s ribs while they are breathing, your child’s nose is opening wider when they breathe (called “nasal flaring”), or your child cannot talk because they are having a hard time breathing. The peak flow range listed will be low.
• Call your doctor immediately! If it is after the office is closed, go to the emergency department or call 911 if you cannot take your child there yourself.
• You should also give all the Green Zone medications AND whatever rescue medications are in your Red Zone. Your asthma action plan will also include how much of the medicine to take and how often. It may be a higher dose of the Yellow Zone medication that you also give more frequently.

Remember

If you have any questions about the asthma action plan, or you do not have one but think your child could benefit, please talk with your child’s pediatrician.

Asthma is a chronic disease of the tubes that carry air to the lungs. These airways become narrow and their linings become swollen, irritated, and inflamed. In patients with asthma, the airways are always irritated and inflamed, even though symptoms are not always present. The degree and severity of airway inflammation varies over time.

Children with asthma may also be sensitive to colds and other viral infections, cold air, and particles or chemicals in the air. Ongoing exposures to these substances will not only worsen asthma symptoms, but also continue to aggravate airway inflammation.

Inflammation of the airways causes them to be oversensitive and “twitchy,” often called “hyperreactive.” When the airways are hyperreactive, they can go into spasms, causing blockage and symptoms of wheezing, chest tightness, and shortness of breath.

​Children with asthma can have symptoms start or worsen when they are exposed to many indoor substances such asDust and dust mitesCockroachesAnimals such as cats and dogsMoldsSecondhand cigarette smoke

Who Gets Asthma?

Asthma is a common condition in childhood. In the United States, 10% to 15% of children in grade school have or have had asthma. It can cause a lot of sickness and result in hospital stays and even death. The number of children with asthma is increasing, and the amount of illness due to asthma may also be increasing in some parts of the country. The reasons for these increases are not exactly known; however, outdoor air pollution and increased exposure to allergens are not likely causes.

Recent studies suggest that how often and how early a child is exposed to certain infections and animals can influence the development of asthma. For example, children who come from large families, live with pets, or spend a considerable amount of time in child care in the first year of life are less likely to develop asthma. This early exposure to common allergens may actually protect against the development of asthma.

Studies have also shown that a child’s exposure to infections early in life can determine whether he develops allergies or asthma. Some infections seem to decrease the risk of developing asthma, whereas one infection, respiratory syncytial virus, increases the risk.

How Is Asthma Treated?

Any child who has asthma symptoms more than twice per week should be treated. One of the most important treatments of asthma is to control the underlying inflammation of the airways. This can be done with medications or by avoiding environmental factors that cause or aggravate airway inflammation.

Knowing the causes and triggers for asthma can allow families to reduce or avoid these triggers and reduce ongoing airway inflammation and hyperreactivity. This can reduce the severity and frequency of asthma symptoms and, hopefully, the need for as much asthma medication.

Instead of skin tests, your pediatrician or allergy specialist may order a blood test that has various names, including specific IgE blood test, in vitro IgE test, and radioallergosorbent test (RAST). (When the test was first invented years ago, it was called RAST, based on the specific way the test was done in the laboratory. Even though that technique is no longer used, the name RAST has kind of hung on.)

The specific IgE blood test is especially useful if skin tests cannot be done because, for instance, a child has eczema over much of his body or cannot be taken off medication that interferes with skin testing. This blood test shows specific sensitivities, as skin tests do, but does so by detecting the presence of allergy antibodies circulating in the blood. If antibodies are in the blood, it usually means the same antibodies are also in other tissues.

The method is not quite as versatile as skin testing because certain extracts are not available for measuring specific IgE using this technique. For example, a specific IgE blood test cannot be used to detect sensitivity to medications and is rarely used to detect insect venom allergy. However, the specific IgE blood test, in general, is adaptable and sensitive enough to detect a wide range of allergies.

The procedure costs more per test than skin testing. It requires only a few minutes of the patient’s time to draw a blood sample and there is no risk of any allergic reaction. The results take from 1 to 5 days, whereas skin test results are available immediately.

Radiographs and Imaging Tests

While sometimes useful, radiographs (x-ray films) are not essential for diagnosing asthma or allergies. In fact, people with asthma usually have normal chest radiographs. However, chest radiographs are sometimes done to make sure children do not have other conditions that can mimic asthma.

Sinus infection can produce symptoms similar to those of respiratory allergies, and children who have respiratory allergies are prone to sinus infections. Your pediatrician may order an imaging test to see if your child simply has a prolonged or recurrent infection, or whether a sinus infection is complicating his allergies.

An imaging test can be done the old-fashioned way, with a radiograph of the head, or it can be performed by computed tomography (CT). A CT scan is more sensitive than a radiograph and shows finer details of the anatomy of the sinuses, which can help your pediatrician decide on the best way to treat your child’s sinus problem.

Finally, imaging tests can sometimes help your pediatrician identify the reason your child snores or has a permanently stuffed-up nose. A radiograph of the upper neck area can show if the stuffiness is caused by enlargement of the adenoid tissue, which sits in the upper throat just behind the nose.

Lung Function Tests

If your child has symptoms indicating possible asthma, your pediatrician or asthma specialist may perform tests to evaluate his lung function. Lung function tests are performed in your pediatrician’s office or a pulmonary function laboratory where special equipment is available. An instrument called a spirometer is used to measure how much air your child can breathe out, as well as how fast the air flows. The technician will place a clip over your child’s nose to prevent air escaping from the nostrils.

The technician will then ask your child to perform breathing maneuvers into a mouthpiece attached to a pulmonary function monitor. The maneuvers aren’t difficult or painful. All your child has to do is take a deep breath, then breathe out forcefully through the mouthpiece. Instead of using a spirometer, the doctor may ask your child to blow into a simpler device called a peak flow meter. Your pediatrician usually has your child perform the lung function test at least 3 times at a sitting to make sure results are consistent.

If lung function testing shows that your child cannot blow air out fast enough, your pediatrician may perform further tests for asthma. Your pediatrician may give your child a dose of bronchodilator medication to see if there is a change in airflow. If airflow is normal or improved after the medication, the result strongly suggests that asthma is present.

Sweat Test

Cystic fibrosis is an inherited disorder that involves many body systems. It causes symptoms in the respiratory and digestive tracts that can mimic those of asthma and allergies. A child with cystic fibrosis may have asthma or allergies, as well. Your pediatrician may order tests to measure the levels of certain minerals in your child’s sweat (commonly called a sweat test). If the results indicate cystic fibrosis, further tests will be done to confirm the diagnosis.

Skin tests, first developed almost a century ago, are still the mainstay of allergy testing. They are easy and safe to do, give fast results, and are relatively inexpensive, which makes them the best way to start looking for specific allergies.

In performing scratch skin tests, drops of allergen extracts (eg, pollens, dust mites, molds, animal danders, foods) are allowed to seep through shallow scratches made in the patient’s skin. The tests can also be performed by the deeper, intradermal technique, in which extracts are injected under the skin. There are pros and cons to both testing methods.

​Scratch tests are painless and very easy to do.They are somewhat less sensitive than intradermal tests; they are also less likely to cause a severe reaction in someone who is highly allergic. The intradermal tests, which let the allergen extracts penetrate deeper into the skin, are highlysensitive, but they can occasionally result in false-positive reactions, indicating allergies where none exist.Your physician may decide to start with scratch tests, then go on to intradermal testing if further information is needed. Before testing, your doctor will ask you not to give your child any antihistamines for 3 to 5 days, as they will interfere with the results of the tests.

If your child has formed specific IgE antibodies through earlier exposure to one of the substances being tested, the skin test area will redden and swell into a disk that looks like a mosquito bite around the puncture site. This skin reaction usually peaks within 15 to 20 minutes after the test extracts are applied, and then gradually clears up. The skin where the tests were done may feel itchy for a few hours.

Skin Tests Must Be Done by an Experienced Physician

Although a positive result to scratch or intradermal skin testing strongly suggests that your child has formed lgE antibodies against a specific allergen, it does not follow that your child will definitely develop allergy symptoms when exposed to that particular allergen in the environment.

As a rule, the bigger the skin test reaction, the higher the chances are that your child is allergic and will sneeze, itch, or break out in a rash. However, in some cases the skin reaction is trivial while the symptoms are overwhelming, and vice versa. Further, even though your child may have diminished symptoms as he gets older, the skin test result can remain positive. It is important that tests be conducted and results interpreted by someone trained and experienced in allergy skin testing.

This Is Only a Test

Many parents and children are afraid of having allergy skin testing because they’ve heard false reports that it is painful and upsetting. Scratch tests, the form of testing most often used in children, are mostly painless because they are done on the surface of the skin, where there aren’t any nerve endings to register pain.

Furthermore, new test devices are available that can do up to 8 tests at a time and allow scratch testing to be done quickly and without injury. The intradermal technique uses a very fine needle to penetrate the surface of the skin. It is “felt” a little more than scratch testing but is still not very painful.

Many people also falsely believe that children have to reach a certain age before they can be tested. In fact, age is no barrier to skin testing; positive results can be obtained at any age. For example, in infants and toddlers who have eczema and suspected food allergy, skin tests often reveal sensitivity to milk or egg. Once parents have this information, they can keep those foods out of their child’s diet to control allergy symptoms.

Finally, experienced doctors and nurses perform allergy testing on a daily basis. They know how to take away fears and put children—and parents—at ease.

Every fall, 5-year-old Timmy develops a runny nose, itchy, puffy eyes, and attacks of sneezing. His mother shares the problem, which she dismisses as mild hay fever, and something her son has to learn to live with. Lately, however, Timmy has also suffered attacks of wheezing and shortness of breath when he visits his grandmother and plays with her cats. Timmy’s pediatrician suspects allergic asthma, and wants him to undergo some tests.

Timmy’s symptoms are by no means rare among children across the United States. Allergies and asthma often start in childhood and continue throughout life. Although neither can be cured, with proper care they can usually be kept under control. Allergies are caused by the body’s reaction to substances called “allergens,” which trigger the immune system to react to harmless substances as though they were attacking the body.

When to Suspect an Allergy

Some allergies are easy to identify by the pattern of symptoms that follows exposure to a particular substance. But others are subtler, and may masquerade as other conditions. Here are some common clues that could lead you to suspect your child may have an allergy.

Repeated or chronic cold-like symptoms that last more than a week or two, or that develop at about the same time every year. These could include:Runny noseNasal stuffinessSneezingThroat clearingNose rubbingSnifflingSnortingSneezingItchy, runny eyes

Itching or tingling sensations in the mouth and throat. Itchiness is not usually a complaint with a cold, but it is the hallmark of an allergy problem. Coughing, wheezing, difficulty breathing, and other respiratory symptoms. Recurrent red, itchy, dry, sometime scaly rashes in the creases of the skin, wrists, and ankles also may indicate an allergy.

Eczema

When it comes to rashes, the most common chronic inflammatory skin condition in children is eczema, also called atopic dermatitis. Although not strictly an allergic disorder, eczema in young children has many of the hallmarks of allergies and is often a sign that hay fever and asthma may develop. The rate of eczema, like that of asthma, is increasing throughout the world. Where asthma is rare, the rate of eczema is also low.

When to Suspect Asthma

Although allergies and asthma often go together, they are actually two different conditions.

• Asthma is a chronic condition that starts in the lungs.
• Allergies are reactions that start in the immune system.

Not everybody with allergies has asthma, but most people with asthma have allergies.

Asthma Attacks

The airways of the typical child with asthma are infl amed or swollen, which makes them oversensitive. When they come in contact with an asthma “trigger” — something that causes an asthma attack — the airways, called bronchial tubes, overreact by constricting (getting narrower).

Many different substances and events can “trigger” an asthma attack:

• Exercise
• Cold air
• Viruses
• Air pollution
• Certain fumes
• Other allergens

In fact, about 80 percent of children with asthma also have allergies and, for them, allergens are often the most common asthma triggers.

Common Allergens in Home and SchoolIn the fall, many indoor allergens cause problems for children because they are inside of home and school for longer periods.Dust: contains dust mites and finely ground particles from other allergens, such as pollen, mold, and animal danderFungi: including molds too small to be seen with the naked eyeFurry animals: cats, dogs, guinea pigs, gerbils, rabbits, and other petsClothing and toys: made, trimmed, or stuffed with animal hairLatex: household and school articles, such as rubber gloves, toys, balloons; elastic in socks, underwear, and other clothing; airborne particlesBacterial enzymes: used to manufacture enzyme bleaches and cleaning productsCertain foods

Controlling Allergy Symptoms

• It’s helpful to use air conditioners, where possible, to reduce exposure to pollen in both your home and your car.
• Molds are present in the spring and late summer, particularly around areas of decaying vegetation. Children with mold allergies should avoid playing in piles of dead leaves in the fall.
• Dust mites congregate in places where food for them (e.g , flakes of human skin) is plentiful. That means they are most commonly found in upholstered furniture, bedding, and rugs.
• Padded furnishings, such as mattresses, box springs, pillows, and cushions should be encased in allergen-proof, zip-up covers, which are available through catalogs and specialized retailers.
• Wash linens weekly, and other bedding such as blankets, every 2 to 3 weeks in hot water to kill the dust mite.
• Pillows should be replaced every 2 to 3 years.

Working With Your Child’s Pediatrician

Your child’s allergy and/or asthma treatment should start with your pediatrician. If needed, your pediatrician may refer you to a pediatric allergy specialist for additional evaluations and treatments, depending on how severe the child’s symptoms are. Although there are many over-the-counter antihistamines, decongestants, and nasal sprays, it is very important that you work with a pediatrician over the years to make sure that your child’s allergy and asthma are correctly diagnosed and the symptoms properly treated.

When I was growing up, peanut butter and jelly sandwiches were really common in the school lunchroom. These days, most parents wouldn’t even think of sending one. We’ve moved from peanut-free lunch tables to peanut-free schools—and many camps and afterschool programs have banned anything peanut too.

They do it to save lives. Not only has the prevalence of peanut allergy doubled in Western countries over the past 10 years, it is the leading cause of food allergy related death in the United States.

Finally we may have an answer, and it is the simplest answer of all: eating peanuts. Not actual peanuts—they are a serious choking hazard—but things made from peanuts, like peanut butter.

Previous Recommendations:

For many years, experts thought that the best way to fight peanut allergy was to avoid peanut products in the first years of life—that’s why in 2000 the American Academy of Pediatrics (AAP) recommended that any child at high risk of peanut allergy (like those with a family history of it, or with other food allergies, or eczema) not eat any before they turned 3. But that didn’t help, which is why in 2008 the AAP stopped recommending it.

Research on Peanut Allergies:

Around this time, researchers in the UK noticed something interesting: peanut allergy in Jewish children living in the UK was about 10 times more common than it was in Jewish children living in Israel. Since these children shared a similar ancestry, the difference had to be something that they were doing.

It turned out there was a big diet difference. Children in the UK rarely ate peanut products in the first year or so of life—whereas children in Israel commonly ate a snack called Bamba, a corn puff made with peanut butter. The researchers wondered: Could this be the important difference—that the Israeli children ate peanut products from an early age?

So they tested it. They did a study on about 600 babies who had severe eczema or egg allergy, which are known to increase the risk of peanut allergies. They divided them up into two groups: one was given Bamba to eat regularly (if they didn’t like Bamba, they could eat smooth peanut butter), and the other was told to stay away from foods containing peanuts. They did this until the children were 5 years old.

At 5 years, only 3 percent of the kids who ate peanut products were allergic to them—compared with 17 percent of those who didn’t eat peanuts. This included children who tested positive for a peanut allergy as infants (those with strong positive tests, however, were not included in the study).

New Guidelines on the Introduction of Peanut Products

When this research was released, the National Institute of Allergy and Infectious Diseases came out with guidelines to help pediatricians and parents understand and use this news. The AAP endoresed those guidelines, and in their new clinical report underlines their importance.

The guidelines divide babies into three groups:

• Those with severe eczema (persistent or recurrent eczema who need prescription creams frequently) and/or egg allergy
• Those with mild to moderate eczema
• Those who don’t have any eczema or food allergy

For the first group, those with severe eczema and/or egg allergy, testing for peanut allergy is recommended—and parents should talk with their doctors about how and when to give peanut products. If testing shows an allergy, it may be a good idea to do that first taste of peanut product in the doctor’s office. Parents of babies in this group should talk to their doctor early, like at the 2 or 4-month checkup, because the recommendation is that these babies should get peanut products between 4 and 6 months.

There is no testing needed for babies with mild to moderate eczema, although they should still talk with their doctors about their child’s situation and needs. These babies should try peanut products at around 6 months of age.

The babies who don’t have any eczema or food allergy can have peanut products along with other foods based on their family’s preferences and cultural practices. It’s not so important to do it early, but it’s fine if parents do.

It’s very important that parents not give babies whole peanuts or chunks of them (or chunky peanut butter) because babies could choke. Smooth peanut butter mixed into a puree is better, as are snacks or foods made with peanut butter.

We don’t know if this will work for other food allergies, so if there are other allergies you are looking to prevent, talk to your doctor.

A peak flow meter (or, rarely, a small electronic portable spirometer) is sometimes recommended as part of a treatment plan. These handheld devices measure how fast a person can blow air out of the lungs. Asthma causes patients to not be able to blow air out fast because their airways are narrowed, so a low measurement with this device suggests problems are occurring with your child’s asthma. These measurements can help warn a patient or parent that extra medication is needed to fend off more severe asthma symptoms. The results can also be useful for the patient who does not adequately perceive worsening airway obstruction or who has difficulty distinguishing anxiety or hyperventilation attacks from asthma.

When your child is having asthma problems, a peak flow reading puts a number on how she is doing, much as a thermometer shows how high a temperature is. Your pediatrician or asthma specialist will show you how to record your child’s baseline measurements at a time when she is doing well with her asthma. This is referred to as her “personal best.” When your child’s asthma is not doing well or is at risk of flaring up (eg, during a “cold”), a peak flow reading can be obtained and the value compared to the child’s personal best. Using a simple range of color zones—green, yellow, and red, like traffic lights—specific recommendations can be spelled out as to what needs to be done to prevent a full-blown asthma attack based on what color zone the patient falls into with her peak flow measurement.

How to Use a Peak Flow Meter

Your child’s peak flow–based asthma treatment plan uses his own personal best peak flow reading because every child is unique. Your child’s peak flow may be higher or lower than that of another child even though their age, sex, and height are identical.

To find your child’s personal best, your pediatrician will instruct him to use the peak flow meter at the same time every day for 2 to 3 weeks during a period when he doesn’t have any symptoms and asthma is under good control.

​To obtain a peak flow measurement, have your child do the following:Stand up.Place the peak flow device indicator at 0.Take a deep breath, then place the device well in to the mouth.Close his lips around the mouthpiece and keep his tongue clear of the opening.Blow once as hard and fast as he can. Note the reading.Repeat steps 2 through 5 twice more and write down the highest score.

After your child has established his personal best your doctor may ask him to use the meter for readings when he is beginning to have symptoms, or when he has a “cold” (a time when asthma commonly gets worse). The doctor may also ask you to monitor his peak flow when adjustments have been made to his medication program, whether it be up or down, to detect any change in asthma control.

​Starting at about age 4 or 5 years, your child can learn how to use a peak flow meter.The following color zone system is commonly used with peak flow monitoring:Green means that the airflow score is at 80% to 100% of your child’s personal best peak flow (the targeted peak flow value determined by your child’s pediatrician); his medications don’t need to be adjusted and he may continue full activity.Yellow means caution, just as it does on the road with a traffic light; airflow is between 50% and 80% of your child’s personal best and certain additional asthma medications should be started or increased to ward off symptoms.Red means danger; your child’s score is less than 50% of his peak flow. Have your child take his quick-relief medications (usually a bronchodilator at a high dose to open up the airways and steroid pills or liquid to calm inflammation) if it is part of the asthma action plan worked out between you and your pediatrician or asthma specialist. Call or see your physician soon, or go for emergency care, if the peak flow reading stays below 50% despite the treatment.

The peak flow meter provides one way to measure asthma objectively, but it’s critical that the child and everyone else in the family not rely on just a peak flow number for assessment of how a child’s asthma is doing. Symptoms are as important, probably even more important, than a peak flow reading. It is not uncommon for symptoms to detect a flare-up of asthma even before peak flow measurements do.

​​​​​​​​​For children allergic to nickel, anything from jeans with metal buttons to handheld electronics can cause a red, itchy rash. Called nickel-allergic contact dermatitis, an allergy to nickel affects an estimated 1.1 million children in the United States.

An allergy to nickel is not life-threatening, but it can be uncomfortable enough to get in the way of a child’s sleep and cause them to miss school. Sometimes, an allergic reaction to nickel is mistaken for an infection, especially near broken skin like a pierced ear. The allergy also has been linked to severe hand eczema later in adulthood.

What does an allergic reaction to nickel l​ook like?

The skin allergic reaction to nickel looks like eczema. Signs and symptoms include an itchy rash with redness, swelling, scaling and possibly a crusty appearance. The rash generally appears on the area of the skin that comes into contact with the metal. If the metal exposure is ongoing, sometimes a rash may show up in more distant parts of the body. Once children become sensitive to nickel, gradually worsening rashes may develop each time they are exposed to nickel again. 

How to help prevent nickel allergy reactions

Although there is no cure for nickel allergy, here are a few ways to help prevent reactions:

• Clothing & accessories. Avoid clothing with metal buttons, snaps, rivets and zippers. Look for belts, watches and jewelry and other accessories that are labeled “nickel-free,” or buy items that are hypoallergenic are or made of surgical-grade stainless steel, gold, silver, or platinum.​
• Cover or coat surfaces. Sew a piece of cloth over the metal to prevent direct contact with skin. It may also help to put two coats of clear nail polish on metal that touches skin. This is not an ideal solution, since nail polish can chip off and needs to be touched up–especially after washings.
• Electronic devices. Place a nickel-free case around your child’s tablet or phone that covers the parts made of metal.
• Coins & keys. Advise your child not to keep loose coins and keys in pockets.
• Seating. Avoid sitting on metal chairs or plastic chairs with metal tabs while wearing shorts.
• Ear piercing & braces. Avoid ear piercing, at least until after a child is past the age when they might get braces. This helps prevent sensitization to nickel that can get worse while wearing metal braces. If your child does get pierced ears, choose posts that are nickel-free or made of surgical grade steel that is less likely to release nickel. It is also a good idea to wear plastic posts until the skin heals from piercing.
• Cosmetics. Cosmetics and other beauty products that contain metal should be avoided. Nickel allergy has been linked with nail polish from a bottle that contains nickel metal shaker balls.
• Foods & cooking. Particularly if a child has a known nickel allergy, it might be useful to avoid foods that contain nickel. This includes chocolate, nuts, soy products, black tea, seeds, and commercial salad dressings. Choose fresh or frozen rather than canned food when possible. Don’t use stainless steel pots and pans to cook acidic foods that contain acidic ingredients like tomato, vinegar, or lemon.
• Tap water. Run tap water for a few seconds before washing, drinking, and cooking to help flush out any nickel that can leach from pipes and fixtures.
• Tattoo ink. ​Teens and young adults who are allergic to nickel should use extra caution if they are considering getting tattoos, since some inks contain nickel.

Treatment for nickel allergy

In addition to recommending ways to help avoid exposure to nickel, your pediatrician may recommend short-term treatment with a steroid ointment or another anti-inflammatory medication.

​​​After confirming an asthma diagnosis, your pediatrician will grade the severity of your child’s condition. This grading takes into account the frequency and severity of past and current asthma symptoms and the physical examination, and may include measures of lung function including spirometry or peak flow measurements. This information enables your pediatrician to select the right medication and determine the proper dose to keep the condition in check. (See “What Really Matters Is Control, Not Severity” below.) In making a decision about a child’s asthma severity level, the first distinction to be made is whether your child has intermittent asthma (ie, just occasional problems) or persistent asthma (ie, more than occasional). Patients with persistent asthma can have mild, moderate, or severe asthma. Following are more details about the 4 asthma severity levels that arise by making this kind of distinction.

What Really Matters Is Control, Not Severity

It turns out that asthma severity categories are somewhat arbitrary and, in fact, were actually created more with adults in mind than children. They are just a general guide for the doctor seeing your child; your doctor realizes that asthma severity levels, particularly in children, can change over time, so reassessments need to take place on an ongoing basis to verify an individual child’s present asthma severity. Furthermore, the 2007 National Heart, Lung, and Blood Institute “National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma” make a strong point that the overall control of your child’s asthma is really what is most important, not what the severity level happens to be at any time. Adjustments of treatment are based mainly on how well-controlled your child’s asthma is when assessed at follow-up visits.

Intermittent Asthma

A child who has symptoms of wheezing and coughing no more than 2 days a week is con-sidered to have intermittent asthma; nighttime flare-ups occur twice a month at most. Outside of these few episodes, a child with intermittent asthma is free of asthma symptoms.

Any child with asthma symptoms more often than 2 days a week or 2 nights per month, on average, is felt to no longer have intermittent asthma but persistent asthma. Persistent asthma has 3 levels of severity.

Mild Persistent Asthma

In mild persistent asthma, symptoms occur more than twice a week but less than once a day, and flare-ups may affect activity. Nighttime flare-ups occur more often than twice a month but less than once a week. Lung function is 80% of normal or greater.

Moderate Persistent Asthma

Asthma is classified as moderate persistent if symptoms occur daily. Flare-ups occur and usually last several days. Coughing and wheezing may disrupt the child’s normal activities and make it difficult to sleep. Nighttime flare-ups may occur more than once a week. In moderate persistent asthma, lung function is roughly between 60% and 80% of normal, without treatment.

Severe Persistent Asthma

With severe persistent asthma, symptoms occur daily and often. They also frequently curtail the child’s activities or disrupt his sleep. Lung function is less than 60% of the normal level without treatment. Severe is the least-common asthma level.