PEDIATRICS (ISSN 0031 4005). Copyright (C) 1991 by the American Academy of Pediatrics.
Allergy
Pathophysiology
MATERNAL IMMUNE STATUS AGAINST
fi-LACTOGLOBULIN AND COW’S MILK ALLERGY IN THE INFANT
Casmir GJA, Duchateau J, Cuvelier P, Vis HL. Ann Allergy. 1989;63:517-519
Purpose of the Study
The reported frequency of cow’s milk allergy in chil-dren varies between 0.3% and 7.5% (population with earlier weaning has higher incidence). A thorough family history of atopy and cord IgE level at birth have been used to predict infants “at risk.” Previous studies have shown that high cord IgE level (exceeding 1 IU/mL) was predictive of subsequent development of atopic disease. The purpose of this study was to follow-up the predictive relationship of maternal IgG-anti-BLG (IgG against /3-lactoglobulin which is a major cow’s milk antigen) and allergic manifestations in the infant.
Study Population: Subject Section
Mothers. All women were selected from the obstetric
department of St Pierre Hospital in Brussels, Belgium.
Infants. 69 infants were chosen who were born to these
mothers by vaginal delivery and were fed cow’s milk.
Methods
Clinical Evaluation. Every month during the first 6
months of life, infants were examined clinically for al-lergic symptoms. Gastrointestinal signs (diarrhea, vom-iting, colic), atopic dermatitis, and respiratory problems (asthma, chronic cough, rhinitis) were recorded.
Symptomatic children were treated with Alfare (Nes-tle) containing hydrolysates of cow’s milk proteins with minimal allergenicity.
Biologic Investigations. IgG-anti-BLG levels in
moth-ers’ sera were measured using solid-phase radioimmuno-assay method. These levels were expressed in arbitrary units per milliliter.
All children were screened for total IgE levels at 5 days of age.
Specific IgE anti-cow’s milk radioallergosorbent tests (RASTs) were performed in all patients at 1 month of age.
Findings
Clinical Observation. Of the 69 infants followed-up
(exclusively on cow’s milk since birth), 23 had symptoms
before or at 3 months of age. When Alfare was introduced, all 23 became asymptomatic between 3 and 6 months, and 20 of 23 had complete clinical recovery. Cow’s milk RAST was positive in 7 children who were all sympto-matic.
/3-Lactoglobulin IgG Concentrations in Mothers ‘ Sera. /3-Lactoglobulin IgG in mothers ranged from 25 to 900 U/mL. The levels in mothers tended to be higher if their child was asymptomatic and were lower if the child showed early clinical manifestations. Mean of sympto-matic group = 142 U/mL; mean of asymptomatic group = 357 U/mL; this is statistically significant (P < .001).
Neonatal IgE level was elevated (ie, 1 IU/mL) in 48% of symptomatic patients and only in 2% of asymp-tomatic patients.
If neonatal IgE is considered the first criterion (ie, 1 U/mL) and low maternal /3-lactoglobulin IgG as com-plementary (ie, IgG-anti-BLG < 100 U), the clinical outcome of 91% of symptomatic babies could have been predicted.
Specific IgE antibodies against cow’s milk protein were seen in 30% of symptomatic patients, and none in the asymptomatic ones.
Reviewers’ Comments
The higher level of antibodies to BLG in mothers whose babies are asymptomatic suggests that some pro-tection was given to the babies through placental trans-port.
In a mouse model, it has been demonstrated that maternal immunity can regulate an IgE response in the infant mouse and induce a relative state of tolerance toward BLG during exposure to milk.
Further, if used in conjunction with neonatal IgE screening, maternal anti-BLG is very valuable in pre-dicting infants at risk for early development of atopy.
BICHPHUONG NGUYEN, MD
San Francisco, CA
BETTY MILLER, MD
Daly City, CA
ATOPY IN INFANCY PREDICTS THE SEVERITY OF BRONCHIAL HYPERRESPONSIVENESS IN LATER CHILDHOOD
Van Asperen PP, Kemp AS, Mukhi A. J Allergy Clin
Immunol. 1 990;85:790-795
Purpose of the Study
a population at 7 years of age and to relate it to the past and present occurrence of atopy.
Study Population
The population included 52 infants born to atopic parents.
Methods
The infants were followed-up prospectively from birth to 7 years of age. Atopy in the parents was documented by skin testing, history of an atopic disease, and BHR to histamine. The children at 7 years of age were evaluated by clinical history, physical examination, allergen skin tests, and BHR to histamine.
Findings
BHR to histamine was documented in 25% (13/52) of the children with 48% (25/52) atopic on skin testing, with 29% (15/52) who had current wheezing, and with 58% (30/52) who had a history positive for wheezing sometime during the 7-year period of the study. BHR was associated significantly with wheezing and atopy at 5 and 7 years age, but not in infancy. History of atopy was positive in both parents in 19 families and in 1 parent in 26 families. 71% of children with both parents atopic demonstrated atopy, and 29% demonstrated atopy if one parent was atopic. There was no correlation between BHR in the parent and BHR in the child. The children with moderate to severe BHR manifested atopy to a greater degree and at an earlier age than children with slight to mild BHR.
Reviewers’ Comments
The authors postulate that the children with more severe degrees of BHR are most likely to have earlier symptoms of atopy than those with no BHR. Interest-ingly, the children with mild BHR had no correlation with atopy in infancy. The observation that atopy in young children is a predictor for the presence of bronchial responsiveness in midchildhood is an important obser-vation. Strict and rigorous environmental control and thorough avoidance measures in atopic infants and young children possibly may influence their development of future asthma.
ALMA M. HERRERA, MD
Mobile, AL
RUSSELL J. Hopp, DO Omaha, NE
MEASUREMENT
OF CURRENT
EXPOSURE
TO
ENVIRONMENTAL
TOBACCO
SMOKE
Cummings KM, Markello SJ, Mahoney M, Bhargava AK, McElroy PD, Marshall JR. Arch Environ Health. 1 990;45:74-79
Purpose of the Study
This study was performed to examine the relative importance of environmental factors in predicting cur-rent environmental tobacco smoke (ETS) exposure.
Study Population
The subjects were 663 people (18 to 84 years of age), who had never smoked or had stopped smoking, attending a cancer screening clinic.
Methods
History of current or past tobacco use habits, exposure to tobacco at home and work, and recent exposure during the preceding 4-day period was recorded. All subjects were given a lung function test and urine samples were taken for determination of cotinine.
Findings
76% of the subjects reported exposure to ETS in the 4-day period preceding the interview with 28% exposed at work and 27% exposed in the home. Cotinine was found in the urine of 91% of subjects, and these values increased significantly with the number of exposures reported. 84% of subjects who did not live with a smoker had detectable levels of cotinine.
Reviewer’s Comments
This study demonstrates the prevalence of exposure to tobacco smoke despite lack of direct contact with the substance in the home. Information of this sort can be used to stress the importance of decreasing smoking in public places and thereby decreasing the exposure of nonsmokers as well as potentially decreasing the related morbidity.
Diagnosis
ALMA M. HERRERA, MD
Mobile, AL
PROBLEMS
IN DEFINING
NORMAL
LIMITS
FOR
SERUM
lgE
Klink M, Cline MG, Halonen M, Burrow B. J Allergy Clin
Immunol. 1990; 85:440-444
Purpose of the Study
This article describes the distribution of serum IgE levels in subjects aged 6 years or older, enrolled in the general population study, without positive skin tests and without known asthma. They were compared with sub-jects who had asthma, allergic rhinitis, and positive skin tests.
Methods
IgE levels of subjects 6 years of age or older. The analysis was limited to 2657 subjects who had both serum IgE level and allergy skin testing at the time of enrollment of this study. There were 1569 subjects with negative allergy skin tests and without current asthma. Distributions of log serum IgE for both males and females are presented in the article.
Findings
Subjects with negative skin testing and without current asthma were compared to subjects with asthma and with positive allergy skin testing. Distributions of serum IgE levels in these groups were vastly different, but defining an upper limit of normal serum IgE levels was difficult. There was no single level of IgE that distinguished be-tween these two groups.
Reviewer’s Comments
Large population studies such as these show that serum IgE levels are in continuum both in allergic and nonal-lergic subjects. The determination of a single serum IgE level in the clinical setting should not be used as reference for deciding which patients should or should not be sent to the allergist for further evaluation.
RUSSELL J. Hopp, DO
Omaha, NE
Treatment
MEASLES
IMMUNIZATION
IN CHILDREN
WITH
CLINICAL REACTIONS TO EGG PROTEIN
Kemp A, Van Asperen P, Mukhi A. AJDC. 1 990;1
44:33-35.
Purpose of the Study
This study was performed to provide an historical review of the safety of measles-mumps-rubella (MMR) immunization in 35 pediatric patients with hypersensitiv-ity to egg.
Study Population
The authors examined 32 children aged 11 to 101 months who had clinical egg hypersensitivity reactions ranging in severity from immediate urticaria/angioedema localized to the face to generalized urticaria/angioedema plus wheeze and/or stridor. An additional 3 highly allergic patients who had skin tests positive to egg without pre-vious clinical exposure or reaction to egg also were in-cluded.
Methods
Children coming to the author’s immunology clinic for MMR immunization were skin-tested with egg, egg al-bumin, and egg yolk. Skin testing with MMR vaccine was not performed. Following skin testing, the children were immunized in the routine manner, under
observa-tion, with MMR vaccine prepared in chick embryo cell cultures.
Findings
34 of 35 children had significant skin tests positive to egg albumin; 26 of 27 had skin tests positive to egg yolk. In all 35 children, the MMR immunization was given without adverse reaction. The authors concluded from these findings and previous reports of 37 cases of children hypersensitive to egg who had no significant adverse reactions to MMR vaccination that “a reasonable policy is to immunize children with a history of immediate hypersensitivity to egg protein in an area of a hospital where any allergic reaction can be treated if it occurs.” Except in cases with a history of hypersensitivity to egg requiring resuscitation with oxygen and epinephrine, they did not recommend skin testing with MMR material prior to immunization.
Reviewers’ Comments
In editorial comments (p 32, same journal) E. Richard Stiehm, MD, Division of Immunology, Department of Pediatrics, UCLA, strongly disagreed with the authors’ conclusion. He recommended that skin testing with mea-sles vaccine is always indicated in subjects with proven or suspected egg allergy associated with clinical immedi-ate hypersensitivity reaction (ie, hives, swelling of the mouth or throat, respiratory difficulty, hypotension, shock, etc). This is in accordance with the published recommendation by the American Academy of Pediatrics Committee on Infectious Diseases. We concur with Dr Stiehm’s recommendation.
NANCY K. OSTROM
San Diego, CA
A. WESLEY BURKS
Little Rock, AR
ADMINISTRATION OF MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE (LIVE) TO EGG-ALLERGIC CHILDREN
Lavi 5, Zimmerman B, Koren G, Gold R. JAMA.
1 990;263:269-271.
Purpose of the Study
vaccine in a graded challenge to egg-allergic children who had positive skin tests with MMR vaccine.
Study Population
This study included 114 children who had a recent history of immediate-allergic reaction to egg ingestion who were referred to the Immunization Adverse Reac-tions Clinic, The Hospital for Sick Children, Toronto, Canada. Their ages ranged from 13 to 36 months (mean 16 months). Allergic symptoms of egg ingestion included urticaria, angioedema, rhinitis, gastrointestinal symp-toms, respiratory symptoms and/or anaphylaxis.
Methods
All children underwent skin testing by a modified prick method with egg white protein diluted 1:10, MMR vaccine diluted 1:10 and occasionally 1:100 along with negative and positive (histamine 1:10) controls. Positive tests were read as erythema greater than 10 mm in diameter and wheal greater than 3 mm in diameter. If vaccine prick tests were negative, intradermal testing was done with 1:100 and 1:10 dilutions. Positive intradermal tests were read as erythema greater than 10 mm in diameter and wheal greater than 5 mm.
Findings
114 (100%) of 114 referred patients had positive reac-tions to prick testing with egg white protein. 24 (21%) of 1 14 patients had positive skin tests to the MMR vaccine (5 positive to prick testing and 19 positive to intradermal testing). There was a relationship between the severity of the reaction to egg ingestion reported and the likeli-hood of a positive reaction to skin tests with MMR. The more severe the systemic allergic reaction to egg inges-tion, the more likely it was that a patient would have a positive skin test reaction to the vaccine; 22% had a positive reaction if they had had a history of gastrointes-tinal symptoms, 33% if a history of rhinitis symptoms, 45% if a history of angioedema, and 56% if a history of respiratory symptoms with or without anaphylaxis. All 90 patients with a negative skin test to vaccine were immunized without complication with full-dose vaccine. The 24 patients with positive skin tests were vaccinated by a desensitization protocol, first 0.05 mL of MMR diluted 1:100 was given subcutaneously, then 0.05 mL of 1:10 diluted vaccine, then undiluted vaccine 0.05 mL every 20 minutes until a full dose of 0.5 mL had been given. This procedure was done in a short-stay unit at the hospital with close monitoring. 21 (87.5%) of 24 patients with a positive skin test to MMR vaccine had no reactions during the desensitization procedure. 3 (12.5%) of 24 patients with a positive skin test to the vaccine developed generalized urticaria between the sec-ond and fourth doses of the undiluted vaccine during the desensitization procedure. Subsequent doses were then decreased to 0.025 mL until the entire procedure was completed. No treatment was required, and the urticaria resolved within 1 to 2 hours. Of these 3 patients, one had a history of urticaria and angioedema after egg ingestion; one had urticaria, angioedema, gastrointestinal
symp-toms, respiratory symptoms, and anaphylaxis; both of these had positive skin prick tests with vaccine. The third child had only urticaria following egg ingestion and had a positive skin test to intradermal testing with the vac-cine. Specific antibody to measles, mumps, and rubella were measured in 18 of the patients undergoing the desensitizaton protocol, and all 18 had protective anti-bodies to all 3 antigens up to 12 weeks after the procedure.
Reviewer’s Comments
21% of a group of the highly egg-allergic children had a positive skin test to diluted MMR vaccine. The more severe the reaction to egg ingestion, the more likely there will be a positive skin test to MMR vaccine. The MMR vaccine can be administered successfully to these patients via a desensitization protocol. 12.5% had mild allergic reactions during the protocol, and adequate immuniza-tion was still able to be achieved.
ALAN B. GOLDSOBEL, MD
San Jose, CA
ADMINISTRATION OF EGG-DERIVED VACCINES IN PATIENTS WITH HISTORY OF EGG SENSITIVITY
Kletz MR Holland CL, Mendelson JS, Bielory L. Ann Allergy. 1 990;64:527-529.
Study Population
In this study, 3 cases of successful administration of egg-derived vaccines (influenza, measles, mumps and ru-bella) to patients with a history of egg hypersensitivity were described.
Methods
Patients had skin prick testing with 0.9% saline as a negative control, histamine (1:1000) as a positive control, whole egg, egg white, and egg yolk (1:20 wt/vol), Tn-Valent Influenza Vaccine, types A and B (1:10), and measles, mumps, rubella (MMR) (1:10). Intnadermal skin testing was performed with 0.02 mL of both saline and histamine (1:10 000) and 0.05 mL of a 1:100 dilution of either influenza vaccine or MMR vaccine. A method of desensitization to measles vaccine by subcutaneous injec-tion every 15 minutes was described.
Findings
MMR vaccine diluted 1:10; followed 15 minutes later by 10 subcutaneous injections of 0.05 mL of undiluted MMR vaccine, each given every 15 minutes until the total immunizing dose of 0.5 mL was reached.
Conclusion
Despite positive history of egg allergy, egg-contami-nated vaccines (ie, influenza, rubella, yellow fever, ru-beola, rabies, mumps, typhus, rocky mountain spotted fever) can be administered safely after skin testing.
Desensitization by subcutaneous administration of measles vaccine 0.05 mL every 15 minutes is described. An alternate method involving intramuscularly admin-istered influenza vaccine starting with 0.05 mL and giving increments of 0.05 mL every 15 to 20 minutes is men-tioned (ie, 0.05, 0.10, 0.15, 0.20 mL for a total ofO.5 mL). Desensitization should be performed in a medical fa-cility equipped to treat anaphylaxis. If a positive skin test is present by prick or intradermal skin testing the patient should be desensitized to that vaccine. If intradermal skin tests at a dilution of 1:100 are negative, the egg-allergic patient can be given the vaccine without desen-sitization.
Reviewers’ Comments
Following injections of 0.05 mL of 1:100 and 0.05 mL of 1:10, desensitization via the intramuscular method using undiluted vaccine every 15 minutes appears to be preferable in young children requiring MMR immuniza-tion, because it limits the number of injections to 6 and the time to 1#{189}hours versus 12 injections and 3 hours for the subcutaneous method. The more rapid method has
been used by Murphy and Strunk (J Pediatr.
1985;106:931) for influenza vaccination. This same rapid method has been used safely at the UCSF Pediatric Allergy Clinic for MMR desensitization. Evaluation and “desensitization” should be conducted by knowledgeable physicians.
BETTY MILLER, MD
Daly City, CA
EDWIN A. BRONSKY, MD
Salt Lake City, UT
LACK OF PREVENTIVE
MEASURES
GIVEN
TO
PATIENTS WITH STINGING INSECT ANAPHYLAXIS IN
HOSPITAL
EMERGENCY
ROOMS
Hutcheson PS, Slavin RG. Ann Allergy. 1
990;64:306-307.
Purpose of the Study
This study documented the follow-up care recom-mended to patients after Hymenoptera reactions treated in hospital emergency rooms.
Study Population
Seventy-six patients receiving venom immunotherapy at St Louis University were surveyed randomly regarding
the preventive medical advice they received in emergency rooms in various parts of the country following treatment of their original anaphylactic reaction to an insect sting.
Findings
Thirteen (18%) were given advice concerning avoid-ance of future stings. Twenty-two (29%) were given an adrenalin set. Forty-two (56%) were referred to a spe-cialist (Allergy) for follow-up care.
Reviewers’ Comments
Advice about stinging insect prophylaxis is quite poor as suggested in this report. Hymenoptera anaphylaxis can and does cause avoidable deaths in the estimated one million sensitive patients. Because the majority of pa-tients receive emergency and lifesaving care by emer-gency and private (nonspecialist) physicians, it is imper-ative to reverse the “not so” benign neglect of adequate patient instruction and follow-up care. Avoidance meas-ures and portable epinephnine (ANA-KIT or Epi-Pen) must be made available to all patients. Immunotherapy by qualified physicians has been shown to be 95% effec-tive in preventing systemic reactions to subsequent stings.
EDWIN A. BRONSKY, MD
Salt Lake City, UT
BETTY MILLER, MD
Daly City, CA
INSECT STING ALLERGY: APPLICATIONS OF
MEASUREMENTS
OF SERUM
VENOM-SPECIFIC
IgE
Reisman RE, Wypych JI. Immunol Allergy Practice.
1 990;12:82-92.
Purpose of the Study
To review the application of measurements of serum venom and specific IgE to the understanding of insect sting allergy.
Study Population
The study population included a large group of venom-sensitive patients followed-up for a number of years at the University of Buffalo Allergy Clinic.
Methods
The authors utilized their clinical and laboratory ex-perience to evaluate seven key issues:
1. Comparison of results of in vitro IgE measurements between their laboratory and two commercial labora-tories
2. Cutoff dose of venom used for skin test diagnosis 3. Relationship of titer of venom-specific IgE to clinical
severity
5. Effect of venom exposure on venom-specific IgE 6. Cross-reactivity between venoms
7. When to stop immunotherapy.
Findings
1. In general, there was good agreement of results be-tween the three laboratories, but there were sera in which antibody titers were widely disconcordant.
2. Although 1.0 mg/mL has been recommended as the top dose for diagnostic testing cutoff, nonspecific re-actions will occur and the author recommended a venom dose of 0.1 mg/mL as the diagnostic cutoff. 3. There appears to be no correlation between antibody
titers and the severity of anaphylaxis.
4. Antibody titers in the absence of immunotherapy de-dine at a variable rate from patient to patient. No factors such as age or clinical severity could predict this decline.
5. Shortly after initiation of therapy, titers may increase or remain the same. Throughout a long period, these titers slowly decrease.
6. The subject of cross-reactivity is discussed at great length.
7. The decrease in serum venom-specific IgE has been used as a criterion to stop venom immunotherapy. Forty-one patients who stopped immunotherapy ex-perienced four system reactions (10% patients, 5% stings). All four reacting patients had tolerated several stings during cessation of venom immunotherapy be-fore the re-sting reaction. Two patients had subse-quent stings with no reaction.
Reviewer’s Comments
Venom skin test is the simplest, most sensitive diag-nostic test. If skin test is negative with good history, an in vitro test might be helpful. If there are skin tests of equal intensity to multiple venoms, titers of serum-spe-cific IgE might differentiate between the culprit and cross-reacting venoms. Negative antibody titers after 2 to 3 years of venom immunotherapy strongly indicate that treatment has been adequate and can be discontin-ued.
JAY E. SELCOW, MD West Hartford, CT
Study Population
The results of this study were obtained on 26 women with 43 pregnancies, all receiving immunotherapy to yen-oms.
Methods
A questionnaire was mailed to members/fellows of the Academy of Allergy and Immunology requesting infor-mation about each patient who had received VIT during pregnancy.
Findings
The questionnaire revealed the following results from 43 pregnancies: 7% abortion rate in the first trimester, 4.6% in the second trimester, 1 stillborn at term. These results were not significantly different from the compli-cation rates of the general population. Two adverse re-actions developed during VIT (large local swelling, exac-erbation of asthma that did not require treatment). 38 of 43 were pregnancies in which the patient was begun on VIT prior to pregnancy and was receiving maintenance. The number of venoms administered did not affect the outcome.
Reviewer’s Comments
The results of VIT in pregnancy seem to be very similar to immunotherapy to inhalant allergens where it is al-ready known to be safe. The initiation of immunotherapy during the first trimester, as stated by the authors, must be considered carefully.
ALMA M. HERRERA, MD Mobile, AL
A DOUBLE-BLIND STUDY OF THE EFFECTIVENESS OF A HIGH-EFFICIENCY PARTICULATE AIR (HEPA) FILTER IN THE TREATMENT OF PATIENTS WITH PERENNIAL ALLERGIC RHINITIS AND ASTHMA
Reisman RE, Mauriello PM, Davis GB, Georgitis JW, DeMasi JM. J Allergy Clin Immunol. 1 990:85;1 050-1057.
Purpose of the Study
VENOM
IMMUNOTHERAPY
IN THE
HYMENOPTERA-ALLERGIC PREGNANT PATIENT
Schwartz HJ, Golden DB, Lockey RF. J Allergy Clin
Immunol. 1 990;85:709-71 2.
Purpose of the Study
The purpose of the study was to ascertain the fre-quency of both insect stings and insect-sting reactions during pregnancy, to determine the effect of venom im-munotherapy (VIT) on this frequency, and to evaluate the safety of VIT in pregnancy.
The purpose of this study was to determine the effec-tiveness of high-efficiency particulate air (HEPA) filter in alleviating allergic respiratory symptoms.
Study Population
Methods Study Population
An ENVIRACARE room air filter was placed in the bedroom for 8 weeks. In a random manner and double-blind both to the patient and to the investigator, either an active filter or a blank filter was used for two 4-week periods. Results were assessed by analysis of the patient’s symptoms (congestion, nasal discharge, eye irritation, cough, upper airway itching, asthma, and medication use) as well as a subjective response of the patient comparing the two 4-week periods. Particulate counts were made in the bedroom before the study, at 4 weeks, and at the end of the study.
Findings
The HEPA filter produced a 70% reduction in partic-ulate matter (>0.3 microns as measured by a light-scat-tening particle counter). However, for the total study, there was no difference in the total symptoms/medication scores or individual symptom scores during the placebo and active filter periods. However, analysis of the last 2 weeks of each filter period did demonstrate definite dif-ferences in total and individual symptoms. This analysis suggested active filter benefit, especially for nighttime symptoms of congestion; eye irritation and upper airway itching were also significantly lower during the active filter period. In terms of patient subjective response, 11 noted improvement with filter, 7 with placebo, and 14 showed no difference. Finally, there was no correlation of clinical responses to specific reduction in the count or the absolute particulate count.
Reviewers’ Comments
The previous studies of the effectiveness of room air-filtering devices have been well-summarized in the article of the ad hoc committee which reviewed the effectiveness of air-cleaning devices (J Allergy Clin Immunol. 1988;82:661-669). Previous studies using laminar flow devices have suggested a mild benefit. This study mdi-cates some improvement but also notes the difficulty in motivating patients to do routine environmental control measures such as animal avoidance and cessation of smoking. For the markedly sensitive patient, however, especially those who have done standard environmental control measures and are trying to maximize the control measures, this study indicates a small degree of benefit which could be valuable for that individual patient.
THOMAS J. FISCHER, MD
Cincinnati, OH
ALMA M. HERRERA, MD
Mobile, AL
DIFFERENTIAL COGNITIVE EFFECTS AFTER
TERFENADINE
AND CHLORPHENIRAMINE
Meador JK, Loring DW, Thompson EE, Thompson WO. J Allergy Clln Immunol. 1989; 84:322-325.
The study population was composed of 24 healthy volunteers with a mean age of 31 years.
Methods
Subjects took either Terfenadine (60 mg), Chiorphen-iramine (8 mg), or a placebo, followed 3 hours later by post-drug electroencephalographic responses which in-cluded a P3 which reflects active cognitive processing of information. Certain drugs may affect the central nervous system adversely and slow P3 latency.
Findings
The authors compared the change in P3 latency from pretreatment to posttreatment for each subject. The pre/ posttreatment differences were greater for Chlorpheni-ramine subjects than for placebo subjects (P < .004) and for Terfenadine subjects (P < .01). In a comparison of subjective sedation there was no difference between pla-cebo and Terfenadine, whereas there was a significant difference for Terfenadine versus Chlorpheniramine.
Reviewer’s Comments
Antihistamines in many forms are common over-the-counter and prescribed medications for children with various upper respiratory tract problems. Long-term an-tihistamine therapy potentially may have detrimental effects in cognitive function especially in school settings. This fact should be considered when prescribing long-term antihistamine therapy in children with allergic con-ditions.
RUSSELL J. Hopp, DO
Omaha, NE
INFLUENCE OF ANTIHISTAMINE PRETREATMENT ON VANCOMYCIN-INDUCED RED-MAN SYNDROME
Sahai J, Heady
DP, Garns
R, Berry A, Polk RE.
J InfectDis. 1989;160:876-881.
Purpose
of the StudyThe purpose of this study was to determine if pretreat-ment with H1 and H2 antihistamines prevented the oc-currence of vancomycin-induced “red-man syndrome,” which is characterized by prunitis, erythema, and some-times angioedema.
Study Population
Twelve healthy male volunteers (21 to 28 years of age) without any previous exposure to vancomycin were in-cluded in the study.
Methods
of hydroxyzine and ranitidine; or (4) placebo. This was followed 2 hours later by an intravenous infusion of
vancomycin (1000 mg) for 60 mm in 200 mL of 5%
dextrose. Blood samples were obtained for serum hista-mine and vancomycin concentrations during and 60 mm-utes after the end of the infusion. Subjects were moni-tored for blood pressure changes and development of erythema and also were asked to report the intensity of pruritis. The study was done in a double-blind fashion. The same subjects were retested with a different antihis-tamine regimen (or placebo) after a 7-day washout.
Findings
Pretreatment with hydroxyzine alone provided signif-icant protection against vancomycin-induced erythema and pruritis (P < .05), whereas the effect of ranitidine did not differ from placebo. The combination of raniti-dine and hydroxyzine offered no advantage over hydroxy-zine alone.
Reviewer’s Comments
Vancomycin-induced red-man syndrome may occur in up to 80% to 90% of patients receiving this drug; it is due to histamine release into the plasma. As vancomycin is used frequently for patients with penicillin allergies, the allergist may be consulted for help in treatment of these patients. The prevention of red-man syndrome by hy-droxyzine would be useful in the treatment of patients requiring vancomycin.
ROBERT L. ROBERTS, MD, PHD
Los Angeles, CA
Upper
Airway
Disorders
PfhnnhuinInnv
RELATIONSHIP BETWEEN MILK INTAKE AND MUCUS PRODUCTION IN ADULT VOLUNTEERS CHALLENGED WITH RHINOVIRUS-2
Pinnock CB, Graham NM, Mylvaganam A, Douglas RM.
Am Rev Respir Dis. 1 990;1 41:352-356.
Purpose of the Study
This study was performed to investigate the widely held belief that “milk produces mucus.”
Study Population
Included in the study were 60 adult volunteers, aged 18 to 35 years, who were nonsmokers, free of respiratory disease, and not taking regular medication.
Methods
Cross-sectional Study Design. After completing a
per-sonal history and dietary questionnaire, subjects were
inoculated with Rhinovirus-2 and then lived communally for 10 days with food supplied by a caterer. At the onset of symptoms subjects were randomized to take either aspirin (4 g), paracetanol (4 g), ibuprofen (1.2 g), or placebo. Subjects recorded on a 4-point scale the severity of the following symptoms: runny nose, blocked nose, postnasal drip, loose cough, dry cough, and congestion. In addition, nasal secretion weights were measured by weighing tissues before and after use.
Findings
Fifty-six volunteers were infected successfully and shed virus on at least 4 days. Data were analyzed on 51 patients for whom satisfactory diaries were kept. There was no significant difference in overall symptoms or mucus production in the 4 treatment groups. However, patients taking aspirin, paracetamol, and ibuprofen re-ported higher nasal obstruction scores (P = .022) and experienced more nasal tubinate swelling (P = .026) than did those taking placebo. When present, a nonsignificant trend was observed for the patients’ cough to be loose with increasing dairy product intake. Of the subjects who believed before the study that milk was bad for colds, 80% believed it produced more mucus, perceived them-selves as more symptomatic, and drank less milk during the study than those who did not believe “milk makes mucus.” However, this increased loose cough was not accompanied by a parallel increase in the measure of mucus weights.
Reviewer’s Comments
This is the first of three reports studying the possible effects of milk intake on mucus production. The next two studies will involve 5- to 17-year-old asthmatic children and 12-month-old infants. Although the authors conclude “that no statistically significant overall association was detected between milk intake and the symptoms of mucus production in healthy adults symptomatic or asympto-matic, with rhinovirus infection.” It must be remembered that the study design was cross-sectional; if there was simultaneous and opposing association between milk in-take and mucus production, this type of study design would not be able to distinguish a difference. The authors pointed out that a negative finding in this study cannot be accepted at this time as a basis for rejecting the belief that milk produces mucus. Nevertheless this is an impor-tant study which looks at a commonly held belief and attempts to document the facts objectively. Obviously pediatricians and pediatric allergists will be extremely interested in the results of the next two studies.
JAMES P. KEMP, MD
San Diego, CA
INFLUENCE OF NASAL ALLERGIC REACTIONS ON THE CLEARANCE OF MIDDLE EAR EFFUSION
1991;87;985
Pediatrics
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