Penicillin Allergy (yes and no)

Obviously, penicillin is a very important and useful drug.  Most studies cite 10% of Americans identify as being penicillin allergic (pcnA).  However, later studies now suggest that this number is likely grossly overstated.  The actual number is likely around 1%, and 95% of pcnA diagnoses are inaccurate.

How does this happen?  Not infrequently, people self report their child as pcnA because one parent is so diagnosed.  However, most evidence indicates only a slight increase in risk–2 or 3%– with one parent allergic.  There is a somewhat greater risk if both parents are pcnA; however even in this instance guidelines do not recommend assuming allergy or avoiding use of penicillin, but rather test for accurate diagnosis.

A second problem is symptoms.  pcnA is caused by developing specific antibodies (“IgE”)to the penicillin molecule, causing hives, blisters, wheezing, joint inflammation, and, more ominously, swelling of lips, tongue, or throat.  The danger here–besides their own problems– is the risk that subsequent exposure can result in life threatening anaphlyaxis (shock, collapse).  Other symptoms often associated with use of penicillin(as for most antibiotics)–headache, nausea, abdominal pain, diarrhea–while upsetting and uncomfortable –are not caused by IgE, are not “allergic”,  and carry no risk of anaphylaxis.  But people may tend to conflate those other unpleasant but less dangerous side effects and will report that experience as “allergy.” So we doctors must look at these reports carefully.

Another cause can be timing.  Most URI’s–at least 95%–are viral. Recent studies find that urgent care centers  prescribe antibiotics for up to 40% of children treated there for these conditions.  Now, many of these viruses progress over 3-5 days and will then resolve with the breakout of a rash (for example, roseola–but there are lots of others).  So many of these kids can be seen at urgent care on, say, day 2 of the roseola like viral illness, diagnosed (over diagnosed?) with bacterial infections like otitis media, and then subsequently break out in the typical illness ending rash on day 4 or 5–the next thing you know, 2+2=3 and we have an (erroneous) diagnosis of pcnA.  This is just one more example of how temporal association does not establish causality, and, I say, another reason to access these establishments with caution.

This is not a trivial matter.  pcnA patients treated with alternate drugs after surgery tend to have more complications and poorer outcomes than those treated with penicillin.  pcnA patients have to take other, more “broad spectrum” type antibiotics which place them at greater risk for serious–sometimes life threatening–secondary infections like MRSA, clostridium dificile (“Cdif”), or “VRE”–vancomycin resistant enterococci.  Moreover, recent data indicate that up to 80% of people with actual IgE mediated pcnA will lose their sensitivity over time, enabling them to take penicillin again safely.  I will note here that, given the risks, this must be evaluated carefully beforehand to assure patient safety.

So if you have concerns about pcnA in your child let me know.  We can discuss it, test or refer to clarify this important issue.  Thanks for following.

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Avoid Toxins

Nutritious  food and a safe environment is, of course, a basic requirement for a healthy upbringing.  Currently there are > 10,000 chemicals allowed as additives in food and food contact materials in the US.  There is growing evidence that at least some of of these products pose significant health risks for children.  There are several reasons why these chemicals are riskier for kids.  Children are smaller so the per kilogram ingestion dose is typically larger; their organs are still developing; and lastly children will likely carry these ingested materials internally for decades longer.

Questions raised by some of the newer research involve odd sounding chemicals with even stranger spellings–bisphenols, phthalates, perfluoroalkyls, perchlorates–used to enhance the functionality of food storage products made of plastic or metal, that may seriously impair  the function of endocrine, neurologic, or metabolic function.  The American Academy of Pediatrics feels that the Food and Drug Administration needs to take additional steps to “raise its game” with respect to these and many other additives. Some of the steps recommended include update and strengthen the “generally regarded as safe (GRAS)” process, prioritize retesting of previously approved agents, leverage expertise across agencies to streamline communication for better policymaking, dedicate more resources ($) to the effort, expand the scope of research and testing, and expand efforts at transparency of information for the public.

Under the current federal Administration, the present priority is clearly in the opposite direction towards cutting back on research and regulating these products as they feel that those steps are burdensome to industry and thus a drag on economic development and job creation.  I will limit my political commentary about that here to pointing out that generally the AAP does not agree with that priority and feels that children’s health is placed at risk by that approach.  Suffice to say that it is unlikely that we will see these policy preferences, as expressed by the AAP, become reality any time soon. Thus it is left to us to take the initiative to shield children from exposure to these potential hazards.  Keep the following in mind:

  1. Prioritize consumption of fresh or frozen fruits and vegetables when possible and support that effort be developing a list of low cost sources of that type of produce.
  2. Avoid processed meats, especially maternal consumption during pregnancy.
  3. Avoid microwaving food or beverages (including infant formula and pumped human milk) in plastic
  4. Avoid placing plastics in dishwashers.
  5. Use alternatives to plastic, such as glass or stainless steel, when possible.
  6. Check the recycling code on the bottom of products to find the plastic type, and avoid products with recycling codes 3(phthalates), 6(styrenes), and 7(bisphenols) unless they are labeled “biobased” or “greenware” indicating that they are corn based and do not contain bisphenols.
  7. Encourage hand washing before handling  foods and/or drinks, and wash all fruits and vegetables that cannot be peeled.

Bottom line: be aware that as a matter of public policy in the present environment it is largely up to you to monitor the safety of the products used for your children.  Keep that in mind during future political campaigns.

Thanks for following.