Kim Mudd

The impact of food allergy on the daily activities of children and their families.

BACKGROUND Food allergy affects a significant number of children, and its management requires considerable time and vigilance. OBJECTIVE To determine the impact of food allergy on the daily activities of food allergic children and their families. METHODS Caregivers of food allergic children from a university-based allergy practice completed a questionnaire that evaluated their perception of the impact of their childs food allergy on family activities. RESULTS Of the 87 families who completed the study, more than 60% of caregivers reported that food allergy significantly affected meal preparation and 49% or more indicated that food allergy affected family social activities. Forty-one percent of parents reported a significant impact on their stress levels and 34% reported that food allergy had an impact on school attendance, with 10% choosing to home school their children because of food allergy. The number of food allergies had a significant impact on activity scores, but the existence of comorbid conditions such as asthma and atopic dermatitis did not significantly affect the results. CONCLUSIONS Food allergy has a significant effect on activities of families of food allergic children. Further study is needed to determine more detailed effects of food allergy on parent-child interactions and development.

The distribution of cat and dust mite allergens on wall surfaces

This study was undertaken to determine the distribution of cat and dust mite allergens on wall surfaces and to assess the value of wall-wipe samples as a measure of allergen exposure. Paired samples were collected from 31 homes, 20 homes with cats and 11 homes without, by vacuuming 1 m2 of carpet and by wiping 1 square foot of an adjacent wall. Felis domesticus allergen I (Fel d I) was detected in 30 of 31 settled dust samples (range, not detectable to 832,000 mU/gm; median, 10,250 mU/gm) and in 27 of 31 wall-wipe samples (range, not detectable to 113.7 mU per filter; median, 1.2 mU per filter). There was a significant correlation between Fel d I content in settled dust and wall-wipe samples (rs = 0.73; p less than 0.001). To assess the reproducibility of the wall-wipe method, multiple wipe samples were obtained from 20 homes, revealing a mean coefficient of variation of 110%. In contrast to Fel d I, although Dermatophagoides farinae allergen I was detected in 23 of 25 settled dust samples (range, not detectable to 11,888 ng/gm; median, 1178 ng/gm), it was detected in only four of 25 wall-wipe samples. We conclude that cat allergen, but not dust mite allergen, is widely distributed on wall surfaces and that wipe samples provide a simple and effective means of assessing household exposure to cat allergen.

Patterns of Inhaled Antiinflammatory Medication Use in Young Underserved Children With Asthma

BACKGROUND. Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications. METHODS. This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention. RESULTS. Although exposure to ≥1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting β agonist fills for 12 months. Only 20% of children obtained ≥6 inhaled corticosteroids fills over 12 months. Obtaining ≥3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting β agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the childs asthma. CONCLUSIONS. Overreliance on short-acting β agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.

Extension of food allergen specific IgE ranges from the ImmunoCAP to the IMMULITE systems

BACKGROUND Quantitative measures of food specific IgE antibody using the Phadia ImmunoCAP method have documented value in the diagnosis of food allergy. OBJECTIVE To define factors that could be used to relate IMMULITE-measured IgE antibody levels for chicken egg white, cows milk, and peanut into ImmunoCAP-comparable quantities that could then be correlated with published levels that have been generated with the ImmunoCAP system. METHODS Serum samples from 328 patients (median age, 5.4 years; age range, 1-18 years; 32% female) who were known to be IgE positive (>0.1 kU/L) to chicken egg white (n = 120), cows milk (n = 135), and/or peanut (n = 304) were analyzed in both the ImmunoCAP and IMMULITE autoanalyzers. RESULTS IgE antibody levels from both assays for each of the 3 food specificities were highly correlated: r(2)= 0.95 for egg white, r(2) = 0.93 for milk, and r(2) = 0.95 for peanut (P < .001). Empirically determined IMMULITE/ImmunoCAP ratios (mean ± 1 SD) were 4.85 ± 1.79 kU/L (egg), 2.33 ± 1.0 kU/L (milk), and 1.86 ± 0.98 kU/L (peanut). For milk and peanut, the IgE antibody levels for individuals who either passed or failed a food challenge were not significantly different between the assay methods. Because of the small sample size of egg white challenged patients, no statistical analysis was performed. CONCLUSION These data indicate that specific IgE levels to egg white, milk, and peanut measured by the IMMULITE and ImmunoCAP systems are highly correlated and that differences between the systems are circumscribed and modest (IMMULITE was a mean of 2- to 5-fold higher than ImmunoCAP).

Asthma as a Predictor of Obstructive Sleep Apnea in Urban African-American Children

Background. Asthma is a known co-morbid factor in childhood obstructive sleep apnea (OSA); however, little is known about the effects that asthma might have on the severity of OSA. We hypothesize that children with concomitant asthma and OSA have more severe OSA. Methods. We conducted a prospective study of 50 children with OSA diagnosed by polysomnography referred for tonsillectomy and adenoidectomy (T&A). The presence of concomitant asthma was determined by ISAAC questionnaire and spirometry. Atopy to common allergens was determined by skin prick testing. Due to the relatively small sample size, we limited hypothesis testing to cross tabulations with Fishers Exact Test and t testing. We also employed a parsimonious ordinary least squares (OLS) regression assuming a large effect size. Results. Subjects (n = 50) included 32 males and 41 African-Americans. Age at T&A was 9.3 ± 3.4 years (mean ± S.D). Thirty-two subjects reported a history of asthma during their lifetimes, but the ISAAC questionnaire detected only 30 subjects. Twenty-two subjects reported current asthma. Atopy was found in 27 subjects. Apnea-hypopnea index (AHI) was lower in the current asthma group than in the lifetime asthma group but did not reach statistical significance. However, AHI was significantly higher in subjects with poorly controlled asthma. Further, in a parsimonious OLS model controlling for sleep efficiency and age, a history of lifetime asthma increased the AHI by 8.8 (p < 0.05). Discussion. In urban African-American children referred for T&A to treat OSA, a history of poorly controlled asthma is associated with more severe OSA.

Pharmacy Fill Patterns in Young Urban Children with Persistent Asthma

Background. Medication adherence impacts healthcare utilization. Pharmacy records are useful to establish fill patterns. Objective. Use pharmacy records to establish medication patterns fill patterns for comparison to healthcare utilization. Methods. Pharmacy records of 175 children with persistent asthma were collected and compared to healthcare utilization. Results. Majority of subjects had significant healthcare utilization, low numbers of rescue medications, and poor controller medication fill rates. Those with more rescue medications had more healthcare utilization and more controller medications. Conclusions. Pharmacy fill patterns demonstrate few rescue and/or controller medication fills. Those with more rescue medications reported increased healthcare utilization despite controller medications.

A hospital-based screening program for natural rubber latex allergy

BACKGROUND Natural rubber latex (NRL) allergy has become an important occupational health problem for health care workers, of whom approximately 10% are reportedly sensitized. Some medical facilities have chosen to convert entirely to NRL-free gloves, but others have found this to be financially or logistically unfeasible. OBJECTIVES The goals of this study were 1) to devise a NRL allergy screening program that could identify sensitized (at-risk) employees for the purpose of providing them with a safe working environment; and 2) to develop a glove conversion plan that would lead to the removal of all NRL gloves from the institution. METHODS A multidisciplinary University of Maryland Medical System NRL risk team developed a mandatory NRL screening program for all newly hired employees and any existing employees transferring into or within patient care positions. Employees were screened with a clinical questionnaire and a serology for immunoglobulin (Ig)E anti-NRL. Some employees voluntarily received an experimental NRL skin test to evaluate their skin reactivity to NRL. Each employee reporting respiratory or systemic symptoms associated with NRL exposure was evaluated by an allergist. RESULTS During the 15-month study period from April 1998 to July 1999, 1,795 employees were screened for NRL allergy. Of the whole group, 8% (144 of 1,795) were NRL-specific IgE antibody-positive by CAP radioallergosorbent test (Pharmacia-Upjohn Diagnostics, Kalamazoo, MI) and/or NRL skin test, 57.3% of whom reported symptoms with powdered NRL glove exposure. The NRL IgE-positive rates of nonpatient-care employees (who did not use NRL gloves on a regular basis) and direct patient-care employees was 5.9% and 8.6%, respectively. Most NRL-sensitized employees were successfully accommodated with the use of synthetic gloves and continued to work in the positions for which they were hired. CONCLUSIONS The University of Maryland Medical System NRL screening program has been successful in identifying at-risk employees and ensuring them a safe working environment during a progressive conversion of the hospital to a NRL-safe environment.

Prescription fill patterns in underserved children with asthma receiving subspecialty care

BACKGROUND Children with asthma receiving specialty care have been found to have improved asthma outcomes. However, these outcomes can be adversely affected by poor adherence with controller medications. OBJECTIVE To analyze pharmacy fill patterns as a measure of primary adherence in a group of underserved minority children receiving allergy subspecialty care. METHODS As part of a larger 18-month nebulizer use study in underserved children (ages 2-8 years) with persistent asthma, 53 children were recruited from an urban allergy practice. Pharmacy records were compared with prescribing records for all asthma medications. RESULTS Allergist controller prescriptions were written in 30-day quantities with refills and short-acting β-agonists (SABAs) with no refills. Only 49.1% of inhaled corticosteroid (ICS), 49.5% of combination ICS and long-acting β-agonist, and 64.5% of leukotriene modifier (LTM) initial and refill prescriptions were ever filled during the 18-month period. A mean of 5.1 refills (range, 0-14) for SABAs were obtained during 18 months, although only 1.28 SABA prescriptions were prescribed by the allergist. Mean times between first asthma prescription and actual filling were 30 days (range, 0-177 days) for ICSs, 26.6 days (range, 0-156 days) for LTMs, and 16.8 days (range, 0-139 days) for SABAs. CONCLUSION Underserved children with asthma receiving allergy subspecialty care suboptimally filled controller prescriptions, yet filled abundant rescue medications from other prescribers. Limiting albuterol prescriptions to one canister without additional refills may provide an opportunity to monitor fill rates of both rescue and controller medications and provide education to patients about appropriate use of medications to improve adherence.

Asthma Management Practices at Home in Young Inner‐City Children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with childrens asthma morbidity. Caregivers of 100 inner‐city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.

Seasonal Patterns of Controller and Rescue Medication Dispensed in Underserved Children with Asthma

Objective. To determine whether temporal trends exist for short-acting beta agonist (SABA), oral corticosteroid (OCS), and anti-inflammatory prescription fills in children with persistent asthma. Method. This was a longitudinal analysis of pharmacy record data and health information data obtained by parent report over 12 months for children with persistent asthma 2 to 9 years of age. Eligible children had to report current nebulizer use and one or more emergency department visits or hospitalizations within the past 12 months. Results. Children were primarily African-American (89%), male (64%), received Medicaid health insurance (82%), and were a mean age of 4.5 years (SD 2.1). Few families (11%) reported any problems paying for their childs asthma medications at baseline or at the 12-month follow-up. There was a high degree of association between filling a rescue (SABA or OCS) and controller (leukotriene modifier, inhaled corticosteroid, cromolyn) medication during the same month for all months with Pearsons correlation coefficients ranging from a low of 0.28 for October to a high of 0.53 in September. Short-acting beta agonist fills were significantly more likely to be filled concurrently with inhaled corticosteroid fills. However, significantly fewer prescription fills were obtained in the summer months with an acceleration of medication fills in September through December and an increase in early spring. Conclusions. There was a summer decline in both inhaled corticosteroid and SABA fills. Timing of asthma monitoring visits to occur before peak prescription fill months, i.e., August and December for an asthma “tune-up,” theoretically could improve asthma control. During these primary care visits children could benefit from more intensive monitoring of medication use including monitoring lung function, frequency of prescription refills, and assessment of medication device technique to ensure that an effective dose of medication is adequately delivered to the respiratory tract. Additionally, scheduling non-urgent asthma care visits at pre-peak prescription fill months can take advantage of “step down” during decreased symptom periods and when appropriate restart daily controller medications to “step up” prior to peak asthma periods.