Archive for May, 2009

The simplest and most certain test for any sensitivity reaction is to expose the person concerned to the substance under suspicion and see what happens. This is known as a

challenge test. With true allergies, challenge tests are powerful tools, but they are also alarmingly close to reality. The risk of provoking a severe reaction requires a very

cautious approach.
By comparison, an indirect test – a roundabout way of seeing how the body responds, such as the skin-prick test (see p. 91) – has the advantage of rarely producing dangerous

reactions. The downside is that indirect tests can be misleading, precisely because they are not like the real-life situation. No indirect test is perfect – there are always

false positives and false negatives (see box on p. 91).
Challenge tests
If you undergo a challenge test with food or an airborne allergen, you will also be given dummy challenges with an innocuous substance which is indistinguishable from the item

being tested. Neither you, nor the tester who is scoring the reaction, should know which is which. This is called a double-blind trial because, to eliminate all possible bias,

both of you are in the dark. (The full name is a ‘double-blind placebo-controlled trial’ – the dummy challenge is also called a ‘placebo challenge’ or ‘control challenge’.)
The double-blind trial is a standard medical procedure and does not imply that the doctors think you are faking symptoms. Psychological forces are powerful things, and just

thinking that you might react to a test can be enough to produce a reaction – the process that generates the symptoms is largely unconscious.
Food challenge
A food challenge – eating the food that is under suspicion – is a key test for food intolerance (see p. 197). It is sometimes used for food allergy and other forms of food

sensitivity too, as a follow-up to skin tests. Some allergists use a food challenge only if the skin test is at odds with actual events reported by the patient. Other allergists

use food challenge more readily, to confirm skin-test results, and to assess the severity of the reaction.
Extreme caution must be exercised with immediate food allergy, because of the considerable risks involved. The test must be done under medical supervision with resuscitation

equipment to hand. A challenge test should never be done for true food allergy without some careful preliminary tests on the face and the lips (see box on p. 23). Even if these

tests produce no reaction, only tiny amounts of the food should be eaten to begin with.
Bronchial challenge
This type of test involves inhalation of an airborne allergen – such as pollen – suspected of causing asthma. Bronchial challenge carries the risk of provoking a severe asthma

attack, and few doctors use it unless there are compelling reasons to do so – such as demonstrating that someone’s asthma is due to an allergen encountered at work.
Skin-prick tests
This is an indirect method of detecting true allergic reactions. It is one of a family of skin tests that use a similar approach. The three different tests in this family are

known as: skin-prick tests or prick tests, puncture tests, and scratch tests.
For the skin-prick test – the technique used in Britain – a small drop of liquid containing an allergen, such as grass pollen, is placed on the arm. The doctor makes a small

prick in the skin, under the drop of liquid, allowing a minuscule amount of the allergen to get into the skin. A positive reaction is recorded if a red bump develops soon

afterwards. For accuracy, the bump must be compared to positive and negative controls (see below).
The puncture method is very similar to the skin-prick test but uses a slightly different technique for breaking the skin. The term prick-puncture test covers both techniques.
With the scratch method, the skin is scratched lightly, and the allergen solution is then applied over the scratch. This method gives less consistent results than prick-puncture

testing.
It is important to include a negative control in the test – a skin-prick test with plain salt water (saline). This should not produce much of a bump – if it does, the skin is

clearly over-reactive and the tests more difficult to assess. The doctor should also include a positive control – a skin-prick test with histamine, the substance that plays a

central role in allergic reactions. This should always produce a bump. If it does not, the skin is decidedly under-reactive, and the tests are invalid.
Taking antihistamines will make the skin under-reactive, and you should stop taking them before the testing, for a period ranging from a day to several weeks – it varies

depending on the particular antihistamine. Ask your doctor for specific instructions about stopping these and other drugs before testing.
Skin tends to be over-reactive to testing in people with dermatographism (see p. 52). Blood tests for specific IgE,
such as RASTs (see p. 92), are needed for anyone who has this condition. Eczema sufferers with a rash over large areas of the body may also require blood tests, if there is too

little clear skin for testing.
Skin-prick tests can produce both false positives and false negatives (see box below). Some allergic diseases will give a lot of false negatives and relatively few false

positives, while for others the reverse is true. The allergen itself influences the rates of misleading reactions: for example, tests for soya allergy are notoriously

unreliable, whereas those for peanut are far more accurate. The age of the person being tested also makes a difference. With all these influences at work, interpreting the test

responses is a real art, and the doctor’s experience counts for a lot.
All sorts of people offer skin-prick tests, including alternative practitioners. Get them done by a qualified doctor, preferably by an allergist, who will know how to make sense

of the reactions.
Note that the purpose of these tests, and of blood tests for specific IgE, is to identify the allergens that are bringing on your symptoms, not to predict how strongly you will

react to those allergens. The tests may give some Indication of the intensity of your reaction, but they cannot be regarded as a good guide to how you will respond to the

allergen in the future.
The safety record of skin-prick tests is very good. Occasionally a systemic reaction (anaphylaxis) occurs with these tests, but there are no records of any deaths. Nevertheless,

if you suffer from severe asthma or have experienced anaphylactic shock in the past, it is advisable for the doctor to have adrenaline and resuscitation equipment available.

Those with strong allergic reactions to latex may also react badly if they are tested with an allergen that cross-reacts with latex (e.g. cypress pollen), not just when tested

with latex itself. Taking beta-Mockers (see box on p. 150) increases the risk of a life-threatening reaction for anyone in these higher-risk categories.
False positives and false negatives
Apart from challenge tests, none of the tests used for allergy works with 100% accuracy. Most give both false positives and false negatives.
A false positive means that there is a positive test but no actual reaction when the allergen is encountered (e.g. eaten or inhaled). A false negative means that there is a

negative test result despite a genuine reaction (as shown by a challenge test, for example).
A test that gives relatively few false positives has good positive predictive value – in other words, if it suggests you are allergic to something, you probably are.
A test that gives relatively few false negatives has good negative predictive value. If it comes up negative, you are probably not allergic to that allergen.
Some tests for allergic reactions show good positive predictive value but poor negative predictive value, while for other tests the reverse is true.

Controversy abounds in medicine, especially when it comes to alternative forms of treatment, but there is one thing that almost everyone agrees on: feeling calmer and more

relaxed is good for your health. There are many ways in which a person’s mental and emotional state can affect their allergies or other sensitivity reactions (see pp. 232-7),

and these help to explain the beneficial effects of relaxation.
There are several different types of approach that can help in the quest for a calmer state of mind and a more relaxed state of body:
• Straightforward relaxation techniques which you learn and then practise for yourself, either on a daily basis, or whenever you need them, or both. Examples include

relaxation exercises of various kinds, biofeedback, autogenic training and self-hypnosis.
• Relaxation techniques that are rooted in spiritual practice, such as meditation, yoga, t’ai chi or chi kung (ql gong). Some other martial arts, in addition to t’ai chi,

also have a strong element of spiritual practice.
• Treatment techniques such as massage, aromatherapy, reflexology and short courses of hypnotherapy, that are intended to help you feel more relaxed. Acupuncture (see p.

214) can also have this effect. Some therapists providing this type of treatment will also teach you simple relaxation exercises to use at home.
• Investigative approaches that look into the fundamental causes of tension, and attempt to deal with deep-seated emotional problems: psychotherapy (in its many different

forms), psychoanalysis, long-term hypnotherapy when this has psychotherapeutic aims, and biodynamic massage.
In the long run, approaches that make you dependent on another person (an aromatherapist or reflexologist, for example), in order to feel relaxed, are usually less helpful than

those that give you an active role. If you are learning and practising a technique, as with relaxation exercises or yoga, this puts you in charge of your state of mind.
The techniques that are rooted in spiritual practice, especially meditation and yoga, are particularly helpful because they invite you to take a very broad view of the problems

that face you, and the situations that cause you stress. Firstly, rather than focusing very narrowly on your own tense muscles and recurring difficulties, they look at the human

situation as a whole – at the basic causes of tension and unhappiness in human beings. Secondly, rather than trying to graft a relaxed viewpoint onto a horribly unrelaxed daily

existence (which is what most of us now endure) a regular meditation practice can result in a fundamental and long-lasting change in outlook, with a greater sense of wholeness,

direction and stability. This is something that happens naturally within the stillness of meditation practice, and it should be very much an individual process of change, not

something imposed from outside. At a purely practical level, a spiritual practice tends to improve relationships with other people, and since a great deal of our stress is

caused by the people around us, any improvement in our social interactions can reduce stress enormously.
Some kind of psychotherapeutic approach may be the best choice for those who have tried and failed with other techniques, or achieved only a temporary reduction in stress

levels. By tackling the problems at a deeper level, it is often possible to achieve a more profound and long-lasting solution.
Many people discover that, whenever they try to relax or to meditate, they feel even more agitated and anxious. Others begin to cry, or show other signs of distress. Not

surprisingly, people who react in this way quickly give up their attempts to unwind, because their responses are so disturbing. Underlying these reactions to relaxation

exercises there may be deep-seated problems, usually going back to childhood, that can only be held at arm’s length with the help of a tense and always-busy approach to life.
Constant mental activity is part of this defensive strategy, which is why relaxing or meditating is such a frightening experience. Although it is tempting to run away from the

problem, by plunging back into a life of frenetic activity, mental and physical, this is ultimately no solution. Some form of psychotherapy is usually needed to deal with these

long-standing problems.
Whatever you decide to try, make sure that the teacher or therapist seems a calm and relaxed person. You should also look for someone who is sympathetic and supportive about

your illness. Avoid like the plague those who attribute all allergies and other physical symptoms to mental or emotional problems. Such people can cause immense psychological

damage – if you don’t get 100% better it will, of course, be your fault.
Hypnotherapy
Hypnosis has a distinctly shady reputation, because of its use – or misuse – in stage and television performances. If hypnosis were not so valuable medically, it would probably

be rejected entirely by conventional medicine, on the strength of this reputation. The fact that hypnotherapy is used by some entirely mainstream doctors, as a legitimate

treatment for conditions such as atopic eczema, is a great testament to its effectiveness.
Hypnosis is certainly a mysterious phenomenon, and it is difficult to say exactly what happens when a person is hypnotised. Dr Ruth Lever, a qualified doctor who combines

hypnotherapy with conventional medical practice, describes the hypnotic state as ‘not a form of unconsciousness but rather an altered form of consciousness, in which the patient

is more open to suggestion than he would normally be, and in which a corridor is opened between the conscious and the subconscious mind’.
It is certainly not true that the hypnotised person is under the control of the hypnotist or hypnotherapist. Autonomy is retained, and no one under hypnosis can be forced to do

anything that is really against his or her will. While the person may experience a different state of mind, he or she remains aware of what is going on in the room and anything

that is said.
The exact change in mental state during hypnosis varies greatly from one person to another. Some people respond far more readily than others, and go into a deeper hypnotic

state. (These same people are more susceptible to placebo effect, a psychological response to drugs or other forms of treatment –see p. 233.)
At one time, it was thought that only adults could be hypnotised. Children seemed to be immune to hypnosis, but in fact they are just immune to the particular hypnotic

techniques used for adults. With the right techniques, children can also be hypnotised.
Hypnotherapy treatment can be quite brief, taking only a few sessions. This approach relies on suggestions from the therapist to achieve relaxation, a change in perceptions

(e.g. that the skin feels cool and smooth, for someone with atopic eczema) and a change in habits (e.g. stopping scratching).
Another approach is to use hypnosis as a means towards achieving personal insight into emotional problems by accessing suppressed memories. This is a long-term treatment, which

has much in common with psychotherapy. It should only be practised by those who have full psychotherapy training.
Scientific studies show that hypnotherapy can be of benefit in both asthma and atopic eczema. Make sure you get a really well-qualified hypnotherapist –preferably someone who

also has conventional medical training, or psychotherapy training, and plenty of experience.
You may be given exercises in self-hypnosis to do at home, or tapes, possibly music tapes to be played at bedtime for children with eczema. These can be very useful in

reinforcing the messages from the hypnotherapy sessions about sleeping deeply and not scratching,Relaxation exercises
Acquiring the knack of relaxing is a very personal thing – what works for one person will be useless for another. You may have to try several different techniques before you

find one that is right for you.
Guided imagery is often an effective method, and increasingly popular with the widespread availability of relaxation tapes. The tape will ask you to sit in an armchair, or lie

down, and picture the scenes described (’waves are lapping gently on the golden sand…’ etc.). If you are able to visualise the scene, this should induce a more relaxed state

of mind – rather like the relaxation you get from watching a good film.
There are also tapes of special music, or music combined with natural sounds (waves, seagulls etc.) that are intended to produce a relaxed state of mind. Much of this music is

incredibly banal, and it may irritate you more than relax you! However, there are also some excellent tapes available, so shop around.
One time-honoured method of relaxing is to sequentially contract, and then release, muscles in each part of the body, beginning with the hands or feet. This is known as

Jacobsonian systematic relaxation training or progressive muscle relaxation. A study of children suffering from asthma found that this training increased the peak flow by an

impressive 32% for some children, although others did not do quite so well.
Autogenic training
Based loosely on self-hypnosis, autogenic training is a very down-to-earth approach to relaxation which may be useful for anyone who is wary of things esoteric. You are taught

to concentrate on different parts of your body in turn and imagine them growing warm and heavy. Beginning with ‘my right arm is heavy and warm…’ (repeated three times, either

out loud or in your head) you work your way through the rest of the body: ‘my left arm…’ , ‘both my arms…’ , ‘my right leg…’ etc.
You could, in theory, teach autogenic training to yourself, using a book, but it is helpful to have to go to a class. The teacher can encourage you to persist when you feel

discouraged by your slow progress, and can help with any problems that arise.
Teachers of autogenic training often add more specific lines at the end of the exercise, such as ‘my breathing is calm and regular’ for asthmatics, or ‘my skin is soft and cool’

for someone with eczema. A study of asthmatics found that they performed better in basic lung-function tests after eight months of regular autogenic training.
Autogenic training can sometimes evoke strong reactions if there are long-standing problems or suppressed feelings and memories. In these situations, the training sessions may

need to incorporate some elements of psychotherapy. Teachers vary in the extent to which they can offer this.
Yoga
Yoga, in its original form, provides a complex religious philosophy of life. If followed with dedication, it affects the whole person –physical, mental, emotional and spiritual.

Those who have practised yoga seriously for many years achieve a great deal of mental focus and calmness, plus a surprising level of control over bodily functions such as blood

pressure and heart rate. These profound changes are achieved through a combination of breathing exercises (pranayama), yoga postures (asanas), meditation, cleansing practices

and careful attention to diet and way of life.
Yoga has now been practised in the West for over a century, and during that time it has been watered down and very thoroughly Westernised. There are now forms of ‘yoga’ that

consist of little more than stretching and relaxation.
For the greatest benefits from yoga, look for classes with a more rigorous approach. If the particular kind of yoga is specified, e.g. Hatha yoga or Kundallni yoga, the chances

are that you’ll be getting something more authentic,
lyengar yoga is the most common form taught in the West, but it is rather narrow, concentrating almost entirely on postures. A form of yoga that includes breathing exercises is

probably more useful, especially if you have asthma.
Before you sign up for a class, talk to the teacher and find out what it includes. If you are asthmatic, make sure the teacher is really experienced in working with asthmatics.

It is all too easy to get the yoga breathing exercises wrong, making the breaths too deep. This can turn into a form of hyperventilation (see p. 226).
Approaching the breathing exercises with a ‘got to get this right’ attitude is another pitfall for Westerners doing yoga. Most of us have the unfortunate habit – acquired in

early childhood – of tensing up and ‘really trying’ when we are taught anything. This is a major obstacle to doing yoga breathing correctly. Eastern attitudes are much more

easy-going and this helps asthmatics much more, because relaxing as you breathe is the key to it all.
Meditation
Basic meditation involves stilling the mind – either emptying it of all thoughts, or focusing it on one very simple object. This is fantastically difficult for most people at

first, but with time, and regular daily meditation, it gradually becomes easier.
Many different forms of meditation exist. Most are part of a spiritual tradition such as Hinduism, Sri Lankan Buddhism, Tibetan Buddhism, Zen Buddhism, or Taoism (Daoism).

Meditation also forms part of yoga, and it is a cornerstone of most martial arts, though this tends to be played down when these are taught in the West. In each case, meditation

takes a slightly different form and has different psychological effects.
A practice known as transcendental meditation (TM), is one of the most widely available – the teaching is arranged by a large international organisation, and can prove

expensive. It is cheaper, and probably better in the long run, to go to classes in a local Buddhist centre or consult one of the many books and tapes on this subject. ect.
Biofeedback
This is the most thoroughly scientific, rational and high-tech of alternative treatments. Biofeedback uses technology to measure the state of some part of your body – a part

that is usually under automatic control, such as the electrical activity in your brain –and relays this information back to you (hence bio-feedback) .
The feedback is shown by means of swinging needles on dials, flashing lights or bleeping sounds. The idea is that you gradually learn to influence the signal, by noticing that

it has changed very slightly in the desired direction, and then re-running (in your head) the thoughts or feelings which apparently led to that change.
In quite a short space of time, you can, with this method, alter bodily states that are beyond voluntary control in most people. Scientific studies show that biofeedback can

teach people to regulate their heartbeat, for example, or reduce the amount of acid produced by the stomach. Although yoga practitioners have long claimed to be able to

influence such bodily functions. it was only with the invention of biofeedback that scientists accepted this was possible.
Biofeedback can also teach asthmatics to relax tight airway muscles, something that has been demonstrated convincingly in scientific trials. Unfortunately, the specialised

equipment needed for this particular form of training is not generally available.
If you sign up for biofeedback, you will probably be trained with equipment that measures the electrical resistance of the skin (this varies with how tense you are) or the

electrical activity of the brain. This kind of equipment can help you learn to relax at will.
Massage and aromatherapy
There are many different varieties of massage, and most are relaxing to some extent. Regular massage treatments may improve your general sense of calmness and your ability to

cope with life’s stresses and problems. In the case of long-standing asthma,
massage may also help with tension in the muscles of the chest, back and neck, which frequently develop during asthma attacks.
Aromatherapy is really a form of massage, with the use of scented oils. Bear in mind that the strong smell of some oils can provoke asthma attacks (see p. 39), while other oils

can irritate the skin of people with atopic eczema or contact dermatitis.
Biodynamic massage involves a much more subtle touch than other forms of massage and it has different aims. The central objective is to identify bodily tensions that are a

result of repressed memories or blocked impulses, and to rebalance the energies of the body. Think of this more as psychotherapy than as massage. It can be very helpful.
Reflexology and zero balancing
Reflexology is based on the belief that specific zones on the soles of the feet correspond to particular parts of the body, and that stimulating those zones on the feet (by

gentle pressure) can induce a healing process at distant points in the body. It may or may not be true – certainly, having your feet massaged is immensely pleasurable and can

induce a profound relaxation.
Zero balancing is a sequence of static touch, gentle holding and light pressure, applied to specific parts of the body. It can induce a state of great well-being and calmness.
Psychotherapy
The basic tenet of psychotherapy is that it is much more painful and exhausting to keep on repressing bad memories than it is to bring them out into the open, in a safe

therapeutic situation, which allows you to process them and move on. Dealing with deep-seated problems lets you relax and live life more fully. In some cases it may help with

physical symptoms, such as allergies.
There is a bewildering choice here, with so many different varieties of therapy on offer. Fortunately, according to recent research, they a// work to about the same extent, as

long as you have a good rapport with the therapist. But if you don’t click, the therapy usually doesn’t work, however expert the therapist might be. So make sure you have an

introductory meeting before committing yourself to a course of therapy, and don’t be afraid to say ‘no’ and try someone else, if you don’t feel quite right with the therapist.
Counselling can also be valuable, and again you will do much better with someone you feel at home with, but who is not afraid to challenge you when necessary.

Investigating Food Intolerance

COLICKY BABIES
If you have followed the measures described on pp. 78-9 but have had little or no success in reducing colic symptoms so far, it makes sense to look into the possibility of a food sensitivity reaction (either intolerance or a mild allergy) to food proteins. This is a very different problem from lactose intolerance (an inability to digest the milk sugar, called lactose, due to a shortage of lactase - see p. 79), although the two can get entangled, creating a complex and confusing set of responses.
The complications arise because, when there is diarrhoea as a result of allergy or intolerance (or from any other cause, including infections) it temporarily strips the gut of its lactose-digesting capacity. This problem is called secondary lactase deficiency, and it will correct itself quite quickly once the real cause of the diarrhoea is eliminated.
Unfortunately, the routine medical tests for lactase deficiency do not distinguish between this temporary problem and the much rarer primary lactase deficiency, which is inherited and life-long.
So if your child has had these routine tests, and you have been told that they show primary lactase deficiency, it remains possible that the real problem is a reaction to milk proteins (or proteins from other foods), and that the lactose intolerance is an effect of this, which adds to the diarrhoea, but is not the root cause of it. If so, eliminating the offending food from the baby’s diet (or the mother’s) will produce impressive results, whereas reducing or eliminating lactose only helps a little.
The purpose of the dietary investigations described here is to discover which foods are causing problems for your baby. In the case of bottle-fed babies, the answer is usually cow’s milk – and this is often the culprit for breast-fed babies too, but not necessarily.
For a breast-fed baby it can be any food that the mother is eating. A tiny proportion of what the mother consumes goes through into the breast milk, and these few molecules of food are enough to provoke a reaction in the child.
Bottle-fed babies
For bottle-fed babies, proceed as follows:
•    Change to an alternative milk-free formula (see box on p. 66). Wait two weeks before concluding that there is no improvement – recovery can take time – and try another type of formula before you decide this is not the answer.
•    If there is no joy with alternative infant formula, consider the possibility of relactation: stimulating the flow of your own breast milk once again. Breast-feeding support groups (see page 255) can give you advice. Avoid all dairy products while breast-feeding and take a calcium supplement.
For babies who are old enough, and who have severe symptoms, early weaning is one option, but this must be done very carefully:
•    Keep all dairy products out of the baby’s diet – read labels carefully on prepared foods and know all the different names used for milk (see page 173). Test beef cautiously as it shares some proteins with milk.
•    To avoid new food sensitivities developing, keep eggs, fish. wheat, chocolate and oranges off the menu until the child’s first birthday, then introduce them gradually. Avoid peanuts and other nuts for three years if possible.
•    Keep maize (corn) out of the diet for the first six months, because it is a common ingredient in formula feeds, and the child may have become sensitive to it. Note that some medicines contain corn syrup, but this will only affect those who are very sensitive. A pharmacist can check the full list of ingredients in medicines, and suggest alternatives.
•    No food should be given to the baby every day, or in large amounts. You can use unusual starchy foods, such as sweet potatoes, yams, culnoa and millet (see p. 195), to ring the changes. These all make excellent baby foods.
•    Never force a child to eat any food that is disliked. Try serving it again, once or twice, but give up if there are still fierce objections to the smell or taste – these are often a sign of intolerance or allergy.
•    Ask your doctor to refer you to a paediatric nutritionist so that the diet can be checked. A calcium supplement will probably be needed. Other vitamins or minerals may also be lacking.
Breast-fed babies
For breast-fed babies, the approach is quite different – the main focus here is on what you, the mother, eat and drink.
Firstly, start keeping a food diary, and a record of the baby’s symptoms. Are there any detectable patterns? Does the colic get worse if you drank red wine on the previous day, for example? Note that sometimes the time-gap is more than a day, but it should be reasonably consistent for any one food.
At the same time, eliminate all items other than breast milk from the baby’s diet, including:
•    any solids (e.g. baby foods)
•    fruit juice
•    medicines or vitamin drops that contain other ingredients (e.g. colouring or corn syrup)
•    nipple creams containing arachis oil (peanut oil).
Ask your doctor or pharmacist for alternative versions of medicines or vitamins, without added ingredients. Give boiled water to make up for fruit juice. Wait a week or so to see if things improve.
For the next stage, cut out coffee, tea and all alcoholic drinks. Allow a week for this, and continue with the food/symptom diary meanwhile. If there is no improvement, go on to the next stage, while still avoiding coffee, tea and alcohol.
For the next stage, compile a list of suspect foods, based on your food diary. Add to this list:
•    cow’s milk and all milk products
•    any foods that you craved when pregnant
•    any foods that you normally eat in large amounts
•    anything you dislike but have been eating because it’s ‘good for you’ or ‘good for the baby’
•    any of the following foods if you eat them regularly: eggs, wheat, oranges and other citrus fruits (lemons, grapefruit etc.), tree nuts, peanuts, fish, chocolate, chicken and beef.
Once you have your list prepared, talk to your doctor. Say that you would like to try eliminating cow’s milk for two weeks to start with, and then – if the colic has not cleared up – all the other foods on your list as well (again, for two weeks). You will need to take a calcium supplement. If there is strong opposition to your plans, based on a fear that your diet will be inadequate, ask for a referral to a nutritionist. Obviously this needs to be arranged promptly. The fear of under-nutrition, which is dangerous for both yourself and the baby, is a very reasonable one, but with sensible precautions any mother can safely carry out this investigation.
Eat at home during this time, as you cannot possibly know all the ingredients in cafe or restaurant meals. Read the labels on packaged meals and watch out for synonyms (see pp. 172-4).
If your baby recovers, and you want to pinpoint the problem food so that your diet becomes less restricted, you can test foods individually. Wait until there has been no sign of colic for a week. Choose one food and eat a portion every day for a week. If the colic does not reappear, cut out this food again and choose a second food to test – again, eat this daily for a week. Stop eating the food sooner if the colic returns. (Foods that proved safe can be reintroduced again later, but you need a break after the testing week.) Test cow’s milk last.
Some babies get better during the exclusion phase but do not respond to any of the foods when tested. The temporary break from the problem food seems to be all they need to lose their sensitivity. In such cases, the mother can go back to an unrestricted diet, but not to exactly the kind of diet she ate before – no food should be eaten every day, nor in large quantities, or the colic may return.
Many babies get over their sensitivity after one or two months without the problem food, so it is worth testing again after a while, especially if you are eating a very restricted diet.
Where cow’s milk turns out to be the offender, goat’s milk or sheep’s milk might be tolerated, but wait until the baby is completely free of symptoms and experiment cautiously. Alternatively, drink one of the new milk substitutes now available (see p. 183).
If the baby clearly responds to a food in the mother’s diet (for example, cow’s milk or peanuts), this food should be given cautiously when first introduced to the child after weaning, in case he or she has a true allergy to it. An allergy test may be helpful in deciding whether to introduce the food at all.

Plants make a great many different chemical substances, mostly for the purposes of dissuading other living beings — fungi, insects and grazing animals — from consuming their

leaves, roots and fruits. These chemical substances are extraordinarily potent and diverse. Many taste disgusting, some are virulent poisons, and many will induce vomiting or

diarrhoea. None of these effects are surprising, given that substances such as these are produced to defend the plant. However, some of the chemical substances produced by

plants happen to have a beneficial drug-like action for people suffering from certain diseases. The effects of these substances are utilised in herbalism, sometimes known as

botanical medicine.
Over the millennia, herbalists have, through trial and error, tried to discover which plants have worthwhile effects. Indeed, this process probably began with our ape ancestors

– chimpanzees have been observed, when they are ill with parasitic infections, for example, to carefully select and eat particular leaves that have therapeutic effects. If

chimpanzees do this, it is a fair guess that the ape-like ancestors of human beings also did so.
At some point in human history – or prehistory – this use of wild plants became a systematic and specialised activity, now known as herbalism. No doubt the patients who went to

see herbalists (like patients visiting their doctors today) expected a cure for every ill, and no doubt herbalists felt bad about telling anyone that the problem was incurable.

At this point, quite a bit of wishful thinking and placebo effect (see p. 233) probably found its way into herbalism. The outcome was a mixed bag of herbal remedies – some that

worked, some that had no effect at all (apart from placebo effect), and a few that were positively toxic but whose bad effects escaped notice because of the seriousness of the

diseases being treated.
In recent times, a few herbal remedies have been put through rigorous scientific tests. As one might expect, some work and some don’t. More details of those that have been shown

to work
for allergies are given on p. 221. First, however, it is important to consider some of the misconceptions that surround herbal medicine, especially those relating to side

effects. These misconceptions are rooted in the basic philosophy of herbalism, so it is also important to look at this – and at other points of view about herbal treatment.
The ‘Mother Nature’ viewpoint
Some modern herbalists maintain that, for every human ill, nature has created a complete cure somewhere in the plant world – the job of herbalists is simply to identify that

cure. This belief is essentially religious and anthropocentric – that is, it assumes that the welfare of human beings is the central focus of the plant world. This goes against

common sense, because it suggests that plants produce a complex array of chemical components, not for their own benefit, but for ours.
A related idea, and one that is far more widely accepted, is that anything ‘natural’ must automatically be either harmless or positively beneficial to human beings. It’s a nice

idea, but nothing could be farther from the truth, as a quick survey of the plant world shows: hemlock is natural, belladonna is natural, and ricin –the most deadly poison known

– is natural. All come from plants.
Belladonna, of course, while being deadly poisonous in sufficient quantities, is also a medicinal plant. Its most significant ingredient, atropine, is a useful drug-like

substance in small amounts, and a poison in larger amounts. There is no sharp dividing line between these positive and negative aspects – even a small beneficial dose will have

some undesirable effects too.
In other words, herbs produce side effects, in just the same way that medicinal drugs do. This is almost inevitable – anything that alters body functions enough to act as a drug

will usually have some other unwanted effects.
In the case of herbal medicines, there is an added complication. Plants contain dozens, even hundreds, of different chemical substances, many of which have no benefits for

humans at all –they are just plain toxic. These plant toxins can produce various unpleasant effects of their own, to add to the side effects of the useful ingredients. So the

possibility of side effects is actually higher with herbal medicines than with medicinal drugs.
The side effects that occur with herbal treatment are sometimes very serious. Deaths have occurred in some cases, and in others, irreversible damage (e.g. to the liver) has been

done.
The ‘pure-is-best’ viewpoint
Many modern anti-allergy drugs were first obtained from plants –cromoglycate (see p. 148), for example, was originally extracted from the roots of an Egyptian plant called

ammivisnaga. The ground-up roots of this plant contain a great many other things besides cromoglycate, whereas the pharmaceutical preparations of cromoglycate are pure and of

known strength. This pure form of the drug has also been tested very thoroughly by pharmaceutical companies, in order to demonstrate its effectiveness, to identify the correct

dose, and to look for any serious side effects.
An advocate of scientific pharmacology would maintain that, with modern drugs, the patient is just taking the substance that works, not a mysterious cocktail of unknown plant

chemicals. In other words, you know what you are getting with a drug. You also know it has a good chance of working, and a relatively small chance of causing serious side

effects. With a herbal remedy, you are, to some extent, taking a leap in the dark.
Ephedra sinica, the herb known to the Chinese as Ma-huang, illustrates this point well. It contains a mixture of substances, including the powerful drug called ephedrine – it

was named after the plant. Ephedrine (see p. 156) can relieve the narrowing of the airways that occurs during an asthma attack. The presence of ephedrine gives Ma-huang the

ability to ease asthma, although it is more often recommended to help with weight loss. Unfortunately, over-use of Ma-huang can cause a spasmodic
contraction of the blood vessels in the brain, which can result in injury or death. Liver toxicity has also been recorded (see p. 220).
As for its anti-asthma ingredient, ephedrine, although this drug was once important in conventional asthma treatment, it is rarely prescribed now. Ephedrine has long been

superseded by other asthma-relievers that have a more precise effect on the airway muscles, and so produce fewer side effects.
The multiple-action viewpoint
Practitioners of Chinese herbal medicine, in preparing a treatment for atopic eczema, combine ten or more different herbs. There are some conditions, they say, that can be

treated with a single plant, but atopic eczema is not one of those. It requires a mixture – and none of the ingredients of that mixture, taken alone, has any effect. What they

are claiming is that the different drug-like substances in the herb mixture have a synergistic action, working together to treat the disease.
This same idea is sometimes applied to the many different chemical substances found in a single plant. Some herbalists argue that a herbal remedy is better than a modern drug

precisely because it contains a cocktail of different drug-like substances, the effect of one augmenting or balancing that of another.
There is no actual evidence to support this claim, but the fact that Chinese herbal mixtures have some success in treating difficult allergic diseases (see p. 221) demands that

Western doctors at least take the possibility of synergistic action seriously.
It might seem that this multiple-action viewpoint goes against the whole grain of Western scientific pharmacology – the ‘pure-isbest’ approach. However, Western medicine

frequently treats certain allergic diseases, such as asthma and chronic sinusitis, with a mixture of drugs.
Using herbal remedies safely
Always talk to your doctor before taking any herbal medicine, because of the risk of side effects, or interactions with any conventional drugs that you may be using.
If possible, get herbal treatment from someone who is also a doctor qualified in conventional medicine. Ideally, your herbalist should have access to laboratory facilities and

should order blood tests to monitor your reaction to the herb(s). Monitoring every 1-3 months is necessary with some herbs, to check for serious side effects such as toxicity to

the kidneys or liver (see p. 220).
Before buying herbal remedies from a health-food shop or via the Internet, contact the manufacturer and ask to see detailed reports of trials showing that the product is safe.
Think very carefully before taking a herb that has not The Chinese approach
One fundamental concept of Chinese medicine is that, rather than just matching the remedy to the disease, the treatment should also be based on the particular characteristics of

the patient concerned. This idea is shared by some other Eastern systems, such as Ayurvedic medicine.
Whereas a Western doctor might see you as a person with atopic eczema, a traditional Chinese doctor sees you as a person with a certain constitution which has got out of balance

and so produced symptoms in the skin. The constitution is usually the main focus of treatment, not the eczema. This approach means that different eczema patients get different

herb mixtures, and the same is true for other allergic diseases.
A traditional Chinese doctor will assess your constitution by taking your pulses (there are several in Chinese medicine, not just one), asking various questions, and studying

the appearance of your tongue – the same sort of diagnostic process that is used prior to acupuncture.
For the purposes of scientific investigations, where a uniform treatment is necessary, this traditional approach has been modified. A single standardised treatment is applied to

a particular disease – and the disease itself is diagnosed by Western medical criteria. Whether this is really comparable with traditional Chinese herbal medicine is open to

question. The same caveat applies to any off-the-peg Chinese herbal formula that is sold direct to the public, rather than being prescribed for an individual patient by a

trained practitioner.
The traditional philosophy of Chinese medicine makes for a lot of variability in herbal preparations. That is why categorical statements about side effects cannot be made –

while one mixture used for atopic eczema may contain a potentially toxic ingredient, another mixture may not.
undergone full safety trials. Find out all you can about the herb and discuss the matter with your doctor. Don’t fall for the ‘it must be safe – people have been taking it for

centuries’ argument. If a herb is only toxic to a minority of people, and its bad effects are slow to emerge (so people don’t get ill or die immediately after taking it for the

first time), its deadliness can escape notice for a very long time, perhaps indefinitely. In the case of pharmaceutical drugs, highly sophisticated information-gathering systems

are needed to ensure that such rare-and-slow effects are noticed (see p. 137) but nothing of the kind exists for herbal medicines.
Above all, do not neglect vital medical treatment (e.g. inhaled steroids for asthma) while trying out herbal remedies, as this can be dangerous. Always follow your doctor’s

advice about your drug treatment.
Risks to the liver
Among the side effects recorded for herbal treatment, liver damage is especially alarming. Deaths from liver failure have occurred with both Western and Chinese herbal

treatment. Liver toxicity has been recorded with the following herbal remedies: kava-kava, chaparral, germander, skullcap, mistletoe, senna, valerian root, jin bu huan, and

ma-huang or ephedra (Ephedra sinica). Some Chinese herbal teas prescribed for atopic eczema may also affect the liver, but this is not true of all eczema preparations – several

of the most widely used ones appear to be relatively safe.
Any medicinal herb might, in certain people, harm the liver. Should you feel ill while taking a herbal remedy, stop taking it immediately and see your doctor. The early symptoms

of liver toxicity, which you should watch out for, include jaundice (yellow
skin, and a yellowish tint to the whites of the eyes), pale faeces, dark urine, nausea and pain (usually in the region of the stomach).
Illicit steroids
Be very cautious indeed about pots of Chinese herbal cream sold for atopic eczema. Analysis of a selection of such creams found that two-thirds illicitly contained powerful

steroids – the very drugs that the people buying the creams were anxious to avoid. The dose of steroid in these herbal creams was alarmingly high, considering the purposes for

which some of them had been prescribed – such as use on the face of a baby. A substantial risk of serious side effects exists with these adulterated creams.
Sensitivity reactions to herbs
Like other natural products, herbs can provoke a true allergic reaction, and anyone with a tendency to allergies is at particular risk. Although any herb could, in theory, cause

such a reaction, some seem especially likely to do so:
•    Echinacea, which sometimes causes anaphylaxis or an asthma attack. Severe reactions may occur even in people taking it for the first time, if they are already allergic

to other plants in the daisy family (such as ragweed or mugwort).
•    Preparations containing royal jelly (obtained from honeybees) have sometimes caused near-fatal anaphylaxis in those allergic to pollen. Propolis, obtained from bees,

should also be treated with caution.
Contact dermatitis often occurs with tea tree oil and some other plant-derived substances applied to the skin (see p. 55).Herb—drug interactions
Using herbal remedies and taking medicinal drugs at the same time can be hazardous. These are the herbs that interact with anti-allergy drugs:
•    aloe vera, buckthorn, cascara sagrada bark, ginseng, and senna pod or leaf can all interact with steroid tablets
•    squill, lily of the valley and pheasant’s eye can increase the action and side effects of betamethasone (a steroid); rhubarb root also interacts with this drug
•    kava-kava, if taken with cetirizine (an antihistamine) can increase side effects such as drowsiness and poor coordination; it may have the same effect with other

antihistamines.
Note that many drugs prescribed for conditions other than allergies may interact with herbs. Some of these interactions can be serious, so check with your doctor before taking

any herbal medicine.
Herbs that may work for allergies
Of the herbal treatments that have been tested, the following appear to have potential benefits for people with allergies:
•    Chinese herbal teas for atopic eczema have shown good effects in scientific trials in Britain with both adults and children. Patients with widespread and persistent

eczema —which is particularly difficult to treat — were chosen for these trials. The puzzling thing is that when exactly the same herbal treatment was studied in Hong Kong, with

Chinese youngsters suffering from eczema, there was no improvement.
A combination of Chinese herbal medicine and acupuncture shows some limited benefits for hayfever patients (see p. 215). Pilot studies also suggest that a Chinese herbal

medicine formula may work for asthma.
More surprisingly, another mixture of herbs shows promise in reducing sensitivity for people with severe food allergy (so that there is less risk of fatal anaphylaxis from

accidentally eating the culprit food). Further research is needed to confirm these results. It is hoped that daily treatment for about six weeks will give 6-12 months’

protection.
If you are interested in trying Chinese herbal medicine, it is advisable to be monitored properly, as liver toxicity has sometimes occurred (see p. 220). See a reputable,

medically qualified practitioner, who can vouch for the contents of the herbal mixtures (imported ready-made mixes sometimes contain drugs such as steroids). Be warned that the

stuff tastes vile, and you have the daily chore of boiling it up before taking it. It can have a very mild laxative effect at first. Don’t use Chinese herbal creams unless they

are guaranteed steroid-free (see p. 220).
•    Euphorbia acaulis has shown good effects with atopic eczema. Liquorice root may also help, but can have serious side effects if taken in large amounts.
•    Evening primrose oil taken in capsule form, is known to calm inflammation, and might be helpful for atopic eczema. Don’t chew the capsules, as irritation of the throat

can occur. Epileptics should not take this oil.
•    Ginkgo biloba seems to reduce the reaction to allergens. For those with asthma it may also calm inflammation in the airways.
•    Ayurvedic medicine utilises two herbs, Coleus forskohN and Tylophora asthmatics, in the treatment of asthma. The former relaxes the airway muscles, in much the same way

as beta-2 reliever drugs, making the airways open up. The latter has more general benefits in asthma, but also some unpleasant side effects: it can cause nausea and soreness in

the mouth.
•    Saiboku-to is a Japanese herbal treatment for asthma. Studies suggest that it may have beneficial effects on airway inflammation and may allow a reduction in the dose of

steroids needed.
•    Butterbur has received a lot of publicity following a study which appeared to show that it was as good as the antihistamine cetirizine for hayfever However, the study

did not assess actual symptoms of hayfever, only the patients’ sense of wellbeing. Some preparations of this drug contain substances that could cause cancer, or carry a risk of

liver toxicity. Trials of butterbur for atopic eczema have shown no benefits.
•    Perilla seed oil appears to damp down allergic responses, and may help some asthma sufferers.
Omega-3 oils
These oils are derived from certain types of fish. They are obviously not herbs, but they are often sold alongside herbal remedies in health-food shops, which is why they are

included here. Generally speaking, omega-3 oils have a calming effect on inflammation,
but occasionally they provoke skin rashes, and asthmatics who are sensitive to aspirin may find that they gradually get worse if they take omega-3 oils. This is probably due to

problems with the production of messenger chemicals called prostaglandins in people with aspirin sensitivity (see box on p. 151). The connection is that omega-3 oils can act as

raw materials for the manufacture of prostaglandins and leukotrienes. The details of how omega-3 oils cause trouble for aspirin-sensitive people are not yet understood.

Few newborns are already capable of mounting an allergic reaction to dust mite. Actual symptoms of allergy may not appear for several months or years, but the essential first

step – making the allergy antibody, IgE, against the mite allergens – seems to have occurred already for some babies.
In situations where IgE does the job it is supposed to do –protecting against worms and other parasites (see p. 13) – this advance programming of the immune system before birth

has definite advantages. A child whose mother is infected with parasites is born with the ability to make IgE against those parasites, even though he or she has had no direct

contact with them before birth. The baby’s immune system has been forewarned of the likely hazards of life in the outside world.
While this is obviously valuable in conditions where parasitic infections are rife, emerging into a carpeted and well-upholstered world with IgE against dust mite already in the

bloodstream is a serious disadvantage, because it can pave the way for rhinitis and asthma. Given the trouble caused by dust-mite allergen, some doctors think that women should

try to reduce their exposure to it during the second half of pregnancy, so that little or none reaches the unborn child. At present it is not known for sure if this can make a

difference to the risk of allergies developing in a child, but it seems plausible.
What is pretty clear, from several previous studies, is that the level of house-dust mite in the home immediately after birth can make a distinct difference as regards the

chance of allergy developing. Minimising a newborn baby’s exposure to dust mite is worthwhile, and the measures needed to achieve this are described on pp. 244-5.
Carrying out these measures will raise the level of dust-mite allergen in the air temporarily, so it makes sense to do the work in the early stages of pregnancy (or – even

better – before conception), rather than expose yourself and the foetus to a tremendous burst of allergen later on in pregnancy. Or, get someone else to do the work, and stay

away while it is done.
There may be other potential allergens which you should try to eliminate from your home before the baby arrives, such as mould allergens (see p. 122).
Pregnancy
First and foremost – don’t smoke while you are pregnant, or afterwards (see box on p. 107). Any other smokers in the household should smoke outdoors.
What about your diet during pregnancy? Certainly you should eat a good balanced diet with plenty of fruit and vegetables. Taking a small supplement of vitamin E, or eating

plenty of sunflower seeds and oil, would be a good idea. Women with a low
intake of vitamin E and antioxidants (see p. 206) during pregnancy run a higher risk of having an allergic child.
Should you also avoid any foods? Food allergens, such as those from cow’s milk, do reach the foetus, passed from the mother’s blood to the baby’s blood via the placenta. And a

few babies are born already capable of making IgE against food allergens. On the basis of these findings, some doctors have suggested that avoiding potentially allergenic foods

(such as eggs, cow’s milk and peanuts) during pregnancy might help to reduce the risk of food allergy. However, evidence from research trials in which pregnant women followed a

restricted diet, and their children were later studied for allergies, does not show any convincing benefit. And in some studies, the women on restricted diets have not gained as

much weight as they should, and the babies have been slightly below average weight at birth. Most doctors now think that dietary restrictions during pregnancy are not worthwhile

– it is more important to eat well and get enough nutrients.
It does seem sensible not to overeat any particular food during pregnancy, although there is no scientific evidence on this point (simply because researchers have not yet looked

for such evidence). In particular, don’t overdo it with milk and milk products. Make sure you get enough calcium, obviously, but don’t force yourself to drink huge amounts of

milk, especially if you have any distaste for it. Talk to your doctor, midwife or health visitor about the possibility of a calcium supplement, if you dislike milk.
Breast-feeding
‘The cornerstone of allergy prevention is breast-feeding,’ according to Dr Erika Isolauri of Tampere University Hospital in Finland.
At one time, this would have been a controversial statement, but there is now a substantial body of scientific evidence to support the ‘breast-is-best’ idea in relation to

allergy prevention. A number of different studies have shown that exclusive breast-feeding, up to at least four months of age, reduces the risk of developing food allergy or

atopic eczema (or both) in the early years of life.
Exclusive means exactly that – no solids at all until after four months (and six months is better), and no supplementary feeds with infant formula, which is made from cow’s

milk, and therefore contains cow’s milk allergens. Unfortunately, it is sometimes far from easy to ensure that formula feeds are not given just after birth, by well-intentioned

nurses on the maternity ward. Given what we now know about the immune system of the newborn, this is the worst possible time to be delivering an onslaught of potentially

allergenic cow’s milk proteins.
Quite apart from the immediate effect of introducing cow’s milk allergens to the baby, a bottle can disrupt the development of a good breast-feeding relationship between mother

and child, and may lead to the early abandonment of breast-feeding.
Why should this happen? Firstly a different technique is needed for sucking on a bottle teat, and your baby may never develop the knack with nipples if given bottles at an early

stage. Secondly, allaying the baby’s hunger with a bottle can also mean that he or she demands less at the next breast-feed – and since the mother’s milk supply is partly

influenced by the level of demand, this can be detrimental. Some experts believe that occasional bottle-feeds can start a downward spiral of ever-diminishing supply from the

mother.
Dr Arne Host of the Department of Paediatrics at Odense University Hospital in Denmark, who has made a special study of breast-feeding, recommends giving a little boiled water

as a supplement during the first 3-4 days of life, if the breast milk supply is inadequate. After that time, the mother’s own supply should increase to meet the needs of her

baby. Introducing bottle-feeds at an early stage can prevent this delicate balance of supply-anddemand from ever being achieved.
Sometimes (though this is rare) despite everything being done just right, a mother’s supply of milk never quite matches her infant’s appetite. When this happens, and the child

concerned is from an allergy-prone family, the breast milk should be supplemented with an ultra-safe formula feed called a hydrolysate (see box on p. 66).
Hydrolysates should also be used for infants at high risk of allergy who, for whatever reason, cannot be breast-fed. Note that there are two categories of hydrolysate –

extensively hydrolysed formula and partially hydrolysed formula. For the purposes of allergy prevention, an extensively hydrolysed formula should always be used because it has

the lowest risk of causing food allergies.
Preparing to breast-feed
Because breast-feeding is natural, many first-time mothers just assume it will come naturally. Sadly, it often doesn’t.
Cracked nipples are a major obstacle. They are the equivalent of chapped hands, and are often caused by the baby not having ‘latched on’ correctly to the nipple. Help from an

expert breast-feeding adviser, right from the start. can avoid this problem.
Because cracked nipples are so sore, breast-feeding can then become a major ordeal rather than a pleasurable experience as it should be. What is more, infectious bacteria can

enter the breast through the cracks in the skin, causing mastitis, which is painful and may require antibiotic treatment: this is not necessarily a good thing for the baby (see

p. 247).
You can minimise the chance of cracked nipples by making the skin on the nipples tougher and more resilient, so that it does
not crack. Start during pregnancy, in about your fourth month. When you have a bath or shower, rub your nipples vigorously with your flannel for a few minutes. After three weeks

of this, graduate to a soft toothbrush, and brush them gently, then more firmly when they feel ready. Progress to a medium, and then a hard toothbrush.
Breast-feeding support groups can be immensely helpful, when you start breast-feeding, or when you feel things are not going right. Some groups have local advisers. all mothers

themselves with first-hand experience of breast-feeding. Having such an adviser with you, watching you breast-feed your new baby and making suggestions, or pointing out where

you are going wrong, can make all the difference. Look for such a group locally, and establish contact with them well before your due date. You may be able to have an adviser

with you at the birth, to help the baby take his or her first feed: this is of enormous value.
Having prepared yourself, you then have to prepare the nursing staff in the hospital where you will give birth, for the fact that you want to breast-feed exclusively. That means

no supplementary feeds from the staff – not even one bottle. The risks of this practice, in sensitising vulnerable babies to cow’s milk, are still not widely known, so you may

need to be persistent and make your feelings very clear. Talk to your midwife about this well before your expected delivery date, and find out what policy the hospital has about

supplementary feeds. Then see the relevant staff at the hospital.
The nurses are most likely to give the baby a bottle because he or she is crying while you are asleep, and they don’t want to wake you. Staff change all the time, so you will

probably need to put a notice on the crib or cot, to be certain that the baby is never bottle-fed while you are sleeping. If this seems ‘over-the-top’, consider the experience

of British researchers investigating allergy prevention who wanted to ensure that a group of newborns were never given supplementary feeds. They put warning stickers on both the

babies’ cots and the mothers’ beds, as well as asking the midwives and mothers to be very vigilant. Despite this effort, several of the babies being studied were given bottles.
Sometimes nurses give a bottle because they believe that the baby is not getting enough milk from the breast. The idea that mothers “don’t have enough milk”, and that this is

quite a common problem, is part of the medical folklore of breastfeeding today. In fact, true milk insufficiency is very rare. Most cases of poor milk supply arise because a

good breastfeeding relationship between mother and child is never established – and supplementary bottle feeds are partly to blame.
It is entirely possible that your milk supply will not be quite adequate in the first few days, but it should increase rapidly. The best thing, if breast- milk supply is

inadequate, is to give boiled water as a supplement during the first 3-4 days of life (see left).
Some preliminary evidence suggests that mastitis may alter the profile of immune cells in the milk, and that this might possibly increase the risk of the child’s own immune

system becoming allergy-prone. A key preventive measure is not to let the breasts become engorged with milk: the build-up of milk can lead on to mastitis. Learning to express

milk (by hand or with a breast pump) will be useful for times when your breasts feel over-full. Talk to a breast-feeding adviser.
Diet during breast-feeding
Pretty much everything you eat works its way into breast milk, though in very tiny amounts.
The food molecules that get through into breast milk can certainly affect babies who are already sensitised to a food. Cow’s milk is the classic example — cow’s milk proteins

get into human milk if the mother consumes any milk, cheese, yoghurt or other milk products. Babies who have already been sensitised to cow’s milk (by a supplementary

bottle-feed, for example, or even in the womb — see p. 241) react badly to the breast milk, unless the mother avoids all dairy products.
What is less certain is whether the traces of allergen in breast milk — cow’s milk allergen or that from any other food — might be capable of starting off allergy or

sensitivity. Are these minute traces enough to sensitise babies with a strong tendency to allergy? If they are, then mothers of high-risk infants might be well advised to avoid

certain allergenic foods while breast-feeding. Some studies do suggest that there is a reduction in food allergy if breast-feeding mothers avoid cow’s milk, eggs, nuts, fish and

soya. But if this restrictive diet makes your life impossible, then it is better to breast-feed your baby and eat what you like, than not to breast-feed at all.
Unfortunately, some babies do get eczema, in spite of being exclusively breast-fed. If this happens with your child, there are a number of steps you can take to deal with the

problem (see box on p. 248).
Treating the gut flora
Taking a probiotic or bacterial replacer (see p. 205) during the later stages of pregnancy, and continuing with this while breast-feeding, may reduce the risk of atopic eczema

in your child.
Weaning — when and how
The key to reducing the allergy risk for babies is to turn that old political jibe ‘too little, too late’ on its head. Research shows that, with weaning, it is ‘too much, too

early’ that increases the chance of allergic reactions developing. Suddenly presenting an infant of three months with a wide variety of solid foods, including potent allergens

such as eggs, peanuts and fish, can increase the likelihood of food allergy and/or eczema developing. Weaning late, with a limited number of safe foods, should be your goal.
At least four months of exclusive breast-feeding, and preferably six months, is now the standard recommendation for allergy prevention, and it is well supported by scientific

evidence.
But how long should breast-feeding continue after weaning begins? There is little concrete evidence here, but there is a strong belief in the medical community that

breast-feeding should go on for several more months, up to or beyond one year of age if possible, allowing the weaning process to be very gradual. The idea is to introduce new

foods one at a time, alongside breast milk.
As well as allowing the baby’s immune system lots of time to adjust to each new food, prolonged breast-feeding may help in another way as well. Recent research shows that breast

milk contains a great many substances which influence the baby’s immune system, nudging it in the right direction — away from any tendency to allergies.
Avoid those expensive little jars of ready-made baby food. Most contain potent allergens such as cow’s milk, wheat or soya. Making your own baby foods is not difficult, and is

the best way to ensure that your child gets only low-risk foods.
Reducing the risk of peanut allergy
Peanut oil, which contains traces of peanut allergen, is an ingredient of some skin creams. Recent research from the United States shows that babies treated with such creams

were seven times more likely to develop peanut allergy later. In the past, concern has focused on traces of peanut allergen that the baby swallows — either in the breast milk

(because the mother has eaten peanuts) or from her nipple cream. What this new research suggests is that peanut allergens absorbed through the baby’s skin are much
more likely to cause sensitisation. Don’t use any skin products if they have ‘Arachis oil’ or ‘Arachis hypogaea’ in the ingredients list — and steer clear of any cream without a

detailed ingredients list. In the same research study, soy formula also emerged as a risk factor: feeding a baby on this doubled the chance of peanut allergy developing later.

Good health is one of the most important things we can give our kids,’ says Martha, now in her sixties with two grown-up children.
`When I see how bad my daughter’s asthma is, and how hard her life is sometimes because of it, I do feel bad about the fact that I smoked when I was pregnant. But we just didn’t

know in those days. Even my doctor smoked. No one thought anything of it.
`I stopped when she was little, because it seemed to me that her wheezing got worse whenever I lit up. I’m sure that stopping then was better than nothing. It must have helped.
`In any case, there’s no point feeling guilty about things now - that won’t change anything. But if I’d known what damage it could do, I would have stopped sooner.’ Martha’s

regrets stem from the discoveries made in the past decade about the effects of smoking on allergies. We now know that smoking during pregnancy increases the amount of IgE (the

allergy antibody) in the blood of a newborn baby - an indication that he or she is at an increased risk of developing allergies. After the birth, exposing a child to cigarette

smoke continues to encourage high levels of IgE in the blood, as well as irritating the airways and making asthma more likely to develop.
The research on smoking is just one part of a worldwide research effort, during the past 20-30 years, into the possible causes of the allergy epidemic. That research can help

parents who are themselves atopic (allergy-prone) to reduce the risk of passing their allergy problems on to their children.
Who should be implementing these preventive measures? Firstly, any prospective parents who have allergies themselves, or had them as children. They are at higher risk (compared

to a non-allergic parent) of producing a child who is susceptible to allergies. The risk is especially high if both parents have or have had them at some point in their lives.
Secondly, these preventive measures could be worthwhile for parents who don’t have allergies themselves, but who come from atopic families (families with a tendency to allergy).

If you or your partner have brothers, sisters or parents with allergies, you are more likely than the average person to produce allergic children.
Finally, if you already have one allergic child - even though you and your partner don’t have allergies yourselves, and no one else in the family does - there is a

higher-than-average chance that subsequent children will have allergies. Your allergic child is a sign that the genes for allergy are there.
Given the important role that genes play in allergy (see p. 8), preventive strategies make a lot of sense for parents-to-be with allergies in the family.
Unfortunately, this is a topic which often generates confusion - some people assume that if a trait is genetic, it will inevitably come out in the child, and that nothing can be

done to prevent this happening. Although that is true for some inherited traits, such as metabolic abnormalities (see upper box on p. 75), it is not at all the case for allergy.
Developing allergic disease is not inevitable unless a child has a very big dose of the genes that favour allergy. Only a few children - generally those whose mother and father

are both badly affected by allergies - will come into this category. Even with these very high-risk children, following the measures described here will probably help to reduce

the severity of their allergic problems.
For most children at risk of allergies, even though they have some pro-allergy genes, there has to be an unfavourable environment to actually produce allergic disease.

‘Environment’ here means everything external that affects the child, including diet, air quality, allergens, diseases and medical treatment. Factors occurring before birth, such

as the mother’s lifestyle during pregnancy, are also part of the child’s environment. It is the interplay between genes and environment that will decide whether your child

develops allergies or escapes them.
This interaction is not a simple one, however, and different aspects of the environment operate in different ways. Firstly, there are some environmental factors that work at the

most fundamental level -conspiring with the pro-allergy genes to make the overall tendency to allergy far stronger. These are factors such as cigarette smoking by the mother

during pregnancy, or excessive hygiene during childhood, which influence the fundamental make-up of the child’s immune system. Secondly, there are environmental factors, such as

early exposure to house-dust mite or grass pollen, which can cause trouble by provoking specific allergic reactions. Note that factors like these will not become important

unless the allergic tendency is already there.
Efforts to reduce the risk of allergy operate on both types of factor.
On the one hand, there are measures such as quitting smoking or easing up on hygiene, which tackle the allergic predisposition itself. These measures are, in effect, trying to

make a Western child’s immune system more like the immune system of a child from a poor rural village in the developing world, whose chance of developing allergy is very low

indeed.
On the other hand, there are measures such as reducing dust-mite levels, that try to stop the development of particular allergic reactions.
Obviously, if measures of the first kind could be truly successful, there would be little or no need for measures of the second kind. But this kind of success is very difficult

to achieve in modern Western society. Although we can certainly improve matters a great deal, and lessen the tendency to allergy, the conditions that would completely reverse it

are beyond our reach at present. So both kinds of preventive measure remain necessary.
In reading the pages that follow, it is important to keep things in perspective, and not feel excessively anxious about your child. Do what you can, but don’t feel guilty if you

can’t manage everything that is suggested here. And if you already have a child with allergies, please don’t feel guilty about things that might have contributed to this. Only

hindsight is perfect, and you no doubt did the best you could, given the information you had at the time, and the many other constraints and difficulties that you faced. That is

the best that any of us can do.

No single factor lies behind the allergy epidemic — the causes are many and various (see p. 20). What this means for parents interested in allergy prevention is that there is no

single measure which will ensure that your children do not develop allergies. Instead there are a great many different things that can be done, each of which reduces the risk to

some extent. The more of these you do, the lower the risk becomes.
Avoiding allergens
Starting before the birth is best, if you want to reduce allergen exposure for your child (see p. 240). But if you have missed the boat with that one, don’t despair – there is

still a lot to be gained by reducing allergen exposure at a later stage.
If you are ridding your home of allergens after the child’s birth, bear in mind that things will get worse before they get better– there will be a temporary surge in airborne

allergen as a result of the clean-up operation, and you will need to protect the child from this. The best strategy is for the child to be away for a few days while the work is

done, especially if you are taking out carpets, furniture or mattresses. Remember to protect yourself as well, if you are allergy-prone (see p. 109).
One of the most important steps you can take to reduce allergen levels is improve the natural ventilation of your home. This lowers the humidity (assuming you don’t live in an

extremely humid climate), which helps combat both moulds and dust mites. Ventilation also flushes out allergens in the air, especially cat, dog and mould allergens. Half the

problem with modern houses is that the airtight seals around doors and windows, introduced to conserve heat and save energy, turn the indoor air into a rich stew of allergens

and irritants.
House-dust mite
Avoiding high levels of house-dust mite in the home is one of the most valuable things you can do to reduce the risk of allergies in your child. Not only is house-dust mite a

powerful allergen in its own right, it may also act as an agent provocateur as far as the immune system is concerned (see p. 12), and may help to initiate allergic reactions to

other potential allergens – such as those from pets or indoor moulds.
Even if you do nothing else to protect your new baby from mite allergen, at least buy a new mattress and pillow for the cot, with ready-fitted allergen-proof covers. Do the same

for the portable crib, if you have one. Choose anti-mite products that are designed for babies and are guaranteed safe – there is a risk of suffocation with some loose covers

sold for older children and adults (see p. 245).
You may want to eliminate house-dust mite from your own bed as well as the baby’s, because there will probably be times when you take the baby into bed with you for a feed or a

cuddle – and times when, as a toddler, he or she just barges in! It is good to know that your child is still breathing air free from dust-mite allergen in these circumstances.
Deal with your own bed as soon as you can. Some doctors believe that lowering your exposure to dust mite during pregnancy may reduce the risk of sensitising your baby before

birth (see p. 241).
When taking anti-mite measures with your own bed, make sure that there is no risk of suffocation to the baby from the allergen-proof materials used. Microporous membranes based

on plastic could, if sucked onto the baby’s face during sleep, cause suffocation. Loose covers on duvets are worrying in this respect. Buy a new duvet with a built-in

allergen-proof cover, for preference, or a duvet that can be laundered at 60°C or above.
All the other measures for combating dust mites, described on pp. 114-17, will help to protect your child. Buy a good anti-allergen vacuum cleaner if you possibly can, and keep

your baby out of the room while vacuuming if you can’t (open the windows too). Make sure the baby only has new soft toys, preferably washable ones (see p. 116).
It is also an excellent idea to reduce dust-mite levels in the carpets and soft furnishings (see p. 117), because children tend to have very close contact with these in their

early years. A crawling baby, motoring enthusiastically around the sitting room floor, is stirring up the stockpile of dust-mite allergen that is found in any carpet, and

inhaling it in full measure. An adult walking around the same room has a far lower exposure, because dust-mite allergen, being relatively heavy, stays near the ground.
The best option is to go for non-carpet flooring, which doesn’t encourage dust mites. Parents tend to worry about the hardness of this, for a baby or toddler. In fact babies are

far more robust than we generally believe, and a hard floor is no problem for a small child who has never known the luxury of carpeting.
If you really hate the idea of your baby having anything other than carpet to play on, the next best option is to get new carpet, so that you start with zero dust mites. You

must then prevent dust-mite numbers from building up too much, by means of good ventilation, or with the use of a powerful dehumidifier (see p. 117).
Although the first year is the most vulnerable time for your baby, you mustn’t let your guard drop too much as time passes. The moment when a toddler moves from a cot to a ‘big

bed’ is sometimes the beginning of allergy symptoms because, after carefully protecting their child from dust mites in infancy, parents then put him or her into a bed with a

used mattress. This sudden exposure to a high dose of
dust-mite allergen can be the start of asthma. Get a new mattress if you can, and put allergen-proof covers on it. Alternatively, put allergen-proof covers on the existing

mattress.
Moulds
Mould spores are another potent allergen, and you should avoid bringing up a vulnerable child in a damp house if you can, because moulds will be growing there in abundance. Some

new research suggests that heavy exposure to mould allergens in childhood makes allergies in general much more likely. Even in a house that is not obviously damp, it is a good

plan to reduce indoor humidity (see p. 119). Carpets and furnishings that are full of mould spores (see p. 122) should be replaced.
Pets
What about pet allergens – should you find another home for your cat or dog when you are expecting a baby? This is a difficult question because the latest research shows that

pets are a double-edged sword as far as allergies are concerned.
A baby with allergic tendencies who is born into a house with a resident cat or dog is more likely to show allergic reactions to cats or dogs some years later. On the other

hand, there is research showing that having a pet in the house reduces the risk of allergies overall, especially for a child with no brothers or sisters. This is probably

because the pet boosts household levels of endotoxin (see p. 21), and generally makes the environment less hygienic for the child, fulfilling the same anti-allergy role as

brothers and sisters would in the early life of a child (see p. 246).
If you are planning to give your child the kind of grubby childhood that seems to protect against allergy (see p. 246), the additional protection provided by a pet is probably

unnecessary. Or, you could view your pet as having both pros and cons, and decide to keep it, while implementing all the other anti-allergy measures described here. If you do

this, ensure that the house is well ventilated (so pet allergens don’t build up to very high levels) and keep the pet out of the child’s bedroom so that he or she is not

breathing huge amounts of pet allergen while asleep. You could also wash the pet regularly (see p. 125) to reduce allergen levels.
If your child begins to show any signs of allergy to the pet, you must then find it another home.
Avoiding irritants
As well as increasing ventilation and eliminating cigarette smoke from the home completely, it may be worth evicting certain specific items that produce irritant gases.
The main ones are:
•    gas cookers (if you can’t afford to switch to an electric cooker, at least improve the ventilation in your kitchen as much as possible)
•    easy-clean plastic wall coverings and flooring
•    materials such as chipboard and MDF, which give off formaldehyde.
The evidence regarding the possible role of these in increasing the risk of allergies and asthma is described on pp. 128-9. In addition, although there is no evidence on this

point, common sense would suggest getting rid of any plastic or lacquered items that have a powerful smell.
Generally speaking, although traffic pollution can act as an irritant, it seems to play a lesser role in causing allergies and asthma than most people imagine. However, it may

sometimes play a part, especially if there are high levels of diesel fumes in the air (see p. 131).
Infections - friend or foe?
A large group of Italian military cadets were recently studied by doctors interested in the causes of allergy. By taking blood samples and testing them for antibodies to common

infections, the doctors could see what diseases the men had been exposed to early in life. At the same time, the young conscripts were assessed for allergies.
Allergies were least frequent among the young men with antibodies against three common infections that are dispersed via food and faeces – Hepatitis A, Toxoplasma gondii and

Helicobacter pylori. Only one in twelve of the cadets in this group had allergies.
Among the men with no antibodies against any of these infections, the rate of allergy was nearly three times as high – one in five of these cadets had allergies.
The doctors who carried out this experiment believe that these three infections are not necessarily important in themselves, but that they identify individuals who were ‘reared

in an environment that provides a higher exposure to many other orofecal or foodborne microbes’. In other words, they grew up in the kind of household where washing your hands

before meals wasn’t considered too important.
This study adds to the growing body of evidence (see p. 21) which shows that an over-clean environment during childhood encourages the development of an allergic disposition.
Those with lower rates of allergy include:
•    children raised on farms with livestock. The more exposure the children have to farm animals, the less the likelihood of them developing allergies.
•    children from homes with high levels of bacterial endotoxin in the household dust (see p. 21)
•    children who have fewer baths, and wash their hands less often (see p. 21)
•    children with brothers and sisters, especially those with older siblings. Some of the protection here may be due to the impact of the mother’s hormones and immune system

on the foetus in the womb: these effects change with successive pregnancies. But close contact with older siblings, and thus exposure to more microbes, probably plays a part.
•    children who go into kindergarten, nursery school or day care with other children at an early age – this is only valuable for children without brothers and sisters
•    children with pets at home – the benefits are much more pronounced for children without brothers and sisters.
The Italian study is especially important because, for the first time, it gives detailed information about the kinds of infections that make a difference in allergy prevention.

The military cadets were also checked for antibodies to measles, mumps, rubella, chickenpox and herpes. None of these infections gives protection against allergies – only

infections carried in food and faeces do.
Exactly what practical use you make of these discoveries is up to you. For most of us, the importance of hygiene was so firmly instilled during our own childhood that it is

quite hard to suddenly become more relaxed about it. But do let your children play in the garden, if you have one, and don’t worry so much about how dirty they get. Encourage

them to do some gardening – medical researchers believe that harmless bacteria in the soil may be particularly important in educating the immune system away from allergies (see

p. 21). Let them play with pets, as long as the animals are not carrying harmful parasitic worms (talk to your vet about whether pets should be treated for parasites). Ease up

or, hand-washing and, if this is your first baby, make sure he or she plays with other children as early in life as possible.
A few chest infections do seem to increase the risk of asthma, notably Respiratory Syncytial Virus (RSV). If this Infects babies, it provokes an IgE-reaction (see box on p. 12)

which may encourage the development of allergies. Unfortunately, there is very little you can do to protect your child from this common virus, but it makes sense not to take the

baby to a hospital for unnecessary trips (visiting relatives, for example) because RSV infections are often picked up in hospital.
Taking care with antibiotics
The possible role of antibiotics in making allergies more likely to develop is an exceedingly controversial topic. Before making any practical decisions in this respect, you

must consult your doctor. Never go against your doctor’s advice, if he or she thinks that antibiotics are necessary.
Several different studies have now produced evidence of a link between antibiotic use before the age of one or two, and the later development of allergies, asthma or both. The

best of these studies was carried out by doctors in Oxford, who followed 1900 children up to the age of sixteen. Among children at risk of allergy (because their mothers had

allergies) taking antibiotics before the age of two was linked with an increase in the rate of allergy from 32% to 54%. The more courses of antibiotics a child received, the

greater the risk.
The type of infection for which the drugs were prescribed was not important, as far as the risk of allergy was concerned, but the type of antibiotic did make a difference.

Broad-spectrum antibiotics, which kill a wide range of bacteria, were more risky –suggesting that the depletion of friendly bacteria in the gut (see p. 204) could be responsible

for increasing the allergy risk. Penicillins seemed less likely to promote allergies than erythromycin or cephalosporins.
This research is not widely known, as yet. And because there is a widespread assumption that giving an antibiotic can do no harm, even if it is unnecessary, antibiotics are

sometimes prescribed when they serve no purpose. In particular, antibiotics are often given for virus infections, especially in childhood, despite the fact that antibiotics are

of no value whatever against viruses. Research shows that doctors are sometimes responding to pressure from anxious parents when they prescribe antibiotics – it is difficult for

some parents to accept that a virus infection cannot easily be treated and just has to ‘run its course’. (Although there are drugs that combat viruses, these are expensive and

produce unpleasant side effects – they are reserved for very serious virus infections such as hepatitis.)
Obviously. when a child needs antibiotics to deal with a serious infection there can be no question about giving them. This is why you should always follow your doctor’s advice.

But it is also worth asking the doctor the following questions before giving antibiotics to your child:
•    are you sure that this is a bacterial infection, and not a virus infection?
•    would it be possible to do tests and check that it is a bacterial infection, before prescribing antibiotics?
•    what is the chance of the child overcoming the infection without antibiotics?
•    would it be dangerous to wait and see if the infection clears up naturally?
Vaccination
The same Oxford research team that investigated antibiotics (see left) also looked at the question of vaccination and allergy. They found a link between vaccination for

pertussis (whooping cough) and increases in asthma, eczema and hayfever. However the increases were not large, and a study from Sweden found that whooping cough vaccination did

not have any effect on rates of allergy and asthma. And researchers in Ethiopia have found that whooping cough vaccination actually reduces the risk of allergy in their country.
This is clearly a complex issue. The contradictory results from different parts of the world suggest that the ‘big picture’ is what counts here – the overall combination of

childhood infections, antibiotic treatment and exposure to harmless bacteria such as those in the soil or from animals. Depending on this big picture, vaccination against

whooping cough may push the allergy risk one way or the other.
There are many other arguments both for and against vaccination and, given our current state of ignorance about the possible effect on allergy, these other considerations are

probably more relevant. Discuss the matter in detail with your doctor before making a decision.

Doctors in Japan recently tried a very simple experiment in allergy prevention. They chose babies suffering from atopic eczema who were allergic to foods, but not allergic to

house-dust mite. Dividing the babies into two groups, the doctors put special allergen-proof covers, designed to protect against house-dust mite (see p. 115), on the mattresses

of all the babies in the first group. Babies in the second group were given ordinary cotton covers.
When the babies were one year old, they were tested again for allergy to house-dust mite. Two out of three children in the second group now gave a positive skin test to

house-dust mite.
By comparison, only one in three of the children from the first group gave a positive skin test. In other words, using the anti-allergy covers for these high-risk children had

cut by half the number who developed an allergic reaction to dust mite.
As this experiment shows, even if a child has already developed allergies, it is not too late to bring protective measures into play. Indeed, an allergy problem in infancy, such

as atopic eczema, can be seen as a warning sign to parents, telling them that they should reduce the child’s exposure to allergens as much as possible.
As well as reducing dust-mite levels, you should minimise your child’s exposure to moulds at home by limiting indoor humidity (see p. 119) and cleaning up any existing mould

growth (see pp. 122-3). This will lessen the chance of mould allergy developing.
Try to avoid staying, even temporarily, in any house that is damp or has old carpets and mattresses. When you are moving house, or carrying out any kind of renovation work,

remember that this will stir up a lot of dust-mite and mould allergens. Protect your child by arranging for a stay away from home.
This pro-active approach should not just apply to airborne
allergens, but also to food, in the opinion of some experts. They
suggest that any child with a true allergy to cow’s milk or egg
should not be given peanuts, tree nuts, fish or shellfish until three
years of age, to avoid sensitisation to these potent food allergens.
Pets are a more difficult issue, with both pros and cons as
regards allergy-prone children (see p. 245). If you decide to keep
your cat or dog, always ventilate the house well, and wash the animal regularly if you can (see p. 125). Be alert for your child developing an allergic reaction to your pet –

don’t turn a blind eye to the symptoms, as parents sometimes do because they are reluctant to accept that the child has become allergic to the family’s much-loved pet. If your

child does develop an allergy to the pet, the best option is to find the animal another home as quickly as possible (see p. 124).
Breast-fed babies with atopic eczema
Although breast-feeding is a good way of protecting children against atopic eczema, it is no guarantee. Sometimes babies become sensitised to food, in spite of being breast-fed,

and then they may react to traces of that same food, eaten by the mother and coming through in her breast milk.
Skin-prick tests (see p. 91) may help to identify the foods responsible for the eczema. Otherwise, a simple elimination diet by the mother, as used for colic (see p. 203), may

pinpoint the offending food. Keeping that food out of the mother’s diet will often clear the baby’s eczema.
Sometimes a breast-fed child’s eczema remains severe, despite the elimination of suspect foods from the mother’s diet. In this case, what should be done? New research from Or

Erika Isolauri – a staunch advocate of breast-feeding – suggests that the best option at this point is to stop breast-feeding promptly. Her research team found that breast-fed

children with persistent eczema had a slower growth rate. If these babies are switched to hypoallergenic formula – either an extensively hydrolysed formula or an artificial

amino-acid formula (see box on p.66) – their eczema symptoms usually subside, and their growth picks up.
Is vaccination safe for those with allergies?
The influenza vaccine and a few others (e.g. yellow fever) are grown in eggs and are not usually given to people with egg allergy. Measles vaccine is grown in cells taken from

eggs and may contain a minute trace of egg allergen, but only those who are extremely sensitive will react: there should be resuscitation equipment available for children who

have had anaphylactic reactions to egg and for those with severe asthma as well as egg allergy. Some vaccines come in vials with latex seals that are designed to be pierced by

the needle of the syringe. A different method should be used for latex-allergic patients. Smallpox vaccine (for bio-terrorism threats) is dangerous for children with atopic

eczema.
Never too late?
The role of modern ultra-clean lifestyles in promoting allergies is now well established (see p. 21). If your child already has allergies, it may seem as if these discoveries

have come too late to help —but that is not the case. Some research suggests that the battle for supremacy between Th1 and Th2 cells (see p. 11) — the unseen power struggle

which decides whether a child will be allergy-prone — is not really settled until some time between the ages of five and seven years. So there is still some potential for

intervening right up to this age. Some studies have suggested that the immune system can be pushed away from an allergic disposition at an even later age, right into adulthood,

by exposure to endotoxin, a bacterial product found around livestock and in `lived-in’ homes.
Several research groups are working on vaccination strategies (for example, using extracts of soil bacteria) that might also be able to achieve this. The initial results are

promising and they suggest that these vaccines can even help adults with allergies. Unfortunately, such treatments will not be available for many years. In the meantime, you can

probably reduce your child’s chance of developing new allergies, and perhaps make the existing ones less severe, by easing up on hygiene (see p. 246).
Fresh air and exercise
With the boom in watching TV and videos, and playing on computer games, some modern children hardly go outdoors at all. As far as allergies and asthma are concerned, there are

two big disadvantages to being a juvenile couch potato. For a start, the couch is also home to dust mites in their millions, and secondly the child is not running about and

using his or her lungs to the full. Airways that are never stretched (because the child never gets out of breath) lose their youthful flexibility in time. Once this has

happened, the airways can never be stretched to their full capacity. Some doctors believe that this may make asthma more likely to develop, or help to make it more severe once

it has developed. Inactivity also encourages obesity, which increases the risk of asthma developing.
Getting outside and running around, or engaging in other vigorous exercise, should be encouraged for any child with allergies. Obviously, you should balance this against the

need to protect the child from pollution peaks and (if your child has hayfever) pollen peaks. Children with exercise-induced asthma should use their reliever inhalers to allow

them to take exercise (see p. 41).
Keep the air at home free from irritants such as nitrogen dioxide (see p. 128), formaldehyde, air fresheners, paint, polish and strong-smelling cleaning fluids. These may

encourage new allergies to develop, and can make existing asthma worse.
Medical treatments
Antihistamines may have a preventive role in very young children with allergies. A study of one- to two-year-olds with atopic eczema found that the antihistamine cetirizine,

taken daily for 18 months, halved the chances of the children developing asthma later.
The children who benefited in this study were those with several risk factors for becoming asthmatic. They had moderate to severe atopic eczema, at least one close relative with

allergies, and allergic sensitisation to pollen or house-dust mite, as shown by skin-prick tests (see p. 91).
The cetirizine was taken at fairly low doses and had no bad effects on the children in this study. What is more, it seemed to benefit their skin as well as reducing the risk of

asthma: those taking the drug had less need of high-strength steroid creams. There is some controversy about the validity of these results, so few children with atopic eczema

are receiving antihistamines at present.
No one yet knows if other antihistamines might have the same effect as claimed for cetirizine. Ketotifen, which is an atypical antihistamine (see p. 159), may do so.
Immunotherapy may also have a protective effect. One study, involving children suffering from nasal allergies, found that those given immunotherapy were less likely to develop

asthma (see p. 165). Another study shows that immunotherapy for children with mite allergy halves the risk of their developing new allergic reactions to other allergens.

Egg-Free Diets
Tempura-style vegetables
There is nothing quite like an egg, especially when it comes to baking. Egg protein is the magical

ingredient that holds together a pancake, and creates the light and delicate structure of sponge cakes,

batter, souffles, mousses and meringues.
Unfortunately, egg protein is also a potent allergen for some people, and a source of intolerance

reactions for others.
Egg replacers, designed mainly for cake making, are one answer. They can be purchased from specialist

suppliers (see p. 255) or ordered via your local health-food shop. These are protein-rich mixes which

aim to simulate the structural properties of eggs, not the flavour. Recipes are usually supplied with

the replacer, and it is best to follow these recipes at first, for guaranteed results. Once you have

got the feel of using the egg replacer, you can experiment with substituting it for eggs in other cake

recipes.
Note that these egg replacers make no attempt to simulate the richness and characteristic taste of

eggs. You may need to add extra butter or other fats to your cake mix if using egg replacers. Vanilla

extract can also improve the flavour of an egg-free cake.
Can cooking make eggs safe?
Cooking changes proteins, as eggs illustrate vividly. When a hot oven turns liquid egg white into a

hard meringue, or a sloppy cake mix into a firm sponge, the visible effect is due to the egg protein

being fundamentally changed.
Heating changes the basic molecular structure of the egg protein, in a process called denaturing.

Whereas natural egg protein is liquid, denatured egg protein is solid.
Denaturing egg protein has subtle effects, as well as these obvious ones. When the structure of the

molecule changes, some of the epitopes (the key features recognised by allergy antibodies — see box on

p. 15) are obliterated. For a few allergy sufferers — those who react only to the epitopes affected by

denaturing — thorough heating can therefore turn the egg allergen into a harmless substance.
If eggs are hard-boiled, the denaturing process occurs to the fullest possible extent. Consequently,

some people with egg allergy can eat hard-boiled eggs without ill-effects. However, the same people

still react badly to lightly cooked eggs, such as those in a souffle or omelette because, with partial

cooking, the denaturing process is incomplete.
Cakes made with eggs pose an interesting question — given that the cooking process for cakes is

prolonged and at a high temperature, could they too be safe? This is something that allergists have not

so far investigated.
If you want to test your response to hard-boiled eggs, you must do so under full medical supervision

with resuscitation equipment available. Those who find that they can tolerate hard-boiled eggs might

then want to test their reaction to cakes made with eggs. Again, there must be medical supervision for

the test, in case of severe life-threatening reactions. You will, of course, have to convince your

allergist that such a test is worthwhile.
Egg protein is not unique in being susceptible to denaturing — most proteins can be denatured, some by

heat, some by other means. But only in a few cases (tuna fish, and fresh fruits and vegetables — see p.

110) does denaturing tend to destroy the allergenic epitopes.
Very rarely, changing the structure of a protein by cooking may actually create an allergenic epitope

where none exists in the raw protein. There have been cases of individuals with an allergy to cooked

fish but not raw fish, and to pecan nuts in
biscuits but not uncooked pecans. Roasting peanuts makes them much more allergenic.
Tempura-style vegetables
Beer is a good alternative to eggs for making a batter and gives this Japanese batter a wonderfully

light crisp texture. Have all the vegetables ready prepared so you can cook and eat the tempura as

quickly as possible.
PREPARATION TIME: about 45 minutes MAKES: 4-6 servings
400-500g (14oz-11b 2oz) prepared vegetables cut into bite-sized pieces -choose from red pepper,

asparagus, broccoli, spring onion or red onion, carrot, courgette, baby corn, button mushrooms,

aubergine
150g (5/oz) self-raising flour, sieved,
plus extra for coating vegetables
1 tsp salt
2 tbsp sesame seeds
250ml (9fl oz) lager or Japanese beer vegetable oil for deep-frying
To serve:
equal quantities soy sauce and dry sherry
mixed together, or sweet chilli sauce
Toss the prepared vegetables in flour until lightly coated then shake off the excess. Heat the oil in a

large saucepan over medium heat until a cube of bread dropped in turns brown in 30 seconds.
Mix the measured flour, salt and sesame seeds and quickly stir in the beer - don’t worry if the mixture

is slightly lumpy. Dip the vegetables in the batter, a few pieces at a time, and then immediately into

the hot oil. Cook until crisp and golden.
Drain on kitchen paper and keep warm in a hot oven. Continue in the same way until all the vegetables

are cooked.
Serve with a dipping sauce made of soy sauce and dry sherry, or dip in sweet chilli sauce.
Caramelised onion tart
Caramelised onion tart
This makes a good substitute for quiche and other egg-based flans. The long, slow cooking of the onions

is important to bring out their natural sweetness.
PREPARATION TIME: 45 minutes COOKING TIME: 30 minutes MAKES: 6-8 servings
1 k (21b 4oz) onions, halved then thinly sliced
4 tbsp olive oil
125g (41/2oz) streaky bacon, finely chopped
1 tsp caraway seeds
salt and freshly ground black pepper 350g (1 2oz) bread dough or puff pastry
Place the onions in a very large saucepan with the oil, bacon and caraway seeds and cook over medium

heat, stirring occasionally, for about 30 minutes until the onions are softened and lightly

caramelised. Season generously.
Roll out the dough thinly and use to line a deep 24cm (91/2in) fluted flan tin. Prick the base with a

fork then fill with the onion mixture. Cook on a baking sheet in a preheated oven at 230°C/450°F/gas

mark 8 for 30 minutes until the dough or pastry is crisp and golden.
Feta in a crisp polenta jacket
Variations: replace the bacon with 125-1758 (41/2-6oz) crumbled goat’s cheese or 125-175g (4/,2-6oz)

diced smoked tofu, for a vegetarian version; or add a handful of pitted olives.
Feta in a crisp polenta jacket
The oil must be really hot to ensure a crisp crust for these delicious cheese croquettes.
PREPARATION TIME: 15 minutes MAKES: 4 servings
vegetable oil
200g (7oz) feta cheese, cut in 8 fingers 40g (I Y2oz) cornmeal
To serve:
salad of your choice, e.g. tomato, cucumber, red onion and flat-leaf parsley, or skinned and charred

red peppers with rocket
Pour the oil into a saucepan and set over a high heat. Meanwhile, dip the cheese fingers in Iced water

for about 1 minute then roll in the cornmeal until evenly coated. Deep-fry for 1-2 minutes until crisp

and golden. Drain on kitchen paper and serve at once on top of the salad.
Egg-free pancakes
Tofu filling for a savoury flan
This very simple savoury flan filling makes an egg-free, milk-free substitute for quiche. This recipe

makes enough filling for a 20cm (Bin) pastry case.
PREPARATION TIME: 5 minutes COOKING TIME: about 25 minutes
250g (9oz) tofu, natural or smoked 1 tbsp wine vinegar or lemon juice 1 tbsp dried mixed herbs
200ml (7fi oz) soya milk
Combine all the ingredients in a blender and pour into a pre-baked flan case. Cook in a preheated oven

at 190′C/375′F/gas mark 5 for about 25 minutes until set.
Variations., add either sauteed chopped onion; chopped cooked ham with spring onion; roasted

vegetables, such as carrot, peppers and tomatoes; or cooked spinach, beetroot or broccoli.
Tofu mayonnaise
This mayonnaise can be flavoured with chopped herbs, roasted garlic puree or tomato puree. It will

keep, covered, in the fridge for 3-4 days.
PREPARATION TIME: 5 minutes MAKES: approx. 250ml (9fl oz)
Lemon cake
100g (3%oz) soft tofu
100g (3%zoz) Greek yoghurt
1 tsp English mustard
1 tbsp Dijon or wholegrain mustard
iced water
salt and pepper
Blend all the ingredients except the water, salt and pepper in a liquidiser. Season to taste and thin

as required with iced water.
Avocado dressing
This dressing is delicious with tomato salads, prawns or grilled steak. Keep it tightly covered

otherwise it will discolour quickly.
PREPARATION TIME: 5 minutes MAKES: approx. 250ml (9fl oz)
1 medium-sized ripe avocado
4 tbsp vegetable oil
2 tbsp white wine vinegar or lemon or lime juice
iced water
salt and pepper
Halve, stone, peel and chop the avocado and blend in a liquidiser with all the remaining ingredients

except the water, salt and pepper until smooth. Season to taste and thin as required with iced water.
Egg-free pancakes
These pancakes can be served with either savoury or sweet fillings.
PREPARATION TIME: 25 minutes MAKES: 10
100g (3V2oz) plain flour
2 tbsp arrowroot powder
300ml (V2 pint) milk
vegetable oil or melted butter for frying
To serve:
golden syrup, jam or lemon juice and caster sugar
Mix the flour and arrowroot, then stir in the milk to give a smooth batter. Leave to rest, ideally for

20 minutes.
Heat 1 tsp oil in an 18cm (7in) nonstick frying pan and pour in 2-3 tbsp batter, enough to just cover

the base of the pan, swirling it as it falls into the pan to give a thin layer. Cook until golden on

one side then carefully turn and cook the other side. Repeat until all the batter is used up. To ensure

a crisp result every time, make sure the fat is hot.
For a sweet pancake, serve with golden syrup, jam, or lemon juice and caster sugar.
For savoury pancakes, fill with a white sauce flavoured with smoked fish and prawns, or ham and

parsley, or ratatouille and cheese.
Raspberry and sherry syllabub trifle
Syllabub makes an unusual topping for this trifle with its egg-free shortbread base, but if you prefer,

make a custard with custard powder and top with whipped cream. Vary the fruit with the seasons -

poached pears, fresh orange, and cooked cranberries are all suitable.
PREPARATION TIME: 15 minutes MAKES: 6-8 servings
I 75g (6oz) butter shortbread
6 tbsp medium or sweet sherry
225g (8oz) fresh or frozen raspberries 284ml carton whipping cream
50g (13/4oz) caster sugar
To serve:
25g (1oz) toasted flaked almonds
Roughly break the shortbread and put in the bottom of a trifle bowl or any decorative serving bowl.

Sprinkle with 2 tbsp sherry then top with the raspberries. Whip the cream and sugar with the remaining

sherry until it holds its shape, then pile on top of the raspberries. Chill until required, then, just

before serving, sprinkle the top with flaked almonds.
Lemon cake
This cake has a tangy lemon flavour and a slightly dense texture. Serve it plain or with fresh berries

and whipped cream or creme fraiche. Try replacing the lemon with orange.
PREPARATION TIME: 15 minutes
COOKING TIME: about 1 hour
MAKES: 1 x 19-20cm (71/2-8in) cake
100g (3112oz) butter, melted
200g (7oz) caster sugar
250g (9oz) self-raising flour, sieved 1 tbsp baking powder
250g (9oz) natural yoghurt
finely grated zest and juice of 1 small unwaxed lemon
1-2 tbsp milk (optional)
To serve:
icing sugar
Butter a 19-20cm (71/2-8in) spring-release tin and line the base with greaseproof paper. Place all the

ingredients in a large bowl and beat well to a firm dropping consistency. You may need to add 1-2 tbsp

milk, depending on the type of yoghurt you have used. Transfer to the prepared tin, level the surface

then bake in a pre-
heated oven at 180′C/350′F/gas mark 4 for 50-60 minutes until risen and just firm to the touch. Cool in

the tin for about 30 minutes, then transfer to a cooling rack until completely cold. Dust with icing

sugar.
Fig, orange and pear shortcake
PREPARATION TIME: 20 minutes COOKING TIME: 45 minutes MAKES: 8-10 servings
250g (9oz) chopped dried figs
finely grated zest and juice of 1 medium
unwaxed orange 1 ripe pear, chopped
250g (9oz) plain flour, sieved
1758 (6oz) butter
100g (3112oz) light muscovado or soft brown sugar
1 tsp ground cinnamon To serve:
icing sugar (optional)
Place the figs, orange zest and juice and the chopped pear in a saucepan and cook over medium heat

until the figs and pear are soft and all the juice has been absorbed. Place the flour, butter, sugar

and cinnamon in a food processor and blend. Alternatively, rub in by hand until the mixture resembles

fine crumbs. Add 1 tbsp cold water and stir until the mixture forms rough lumps. Press half the cake

mixture onto the oiled base of a 19cm (71/2in) spring-release tin. Spread the fruit mixture on top,

then finish with the remaining cake mixture, pressing it down lightly.
Cook in a preheated oven at 180°C/350°F/gas mark 4 for 45 minutes. Cool in the tin. Dust with icing

sugar, if wished, and serve in wedges.
Variations: replace the figs and pear with dried apricots and an apple; or replace the figs with

prunes, dried pineapple or dried mango.
Date and walnut loaf
Dates give this egg-free cake a wonderfully moist texture that is even better after a day or two. Store

in a cool place in an airtight container.
PREPARATION TIME: 15 minutes COOKING TIME: about 45 minutes MAKES: 1 large loaf
250g (9oz) chopped dried dates
100g (3′12oz) light muscovado or soft
brown sugar 25g (1 oz) butter
2 tsp ground mixed spice
1 tsp bicarbonate of soda
275g (93/4oz) self-raising flour, sieved
1008 (3′12 oz) walnut pieces
To serve:
butter (optional)
Place the dates in a large bowl with the sugar, butter, spice and bicarbonate of soda. Mix well, then

pour on 250ml (9fl oz) boiling water. Leave to cool slightly then beat in the flour followed by the

walnuts. Transfer the mixture to an oiled and base-lined 900g (21b) loaf tin. Level the surface and

cook in a preheated oven at 180°C/350°F/gas mark 4 for about 45 minutes, until risen and just firm to

the touch.
Cool in the tin for about 30 minutes, then transfer to a wire rack to cool completely. Serve in slices,

with or without butter.

Avoiding Milk and Lactose
Fruit lassi
There are two quite distinct reasons for avoiding milk: either to avoid milk proteins or to avoid

lactose, the sugar found in milk. It is important not to confuse these two because the details of the

avoidance diet required are different. Only a few people need to avoid both milk proteins and lactose.
Diarrhoea and wind in response to drinking milk, but few other symptoms, usually indicates a reaction

to lactose — but a reaction to milk proteins could be an alternative explanation. If it is a reaction

to lactose, this may be due to either primary lactase deficiency or secondary lactase deficiency — your

doctor can order tests to make an exact diagnosis (see p. 79). Note that a bout of diarrhoea, however

caused, often produces a temporary lactose intolerance (secondary lactase deficiency).
Any symptoms other than (or in addition to) diarrhoea and wind strongly suggest a reaction to milk

proteins. This might be a true allergy, another type of immune reaction to milk (see pp. 72-3), or an

idiopathic intolerance reaction (see pp. 76-7). In theory, skin tests should identify true allergic

reactions to milk proteins. Unfortunately, skin tests are not infallible, and it is possible to have a

genuine allergy or other immune reaction to milk proteins, but give negative skin tests. This is

especially common with babies (see p. 65 and p. 69). There are no accurate tests that can confirm

intolerance reactions to milk proteins.
It is possible to have sensitivity to both milk proteins and lactose.
If tests do not give you a definitive answer, you may have to try both types of diet and see which one

works. Remember that lactose intolerance may be only temporary.
Avoiding milk proteins
If you have a sensitivity reaction to cow’s milk proteins, then you need to avoid:
•    milk and all milk-based drinks, including lactose-reduced milk (if you need to avoid lactose as

well, drops and tablets to reduce lactose — see Using lactase replacers, p. 183 — are safe and could be

used with a tolerated milk, e.g. goat’s milk)
•    cream, yoghurt, creme fraiche
•    all kinds of cheese, cottage cheese and cream cheese (some people may be able to tolerate

Norwegian brown cheese, called Gjetost, which is made with milk whey)
•    white sauce, bechamel sauce and other creamy sauces
•    custard, rice pudding and other milk-based puddings
•    almost all home-made cakes, biscuits, cookies, pancakes and pastry
•    some bread, rolls, waffles
•    almost all chocolate
•    casein, casemate, and lactalbumin in packaged foods (see p. 173); you may be able to tolerate

whey but experiment cautiously.
Unless your sensitivity is fairly mild, you will also need to avoid:
•    butter, except clarified butter (ghee)
•    most kinds of margarine (they generally contain milk derivatives, but
some are milk-free — health-food shops are a good source of these).
As long as you do not have a severe allergy to milk, you should be able to tolerate clarified butter.

Make this by melting butter over a low heat, pouring it into a glass jar, and leaving it to cool in the

refrigerator. The milk proteins will settle to the bottom, and be visible as whitish granules — only

eat the clear butter above this level.
Alternatively, put olive oil into a wide-necked container and place in the freezer. It will solidify,

and can be used as a spread in place of butter.
A few of those with cow’s-milk allergy can tolerate sheep’s milk, and possibly (but less commonly)

goat’s milk. However, most people must avoid these as well. (There are also rare individuals who are

allergic to goat’s and sheep’s milk but not to cow’s milk.) Ass’s milk, if you can get it, is tolerated

by most with cow’s-milk allergy. There are many substitutes for cow’s milk now available, such as soya

milk, almond milk, rice milk and hazelnut milk. Try a health-food shop for these. All can be used in

place of ordinary milk when cooking.
Margarine or clarified butter can be used in recipes that call for butter. Soya yoghurt and cream make

reasonable substitutes for ordinary yoghurt and cream.
Avoiding lactose
If you have lactose intolerance, you must avoid:
•    milk and all milk-based drinks, unless lactose-reduced
•    cream, creme fraiche
•    most kinds of yoghurt, especially mild yoghurt. A very strong, acidic yoghurt may contain

little lactose. The bacteria that make yoghurt turn lactose into lactic acid, so the more acidic it is,

the less lactose it contains.
•    cottage cheese and Norwegian brown cheese, or Gjetost. Other kinds of cheese are usually so low

in lactose that they are tolerated. Only those people with extreme lactose intolerance need to avoid

all cheeses.
•    white and bechamel sauce, custard, rice and other milk-based puddings
•    almost all home-made cakes, since milk is generally used for baking. Items cooked with butter

but not milk, such as biscuits, cookies and pastry, are usually tolerated, as is butter itself, and all

margarine.
•    lactose in medicines. Lactose powder is used in many tablets and capsules, just to bulk out the

drugs. The amount used can be sufficient to evoke symptoms in some people with lactase deficiency.

Certain asthma inhalers also contain lactose (see p. 162), and a small amount may be swallowed. The

lactose from inhalers will affect you only if you have severe lactase deficiency.
Soya-based products, and all other nut- or grain-based milk substitutes, are lactose-free. Sheep’s

milk, goat’s milk and other animal milks (including human breast milk) all contain lactose.
Using lactase replacers
Many people with lactose intolerance are able to eat a more varied diet by using lactase replacers.

These provide a temporary supply of the missing enzyme, lactase (see p. 79), which helps out by

digesting the lactose in milky foods. Lactase replacers must be taken at the same time as the milky

food, and are only effective for that one meal. The more lactose there is in the meal or snack, the

more of the lactase replacer you need – trial and error is the only way of working out how much you

need for a particular food. There are a number of different brands of lactase replacer now available,

and it is worth trying out several. Some people find that they are sensitive to an added ingredient in

some brands. Sources of lactase replacers include health-food shops and specialist suppliers – these

can be located through the Internet (see p. 255).
Savoury white sauce
Savoury white sauce is the base of many dishes. Here the flavour of the wine and stock goes well with

chicken, vegetables or fish.
PREPARATION TIME: 7-8 minutes MAKES: approx. 600ml (1 pint)
50g (13/4oz) milk-free baking margarine 50g (1314oz) plain flour
200ml (7fl oz) dry cider or dry white wine 400ml (14f1 oz) vegetable or chicken stock 1 bay leaf, salt

and pepper
Melt the margarine in a small saucepan and stir in the flour. Cook, stirring, over a low heat for
1 minute then stir in the cider or wine, followed by the stock. Add the bay leaf and simmer, stirring

occasionally, for 5 minutes until thickened. Season to taste.
Variations. add approx. 6 tbsp finely chopped herbs, e.g. parsley, chives, tarragon or chervil; or add

English or French mustard; or add lemon juice.
Sweet white sauce
PREPARATION TIME: 5 minutes MAKES: approx. 300ml (’/?pint)
2 tbsp cornflour
25g (1 oz) caster sugar
300ml (V2 pint) apple or white grape juice 4 tbsp soya cream
25g (1oz) milk-free margarine
In a saucepan, mix the cornflour and sugar with a little of the juice to give a smooth paste then

gradually stir in the rest of the juice and bring to a simmer over a low heat. Simmer for 1-2 minutes

until thickened, stirring all the time. Finally, add the soya cream and margarine.
Variations: melt in 1008 (3-/2oz) or more of milk-free chocolate; or add rum or brandy to taste; or add

4-6 pieces finely chopped stem ginger together with 1-2 tbsp of their syrup.
Pancakes
Soya milk has a slightly thicker consistency than cow’s milk and therefore more is used in this pancake

recipe than would be needed in a traditional one.
PREPARATION TIME: 25 minutes MAKES: approx. 16 small pancakes
150g (5V2oz) plain flour, sieved 2 large eggs
pinch salt
450ml (16f1 oz) soya milk
oil or milk-free margarine for frying To serve:
lemon juice and caster sugar or golden syrup
Combine the flour, eggs, salt and soya milk in a liquidiser until smooth. Alternatively place the

flour, eggs and salt in a bowl and slowly whisk in the soya milk to form a thin batter.
Heat approx.1 tsp oil or margarine in an 18cm (7in) non-stick frying pan and swirl until hot. Pour in

sufficient batter to just cover the base of the pan and cook until golden. Turn and cook on the other

side until golden.
Serve with lemon juice and caster sugar or with golden syrup.
Apple and frangipane tart
An alternative to a milk-based custard tart. The combination of apple and almond is delicious. Serve

freshly baked. It can also be eaten cold, but if possible, warm it a
little before serving.
PREPARATION TIME: 30 minutes COOKING TIME: 1-11/4 hours MAKES: 8 servings
Pastry:
175g (6oz) plain flour, sieved
1008 (3 V2oz) milk-free baking margarine, softened
25g (1 oz) caster sugar
Filling:
50g (13/4oz) milk-free sunflower margarine 1008 (3112oz) ground almonds
100g (3112oz) plus 1 tbsp caster sugar 2 egg yolks
2 tbsp dark rum, brandy or orange juice 2 large dessert apples
4 tbsp apricot jam
Work the flour, margarine and sugar together with 1 tbsp cold water to make a soft dough. Roll out and

use to line a deep 20cm (8in) fluted flan tin. Chill this while you prepare the filling.
Preheat the oven to 190′C/375′F/gas mark 5. Beat together the margarine, ground almonds, 100g (3Y2oz)

caster sugar, egg yolks and rum. Peel, core and roughly chop one apple and stir into the mixture.

Spread this in the pastry case. Core and thinly slice the remaining apple and arrange the slices on

top. Sprinkle with the remaining sugar and bake for 1-1′/’4 hours until risen and golden. Cool slightly

then brush the surface with the apricot jam (warm this gently in a saucepan first).
Coconut rice pudding with mango
This pudding is based on a Thai recipe. The rice pudding will become thicker the longer it cooks and

also as it cools. Make sure the mango is ripe.
COOKING TIME: 30-40 minutes MAKES: 6 servings
175g (6oz) pudding rice, rinsed 50-75g (131-2314oz) sugar
1 litre (13/4 pints) carton rice milk 400ml (14f1 oz) coconut milk To serve:
1 extra-large ripe mango, peeled and diced
toasted coconut shreds
Place the rice in a large saucepan with 50g (13/4oz) of the sugar and the rice milk and coconut milk.

Bring to a simmer, stirring. Simmer gently for 30-40 minutes, stirring occasionally, until the rice is

cooked and the milk absorbed. Add the extra sugar if wished. Serve warm or cold, topped with mango and

toasted coconut.
Baked strawberry creams with strawberry sauce
The riper the strawberries the better, to give intensity to both the creams and the sauce.
PREPARATION TIME: 30 minutes COOKING TIME: 20-25 minutes MAKES: 6
1008 (3112oz) caster sugar
4 tbsp Muscat wine
1 tsp lemon juice
350g (12oz) strawberries, hulled and sliced
4 large eggs, beaten Sauce:
225g (Boz) strawberries, hulled and chopped
2 tbsp icing sugar 2 tbsp Muscat wine To serve:
a few whole strawberries
Preheat the oven to 1 70′C/325′F/gas mark 3. Set six 1 50ml (Y4 pint) ramekins in a small roasting tin.

If you plan to unmould the creams, oil the ramekins lightly.
Place the sugar, wine, lemon juice and strawberries in a saucepan and heat gently to dissolve the

sugar. Bring to the boil and cook, uncovered, for 5 minutes. Cool slightly then puree in a liquidiser

and whisk into the beaten eggs. Pass through a sieve then pour into the ramekin dishes.
Pour hot water from a kettle around the ramekins and cook in the centre of the oven for 20-25 minutes

until lightly set.
Remove the dishes from the tin and allow to cool. Chill, if wished.
Combine all the sauce ingredients and liquidise until smooth. Pass through a fine sieve.
Serve the creams in the ramekins with a little sauce poured on top and decorated with a whole

strawberry, or carefully unmould, pour a little sauce over, then decorate with a whole strawberry.
Variation: oil the ramekins. Dissolve 100g (31/2oz) caster sugar in 4 tbsp water in a small saucepan

over gentle heat, then cook to a rich caramel without stirring. Pour a little caramel into each oiled

ramekin then continue as above. Pour the wine for the sauce into the pan used to make the caramel and

warm gently to dissolve any leftover caramel, then continue with the sauce as above.
Frozen vanilla dessert
This is a cross between a sorbet and an ice cream.
PREPARATION TIME: 30 minutes, plus freezing MAKES: 4-6 servings
1 vanilla pod, split
150g (51/2oz) caster sugar 500g carton soya yoghurt
Place the vanilla pod and sugar in a saucepan with 300ml (1/2 pint) water. Dissolve over gentle heat

then bring to a simmer and simmer for 20 minutes. Leave to cool then remove the pod, scraping all the

seeds from it and returning them to the syrup. Beat in the soya yoghurt and freeze.
You will get the best texture by using an ice-cream machine. Alternatively, freeze in a plastic

container then remove from the freezer and beat the mixture well until smooth (you can do this in a

food processor). Return to the freezer. Repeat this process once or twice.
Baked strawberry cream with strawberry sauce
Variations: add 100g (31/2oz) melted plain chocolate; or add 2 tbsp instant espresso coffee dissolved

in 2 tbsp hot water. Alternatively, dissolve 100g (3/2oz) caster sugar over a gentle heat in a small

saucepan until it turns to a rich caramel; then add 100g (31/2oz) unblanched almonds and stir with a

metal spoon until they start to pop. Transfer to an oiled tray and leave to set. Crush roughly and add

to the basic mixture.
Fruit lassi
This refreshing Indian drink can also be made with frozen fruit, in which case don’t use iced water –

cold will do.
PREPARATION TIME: 10 minutes
MAKES: approx. 1.35 litres (21/4 pints)
500g carton soya yoghurt
50-75g (1314-231aoz) sugar
225g (8oz) berries such as raspberries, strawberries, blackberries or blueberries or the equivalent

weight of chopped fruit such as mango, peach or papaya
600ml (1 pint) iced water
Place all the ingredients in a liquidiser and blend until smooth.
Frozen vanilla desert
Banana and strawberry shake
A special treat for a child who cannot have milk.
PREPARATION TIME: 5 minutes MAKES: 600ml (I pint)
2 large, very ripe bananas
150g (5112oz) strawberries
1112 tbsp olive oil
a little nutmeg or other spice, if liked 200ml (7fl oz) water
Peel the bananas and roughly chop the fruit. Combine all the ingredients in a blender until very

smooth. Serve immediately, or cover tightly and store in the refrigerator.
Variations: use a nectarine or a skinned peach instead of strawberries; use coconut milk (available in

tins) instead of olive oil, and the flesh of a small mango, or half a large mango, instead of

strawberries.

Elimination diet
An elimination diet is a method of diagnosing idiopathic food intolerance (see p. 74) and certain other

forms of food sensitivity where indirect tests, such as skin tests, are unhelpful. The principle of the

elimination diet is very simple. It begins by removing from the body every food that could possibly

cause a reaction, and seeing if this produces a symptom-free state. If it does, the elimination diet

then presents the body with different foods, each in its pure form, to see which ones cause symptoms.
While the principle is simple, the practicalities of the elimination diet can be much more complex, and

it is vital to understand the details fully before you start. There is absolutely no room for

‘cheating’ with this diet – one mouthful of cake is enough to ruin the whole thing. You need forward

planning and a lot of self-discipline, backed up by a good stock of the permitted foods for moments

when hunger overcomes you. Some cooked foods, stored in the freezer in individual portions for quick

defrosting, are a great help.
Doing an elimination diet incorrectly is not just a waste of time. Some people acquire new

sensitivities during the diet, which may make it very much more difficult to do a second elimination

diet. So plan ahead and get it right first time.
The planning stage
First of all, start an accurate symptom diary. This will give you a precise picture of how bad things

are now, before you try any dietary measures. A detailed daily symptom record, covering a period of

about two weeks, can be very useful, whether or not you actually do an elimination diet. It can serve
as a baseline against which to judge the effects of any future treatment.
Before you begin an elimination diet, you must see your doctor and ask if it is safe for you to do the

diet. Read through the next four pages first – the more you know about elimination diets, before

talking to your doctor, the better.
There are some conditions where, although an elimination diet can be very helpful, it should not be

attempted without full medical supervision. Two main causes for concern exist:
•    For people who are undernourished to start with, the elimination diet may be too demanding – it

is difficult to eat enough calories during the first few weeks of the diet, unless an elemental diet is

used as a supplement (see box on p. 196). If you are underweight, or have rheumatoid arthritis or

Crohn’s disease, the possible use of elemental diets is something you should discuss with your doctor.
•    With certain diseases (see list that follows), the testing stage may induce severe symptoms.

Sometimes these can be life-threatening and need immediate medical attention.
Medical supervision during food testing is recommended for anyone with these conditions:
•    Crohn’s disease – testing can bring on a prolonged relapse. Very small amounts of food should

be tested initially, and the quantity slowly increased.
•    Brittle asthma – after a period of avoidance, a culprit food can bring on a severe and possibly

life-threatening asthma attack.
•    Atopic eczema – the risk of reactions is higher if skin tests are positive (see p. 198).
•    Chronic urticaria – occasionally there is an immediate reaction to an offending food. It is

advisable to test foods in very small portions oust a mouthful) at first. If there is no reaction

whatever after four hours, a normal portion can be tested.
Note that an elimination diet is not suitable for anyone with true food allergy (see p. 62). If you

have ever had an immediate reaction to any food, or any symptoms in the lips or mouth, testing foods

can be dangerous. Caution is also necessary if you have ever reacted to a food with violent vomiting

and/or diarrhoea some hours after eating. This could be due to an infection, of course, but such

symptoms can also, very rarely, result from true food allergy (see p. 64). Finally, if you have ever

suffered anaphylaxis from any cause – not just food –the testing phase of an elimination diet might be

risky. Ask your doctor’s advice.
Once you have your doctor’s permission to try the diet, work out how the stages of the diet will fit in

with your life over the weeks or months ahead. Until it is over, eating food made by other people is

virtually out of the question. When eating away from home, you must either take prepared food with you,

or just eat very simple foods – such as permitted fruits or nuts. Think about the practicalities of

carrying food for meals away from home.
Finally, devise the diet you will follow during the exclusion phase (see right), locate shops that sell

the more unusual foods, and stock up on everything required.
You will continue to eat a lot of these foods for the first few weeks of the testing stage, so you may

want to buy extra stocks and refrigerate them for
longer storage, especially if the sources of supply are some distance from your home.
Note that food ingredients in medication could interfere with the results of the elimination diet. For

example, if you are very sensitive to maize (corn), the cornflour that is added to many antihistamines

and other drugs could create much confusion. Food-free medicines are available – talk to your

pharmacist about this initially, then to your doctor if you need a different prescription.
The exclusion phase
During the first part of an elimination diet, you exclude all the foods that you normally eat, plus any

closely related foods. For example, if you normally eat oranges, you should avoid all other citrus

fruits, including lemon, limes and grapefruit, even though you do not normally eat these. If you

normally eat plenty of broccoli, you should omit all its relatives, such as cabbage, kale, spring

greens and cress.
The best way to conduct the exclusion phase is not to follow a set menu, such as the well-known

‘Iamb-and-pears’ diet, but to draw up your own list of permitted foods. This can include foods that you

have never eaten before, and those you eat rarely.
The list should run to at least ten items. One problem with an exclusion phase that consists of only

two foods (as in the ‘Iamb-and-pears’ diet) is that you are bound to eat a huge amount of these foods.

This is asking for trouble if you have a tendency to food intolerance, because you can quite quickly

become sensitive to new foods if eating them in large amounts.
Your list of permitted foods should include:
Some starchy items. These are essential for keeping hunger at bay: try some of the more exotic root

crops, such as sweet potatoes, yams, dasheen and cassava. These are available in large supermarkets and

in small shops catering to Indian, African, Chinese and Caribbean communities. (Cook them as you would

potatoes. In the case of cassava, it must be boiled, not baked.) You can also eat parsnips, turnips,

chestnuts and pumpkin. Tapioca, sago, buckwheat, millet, quinoa and sorghum are other possibilities: a

health-food shop is a good source of some of these. Use rice if it is not normally part of your diet.

Do not include sweetcorn or maize meal, even though you do not normally eat these –corn products are

very widely used in packaged food, and sensitivity to corn is not uncommon.
Several fruits and vegetables that you don’t normally eat. Exotic produce such as mangoes and okra can

help a lot in keeping the diet tasty. Avocados, which are very rich and nutritious, can be included if

you don’t eat them often.
Some protein items. For carnivores, this is the easy part – any meat that you don’t normally eat is

suitable. Consider turkey, rabbit, pigeon or game, for example. (Soak rabbit meat in salt water

overnight to get rid of the strong taste, if you dislike this.) Strict vegetarians have more problems

here, since goat’s milk, sheep’s milk and all birds’ eggs are disallowed – their proteins are much too

similar to those of normal milk and eggs. Soya products such as tofu should definitely be avoided, as

should other pulses initially, because sensitivity to these is a possibility among vegetarians. Quorn,

or mycoprotein, could affect anyone sensitised to yeast, and should not be included. Fortunately the

exclusion phase is fairly brief, so a low intake of protein will not be disastrous. Including some nuts

on your list of permitted foods will help, as these contain protein. If nuts are part of your normal

diet, you may have to resort to rarely eaten kinds such as macadamias, cashews or pistachios.
Elemental diets
An elemental diet is a powder that contains all the nutrients the human body needs but is free from the

substances in food that provoke allergic and intolerance reactions. It is mixed with water to create a

complete substitute for food. Originally designed for space travel, this totally synthetic form of

sustenance is also known as ‘the astronaut’s diet’.
Used alone during the exclusion phase, elemental diets are the basis for the ultimate – and

theoretically foolproof – elimination diet. They sustain you through the exclusion phase, and continue

to provide your basic diet during the testing phase.
For anyone with multiple food sensitivity, using an elemental diet circumvents the problem of finding

ten or more safe foods with which the elimination diet can begin.
Those who are underweight can also benefit from using an elemental diet, simply as a calorie-boosting

supplement during the exclusion phase and testing phase.
Unfortunately, elemental diets taste fairly unpleasant and are quite expensive. You
may need a prescription, so talk to your doctor. Ideally you should get an elemental diet that does not

contain sucrose (sugar).
Some items that make good snacks. Nuts, pumpkin seeds, sunflower seeds, fresh fruit and dried fruit are

all useful for times when you are away from home, or feel hungry between meals. At the outset of the

diet, use only unsulphured dried fruit –available from health-food shops. At a later stage, you can

test ordinary dried fruit (all of which is treated with sulphur preservatives – see box on p. 207).
A cooking oil, preferably one that you have not used much in the past. Use this fairly liberally, to

keep the calorie content of your diet at a reasonable level
Note that this is a very plain diet – you eat the permitted foods and absolutely nothing else. You

cannot use spices, herbs or other flavourings. Salt is allowed, but sugar is out, as are tea, coffee,

alcohol and all soft drinks. You must drink only mineral water and pure juices from permitted fruits.
Don’t use canned or packaged versions of the permitted foods. Buy raw food and cook it yourself. The

idea is to avoid food additives and other contaminants, such as those from the linings of cans.
Throughout this phase, and the next, you must be very careful not to eat too much of any one food.

Never eat any food every day, and stay away from any food that you begin to develop a real passion for

– this is always a bad sign in people with food intolerance. It is better to go a little hungry

(assuming you are not underweight to start with) rather than binge on any of the permitted foods.

Acquiring new sensitivities is all too easy.
Assuming you do have food intolerance, and you have excluded all the foods that affect you, there

should be a complete clearance of symptoms within 7-10 days. The response is usually unmistakable. A

partial or slight response is probably just a coincidence, and should be discounted, except for those

with rheumatoid arthritis (see below).
Be warned that you may feel a great deal worse before you get better. For those who do have idiopathic

food intolerance, the first 5-6 days of the diet can be very unpleasant – usually they suffer the same

symptoms as before the diet, but far more severe.
Some conditions, such as Crohn’s disease and rheumatoid arthritis, may require a longer exclusion

phase, but there is no point in continuing beyond three weeks. Bear in mind that long-term structural

damage to arthritic joints may prevent a complete recovery. A partial but sustained improvement in the

joints, accompanied by a distinct improvement in general health, suggests that food could well be

playing a part in causing the disease, and that it is worth going on to the testing phase.
Symptoms that are only intermittent, such as chronic urticaria or migraine, pose a special problem. You

need to decide, before starting the diet, how long the exclusion phase should continue in order to give

you a clear sign that your state of health is improved. A symptom diary is vital here. If, for example,

your symptom diary shows that you sometimes have a week that is symptom-free but you never get through

two weeks without an attack, then your exclusion phase should continue for two weeks.
You should only go on to the testing phase if you improve during the exclusion phase. If you do not

improve, you have excluded the possibility of food intolerance, and can give up the diet.
The testing phase
This part of the diet, which is sometimes called the reintroduction phase, takes about eight weeks. It

requires careful observation of your symptoms, and constant self-discipline about everything you eat.

You should not stop or delay the testing unless you are ill – it is vitally important to complete it as

quickly as possible.
Foods have to be reintroduced one at a time, with a space between in which symptoms can be observed. It

sounds simple, but this is where errors can easily occur.
During this phase, as well as noting your symptoms daily, you should also record absolutely everything

you eat.
For the first 2-3 weeks you should test foods that are unlikely to cause symptoms. Start by testing

fruits, vegetables and meats that you do not eat very often normally, but which you do like. If they

pass the test, you can use them to vary your diet. This will make life much easier and reduce the risk

of developing new sensitivities.
Next test foods that you do eat reasonably often, but not every day. Leave the most likely culprits –

the foods you eat very regularly, such as wheat and milk products – until you have established a safe

diet that contains at least 25 different foods. This safe and relatively varied diet should be the

backdrop against which you test staple foods.
The testing procedure changes over time, because your sensitivity may decline as the diet progresses.

During the first eight weeks, you should test one food each day, eating a normal-sized portion for

lunch or supper. A reaction to the food might occur quite soon after the meal, or some hours later. Any

symptoms that occur within the following 24 hours should be provisionally attributed to that food.
Unfortunately, bowel symptoms can sometimes take longer to develop – up to 48 hours. This can confuse

things when a new food is being tested every day.
There may also be uncertainty about intermittent conditions such as chronic urticaria. You may not be

absolutely sure that the problem really responded to the exclusion phase. If so, when the symptoms

recur during the testing phase, this may be due to a food, or it may just be coincidence.
Should there be any doubt about which food caused a particular set of symptoms, cut out all the suspect

foods for now, and retest them after a couple of weeks, using a three-day testing procedure (see

below).
When a reaction does occur to a food, stop all testing and go back to the safe diet until you feel

completely better. But don’t wait too long before resuming testing. You need to get through most of the

testing within eight weeks because, for some people, intolerance to the foods begins to fade after

that.
This does not mean that the intolerance has been ‘cured’, unfortunately. A period of eating the food

regularly will soon bring the problem back.
If you are still testing foods after eight weeks, you must change to three-day testing – eat a normal

portion of the food every day for three days, stopping only if you get symptoms. Should you have no

reaction to the food by the end of the fourth day, you can consider it safe. (But leave it out of your

diet for at least another four days.)
There are some special procedures for testing certain foods:
•    When you test wheat, even if it is quite early on, use the three-day test procedure (see

above). Reactions to wheat can be very slow. (If you have rheumatoid arthritis, you should spend a full

five days testing wheat, and eat it at least twice a day.) Don’t use bread to test wheat because this

also contains yeast and other ingredients. Use a pure wheat cereal such as Shredded Wheat – moisten it

with fruit juice if you cannot have milk. Note that some people who react to whole-wheat are sensitive

to the wheat germ, and can tolerate refined wheat, as in white bread and flour. For others only white

flour is a problem – they are usually reacting to additives in the white flour. Careful testing will

sort out these issues.
•    Test milk before cheese and butter. You may react to one but not the others. If you react to

fresh milk, wait a few weeks, then test evaporated milk. Later, you can test goat’s milk and then

sheep’s milk. Some people can tolerate these, but must be very careful not to consume too much of them.
•    You can test yeast using Marmite or yeast-based B-vitamin tablets. Do this before you test

mushrooms, •    At some point, test a canned food. This is to check for reactions to the lining

material used on cans. Choose something that contains no other ingredients or additives, such as

carrots. Test it first in a frozen or fresh form, so that you are sure you don’t have a reaction to the

food itself.
•    Throughout the testing period, continue with cooking all your own food from scratch. At a

fairly late stage in the testing, when you have tested most foods, spend three days eating packaged

food. The idea is to eat a wide range of different food additives all at once. Read the labels

carefully (see p. 172) to check that all the food ingredients are ones which you have already tested

and found safe. You are unlikely to react to these packaged foods, but if you do, you should then

conduct tests with all the individual food additives. You may need some help from a dietitian for this

(see p. 201).
Testing becomes more and more uncertain after 12 weeks. If you
have not completed it by then, reintroduce all the untested foods.
Should your symptoms come back, cut out all those foods again,
then test them individually.
What next?
For anyone who recovers during an elimination diet, and successfully identifies their problem foods, a

period of complete abstinence from those foods follows. After about a year, it is worth testing the

foods again, as the sensitivity may have subsided. (Don’t do this if you have rheumatoid arthritis –

see p. 23.)
If, after a year or two, you find that a food no longer makes you ill, don’t go back to your old ways –

remember that you must only eat the food occasionally. Once every three or four bays is a good rule of

thumb for a food to which you were previously intolerant. You might get away with having it slightly

more often than this, but never go back to eating it daily. If it starts to become your ‘favourite

food’ again – the thing you fancy more often than anything else – watch out.
Good nutrition is an important issue for anyone avoiding certain key foods. If you have cut out all

milk products, for example, you should probably be taking a calcium supplement, unless you eat a lot of

other calcium-rich foods. Ask your doctor to refer you to a dietician or nutritionist if you feel you

need help.
An elimination diet for children with eczema
Before putting your child on any kind of restrictive diet, it is vital that you talk to your doctor.

The risks of malnutrition are far higher for children, and there can be serious long-term consequences,

such as stunted growth or impaired intelligence. You must therefore have medical consent and

supervision for an elimination diet.
For young children with atopic eczema, there is rarely any need for a stringent elimination diet, such

as that described on pp. 194-7. Children are usually sensitised to only one or two commonly eaten

foods.
In the case of recently weaned infants, it is enough to simply cut out individual foods, one at a time.

Avoid each food for two weeks, while observing symptoms carefully.
For older children a simple elimination diet, with an exclusion phase which avoids just the most likely

culprits, works well. The foods that you should exclude at the outset are:
•    any food which has given a positive skin-prick test (see p. 69)
•    any food which you think may have caused digestive symptoms, such as diarrhoea, either now or

in the past
•    eggs, milk and all milk products
•    beef and chicken
•    citrus fruits (oranges, lemons etc.)
•    food additives.
If the child’s skin is no better after a week of this diet, cut out the following foods as well:
•    peanuts and other nuts
•    soya
•    fish
•    wheat and maize (corn)
•    tomatoes
•    lamb.
If there is no response after another week, food is unlikely to be contributing to the eczema.
For the testing phase, use three-day testing, as described on p. 197, if you have fewer than ten foods

to test. Use one-day testing if you have more than ten foods to test.
You should begin by testing a very small amount of the food. Wait ten minutes for any symptoms (not

just skin symptoms – the mouth or stomach may also be affected) then give a little more if nothing has

happened. Build up gradually to testing a normal portion of the food.
A more cautious approach is required for children who give positive skin-prick tests to foods, or have

a history of symptoms in the mouth or digestive tract. They are more likely to suffer severe symptoms

in the lips, mouth and throat – the type of reaction associated with food allergy. Emergency medical

treatment may be needed. You can see if there is any likelihood of a severe immediate reaction to foods

by starting with a test on the face, and then the outer lip (see box on p. 23). If nothing happens, it

is probably safe to go on to the next stage – giving the child a very small amount of the food to eat.

However, you should have medical supervision for Rare reactions
Very occasionally, atopic eczema sufferers on milk-avoidance diets develop a sensitivity reaction to

calcium supplements. There is no scientific explanation for this, but it has been very well documented

in two children. Should you encounter this problem, the answer may be some alternative natural source

of calcium: sardines or other small fish, eaten whole, are one possibility, assuming your child will

eat fish. A dietician can advise on how much is needed per day.
There has also been one well-documented report of a child reacting to mineral water. When the water she

usually drank was changed to another brand, her eczema cleared up. This is very unlikely to be a common

problem.
this procedure in the case of foods that gave positive skin tests. If your child has both severe eczema

and additional symptoms (such as nettle rash, or symptoms in the mouth or digestive tract) it may be

advisable to have medical supervision when testing all foods.
Bear in mind that atopic eczema naturally fluctuates a great deal. To observe the effects of trying out

a food, you need the child’s skin to be in a steady state. That means being absolutely consistent about

applying steroids and moisturisers, avoiding (for the period of testing) any stressful situations that

could provoke a flare-up, not exposing the skin to sudden doses of irritants or airborne allergens, and

keeping scratching under control. Be aware of other factors that could muddy the waters by provoking a

flare-up of eczema – such as teething, or a cold (see p. 44).
If certain foods are identified as provoking eczema symptoms, and you decide to cut the food from your

child’s diet, a nutritional supplement may well be needed. Ask your doctor to refer you to a

nutritionist or dietician.
Other diagnostic diets
These diets are not used by (or even known to) the majority of doctors. While some, such as the

low-nickel diet, have been subjected to rigorous scientific testing and have shown their worth, others

have not been tested scientifically. The evidence in favour of them is purely anecdotal – in other

words, doctors have used these treatments repeatedly and observed good results with some of their

patients. That is not hard science, but it is how innovations in medicine often begin.
There are few risks with any of these diets – the number of foods to be avoided is small, and you are

most unlikely to become malnourished. Your doctor should not object to you trying any of these diets,

however sceptical he or she may be about its possible benefits.
Low-nickel diet
This diet is sometimes of benefit to adults with eczema. There are various pointers which indicate that

the diet may help, as described on pp. 55-6.
Make sure that you have absolutely no contact with any nickel (e.g. in jewellery, jeans studs, watches

or hair clips) throughout this diet, and for at least two weeks before starting it.
Ideally you should also stop treatment with steroids or antihistamines a week or so before starting the

diet. This allows any improvement to be easily observed. Obviously you should get your doctor’s

permission to do this.
The diet could take anything from six weeks to six months to take full effect. Some people have a

complete clearance of their eczema, while for others there is a partial but distinct improvement.
The foods with a high nickel content, which should be avoided as far as possible, are:
•    shellfish
•    green beans and peas
•    beansprouts and lucerne sprouts
•    dry beans and lentils (pulses) of all kinds; soya protein and products containing it (e.g.

vegetarian sausages and burgers)
•    spinach and kale
•    lettuce, leeks
•    wheat bran (avoid bran cereals and other products; replace wholemeal bread with white bread, or

eat it in moderation only – you can get plenty of fibre from fruits and vegetables; do not eat

multi-grain breads at all)
•    oatmeal, millet and buckwheat
•    raspberries, prunes, pineapple, figs
•    chocolate and cocoa
•    tea from drinks dispensers (restrict intake of other tea and coffee, and don’t make them too

strong)
•    peanuts, hazelnuts, almonds and marzipan
•    liquorice
•    sunflower seeds, linseed
•    baking powder, in large amounts
•    vitamin or mineral preparations that contain nickel (check the label carefully), Nickel is also

found in drinking water, and absorbed from certain cooking utensils, so:
•    Do not use items plated with nickel (e.g. tea balls, some tea strainers, egg beaters). The

extremely shiny appearance of nickel makes these easy to recognise.
•    Do not cook acid fruits in stainless steel pans, since the acid leaches some nickel out of the

stainless steel. An enamel cooking pot is safe.
•    Minimise the amount of tinned food that you eat.
•    In the morning, run off the first litre of water from the tap, as this may contain nickel

released from the tap itself.
Several other foods and drinks seem to aggravate the skin of nickel-sensitive people, even though the

foods are not rich in nickel. These foods and drinks should also be avoided:
•    beer, wine
•    herring, mackerel, tuna
•tomatoes, carrots, onions, apples; oranges and other citrus fruits, including their juices.
Low-chromium and low-cobalt diets
Skin sensitivity to chromium or cobalt can, very occasionally, result in a tendency to react to these

same metals when consumed in food or drink (see pp. 56).
Unfortunately, both chromium and cobalt are essential for good nutrition, so avoiding them is fraught

with problems. You would need the help of a really good dietician, or a doctor with a particular

interest in nutritional problems, to guide you through a diet of this kind.
The only measure you can safely take at home is to cut down on excessive consumption of these metals,

for three weeks only, to see if this produces any improvement in your symptoms. If it does, that should

encourage you to seek expert help for a more thorough avoidance diet.
In the case of cobalt sensitivity avoid:
•    all canned and bottled beer.
In the case of chromium sensitivity avoid:
•    beer, wine and cider
•    yeast extract and yeast tablets
•    black pepper
•    calf’s liver
•    wheatgerm and wholemeal bread
•    cheese.
If you also have nickel sensitivity, avoid nickel-rich foods (see p. 199) at the same time.
Low-histamine diet
Histamine in food is mostly produced by bacterial action. The majority of people can break down any

histamine they eat, as long as the amount is not excessive (see box on p. 67).
Temporary susceptibility to histamine may accompany viral hepatitis or other liver conditions.
A permanently impaired ability to detoxify histamine is relatively unusual. When it does occur it can

result in symptoms such as chronic urticaria, migraine or recurrent headaches. A low-histamine diet may

help in these cases. All of the following should be avoided:
Very high histamine content:
•    red wine, champagne
•    tuna, sardines
•    Emmenthal and Camembert cheeses.
High histamine content:
•    beer, white wine
•    anchovies
•    Gouda, Roquefort, Stilton and all other well-matured cheeses
•    salami and other well-matured sausages, Westphalian ham
•    sauerkraut
•    spinach
•    tomato ketchup.
If you improve only partially on this diet, this may indicate that you are on the right track

(histamine is indeed the problem) but that the bacteria in your gut are undermining your efforts with

the additional histamine which they generate. You can investigate this possibility by trying a

low-carbohydrate diet, as described on p. 53.
Low-amine diet
Naturally occurring substances called amines, found in many different foods, can have a drug-like

effect on the blood vessels, making them open up a little and so increasing the blood flow. The effect

is usually small, but some people are more susceptible than others. A low-amine diet is worth trying if

you have chronic urticaria or migraines, and have not improved with other treatments. A low-amine diet

can also be useful in atopic eczema: amines in food are not a basic cause of eczema, but they can

aggravate the rash by increasing blood flow to the skin. To begin with, cut out all foods listed below:
Very high amine content:
•    all cheeses except cottage cheese
•    dark or plain chocolate
•    yeast extract (Marmite etc.), miso, tempeh, tomato paste, tandoori spice mix, stock cubes,

ready-made sauces •    cola drinks, orange juice, tomato juice
•    any dried, pickled or smoked fish
•    sausages, pies and smoked meats, beef liver, chicken skin
•    broad beans, spinach
•    sauerkraut
•    almonds.
High or moderate amine content:
•    milk chocolate
•    soy sauce
•    beer, wine and cider
•    pork, including bacon and ham, salami, chicken liver, offal
•    all fresh or tinned fish, except white fish
•    all nuts except chestnuts and cashews
•    sesame seeds, sunflower seeds
•    avocados, aubergines, mushrooms, tomatoes, broccoli, cauliflower
•    olives and olive oil
•    oranges, lemons and other citrus fruits
•    pineapples, bananas, raspberries, strawberries, pineapples, plums, grapes, dates, figs, kiwi

fruit, passion fruit.
Continue for at least three weeks, and longer if your symptoms are normally intermittent. if you

improve, you can then experiment with reintroducing small portions of foods from the second list, three

or four times a week. Gradually build up to a higher intake, but cut back if your symptoms return.
Organic diet
The objective here is to avoid pesticides, i.e. chemical sprays applied to kill fungi and insect pests.

This may be helpful for people with chemical intolerance (see p. 84).
`Chemical-free’ or ‘unsprayed’ food (crops grown without pesticides) will do just as well as 100%

organic food (which is grown without either pesticides or artificial fertilisers).
The highest intake of pesticides is from fresh fruit and vegetables, so if your budget is tight,

concentrate on buying organic or chemical-free versions of these. If you have a garden, growing some of

your own food will reduce the cost.
You can also reduce the pesticide content of ordinary fruits and vegetables by:
•    Storing them for as long as possible before using them, because the pesticides break down quite

quickly
•    Always peeling them. With difficult-to-peel items such as peaches and tomatoes, pour boiling

water over them and leave them to stand for a few minutes first, as this loosens the skin. Rinse in

cold water, then peel.
•    If peeling is not possible, washing them very well with soap or detergent, then rinsing them

thoroughly
•    Cooking them, as this drives off some of the pesticides; avoid inhaling the steam and ventilate

the kitchen well while doing this.
You should drink mineral water from a reputable source, or use a very high-quality water filter (not a

jug filter).
Additive-free diet
Food additives are occasionally the culprit in chronic urticaria (see p. 53). At the same time as

avoiding additives, people with chronic urticaria should cut out other potential culprits – alcohol,

spices and all aspirin-like drugs (see box on p. 151).
An additive-free diet may also be of value for some people with chemical intolerance (see p. 84).
In the case of children with Attention Deficit Disorder (ADD), also called Hyperkinetic Syndrome, the

role of additive-free diets is a contentious issue (see p. 81).
An additive-free diet is very healthy but quite hard work. It means making all your own food from 100%

fresh, unmodified produce (you cannot have bacon or ham, and even things like cooked chicken and

ready-to-eat salad can contain some additives; so does most restaurant food). Note that wines, beers

and other alcoholic drinks can contain many additives without declaring them on the label. (German

bottled beer is an exception here.) Baked goods sold unwrapped can also contain many additives without

declaring them.
Stop using toothpaste unless it is an additive-free brand. You can buy such toothpaste from a

health-food shop – or use sodium bicarbonate powder instead. Drink mineral water or filtered water (you

need a good-quality filter for this, not a jug filter).
Medicinal drugs can contain colourings and other additives, so you should try to get additive-free

versions. Talk to your pharmacist about this initially.
Assuming the symptoms clear up, testing can begin, but you will probably need medical help to work out

exactly which additives are at fault. It is difficult to organise these tests at home, because most

foods contain such a mixture of additives.
With chronic urticaria, there is the possibility of quite severe reactions on testing, so medical

supervision is desirable. You can undertake cautious testing with small amounts of tap water, spices

and alcohol at home, but make sure you are in a position to get emergency medical help if you need it.

Aspirin or aspirin-like drugs should not be tested at home. Life-threatening reactions are common in

sensitive individuals, and temporary avoidance can heighten your reaction.

Homeopathy
`We believe that a serious effort to research homeopathy is clearly warranted despite its implausibility.’ That was the conclusion of a group of German and American scientific

researchers who, in 1997, looked at every study of homeopathy they could find. This prestigious trans-Atlantic team carefully assessed the scientific validity of each study, and

then considered the data from studies that were of reasonably good quality.
This kind of study, in which all the available research data on a topic are combined, is called a meta-analysis. There were 119 research studies which were good enough to be

included in this meta-analysis and, taken together, these studies suggested that homeopathy does indeed have some real effects. In other words, it produces significantly more

benefits than simple placebo effect – the psychosomatic improvement which tends to occur with any treatment, even a dummy pill (see p. 233).
Some of the most convincing scientific studies included in the meta-analysis were those relating to homeopathic remedies for allergic conditions (see p. 217). But what exactly

does this mean for allergy sufferers? Is homeopathy a treatment that is worth a try? Unfortunately, it is difficult to say.
Firstly, the evidence from the homeopathy meta-analysis is far from overwhelming, as the researchers themselves point out. The observed improvements – the overall differences

between the placebo and the homeopathic remedy – are not huge. Secondly, even if there are some homeopathic treatments that have real effects, it does not mean that every kind

of homeopathic treatment works. Homeopathy is a very broad field, with a multitude of different approaches. The types of homeopathy that have been tested, and appear to help,

may bear little or no relation to the homeopathic remedies that are generally available (see p. 217).
`Let like cure like’
The central idea in homeopathy – often known as the principle of similars – is that a substance which causes a particular set of symptoms can also, if handled in the right way,

cure symptoms of
a similar kind. In the words of Samuel Hahnemann, the German doctor who invented homeopathy at the beginning of the 19th century, ‘Let like cure like.’
The natural substances that form the basis for homeopathic remedies are mostly derived from toxic plants or minerals. (Sometimes extracts from diseased tissue – called nosodes –

are used instead, but this is a relatively recent development. So is the use of allergen extracts, such as pollen, described on p. 217.) Hahnemann himself began with the

standard drugs of his own day, such as belladonna and arsenic compounds. His innovation was to use them in very much smaller doses than his fellow physicians, and to apply them

to entirely different diseases.
Hahnemann worked by first discovering what the effects of the drugs were, when taken by a healthy person (he experimented on himself and his family for this). Then he tried to

match the symptom pattern produced by the drug with the symptoms of a particular disease. For example, he observed that belladonna produces hallucinations and a hot, dry skin –

symptoms that were also seen in children with scarlet fever. He claimed that, by giving belladonna in very small doses, much less than was normally used, he could stimulate the

body to heal itself of scarlet fever.
Hahnemann, unlike his medical contemporaries, also advocated a good diet, fresh air and exercise. And he was heartily opposed to the conventional medicine of his day, a brutal

business that involved a great deal of blood-letting and large doses of very toxic medicines. Considering how useless, and indeed dangerous, the orthodox medicine of the time

frequently was, Hahnemann’s successes were not really surprising.Less is more’
Homeopathy today is the ultimate version of the ‘less is more’ philosophy. A homeopathic remedy is prepared by taking the basic ingredient, dissolving it in water, and then

diluting that solution over and over again. Imagine pouring a bottle of wine into the Pacific Ocean, and you have a rough idea of how dilute homeopathic remedies are. Making

extreme dilutions was an idea introduced by some of Hahnemann’s followers, after his death.
Dilution is only part of the story, however. With each dilution, homeopaths apply a special shaking-and-tapping technique known as percussing. This was originally done by hand,

but now is often done mechanically. Homeopaths believe that percussing makes the active substance more powerful, despite the dilution. The term used by homeopaths is potency,

and a homeopathic remedy of the highest potency is the one that has been most thorDughly diluted and percussed.
In fact, a simple calculation, using the basic laws of physics, shows that there is nothing there at all but water – many homeo pathic remedies are watered down so thoroughly

that not one Jingle molecule of the active substance is likely to remain. It is  which leads medical researchers to use words such as ,nplausibility’ (see p. 216) when talking

about homeopathy.
Nhat homeopaths do
\ homeopath starts by considering all your symptoms (not just allergies, but any other symptoms as well) and various other characteristics that conventional doctors do not

usually consider, including physical appearance and psychological traits. The homeopath then chooses a substance which, if taken at full strength, would produce a comparable set

of symptoms and characteristics. This approach is called classical homeopathy.
In addition, homeopaths often give advice on diet, sleep, exercise and allergen avoidance. As in the early days of homeopathy, this may be the most important part of the

treatment.
Like many other complementary therapists, homeopaths will listen if you need to talk about personal problems and emotional difficulties, and will offer reassurance or advice.

This can be valuable, though not everyone would agree that a homeopath is the best source for such help. There are two distinct traditions within homeopathy – a scientifically

inclined tradition (represented today by experiments with homeopathic immunotherapy – see right) and a highly metaphysical tradition. Among the many ideas floating about within

the metaphysical tradition is the notion that all illness is a result of psychological or moral failings. Attitudes of this kind, which are quite common among complementary

therapists, can be very damaging (see p. 209).
Sometimes homeopaths recommend avoiding certain foods, on the assumption that the patient suffers from food intolerance, though they rarely use an elimination diet (see p. 194),

the only way to achieve accurate diagnosis.
In addition to all this, some homeopaths also give herbal remedies where they think it will help. This approach is called complex homeopathy.
A much more recent development within homeopathy is homeopathic immunotherapy or HIT, which uses an extreme dilution of an allergen (such as pollen or dust mite) to treat people

who are allergic to that substance. While homeopathic immunotherapy was inspired by conventional immunotherapy, the relationship between the two is a very distant one indeed.

The extensive dilution process means that the liquid used for homeopathic immunotherapy is unlikely to contain even one molecule of the allergen. This puts it in a completely

separate realm from conventional immunotherapy, where the presence of the allergen, and the steadily increasing dose with successive injections, is what produces the beneficial

effect (see p. 166).
Does it work for allergy?
Two scientific trials suggest that HIT makes a difference, albeit a small one, for hayfever and pollen asthma. In the meta-analysis described on p. 216, one of these trials was

given a good rating for scientific reliability, and the other was considered fairly good.
Another type of homeopathic treatment that appeared to be effective for patients with allergic asthma was one using a nosode – an extract of the asthmatic airway itself. A small

sample of the airway was taken from each asthmatic patient, diluted and per-cussed, then given to the patient as a treatment. It seemed to work, and the scientific rating of

this trial was very high.
The third homeopathic treatment that appeared to have an effect in valid scientific studies was Galphimia, used for symptoms in the eye caused by pollen allergy.
If you go to a local homeopath, it is very unlikely that you will be given either of the first two treatments – these are only used experimentally, in large research centres.
The Galphimia treatment might be available from a local homeopath, but it will not necessarily be in the same form as the treatment used in the scientific trial.
Note that all the studies described above are trials with a positive outcome. If you are trying to assess homeopathy overall, you should also consider the many trials that found

no effect. For example, a very careful study of homeopathy for children with asthma, carried out at the University of Exeter and published in 2003, found no benefit from

individualised homeopathy treatment.