Posts Tagged ‘food allergy’

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.

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.

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.

Allergy: Selecting the Right Food

An avoidance diet is for people who already know what food or foods affect them, and simply need to

avoid those foods. A diagnostic diet is for those whose symptoms suggest that they might be suffering

from food sensitivity of some kind, and who cannot be diagnosed by indirect methods such as skin tests,

because true food allergy is not involved. A diagnostic diet is intended primarily to show whether or

not food is causing the symptoms.
The diagnostic diets themselves fall into two basic categories. Firstly, there are diets that, by a

process of elimination, identify a particular food (or foods) as a cause of symptoms. Called

elimination diets, these are used to diagnose idiopathic food intolerance (see p. 74) and certain other

kinds of sensitivity reactions to particular foods. An elimination diet is purely diagnostic - simply a

means to establish which foods are at fault. To this end, all commonly eaten foods are avoided at the

outset, and each food is then tested individually. Once an elimination diet is complete, the

information gathered is used to establish a suitable avoidance diet. For example, if milk, wheat and

oranges caused symptoms during the testing phase of the elimination diet, those foods are all avoided

in future.
Secondly, there are specific diagnostic diets, which are a great deal simpler to carry out than

elimination diets. A specific diagnostic diet aims to reduce the intake of a particular substance that

is found in certain foods. The substances concerned -histamine or nickel, for example - are known to

cause particular symptoms in susceptible people.
A specific diagnostic diet simply cuts out all the foods that contain large amounts of the substance
under suspicion. If this diet alleviates the symptoms, and does so consistently, it is plausible that

the substance concerned is indeed the culprit. However, the diet should be stopped and then started

again, preferably several times, to check the response. Once the sensitivity is confirmed in this way,

the avoidance diet which follows is basically the same as the diet used for diagnosis.
Note that there is no agreed terminology for these different kinds of diet, and the definitions given

above will not necessarily be followed in other publications. You may even come across ‘elimination

diet’ being used to mean ‘avoidance diet’, which is particularly confusing. If you are consulting other

sources of information, check the context carefully to see what meaning is intended.
There is one odd man out in this chapter - the diet to protect against asthma, described on pp. 206-7.

It is neither an avoidance diet nor a diagnostic diet, but a health-promoting diet of the kind commonly

advocated to combat other widespread conditions, such as cancer and heart disease. In fact, it has a

remarkable number of similarities to diets that reduce the risk of these other diseases.
The anti-asthma diet is immensely healthy, whereas many avoidance diets carry a risk of malnourishment.

An allergic individual following any kind of restrictive diet - especially a child - should be

medically assessed for the possible risks. That is why it is important to talk to your doctor before

starting any dietary treatment or investigation. A referral to a dietician or nutritionist may be

necessary, and your doctor can arrange this.
When malnutrition does occur as a result of self-treatment, there are often very complex factors at

work. One potential hazard with dietary treatment is that psychological problems can easily become
entwined with obsessions about food. Eating can be a potent form of self-expression, or a way of

exerting control over oneself and others. Many doctors have seen patients who are mistakenly convinced

that food sensitivity is at the root of their health problems, or those of their children. In some

cases, no amount of objective evidence to the contrary will deflect people from such beliefs.
A few people with mistaken beliefs of this kind impose very restrictive diets on themselves - or

sometimes on the whole family. The food rules that they establish may be a way of limiting contact with

the outside world, avoiding other problems and issues by making diet the central focus, or simply

making demands on other people’s time and attention.
The current fad for identifying ‘food allergy’ using very dubious diagnostic tests (see p. 93) will

probably send many more psychologically vulnerable people down this route.
Another unhelpful trend in the dietary field is the wholesale (and usually ineffective) use of

vitamins, minerals and other supplements for a great variety of diseases, including allergy and other

forms of sensitivity. It is important to realise that none of the sensitivity diseases described in

this book has nutritional deficiency as its primary cause, so supplements are not a major part of

treatment in most cases. For the majority of people with some kind of sensitivity disease, a supplement

will make only a small difference, if any. However, it is true that, with some sensitivity problems,

certain supplements may be helpful to certain individuals. The use of Vitamin C in asthma (see p. 207)

is one example of this, and there are some other instances mentioned in Chapter 2.
Generally speaking, it is better to get the vitamins, minerals and other nutrients you need (such as
antioxidants) from food, not from tablets. Studies of adult-onset asthma have shown that only natural

Vitamin E protects against the disease: supplements have no effect.
Many vitamins and minerals, along with various plant and animal extracts, are now referred to as

nutriceuticals - in other words, substances that are classed as nutritional supplements for legal

purposes, but are being marketed as if they were medicinal drugs (pharmaceuticals). Many doctors are

concerned about this, if only because of the duplicity involved. These substances can be sold freely to

the public only because they are, in theory, nutritional supplements, yet they are actively promoted to

the public as if they were drugs.
The marketing is usually indirect, to avoid falling foul of the law, but very effective nonetheless.

Advertisements for the product avoid making any medicinal claims, since these would be unlawful, and

just speak vaguely of ‘health-giving properties’. The specific medicinal claims are made in magazine

articles (which often appear right beside the advertisement), penned by journalists who have been

supplied with a great many ‘facts’ - actually unsubstantiated claims -by the manufacturer of the

supplement. These claims are reproduced uncritically, so the journalists are simply acting as

mouthpieces for the manufacturer. There is no law preventing this.
This is a ruse that circumvents important laws intended to protect consumers from misleading

advertising. Few of these products are likely to be damaging - although there are concerns about some,

especially beta-carotene supplements (see p. 207). What matters here are the large amounts of money

being made from products that frequently have few benefits for those who take them.

What exactly is in ready-made food? People with food sensitivity, especially those with severe food

allergy or coeliac disease, need a simple answer to this question, but frequently they don’t get one.

Research among food-allergy sufferers has found that, in the course of a year, half of them

inadvertently eat the food they are trying to avoid, owing to a lack of information about ingredients.

Restaurants and canteens are responsible for many of these accidents, and most of the fatalities (see

p. 111), but packaged food also plays a part.
Unfortunately, many food ingredients that are potentially allergenic, such as milk and eggs, appear in

packaged food without this being stated on the label in everyday language. The information is usually

there somewhere, however – you just need to know what words to look for.
Decoding food labels
The problems with food labels fall into two general categories:
•    some of the ingredients are described using technical terms. These are usually specific

constituents of the original foodstuff e.g. lactalbumin, one of the proteins found in milk.
•    some manufactured ingredients can be made from different starting materials. So an item such as

‘edible starch’ could be made from either wheat or maize (corn), while ‘hydrolysed protein’ could be

made from soya, maize or yeast, sometimes with wheat added.
One day, no doubt, manufacturers will realise what a burden this type of obscure labelling imposes on

their allergic customers and will start using plain language. In the meantime, food-allergy sufferers

just have to learn all the terms that may be used for their culprit food or foods.
Labels used in health-food shops and delicatessens are another matter altogether. Here the problem is

with exotic-sounding items, such as kamut, which is actually an allergenic food (wheat).
Maize (Corn)
Items always made from maize: cornflour, cornmeal, cornstarch, dextrose, polenta
Items sometimes made from maize: baking powder, cereal starch, edible starch, food starch, glucose

syrup, hydrolysed protein, hydrolysed vegetable protein, malt, malt flavouring, modified starch,

modified food starch, starch, textured vegetable protein, vegetable gum, vegetable protein, vegetable

starch
Note that the gum on envelopes and stamps is sometimes made from maize, and that many medicines contain

cornstarch.
Eggs
Items always made from eggs: ovalbumin
Items sometimes made from eggs: lecithin (In fact this is rare in foods – lecithin is usually derived

from soya. Only in pharmaceuticals is lecithin likely to be derived from egg.)
Terms used for egg on cosmetics and toiletries: Ovum
Fish
Be very cautious when travelling. The use of fish meal as an ingredient of spicy sauces is common in

Southeast Asia, and in some parts of Africa. The strength of the spices may make the flavour of the

fish undetectable.
Milk
Items always made from milk: casein, casemate, lactalbumin, whey
Terms used for milk on cosmetics and toiletries: Lac
If you see the term ‘dairy-free’ on standard packaged foods, you can safely assume that the contents

are free from goat’s and sheep’s milk, as well as cow’s milk. But be more wary with homemade or locally

produced foods labelled ‘dairy-free’ - some
people think that ‘dairy’ refers only to cow’s milk.
Parev or pareve is a term used for kosher (Jewish) food that contains neither milk nor meat. However,

there can be contamination with traces of milk.
Lactose is a sugar produced from milk, and while it is not allergenic itself, it may contain a trace of

allergenic milk proteins. The amounts involved are tiny, and will only affect the most sensitive

individuals.
The label ‘non-milk fat’ sometimes misleads people if they just glance quickly at labels. The fact that

a product contains non-milk fat does not, of course, mean that it is entirely milk-free -remember to

look for all the synonyms of milk (see above).
Nuts
Items always made from nuts: frangipane, marzipan, praline
Standard packaged food will almost always include the nuts by name, but if you are buying other food

(e.g. from a stall selling home-made food) watch out for the above names.
Be very cautious about unrefined nut oils (see p. 110). Almond essence may be produced chemically, in

which case it is safe, but some is made from real almonds and could be allergenic.
Terms used for nuts on cosmetics and toiletries: Prunus, Juglans, Bertholletia, Corylus
Peanuts
Items always made from peanuts: arachis oil, groundnut oil satay sauce
Unrefined peanut oil should be avoided. This is not much used, and unlikely to be encountered except in

Indian and Oriental cooking. Most groundnut oil sold in Britain and Europe, or used in packaged foods,

is refined and considered safe (see p. 110).
Alternative names: arachide, beer nuts, cacahuete, earth nuts, goobernuts, groundnuts, monkey nuts
You are only likely to encounter these names on imported food, or when travelling. Always be very

careful with Indian or Southeast Asian food, where the use of peanuts is very common and often not at

all obvious. Avoid chocolate from Poland, which often contains peanuts that are not declared on the

label.
Items sometimes made from peanuts: hydrolysed vegetable protein. (The usual source is soya or wheat,

but some is derived from peanuts.)
Terms used for peanut on cosmetics and toiletries: Arachis hypogea, Arachis oil
Sesame
Items always made from sesame or containing some sesame: gomashio, halva, hummus (houmus), tahini, the

drink Aqua Libra
Alternative names: ajonjoli, berme, gingelly, teel, til, simsim
Check carefully for sesame in any food from a health-food shop or a stall selling home-made food, and

in foods from the Middle East, or Chinese packaged food (e.g. stir-fry oils). Sesame oil is always

unrefined and therefore allergenic (see p. 110). Watch out for contamination by traces of sesame in

bakeries and delicatessens where goods are sold unwrapped.
Term used for sesame on cosmetics and toiletries: Sesamum indicum
Shellfish
Items sometimes containing shellfish: curry paste, fish sauce and other sauces/pastes used in Southeast

Asian cooking
Standard packaged food should mention shellfish specifically, but you may need to read the label

carefully. Be cautious about bottles of imported sauce, and home-made or takeaway food.
Soya
Items always or usually made from soya: miso, soy sauce, textured vegetable protein, tofu, vegetable

protein
Items sometimes made from soya: hydrolysed protein, hydrolysed vegetable protein, lecithin, vegetable

gum, vegetable starch Changes in ingredients
Unfortunately, the ingredients of a product can change without any obvious warning on the label, or any

change in the packaging. You should always check the label in detail, every time - even on foods that

you have eaten before without any trouble.
Wheat
Items always made from wheat: bran, flour, graham flour, hard flour, strong flour, wholemeal flour

(there are non-wheat brans and flours, of course, but the words ‘bran’ or ‘flour’, without any

qualification, usually mean wheat)
Regional names for particular types of wheat: bulgur or bulgar wheat, Chilton, couscous, dinkel, durum,

einkorn, farro, fu, kamut, semolina, spelt, triticum, triticale (a hybrid of wheat and rye)
Items sometimes made from wheat: baking powder, cereal binder, cereal filler, cereal protein, cereal

starch, edible starch, food starch, hydrolysed protein, hydrolysed vegetable protein, modified food

starch, modified starch, starch, textured vegetable protein, vegetable protein, vegetable starch.
Assume that bread, crispbread, pastry, pasta and noodles are made from wheat, unless definitely

labelled otherwise (and read the label in detail too, because a little wheat is often added to items

such as rye bread and rye crackers).
Note that buckwheat is not wheat at all - it is not even a cereal. Nor does it commonly affect

coeliacs, as is sometimes claimed, though a few coeliacs may develop an intolerance reaction to it,

through eating it very regularly.
For more information on avoiding gluten, see p. 177.
Yeast
Items usually made from yeast: leavening
Items sometimes made from yeast: hydrolysed protein, hydrolysed vegetable protein
Labelling loopholes
Manufacturers do not have to include on the label:
•    Any ingredients used in an earlier manufacturing process e.g. yeast used to make bread for

breadcrumbs, wheat flour added to spices or mustard powder during the grinding process, or bread used

to innoculate blue cheeses with mould -this can leave minute traces of gluten in the cheese.
•    Residues left by substances used during processing, such as wheat flour used to dust processing

lines or prevent dried fruits from sticking together. Manufacturers do not need to declare these

residues on the label because the substance serves no function in the final product and is present in

amounts that are considered insignificant. The vast majority of those with coeliac disease or food

allergy will tolerate such microscopic traces, but the most sensitive individuals may not. Some

coeliacs are even affected by food additives manufactured from cereals (see p. 177).
•    The individual constituents of a composite ingredient (such as salami on a pizza), if that

composite ingredient makes up less than 25% of the finished product. This is called the 25% rule. As

from November 2005, this is all set to change, thanks to the European Parliament. The contents of a

composite ingredient like salami will be listed in full. A few composite ingredients with officially

defined contents (such as jam, or chocolate) can be listed just as ‘jam’ or ‘chocolate’ if they make up

less than 2% of the product. Likewise herb mix or spice mix, if less than 2%. But there are certain

items that must always be listed if they are anywhere in the product, and however small the amount.

They are: milk, eggs, tree nuts, peanuts, sesame, mustard, celery/celeriac, fish, crustacean shellfish

(shrimps, prawns, crab etc), soya, wheat and all other cereals that contain gluten. Sulphur dioxide and

sulphites must be listed if more than 1 Oppm. This list will be reviewed from time to time.
`May contain’ labels
Labels reading ‘May contain nut traces’ are springing up like weeds on packaged food. Similar labels

relating to sesame, milk and eggs are also starting to appear.
Allergy sufferers, suddenly unable to eat foods that they formerly enjoyed, feel very frustrated about

this development. Many suspect that these labels are often just a defensive tactic - warning off

consumers with food sensitivity when the chance of the food containing the allergen is actually very

small. The danger is that some allergy sufferers may stop taking the labels seriously. Teenagers, in

particular, are increasingly dismissive of ‘May contain’ labels, and this is a huge worry for parents.
Could the need for ‘May contain’ labels be eliminated altogether with more careful factory procedures?

The problem here is that, with nuts, perfect cleaning of production machinery is extremely difficult.

Most machines have nooks and crannies in which a nut from one production process can become lodged,

only to free itself later during the making of a non-nut product. It is quite possible that someone

could encounter a whole nut, or substantial pieces of nut, in a non-nut product. That is why no one

with nut allergy, even if it is relatively mild, should disregard ‘May contain nut traces’ labels.
Some makers of confectionery and biscuits have now set up dedicated nut-free production lines, with

stringent precautions to avoid any possibility of contamination. This allows them to market products

that are guaranteed nut-free. If you cannot purchase these locally, you may be able to order them by

mail or over the Internet (see p. 255).
Note that packaged foods that have been produced on nut-free production lines in the past can be

switched to different production lines, that necessitate a ‘May contain nut traces’ label.
In some cases, a product is manufactured in two separate places, one of which is nut-free, while the

other is not. Consequently, the same product may sometimes be sold with a ‘May contain’ label and

sometimes without. Don’t disregard these labels, however illogical they might seem.
Packaging errors
As most people with food allergy are now aware, ready-made foods sometimes go out in the wrong

packaging. Alarming cases that have occurred in recent years include hazelnut yoghurts labelled Toffee

Yoghurt, and Vegetable Bake (containing nuts) sold in packets intended for Vegetable Lasagne (no nuts).
Manufacturers are increasingly aware of the hazards and when mistakes are discovered, allergy

information websites and organisations such as the Anaphylaxis Campaign are quickly informed, so that

they can alert allergy sufferers.
Belonging to such an organisation (see p. 255), and/or checking websites regularly, is definitely

recommended for anyone with food allergy. However, you should bear in mind that no information service

can protect you completely from this hazard. The odds against it are high, but one day you might just

be the unlucky person who first discovers a packaging error by suffering an allergic reaction. To

protect yourself as far as possible:
When is a nut not a nut?
Those with nut allergies often worry about eating nutmeg and coconut. In fact, allergic reactions to

these are rare. People with nut allergy are no more likely to react to nutmeg or coconut than anyone

else.
Tiger nuts or chufa nuts are not nuts at all, but the roots of a sedge plant – they are most unlikely

to cross-react with true nuts.
Peanuts, botanically speaking, are not true nuts at all. They are legumes (pulses). There can be

cross-reactions with soya and/or lupin (proceed very carefully with this novel food ingredient) but

reactions with other pulses are rare. Cross-reactions with tree nuts such as almonds and Brazils are

quite common however (see p. 15). Many people with peanut allergy can in fact eat tree nuts, but they

should be aware that a cross-reaction could develop at some stage.
Because cross-reactions between tree nuts are so common, doctors tend to speak simply of ‘nut allergy’.

However, it is possible to be allergic to one type of tree nut, without being allergic to others.
•    always check that the food in the packet looks like the photograph on the packet
•    double-check, when you serve the food, by noting the conspicuous ingredients of the meal

(carrots, for example), and ensuring that they are indeed on the list of ingredients – any discrepancy

should make you suspicious
•    note the smell and appearance of any ready-made food, before you taste it. Do this even for

very simple things such as flavoured yoghurts
•    only have a very tiny mouthful at first, and if you have any tingling of the lips or other

symptoms, however mild, stop eating immediately (this is helpful for true food allergy only, not for

coeliac disease)
•    be especially cautious about vegetarian food if you are allergic to nuts or soya.
Latex in food
Those with latex allergy may react to very small traces of it in food. This sometimes occurs with

packaged food or restaurant food that has been prepared by workers wearing latex gloves. On one

occasion a highly allergic individual reacted to a water glass that had been handled by someone wearing

latex gloves. The amounts of latex involved are minuscule, and only affect those with severe latex

allergy. However, there is a strong case for workers handling food to wear non-latex gloves, especially

with the rise in cases of latex allergy.
There are also reports of people with latex allergy reacting (usually very mildly) to cold-seal

adhesives in food
wrappers, such as those used for ice cream. The reaction only occurs if the wrapper actually touches

the lips or mouth.

Suffering from a long-term illness, especially if it is severe and sometimes limits activity, can easily make a child feel different from other children, and ‘not good enough’. Children with allergies, especially those with severe asthma or food allergies, may also be very frightened and anxious. At the same time, such children often feel that they have to protect their parents by not revealing their fears.
Children may also think that their illness is a punishment for something they have done wrong. Their guilty feelings can be so powerful that they may not confide in you unless you spend time talking with them about their illness, and encourage them to share their feelings with you.
One of the most valuable things you can do for children with allergies is to build up their self-esteem. This is especially important when they first start school, because they have to adjust to other children there, and learn how to deal with questions about their illness, as well as some unkindness.
For children whose allergies limit what they can do physically, or restrict some normal activities, try to find other interests and hobbies that the child can do well. When talking with the child, always emphasise the positive things – the difficulties that you have overcome together in the past, the measures that the child can take to keep the symptoms under control (such as stopping scratching, applying creams, or using a preventer inhaler) and the areas of Iife where he or she is particularly successful. As the child gets older, introduce the idea that coping with illness makes you a stronger, kinder and more resolute person, one who can cope with any of life’s challenges. Show the child how much you value their maturity and perseverance.
Pay attention to what the child’s friends are
saying – a bit of eavesdropping is allowed – and be prepared to counteract any negative messages. Teach your child to be strong and self-confident about choosing their friends, and to prefer those who are sensible, understanding and supportive. Ask casually about what schoolteachers and other adults say when you are not around, because they can, without meaning any harm, undermine a child’s confidence with thoughtless remarks.
For children with problems that are potentially life-threatening, such as true food allergy, your natural anxieties as a parent can lead you to be overprotective. This can make the child feel smothered, but letting go is far from easy. You somehow have to find a middle path that works for you both.
With asthmatic children, focus on letting them live as normal a life as possible. Avoid saying ‘no’ automatically to things that might induce an asthma attack – such as running around outdoors in cold weather. Take some small risks, and let the child make the decision sometimes – he or she will gain a lot from taking the responsibility, especially if the decision is the wrong one.
This is the only way for children to learn how to manage their own condition. The sooner you can begin letting go, the better the child will cope in his or her teenage years, when it really will be necessary to make some difficult decisions without your help.
A pitfall for parents
In bringing up a child with allergies, remember that there should never be any ’secondary gain’ from illness – absolutely no advantages to having the eczema get worse (easily done by scratching) or starting an asthma attack (some children can bring one on by breathing in a particular way).
If your child has to take time off from school because of ill-health, ask the teacher for work that can be done at home, and check that it really is done. Children who are allowed to benefit from being ill can establish an unhealthy pattern for dealing with life’s difficulties (see pp. 94-5), which may be long-lasting. Such a mind-set can seriously limit a child’s development.
Incidentally, the ’secondary gain’ from illness may be quite altruistic in nature. It can include stopping parents from arguing, or from nagging a naughty brother or sister, as well as more obvious things such as getting a parent’s attention – so be aware of all the circumstances in the family that are affecting the child.
Sometimes a child realises, unconsciously, that attending to illness gives a parent welcome distractions from emotional problems and a comforting feeling of being needed and useful. The allergies can become part of the structure of a family, the glue holding everyone together.
Conversely, long-term illness can tear families apart: according to recent research carried out in the United States, divorce is more common in families where a child suffers from severe asthma.
Doctors frequently notice that severe eczema also can create a lot of tension in the home.
If you feel that a child’s illness is affecting the family badly – in whatever way – talk to your doctor, or someone else who you trust. You may need the help of a counsellor or family therapist to sort things out.
Children and medicines
Parents often feel very anxious about all the medication an allergic child uses. On the whole, the drugs prescribed for allergy are very safe, and only children with severe disease are at risk of significant side effects. These children will be carefully monitored by the doctor.
Needless to say, if you can cut down on the drugs by reducing allergen exposure, avoiding irritants (e.g. tobacco smoke) and implementing some of the other measures described in this book, you should do so. But if the child still needs drugs to control the symptoms, it is far better to accept them than to let the child struggle with all the discomfort, limitations and distress that the illness imposes.
Parents who are very concerned about drugs should talk openly to the doctor about their fears. If there are differences of opinion about drugs within the family, try not to expose the child to the disagreements. Sort out a joint policy in advance and always present a united front to the child. Be consistent and reassuring about drug use, otherwise the child may feel confused and anxious about the situation – or may even learn to manipulate it.
The asthmatic child
Children with asthma should have a management plan (see p. 96) and may benefit from using a peak-flow meter (see p. 97). Once your child is old enough to comprehend the difference between preventers and relievers, explain that using the preventer regularly keeps asthma under control, which means no sudden attacks and less need to use the reliever in public — something which most children find intensely embarrassing. You should oversee the child’s treatment closely until the age of seven or eight, then gradually let the child take over some of the responsibilities.
Coping with food allergy
The following concerns true food allergy (see p. 62), which can be life-threatening, not idiopathic food intolerance (see p. 74).
Protecting a child with severe food allergies is a major task. You will find it enormously helpful to be in contact with other parents who are facing the same challenge. The practical details are everything here, and you can benefit from other people’s ingenuity in solving day-to-day problems. Several support groups exist (see p. 255), offering a wealth of advice.
For very small children, the main task is to ensure that everyone who looks after the child understands exactly what can and can’t be eaten. Child-minders and baby-sitters should spend time with you as ‘apprentices’ seeing what is involved in preparing food for the child – this is far better than just giving verbal instructions. Also make sure that everyone knows how to use the adrenaline auto-injector (see pp. 98-9).
Once children start going to parties, you should always stay at the party for the whole time, and supervise your child closely. Take food that your child can safely eat, but which other children can also share. Some parents put a label on toddlers warning other adults that certain foods are taboo – for children under reading age this is probably acceptable, and does allow you to relax a little, but with older children the dangers of being teased or stigmatised should always be borne in mind.
Plan ahead all the time. Keep a snack box in the car containing food that the child can safely eat. Whenever you go on a trip, however short, have some safe foods with you, in case you get stuck somewhere and the child gets hungry. If you go out to eat, exert maximum caution about the restaurant food (see p. 111). Some parents take along a guaranteed-safe, but super-delicious sandwich or burger, and ask the restaurant to warm it up in a microwave (where appropriate) and serve it at the same time as the other food. If you do this, be sure the staff understand that the food must not touch any other food.
At home, some parents opt for everyone eating the same allergen-free food, on the basis that this makes for being ‘a real family’. Others, finding this too problematic or expensive, make a virtue out of the allergic child having a different meal. ‘I try to make her feel special about having her own food. The allergen-free dinner or cake always looks and tastes really good.’
As children get older, and more independent, you need to educate them thoroughly about avoiding the offending food. Equip them for difficult situations by role-playing. Act out being offered a tempting item of food by another child, and being jeered at for refusing. Act out suffering an allergic reaction to food and getting help quickly, even though people around don’t understand and are uncooperative.
Allergies and schools
When your child starts at a new school, creche, or kindergarten, request a meeting with staff and teachers to talk about the child’s allergies if there is any likelihood of these becoming a problem. Do this well before your child starts at the school, so that any necessary changes can be made. If your child has a serious food allergy or severe asthma, you may have to make several visits because there are usually a number of different people you should meet, and follow-up sessions may be needed with some staff. If all this sounds daunting and ‘not my style’ then you need, for the sake of your child, to develop your skills in dealing with people and being assertive. Talk to a counsellor, or look for suitable training courses.
In addition to ensuring that the school takes good care of your child’s health (see below), you should also discuss wider issues of adjustment to school life. Teasing or bullying can be a problem for children with any kind of health problem. Ask the teacher to keep an eye on your child and ensure that he or she is coping well – for example, that there is no difficulty about using an inhaler in front of other children when necessary.
Eczema
Ensure all staff realise that the skin rash is not infectious, and that they are aware of the need to communicate this to other children. The appearance of the skin can create a lot of problems with class-mates, and teachers need to be alert for taunting remarks or hurtful nicknames.
Unfortunately, children with eczema are very susceptible to infections caught from others, such as impetigo (see p. 44), but you can’t really protect children from such infections without isolating them socially. The best way to tackle this problem is to deploy all the available treatments so that your child’s skin becomes stronger and more resistant.
Food allergy
If your child has food allergy, go and see the catering manager personally. It may be helpful to take some printed material on food allergy with you, plus lists of synonyms for food ingredients (see pp. 172-4) where appropriate. Concentrate on building up a good relationship with catering staff, while ensuring that they understand how dangerous certain foods can be to your child.
Many parents feel more relaxed if they supply their child with a packed lunch that they know is allergen-free. This is often a good strategy, but don’t be complacent. Most allergic reactions in schools involve food given or traded by another child with entirely good intentions. Some schools with food-allergic children have set up a ‘no trading food’ policy, which seems to work well. Other schools establish milk-free or nut-free tables in the canteen, so that friends can sit together and trade food safely. (The mothers of the other children sitting at these tables need to be well versed in food avoidance, of course, so that their packed lunches are as safe as your own.) In the United States, schools have sometimes tried banning nuts or peanuts altogether, where there is a nut-allergic student, but this does not work well.
Some parents prepare a printed information sheet about their child’s food allergy, with a photograph of the child, and put these up at strategic points around the kitchen and canteen area. This information can include instructions on how to deal with anaphylactic shock (see below) and who to contact in an emergency.
Finally, include the art teacher in your rounds – foodstuffs are often used in art and craft projects.
Anaphylaxis
For children with severe food or insect-sting allergies which can lead to anaphylaxis, check that everyone at the school understands the potentially fatal nature of this condition. Key staff must know how to recognise anaphylactic shock and exactly what to do: show them how the adrenaline injector kit works. You could take along an old one, so that they can practise (see p. 150). Injector kits and adrenaline inhalers must be within easy reach, never locked in a cupboard.
Repeat this educational process at the beginning of each new school year, and before school trips. As an additional precaution, your child should wear a bracelet or pendant (see box on p. 95) that informs medical personnel about his or her allergies –this is also vital for children with latex or drugs allergies.
Asthma
If your child has asthma, ask what arrangements are made for inhalers. Children who can take responsibility for their own treatment should keep their inhalers with them. For younger children, the inhaler should be in the classroom, somewhere that is easily accessible (never locked away) and should be taken along during breaks and mealtimes. The child must always be able to get to the inhaler quickly: even a small delay in using it when an attack occurs can have dire consequences. Make sure everyone at the school understands this, that they know how to recognise an attack, and how to react. Assure the teacher that there is little danger of an asthmatic child overdosing, and if other children take a few puffs they will come to no harm.
If the teacher seems to believe that asthma is a psychological problem (some still do), go and see the head. Suggest that a local asthma nurse or doctor comes in and talks to the staff and pupils about asthma.
Ensure that the teacher knows about the effects of cold air and exercise on asthmatics. Talk to the games teacher or sports coach, and the playground attendants. It is vital that the games teacher is encouraging but understanding towards asthmatic children. They should never be told to continue exercising if they feel breathless.
Allergens and irritants in school
Schools today often have soft furnishings and carpets – these may be full of dust mites. If your child is allergic to mites, and if allergy symptoms are frequent at school, have a look around the classroom and see if this might be the cause. Before discussing the problem with the school, learn all you can about dust mites (see p. 114-117) so that you can assess whether proposed solutions to the problem would actually work.
Pets are common in classrooms and they can cause allergic reactions in sensitised children. Moulds flourish in many school buildings, and will affect a child with mould allergy. Poor ventilation is sometimes a major problem in school buildings, especially those where windows cannot be opened.
Irritants in school air include glue, paint, the solvents from felt-tip pens, disinfectants, air fresheners and the fumes produced during science lessons. Make sure the science teacher is aware of the risks and always uses a fume cupboard if irritant gases such as nitrogen dioxide or sulphur dioxide are likely to be given off during an experiment.
Applying sunscreens to children’s skin is now routine in many schools and preschools. Teachers probably won’t think to ask permission, so if your child is sensitive to any common ingredients of creams or sunscreens, let them know in advance.

Let’s hope it never happens - but if it does, knowing what to do could make the difference between surviving and not surviving. The sensible thing is to read these pages - or whichever parts are relevant to you or your child - before you encounter an emergency. It is often helpful to rehearse the procedure in your mind and actually imagine yourself going through the actions described here.
Find out in advance what the local ambulance service is like, and ask your GP for advice about who to contact in an emergency. (If you have latex allergy, check in advance that all local ambulances carry a latex-free kit.) These are the options:
• Call your GP.If the doctor is nearby and the hospital or ambulance station a long way off, this may be the best decision. Doctors in rural areas may have supplies of adrenaline for emergency treatment, and oxygen for those suffering a severe asthma attack.
• Call an ambulance. Where the local ambulance service is dependable, this is always the best option. The ambulance crew will have adrenaline and oxygen.
• Go by car or taxi to the nearest hospital
emergency department. This is not usually a
good plan, because your condition may quick-
ly get worse, and you have no emergency
treatment available. But there may be situa-
tions where it is a sensible decision. Emergencies can occur when you are away on holiday or business. Never stay anywhere without a phone – check that it is working as soon as you arrive. Make sure you have the number of a local doctor and know where the nearest hospital is. A remote holiday cottage can be a dangerous place to suffer an asthma attack or anaphylactic shock.
Anaphylactic shock
This is an extremely serious emergency, requiring immediate medical help. The signs of anaphylactic shock are listed on p.58. In the case of food allergy, there are additional signs in the mouth, lips and throat (see p. 62). Use adrenaline (epinephrine) straight away if you have it – but get emergency medical help as well. With injectable adrenaline (an EpiPen or Anapen – see p. 150), remove the cap and jab firmly into the outer thigh, going straight through any clothing. Never inject into any other part of the body – this can be dangerous.
If you have an adrenaline inhaler (see pp. 155-6) you can use this first to treat symptoms in the mouth, throat and airways, and then use the injector if you still have symptoms. (Improvise a spacer – see p. 100 – if there is difficulty in inhaling the adrenaline.) Anyone whose reactions tend to be severe should use the injector first and follow up with the inhaler if necessary. Overdosing with adrenaline is possible, and can be fatal, but using the inhaler as well as the injector is safe as long as you don’t have a heart condition (see pp. 155-6).
If you do not improve after using the injector, a second one can be used, 10-15 minutes later.
In situations where medical help is not yet available and the symptoms are not abating, another shot of adrenaline can be given every 15-20 minutes. But the maximum number of shots recommended by your doctor should never be exceeded. Keep count of how many you’ve had, and tell medical staff.
An asthmatic who does not have an adrenaline inhaler can use a beta-2 reliever inhaler such as Ventolin (see p. 152) as well as the adrenaline injection, although it probably won’t help very much.
Suppose you know for sure that you have encountered your allergen, but you don’t have any symptoms yet? In Britain, the usual advice is to wait for symptoms, but doctors in the United States say go ahead and use the adrenaline injector if you have reacted very badly in the past. In general, for people with no other health problems, it is better to give an adrenaline injection which isn’t needed than to delay giving one that is needed. Delaying the use of the injector may mean that the reaction gets out of control. Some people put off using the injector because they think it should be saved for when they ‘really need it’. In fact the adrenaline works just as well if you have used it on previous occasions.
Following anaphylactic shock, you should be kept in hospital for 6-12 hours even when everything seems fine. Attacks have recurred as much as eight hours later. Corticosteroids reduce the chance of this happening – ask if these have been given. If you are discharged early and it is a long journey home, consider waiting in the hospital, or nearby, until eight hours after the original reaction.
First aid for anaphylactic shock
A badly swollen tongue or throat can cause suffocation. If there is visible swelling and the person is unconscious or turning blue, try to keep the top of the trachea (the main airway leading from the throat) open. Use the handle of a spoon – one that has very smooth edges. Slide it carefully over the top of the tongue and into the throat. Press down gently but firmly to open the airway.
Someone who is feeling faint or dizzy, or losing consciousness, or (in the case of a child) becoming very pale and floppy, may be suffering from a dangerous drop in blood pressure. He or she is more at risk of a fatal collapse if in an upright position, because not enough blood is reaching the heart. The worst thing is to stand up suddenly, or to move (or be moved) quickly from a lying to a sitting position –death can follow within seconds. The best thing is to lie down, preferably with the legs resting on cushions or a stool so that they are above the torso, and with the arms raised above the chest. Adrenaline can be given while in this position. A stretcher should be used to get the patient to an ambulance.
Latex allergy and emergency treatment
If you have anaphylaxis due to latex allergy, going to hospital can be alarming, as you may suffer further reactions to latex gloves or equipment. Some patients with latex allergy have had such bad experiences in ambulances and hospitals that they become fearful of using their adrenaline injector, since this means they must go to the hospital afterwards. They delay using the injector, which makes the situation worse. Some doctors are now giving such patients all the medicines and training they need to manage their anaphylactic shock themselves, so that they don’t need to attend hospital.
A person who has lost consciousness should be lying down on their side in case they are sick (this reduces the chance of them inhaling their vomit). The same goes for anyone who feels nauseous.
On the other hand, if the major problem at the outset is difficulty in breathing (as it generally is in children) a sitting position is better.
It is unusual for both faintness and severe breathing problems to be present at once. If this occurs, the patient should lie down, and if there is swelling in the throat, a spoon should be used (see left) to keep the airways open.
Insect-sting allergy
If you don’t have an adrenaline injector, get medical help immediately.
If you’ve had a cutaneous systemic reaction (see p. 60) in the past, use the adrenaline injector if there is any difficulty in breathing, hoarseness, stomach cramps, diarrhoea, nausea, faintness, dizziness or confusion. If you are unsure, remember that, unless you have a heart condition, it is usually better to overreact (i.e. use the adrenaline unnecessarily) than under-react.
If you’ve had a severe systemic reaction (i.e. anaphylactic shock) in the past, use an adrenaline injector at the first sign of any reaction other than immediately around the sting.
If there is a honeybee stinger left in the skin, scrape or flick it out sideways using a fingernail, knife blade or credit card – the venom sac is attached and will go on injecting venom for up to 10 minutes if you leave it there.
Don’t try to pull the stinger out – this squeezes the venom sac and pumps more venom into the skin.
Get emergency medical help, and follow the other measures for dealing with anaphylactic shock (see left).
Don’t go alone
If you suffer vomiting or diarrhoea during anaphylaxis, and have to go to the toilet, tell someone to call an ambulance and take someone else with youto the toilet. Do not go in alone and lock the door, in case you collapse.
Asthma attacks
Even those with mild asthma, who have never had a serious attack before, can quite suddenly get into difficulties and require emergency treatment. Don’t be over-anxious about this, because it is unlikely to happen – but do be prepared. Not having your reliever inhaler with you when a severe attack starts is a recipe for disaster – always take it, wherever you go.
Deal with an attack promptly. The sooner you act, the fewer drugs you’ll need in the long run to control the attack. Most asthmatics wait too long and then under-treat their asthma.
The important thing is recognising an asthma attack, and knowing when it is getting out of control. Not all attacks are the same – some come on fast, some come on slowly.
Rapid asthma attacks come on in a matter of hours. You may have been fine all day, but then start to feel very breathless and wheezy, or begin coughing badly. Less than an hour later, despite using the reliever, the breathlessness is worse and it is a struggle to speak or walk across the room. This is a severe attack: don’t delay in getting medical help.
Slow asthma attacks come on over a period of days. At first you are more breathless and wheezy than usual, and your reliever inhaler is not helping much. Asthma wakes you up at night, and you are far more breathless than usual in the morning. This could be the beginning of a severe attack, so don’t delay in getting medical help. If you get to the point where your asthma is disturbing your sleep every night, and in the morning you have difficulty in speaking or walking about, this is a very serious situation – you must see your doctor or go to the hospital now.
A few asthmatics have great difficulty recognising when they are increasingly breathless, and for them, using a peak-flow meter (see p. 97) every day is essential. Indeed, most asthmatics find
Recognising an asthma attack in a very young child
With a young child, these signs indicate a severe asthma attack:
• the nostrils are flared
• the shoulders are unusually high
• the child can say only one or two words between breaths
• the ribs are pushed out, and the spaces between the ribs, and below the chest cage, are sucked in during breathing
• you can hear wheezing (a whistling noise)
• the lips, tongue or fingernails are blue.
If wheezing stops, without any other apparent improvement, this is a very bad sign — it may mean that the airways are now so narrow that no air is passing through them. This is called a ’silent chest’, and indicates an urgent need for medical attention.
that monitoring peak flow is a valuable way of spotting attacks in advance. However, if your peak flow seems normal, and yet you feel breathless and have a tight feeling in your chest, pay attention to your symptoms and get medical help.
Your response to your reliever inhaler is another helpful sign assessing asthma attacks. Things are serious if:
• the reliever inhaler does not seem to be working at all within 10 minutes of taking a puff
• it does not work as well as usual
• it works, but the effect wears off in less than three hours. If you have an asthmatic child, give everyone who normally takes care of the child detailed written instructions for recognising and dealing with an asthma attack. People forget verbal instructions especially in an emergency. A child who is exhausted or upset c. an attack should always be given medical care.
Taking action
If your reliever inhaler is not working well (see above), take another puff to open up your airways – and then take further action. as described below.
If you seem to be in the early stages of a slow asthma attack check your management plan, and if your peak flow has fallen below the recommended level, double the dose of inhaled steroids (twice as many puffs each time) now. Add any other medicines (e.g. steroid tablets) as recommended by the management plan.
Those who don’t have a peak-flow meter or management plan should double the dose of inhaled steroids and make an urgent appointment to see the doctor.
If you are suffering a rapid attack, or a slow attack that has got out of control, you need emergency medical help. Ring for an ambulance, ring your doctor, or go to the hospital – the ideal course of action will vary, depending on where you live (see p. 98).
Use your reliever inhaler until medical help arrives. You can take a puff every 5-10 minutes if needed, but keep a count of how many puffs you’ve had and stop after 30. Some doctors suggest taking up to 30 puffs all at once. (If you have a heart condition, this dose might be dangerous: follow your doctor’s advice.)
If it is difficult to inhale, use a spacer – this can make all the difference, especially for children.
You can improvise a spacer from a plastic cup, a plastic bottle, or a paper bag. Make a hole in the bottom of the cup or bottle, or in one corner of the paper bag, and insert the mouthpiece of the inhaler here. The open end of the cup, bottle or bag goes in or over the mouth – with the bag, you have to bunch it up and hold it around the mouth. Squirt the inhaler repeatedly into the improvised spacer, while breathing steadily in and out.
The six golden rules for asthma attacks
• Breathe as slowly as possible and concentrate on breathing out, not on breathing in. Exhale as fully as you can and your in-breath will follow automatically.
• Never panic – if you do, you may start hyperventilating, and this makes matters much worse (see p. 226). Panicky parents are the worst possible thing for an asthmatic child during an attack.
• Adopt a position that makes breathing as easy as possible. Propping your arms up at about shoulder height can help – for example, sit back-to-front on a dining chair, with your arms folded and resting on the back. Or put pillows on a table, sit in an upright chair, and rest your head and arms on the pillows. Don’t lie down, as this makes matters worse. Open a window, as long as the air outside is not cold, polluted or loaded with pollen.
• Avoid factors that can make an asthma attack worse, for example, vigorous activity, cold air, irritants and allergens.
• Drink plenty of water, fruit juice or other liquids as a lot of water is lost through the surface of the airways during an asthma attack, and you can become dehydrated.
• Don’t take anything to help you sleep, even herbal pills. If your asthma gets worse during the night, you need to wake up so that you can get more air.
After an attack
Asthmatics who have suffered a severe attack are occasionally sent home from hospital before they are completely better. A few people have died as a result of being discharged too soon. So if you feel breathless or otherwise unwell after you leave hospital, don’t hesitate to go back – or seek other medical help.
See your GP or specialist within a few days of any emergency treatment. Don’t be over-confident just after a severe attack – this can be a very vulnerable time. Take more rest than usual and drink plenty of fluids, as you may be dehydrated. Keep taking your preventer inhaler at the increased dose – reducing the dose now could lead to another severe, possibly fatal, attack. Keep taking steroid tablets if you have been given them.
If you produced a lot of mucus during the attack, try to clear it, but without violent coughing. Mucus can sometimes form solid plugs which block small airways. Treatment by a physiotherapist would help, and expectorants – drugs which help loosen mucus –can also be useful (ask your pharmacist about these). Don’t take ordinary cough medicine (see box on p. 163). There are also some breathing exercises which can help to clear mucus (see p. 231).
An asthma attack represents a chance to learn more about preventing asthma – so think about what went wrong. Had you forgotten to take your preventer inhaler regularly? How long is it since you had your medicines reviewed by the doctor or asthma clinic? Have you been using your peak-flow meter daily? Were you exposed to a high dose of allergen or an irritant?
A reaction to aspirin-like drugs
Aspirin sensitivity can begin quite suddenly in someone who has previously taken aspirin without trouble. If you have unexplained chronic urticaria, or polyps in the nose, plus asthma and/or rhinitis, the development of aspirin sensitivity at some time in the future is a distinct possibility (see p. 151).
A sensitivity reaction to aspirin or aspirin-like drugs usually begins between 30 minutes and two hours after the drug is taken. You will have some or all of these symptoms:
• a runny or badly blocked nose, and red eyes
• a feeling of warmth, flushing and sweating
• a general rash
• a sensation of tightness in the chest, a dry cough, increasing breathlessness
• malaise and exhaustion
• vomiting or diarrhoea
• swelling (angioedema) and/or nettle rash (urticaria). If you have such symptoms get emergency medical help immediately because the reaction can quickly develop into severe asthma, shock, collapse and unconsciousness.
If you have asthma, use your reliever inhaler as much as required (up to 30 puffs) until medical help arrives. Anyone who has an adrenaline (epinephrine) auto-injector, or an adrenaline inhaler, can use this as well – up to 30 puffs of the inhaler, or whatever maximum dose is given in the instructions. Tell the ambulance crew and doctors exactly what you have taken.

Allergy and Your Immune System
`The summer used to be such a miserable time for me because I’m allergic to grass pollen. For most of

my life I have had dreadful hayfever, and my asthma would get worse during the summer as well.

Antihistamines knocked me for six, and although there were nose drops that helped a little, they

certainly did not resolve the problem completely. Exam time was always a nightmare when I was a student

- then, as now, it coincided exactly with the pollen season.’
‘Getting a job in Chicago was a turning point in my health. My colleagues were amazed to see me

snuffling through the summer and just accepting that nothing could be done to improve matters. The

whole approach to treating allergies is different there. Eventually someone marched me off to see her

allergist, who said that I should have “allergy shots” and that my health insurance would cover it. The

process was very time-consuming at first, and it took a while to work, but the change is remarkable.

I’ve never regretted having the treatment. Summer is a time I can actually enjoy now.’
Not everyone responds this well to immunotherapy, but for those allergy sufferers who do benefit, this

is an excellent treatment. It tackles allergies right at their source, by teaching the immune system to

react differently to the allergen.
Also known as Specific Immunotherapy (SIT), Incremental Immunotherapy (11T) or simply as

hyposensitisation, this form of treatment was devised by two English medical researchers, Leonard Noon

and John Freeman, who reported their successes with hayfever patients in 1911. Ironically, their

treatment is now less readily available in Britain than in any other industrialised nation. Only a

small minority of British allergy patients receive immunotherapy. The cause of this strange situation

is a ruling made in 1986 by the Committee on the Safety of Medicines (CSM). This states that

immunotherapy must only be given where there is resuscitation equipment available, and that all

patients must wait for an hour after each injection, in case of
side effects. In addition, immunotherapy cannot be used for severe asthma.
The requirement for resuscitation equipment rules out most GP surgeries, and this effectively puts

immunotherapy beyond the reach of many allergic individuals in Britain, owing to the extreme shortage

of allergists and hospital allergy clinics (see p. 89). (In the past, the lack of allergy specialists

meant that most immunotherapy in Britain was given by GPs.)
The CSM ruling was triggered by a number of deaths due to immunotherapy: there were eleven fatalities

between 1980 and 1986, with five of these in the eighteen months just before the report. But almost all

these deaths were due to very basic errors in the way the injections were given – tragic as the deaths

were, the official response to them was inappropriate. Fatal reactions to immunotherapy can be avoided

with close attention to ordinary safeguards (see p. 166-7).
Allergen immunotherapy is still freely available elsewhere in the world, and is regarded as a key part

of allergy treatment. Britain is now out of step with all other developed countries, and most doctors

feel that British restrictions are far too strict.
There are hopes that this situation may change within the next few years, and that more allergy

sufferers may be able to take advantage of this valuable treatment. This could be achieved, in part, by

investing more National Health Service money in allergy clinics and allergy specialists. In addition,

there should be a relaxation of the regulations, so that properly trained GPs can give immunotherapy to

patients who are not at high risk of a fatal reaction. For people whose lives are affected by

allergies, the reintroduction of this treatment (with appropriate safeguards) would be a huge boon.
The uses of immunotherapy
Immunotherapy is mainly used for airborne allergens such as pollen, house-dust mite and mould spores.

Allergies to animals can also be treated with immunotherapy, but the treatment cannot work miracles –

if a cat-allergic person decides to keep the cat, the high dose of allergen inhaled every day limits

the impact of immunotherapy treatment.
People with straightforward allergic reactions affecting the nose and eyes (allergic rhinitis and

conjunctivitis) respond well to immunotherapy. In patients with hayfever, for example, the success rate

(patients showing some degree of improvement) is about 80-90%. When nasal allergies are complicated by

chronic sinusitis or nasal polyps, the chance of success is a little lower.
Some studies of the long-term effects of immunotherapy suggest that, if it is given to children with

hayfever or perennial rhinitis, those children are less likely to develop asthma.
The benefits of using immunotherapy to treat established asthma are less certain. Asthma is a more

complex disease than hayfever, and allergies are only one factor among many (see p. 36), which may

limit the impact that immunotherapy can make. Experience suggests that immunotherapy can be a great

help for an asthmatic with a strong allergic reaction to a single airborne allergen, such as grass

pollen or house-dust mite, but not for other asthmatics. Asthmatics with aspirin sensitivity or chronic

sinusitis are unlikely to benefit.
The value of immunotherapy to children with asthma is a subject of great debate among doctors in the

United States. Some studies suggest that it is of little real benefit, while others are more positive.

One interesting study, that followed asthmatic children for 15 years or more, found that if they were

given a full five-year course of immunotherapy when young, they tended to have fewer asthma symptoms

and need less medication in their late teens and early twenties.
Chronic urticaria (nettle rash) is occasionally due to airborne allergens, in which case immunotherapy

may help. However, immunotherapy is not recommended for atopic eczema. When people with both eczema and

rhinitis try immunotherapy for their nasal allergies, some find that their eczema gets worse.
Insect-sting allergy is a prime candidate for immunotherapy (see pp. 167-8) but food allergy is a

different matter, and is not treated with immunotherapy at present (see p. 168).
Who can get immunotherapy?
As a result of the CSM ruling (see p. 164) remarkably few allergy sufferers in Britain receive

immunotherapy.
Those with insect-sting allergy, who have suffered anaphylaxis (see p. 58), are the most likely to be

offered this treatment. However, even with this frightening and life-threatening problem, which can be

treated with almost 100% success by immunotherapy (see p. 167-8), such treatment is not automatically

available.
A few people with severe hayfever that does not respond well to drug treatment may also be given

immunotherapy. It is worth asking your doctor about such treatment if you feel you would benefit.
How immunotherapy works
Immunotherapy consists of a series of small injections, just under the skin. The liquid that is

injected contains an extract of the offending allergen, for example house-dust mite. The injections are

given at regular intervals, usually once a week, although other schedules are possible (see p. 167-8).
At the outset, a very dilute version of the allergen extract is used, way below the threshold for an

allergic reaction. People who seem highly sensitive, on the basis of their skin tests, start on an

extract that is even more dilute.
For the next injection, a slightly higher concentration of the allergen extract is used, and the

concentration goes on increasing with each successive injection. The idea is to habituate the immune

system to the offending allergen, by very gradually raising the dose. Eventually, when the dose reaches

a level which generally gives beneficial effects, no further increases are made.
If an allergy sufferer reacts badly to immunotherapy injections (see p. 166) on several successive

occasions, the dose may be levelled off before the ideal maximum dose is reached. However, a good

allergist will persist for some time in trying to increase the dose because stopping at a lower level

often results in the treatment being ineffective.
The first stage of immunotherapy, when the concentration of allergen is being increased week by week,

is referred to as the build-up stage. The second stage, when the dose is being kept at the same level,

is called maintenance therapy, and the dose used is the maintenance dose.
There is sometimes an obvious improvement by the time the build-up stage is complete, but not always.

The benefits of the treatment generally appear within six months of reaching the maintenance dose, but

some people have to wait a year or even two before things improve. As the immunotherapy begins to take

effect, symptoms decline and there is often less need for drugs.
A great deal of research effort has gone into finding out what lies behind these changes – in other

words, what is actually happening to the immune system when immunotherapy is effective. The answer is

that a surprising number of different changes may occur and no two allergy sufferers react to

immunotherapy in quite the same way. Frequently there is a shift in the kinds of antibodies the body

produces against the offending allergen. Levels of IgG antibodies (which help to block the allergic

reaction) go up, while levels of the allergy antibody, IgE, tend to stabilise and eventually go down.

The numbers of mast cells (see box on p. 12) may also decline, and they can become less responsive to

the allergen. The balance of power between Th1 cells and Th2 cells may also shift, with the pro-allergy

Th2 cells (see p. 11) becoming less influential.
What can go wrong
The secret of safe immunotherapy is to go at exactly the right speed for the immune system of the

individual being treated. The doctor should look for feedback from the immune system – signs that show

how well it is coping with the steadily increasing dose of allergen – and use these to pace the

immunotherapy schedule.
Going too fast – getting ahead of the immune system’s ability to cope – is hazardous. A major allergic

reaction, called anaphylaxis (see p. 58), can occur, and this is the cause of deaths during

immunotherapy. However, as long as there is injectable adrenaline (see p. 150) and resuscitation

equipment available, even such an extreme crisis can be dealt with safely.
Serious reactions to immunotherapy usually occur:
•    during the initial build-up phase; maintenance therapy is much safer
•    during the pollen season, for those with pollen allergy
•    when a new vial of allergen extract is first being used, because of variations in concentration

(see p. 168-9).
Those most vulnerable to severe reactions are:
•    people with asthma, especially severe or unstable asthma
•    those who have experienced systemic allergic reactions in the past
•    anyone who appears to be extremely allergic, on the basis of skin tests
•    anyone taking beta-Mockers (see box on p. 150).
With care, these fatalities can be avoided. Patients who are given immunotherapy can ensure their own

safety by being well informed about the procedure (see p. 167).
The timing of immunotherapy
There are various different approaches to the timing of immurotherapy. The basic method (which has a

good safety record in the United States where it is very commonly used) starts with injections once a

week. After the maintenance dose has been reached, maintenance injections are given once every 2-4

weeks. The frequency of these may be increased during the pollen season, for people with pollen

allergies.
It is the regularity of the injection schedule that gradually creates, and then sustains, immune

tolerance, so the treatment is only of value to patients who can reliably keep their appointments.
When immunotherapy is successful, it can eventually be discontinued without any reappearance of the

allergic reaction. It usually takes 4-5 years of regular therapy, from the time of the first injection,

to get to this point. The benefits then persist for many years, perhaps indefinitely in some people,

even without any further injections.
Rush immunotherapy
Trying to speed up the process of immunotherapy greatly increases the risk of a severe reaction

(anaphylaxis). However, there are some situations where fast results are needed, and in such cases rush

immunotherapy, also called accelerated immunotherapy, may be used.
During the build-up stage of rush immunotherapy, injections are given every day, or even several times

a day. All the usual safety procedures (see below) are observed with particular care, to reduce the

chance of a severe reaction.
In semi-rush immunotherapy, the build-up injections are given twice a week, and the risks are lower

than with daily injections, but still higher than with weekly injections.
Minimising the risks
If you are lucky enough to be offered immunotherapy treatment under the National Health Service, you

should not feel concerned about accepting the offer. There is very little risk of a bad reaction

because safety procedures are now so stringent.
To minimise the risk of suffering a severe reaction, the doctor will ask you, at each visit, about any

reactions that occurred after your previous injection. Reactions might include redness, itching or

swelling around the injection site, or (more seriously) symptoms elsewhere on the body, such as nettle

rash (urticaria), itchy skin, sneezing, a runny nose, red or itchy eyes, tightness in the throat or

chest, coughing or wheezing. Always make a note of such symptoms, so that you don’t forget to mention

them at the next visit. This is crucially important, as such reactions can indicate that the immune

system is being hurried along too fast.
The doctor will also ask if you have an infection of any kind, as this can alter your reaction. You

should also tell the doctor about any new medicines being taken, as some, such as betablockers (see box

on p. 150), can make a bad reaction to the injection more likely to occur.
Asthmatics can expect the doctor to ask about current asthma symptoms, and to check their peak flow

both before and after an injection. If there are any symptoms, or if the peak flow is less than 70% of

the best-ever value, the injection won’t be given.
Severe reactions can sometimes begin several hours after the injection, so stay within reach of a phone

for about 24 hours. Among United States allergists (who don’t require their patients to wait after the

injection for more than 20-30 minutes) there are some who believe that everyone undergoing

immunotherapy should carry an adrenaline (epinephrine) auto-injector (see p. 150) on the day an

injection has been given, for use in the event of a severe reaction. Anyone who has suffered

anaphylaxis in response to an insect sting will probably have an adrenaline auto-injector anyway, and

this can certainly be used to treat anaphylaxis following immunotherapy. Note, however, that using the

adrenaline is just the first step in treating anaphylaxis (see p. 98) and you must then go back to your

allergist, or to the nearest hospital emergency department, without any delay.
It is sensible to avoid exercise for two hours after an injection. Be extra-cautious during the pollen

season if you are receiving immunotherapy for pollen allergies.
Immunotherapy for insect-sting allergy
`Our daughter has had two really bad reactions from being stung by a wasp. After the second one, the

doctor at the accident and emergency department told us that she nearly died. We got so anxious about

it that we worried every time we left the house in the summer, and it was even worse if she went out

without us. My wife got so upset about it that she wasn’t sleeping well. It was affecting the whole

family badly.
‘Then we heard about desensitisation treatment, and asked our GP, but he said he couldn’t do it.

According to him, they might be able to do it at the hospital, but it might not work, and it was risky

too. We accepted that at first, but then I started doing some research on the Internet, and discovered

that in America and Germany this treatment is absolutely standard – someone like our daughter would

automatically be given it. We felt very angry when we found this out, and went back to the doctor.

Eventually Ann was referred to the allergy department at a hospital, and now she is getting this

desensitisation treatment. I’m pleased about that, obviously, but I still think it shouldn’t have been

such a fight to get it.’
Immunotherapy provides highly effective protection for those with insect-sting allergy, and should be

given to anyone who has had a severe systemic reaction (see p. 60). Some United States allergists also

recommend it for adults who have had a cutaneous systemic reaction (see p. 60), on the basis that they

may well progress to a severe systemic reaction with the next sting.
Studies of people who have suffered severe systemic reactions, and are then treated with immunotherapy,

show that 97% have no systemic reaction to future insect stings. For the 3% who are not fully

protected, the severity of the reaction is much reduced and far less likely to be life-threatening. In

other words, this is an excellent treatment which can save lives.
Targeting the treatment
Choosing the right venom for immunotherapy can sometimes be difficult. Not everyone with insect-sting

allergy sees the insect that caused the reaction. Skin tests may not give the answer either, because

there are often positive reactions to several different venoms. Some of these may be false positives

(see box on p. 91) and it is impossible for the allergist to say which one(s) are actually relevant.

Most allergists will recommend immunotherapy for all of them, using a mixture of venom extracts.
Where the guilty insect was seen and identified, but other venoms also give positive skin tests, a more

difficult decision has to be made. Many allergists carry out immunotherapy for all the venoms that gave

a positive skin test, on a ‘better safe than sorry’ basis. Since there are cross-reactions between

venoms (see box on p. 113), there is some sense in this. Other allergists just give immunotherapy for

the insect that did the deed.
Will immunotherapy against one insect protect against a related insect? With two closely related

insects such as wasps and hornets, which have many allergens in common, it might do – but there is no

guarantee. The problem is that, as well as the shared allergens, each venom also has its own unique

ingredients. It’s impossible to say, with the kind of tests available at present, if an allergic

reaction was to shared allergens or unique ones. So immunotherapy against wasp venom may give

protection against hornet venom, but it will not necessarily do so – and vice versa.
In the case of bumblebee allergy (seen almost exclusively in those, such as horticulturalists, whose

work involves handling bumblebees) a more definite answer can be given – honeybee immunotherapy does

not work. Immunotherapy with bumblebee venom does work, fortunately. The bumblebee extract has to be

obtained from specialist sources.
Injections are given weekly during the build-up phase, unless protection is needed urgently, as with

work-related sting allergy, in which case rush immunotherapy may be used. Once the maximum dose has

been reached, a maintenance injection is needed every four weeks. After a year, this maintenance dose

can be given every 6-8 weeks.
After 3-5 years of immunotherapy, skin tests with insect venoms are usually tried again. If the results

are negative, the immunotherapy will stop. Research now shows that, even if skin tests are still

positive when immunotherapy ends, there’s an 8090% chance that no systemic reaction will occur to

future stings. Some people are not reassured by this, and prefer to continue with immunotherapy for

their own peace of mind. Indeed, research shows that a near-fatal systemic reaction has a long-lasting

psychological impact, and that many people continue to feel anxious despite completing immunotherapy

and reacting negatively to skin tests.
At one time, challenge stings with live insects were given to check whether immunotherapy had actually

worked. Few doctors do this now, but your allergist may be prepared to do a challenge test if you ask.

Adrenaline and resuscitation equipment would be available if a challenge test were used, so any severe

reaction could be dealt with promptly and effectively. The fact that the psychological consequences of

insect-sting allergy are so persistent suggests that challenge tests with live insects may have a

particular value, in demonstrating that immunotherapy has worked. Challenge tests are also helpful for

those who work with stinging insects, such as honeybees and bumblebees, and who need to be sure that

they can go back to work safely.
Immunotherapy for food allergy?
Attempts to use standard immunotherapy for food allergy have been made repeatedly, but without success.

The process of giving the injections is nerve-racking because of the constant risk of a severe

reaction. The risks prevent the dose of allergen being increased very much, so the beneficial effects

are small. While there may be some reduction insensitivity, it is not enough – or not reliable enough –

to be of any practical value.
What doctors are aiming for here, incidentally, is simply to protect against the effects of

accidentally eating a tiny amount of the food – no one is expecting that someone with peanut allergy

will be able to eat peanut butter sandwiches as a result.
Some of the new developments in immunotherapy may be useful for food allergy, as described in the next

section.
The future of immunotherapy
Many different research teams are working on ways of improving immunotherapy – making it more

effective, safer to give, and less time-consuming.
One approach involves altering the allergen, so that it only interacts with those parts of the immune

system whose job is to control allergic reactions (and therefore bring about tolerance). The changes

made to the allergen are designed to make it ‘invisible’ to the parts of the immune system that

actually attack the allergen. The idea is to inject something that can’t cause a bad reaction, and is

therefore 100% safe.
The modified allergens are called allergoids. Another term often used is peptide immunotherapy – this

describes a technique in which the allergens are chopped up into small pieces to make them safe

(allergens are proteins, and a fragment of a protein is called a peptide).
Already, researchers in Germany have made an allergoid from birch pollen that can reduce hayfever

symptoms with a series of just seven injections given before the pollen season.
Meanwhile, a research team in London is working on peptides made from cat allergen, with encouraging

results so far. In a group of asthmatics who were allergic to cats, a series of 4-10 injections, over a

period of 2-8 weeks, produced benefits in about half those treated. The researchers believe that they

can improve on this and help the majority of people with cat allergy, at least enough to survive

temporary exposure to cat allergen (when visiting cat-owning friends, for example). They hope to refine

the treatment sufficiently to enable some cat-allergic people to keep their pet, rather than finding it

a new home. This is a relatively safe treatment that might be given by a GP, rather than only by

specialists. The research team hopes the treatment will be available by about 2009.
Could this kind of technique work for food allergy? Doctors believe that it can, and a great deal of

research work is being done, in both Britain and the United States. A major focus of this effort is

peanut allergy, since this puts so many young lives at risk. Even if the research is successful, It

will be several years before such treatments become available.
Researchers are also working hard to produce standardised allergen extracts – in other words, allergen

extracts that always contain a standard amount of the allergen. The aim is not only to reduce the

number of treatment failures (which can occur if the extract does not contain enough allergen) but also

to avoid mishaps when a new vial of allergen extract is used (differences in strength, between one vial

and another, are sometimes a cause of anaphylactic reactions).
Standardisation is difficult, because the starting materials –skin particles from horses, for example,

or dust-mite droppings –are natural materials and therefore variable. Some samples contain far more of

a particular allergenic ingredient than others.
One way around this problem is to develop accurate methods of measuring the amount of allergen in the

extract. Another approach is to abandon the whole business of making extracts, and produce allergens

artificially, in a laboratory. This is done by inserting the gene for the allergen – the gene for the

Der p1 allergen of house-dust mite, for example – into bacteria. These bacteria then act as production

units, manufacturing large amounts of the allergen every day. With this high-tech approach, the exact

content of the allergen preparations can be controlled.
These high-tech allergen preparations are extremely pure, and therefore very effective – as long as the

person receiving immunotherapy really is sensitised to the particular allergen that is included.

Unfortunately, most natural allergenic materials contain two, three or even more separate allergens. In

house-dust mite droppings, for example, while Der p1 is the allergen that affects most people, there is

also an allergen called Der p2, and a few people are more sensitive to this than to Der pl.
Artificially produced allergen preparations usually include the main allergen only. For the minority of

people who are more severely allergic to one of the other allergens, this extract will not work.

Eventually this problem will no doubt be circumvented by means of more precise skin testing before

immunotherapy begins – skin tests with individual allergens, rather than with allergen extract

containing a mix of allergens.
A third approach is to change from injections to oral immunotherapy – giving the allergen extracts by

mouth. The best results are obtained when the allergen is held under the tongue for a while and then

swallowed. This is known as Sub-lingual immunotherapy or SLIT, and has become very popular in Italy and

France, where it is a common treatment for hayfever. A recent pilot trial among GPs in Britain suggests

that it may be useful, but is not a miracle cure. Overall, the group treated with SLIT had fewer

symptoms during the pollen season, but antihistamines were still needed. There is some evidence from

Italy that SLIT might reduce the likelihood of children with hayfever going on to develop asthma, and

reduce the chance of new sensitivities.
Side effects are unusual with this treatment, and those that do occur are mostly mild – itching in the

mouth, for example. The treatment is safe enough for routine use in children.
Might oral immunotherapy work for food allergy? Other Italian studies suggest that it could. The

objective of these studies is to reduce the risk to children with cow’s-milk allergy from accidental

encounters with ‘hidden milk’ in prepared food or drink. The immunotherapy treatment begins with

miniscule amounts of milk – the doctors start with a single drop diluted in water, each day for a week

– and increase the dose extremely slowly. Antihistamines are given to minimise the risk of a reaction.
The whole process requires enormous patience, but after seven months, the majority of the children

involved can tolerate some milk – between three tablespoonfuls and a small cupful each day.
This is a very encouraging study that should be repeated by doctors in Britain. Because of the risks of

anaphylaxis – which can, of course, be fatal – it does require full medical supervision, and you should

not attempt it at home. Whether this method would work for allergens other than milk is something that

nobody has yet investigated.
A great many other approaches to immunotherapy are currently being tried for food allergy. Many of the

new techniques are highly experimental, and some show great promise, but it will be many years before

they are in use.
One innovation that is closer to being in general use in the United States involves giving the anti-IgE

drug omalizumab (see p. 149) alongside immunotherapy injections. The drug maximises the benefits from

the immunotherapy, and may make the build-up stage (see p. 165) safer, by lowering the risk of

anaphylaxis. For British allergy sufferers, who cannot yet get omalizumab, and whose chances of getting

immunotherapy are vanishingly small, it may seem unkind even to mention such treatments, but we can

only hope that things will improve here in the near future. You might take some comfort from the

thought that, by the time immunotherapy is available again in Britain, there will be a whole host of

highly effective new techniques available for doctors to try.
All the methods described above are forms of specific immunotherapy – they treat an allergy to dust

mites or to grass pollen or some other specific allergen.
A far more radical and ambitious approach to immunotherapy is now the aim of some medical researchers:

blocking the tendency to allergies as a whole.The underlying idea here is to reverse the basic shift in

the immune response, from Th1 cells to Th2 cells. It is this shift to Th2 cells which produces the

allergic tendency (see pp. 11 –13).
Some interesting findings have already been made in this area, including the surprising discovery that

the balance of Th1 cells and Th2 cells can be adjusted even in people with longstanding allergies.

Inspired by discoveries about hygiene and allergy (see p. 21), British researchers have made a vaccine

containing inactivated cells of a harmless bacterium found in the soil, Mycobacterium vaccae. This is

given as a single injection just under the surface of the skin. It has been used for adult patients

with asthma, and for children with severe atopic eczema, with some improvement in both groups. If the

treatment proves as useful as the preliminary studies suggest, this could be a common treatment in a

few years’ time.

Food Intolerance
The comments of those who have recovered from food intolerance after many years of ill-health are always memorable. ‘It’s like getting my life back again,’ said one woman. ‘I had actually forgotten what it felt like to be well,’ said another, ‘the effect of cutting out certain foods was just amazing.’
For most of those with food intolerance, the disease begins very subtly and gradually – first one symptom (persistent and unexplained diarrhoea, perhaps) then, some years later, another (migraine or headaches) and then, when a few more years have passed, another symptom (such as joint pain or muscle aches). Steadily increasing levels of irritability, `fuzzy-headedness’ or inexplicable tiredness may accompany this decline in health.
Most patients have no idea that all these symptoms are connected until they try an elimination diet, and everything clears up at once, quite dramatically. As one former sufferer described it: `Some of the stuff that got better – well, I’d been like that so long I thought it was just the way I was –grumpy and exhausted, and feeling terrible if I didn’t eat meals on time. It was an absolute revelation to feel completely OK again.’
What does ‘food intolerance’ mean?
In this book, food intolerance means any reaction to food where the immune system has no proven central role.
All the people I have described so far have idiopathic food intolerance, which means, food intolerance with no established mechanism – in other words, doctors can’t say exactly how it is caused. This is a highly controversial area.
The definition of food intolerance used in this book means that it also includes metabolic abnormalities, which do have a well-established cause. These are due to defective enzymes (see upper box on p. 75).
The question of what words mean is a key part of the debate over idiopathic food intolerance. At one extreme, you may come across doctors who call this problem ‘food allergy’, using the original meaning of the word ‘allergy’ (see p. 6). (Some of these doctors use terms such as delayed food allergy and masked food allergy, to point up the distinction from true food allergy, but not all do.) Using the word ‘allergy’ in this context causes a lot of aggravation and confusion, so the term ‘food intolerance’ has, for a long time, been widely accepted as a useful one that avoids unnecessary conflict.
You will also hear the term ‘food intolerance’ used to mean idiopathic food intolerance only – this is probably the most common usage. When the term is used in this way, metabolic abnormalities are being thought of as a separate entity altogether.
A new twist has recently been added to this long-standing wrangle over meanings. When mentioning food intolerance in their literature, some of the major medical organisations (those who dispute the very existence of idiopathic food intolerance) now say simply ‘food intolerance e.g. lactase deficiency’. To anyone familiar with this field, it looks suspiciously like an attempt to redefine ‘food intolerance’ so that it means nothing more than ‘metabolic abnormalities’. The idea seems to be that, if you deny a disease a name, it will go away!
In the medical wilderness
The main text of this article is about idiopathic food intolerance, a disease with a distinctly dubious reputation among doctors. Because it is so controversial, few doctors actually look at the evidence that it exists – which is in fact quite strong (see box on p. 77). Such evidence is simply ignored in most of what is written by the major medical organisations debunking idiopathic food intolerance.
This lack of medical recognition is very unfortunate for patients with idiopathic food intolerance, whose debilitating symptoms could be eliminated, rather than simply being treated (usually to little effect) with drugs.
This prejudiced attitude to idiopathic food intolerance also plays into the hands of those offering bogus diagnostic tests and phoney treatments, often at a very high price. These practitioners
– who have moved in to fill the gap left by conventional medicine
– are a considerable part of the problem, helping to give idiopathic food intolerance a bad name.
The waters are muddied even more by the fact that some people who believe themselves to have food intolerance are actually suffering from psychological problems, which they prefer to attribute to food. Many more have picked up on food intolerance as something rather glamorous to suffer from, inspired by all the media reports about food intolerance among celebrities. All these patients are a good source of revenue for the less scrupulous fringe practitioners and are unlikely, therefore, to be discouraged from their beliefs.
Fortunately there are enough conventional but open-minded doctors, often GPs, who have come to realise, through experience with their own patients, that elimination diets have a remarkable curative effect for some people. The ones who benefit are often the doctor’s ‘old faithfuls’ – those with long-term multiple symptoms, who have been referred to innumerable specialists and treated with all kinds of drugs, but who never get much better. The conventional view of such patients is that they have psychological problems that are being expressed as physical symptoms. This may well be true for some – but others have idiopathic food intolerance.
One of our enzymes is missing
Metabolic abnormalities are a distinct type of food intolerance. Unlike other kinds of food intolerance, metabolic abnormalities have a clearly understood cause: an enzyme that carries out a crucial task in the body’s metabolism is either missing or inept. The problem is generally caused by a defective gene and is therefore inherited.
The most common metabolic abnormality is lactase deficiency leading to lactose intolerance (see p. 79) — this may or may not be inherited. Other metabolic abnormalities include:
trehalase deficiency, lack of the enzyme which breaks down a substance in mushrooms and most other fungi, including yeast. galactosaemia, a defect in the enzyme which processes galactose, one of the sugars found in milk (cow’s or human). This is a serious disease and sufferers must avoid milk scrupulously.
fructose intolerance, which is extremely rare. Those affected have an unpleasant taste in the mouth on eating fruit and other sources of fructose, so avoidance is no particular problem.
phenylketonuria, also very rare. Those affected are usually identified early in life, by a routine blood test.
Is it just placebo effect?
Doctors who doubt the very existence of idiopathic food intolerance will say that people who recover on an elimination diet are just experiencing placebo effect — a psychological response that operates with any treatment, whether effective or ineffective, simply because people believe that the treatment will work. But this is to ignore certain facts:
• Placebo effect produces a fairly small improvement in most people — you have to be very suggestible to feel enormously better. By contrast, when people respond to an elimination diet (the standard method for diagnosing idiopathic food intolerance —see p. 194) they usually have a sudden and dramatic improvement.
• Most of those with idiopathic food intolerance have had it for years and tried all sorts of treatments. They have often experienced some small benefit from these, probably placebo effect. When they try an elimination diet, they have a response that is in a completely different league.
• The idea that all the different symptoms are linked has never occurred to many people who try an elimination diet — they are often trying it for just one symptom, and are staggered when everything clears up. Placebo effect relies on expectation.
• Placebo effect doesn’t last very long — it fades over the ensuing weeks and months. Avoiding the culprit food usually produces a lasting improvement for those with idiopathic food intolerance.
Symptoms
The symptoms of idiopathic food intolerance come on slowly after eating the offending food, and the foods to blame are often those eaten very regularly, such as wheat or milk. Consequently, the symptoms from one meal tend to overlap with those from the previous meal and people with idiopathic food intolerance are more-or-less unwell for most of the time. It Is usually not obvious that food is at fault.
All the symptoms of idiopathic food intolerance are common ones that can be caused in other ways. And no two patients have exactly the same set of symptoms.
(As far as doctors are concerned, neither of these attributes gives the disease a respectable air.)
These are some of the symptoms commonly reported:
• headache or migraine
•diarrhoea, sometimes with bloating and wind; this is often diagnosed as irritable bowel syndrome (IBS)
• in children, stomach aches
• occasionally constipation
• nausea and indigestion
• joint pain
• aching muscles
• a constantly runny or blocked nose (this could be perennial allergic rhinitis linked to food – see p. 68)
• glue ear (see p. 29)
• fatigue and a general feeling of vague ill-health.
Asthma and eczema, triggered by specific foods (see p. 68), can also be part of the picture.
In babies, colic is often caused by food intolerance, including foods the mother is eating which come through into the breast milk in tiny amounts (see p. 202).
Less common symptoms include:
• recurrent mouth ulcers
• stomach or duodenal ulcers
• chronic urticaria (see pp. 50-53)
• swelling (angioedema).
The following diseases have also been linked to idiopathic food intolerance in some patients:
• Crohn’s disease
• palindromic rheumatism (intermittent episodes of joint inflammation)
• rheumatoid arthritis.
Psychological problems such as depression, anxiety, or hyperactivity in children can sometimes be due to food (see p. 80) but it is rare for such psychological effects to occur without any physical symptoms.
Remember that every single one of these symptoms and conditions can be caused in some other way. However, the constellation of migraine/headache, joint pain and diarrhoea is highly characteristic of idiopathic food intolerance.
How might intolerance be caused?
No one knows how idiopathic food intolerance is caused. There are probably many factors involved, with a slightly different mix of factors in each patient. This would help to explain why the symptoms are so extraordinarily varied, with no two sufferers exactly alike.
Although symptoms accumulate over the years, some people can in fact pinpoint the moment when their problems began. ‘I had this terrible bout of diarrhoea from eating too much melon. I lived near a farm and they were free, because of a glut, so I just gorged myself on them. Although I was over the diarrhoea in a couple of days, I was never what you’d call “regular” after that, and the least thing would upset me. Eventually the doctor said it was irritable bowel syndrome. When the other problems began, ages afterwards – headaches and hypoglycaemia and fatigue – it seemed like something quite separate. I never associated them in my mind with the diarrhoea.’
Bad diarrhoea can clear the intestines of their beneficial bacteria, known collectively as the gut flora (see p. 204), and this is probably what initiates food intolerance in such cases. Large doses of antibiotics (as are sometimes given before an operation, e.g. a hysterectomy), or prolonged and repeated courses of antibiotics, given for glue ear or acne, can also disrupt the gut flora and lead to food intolerance. A study of hysterectomy patients has shown that antibiotic treatment before the operation tends to result in irritable bowel syndrome – a common symptom of idiopathic food intolerance – afterwards.
A few interesting observations suggest that minor metabolic abnormalities – a defect in certain detoxification enzymes – may sometimes play a part in idiopathic food intolerance. This is especially likely where there is intolerance to food additives, or where there are behavioural symptoms (such as hyperactivity) or symptoms involving the nervous system (such as migraine).
A third factor that could play a part for some patients are food-derived exorphins. These are fragments of proteins (called peptides) produced by the digestion of food proteins. They happen, probably by pure coincidence, to resemble the substances called endorphins that we all produce for ourselves. Endorphins
are our internal painkillers. They modify nerve impulses in the body and brain, reducing sensations of pain, and improving the sense of well-being. The receptors to which they bind are the same receptors that bind morphine and heroin - it is the intensive stimulation of these receptors that makes these drugs so effective.
Food-derived exorphins may sound like the stuff of science fiction, but they have actually been demonstrated in the digestion products of wheat and milk. They may exist for other foods as well. They are nowhere near as strong as morphine, but do seem to improve mood.
These exorphins may explain the strange observation (made repeatedly, by a great number of initially sceptical doctors) that patients with idiopathic food intolerance often eat huge amounts of their offending food, and ‘can’t live without it’. Often they eat the food several times day, sometimes at every meal. With a ubiquitous ingredient like wheat or milk, this is not particularly difficult - wheat cereal and milk for breakfast, a cheese sandwich at lunchtime, pasta with a creamy sauce for supper, a milky drink and biscuits at bedtime.
Any of these abnormalities is likely to be just one factor in a multi-factorial disease.
Diagnosis
Unfortunately there are no simple accurate tests for idiopathic food intolerance. The kind of tests you may see offered commercially (in advertisements in health magazines for example) are very inaccurate, and a waste of money. Consequently, the only way to diagnose idiopathic food intolerance is through an elimination diet, in which you cut out all the foods you commonly eat, and then -if you get better - test them one by one.
It sounds easy but it isn’t, so make sure you read all the instructions for doing the diet before you start (see pp. 194-7). You should also see your doctor and get his or her approval. Some symptoms - such as severe diarrhoea or headaches -should be investigated by conventional methods first, in case there is some serious underlying cause.
The first step in diagnosis is to decide if a food really is the cause of the symptoms, and the second step is to identify the food or foods concerned.
The first step is crucial. One of the problems with the diagnostic tests that are advertised - such as those using samples of hair or blood - is that they begin with the second step. In other words they assume that food is the problem (see p. 93).
When it comes to the second step, remember that although common foods are often the culprits, almost anything that is eaten can cause idiopathic food intolerance. Every patient with this problem is different in the foods they react to.
Treatment
Avoidance of the food is usually the best treatment for idiopathic food intolerance - however most people do not have to avoid their problem foods for ever. After a while - it could be six months or it could be three years - you can usually go back to eating it again, but in moderation. You must never start eating the food in large amounts again, and it is best not to eat it every day - certainly not at almost every meal, which is the usual pattern for cow’s milk and wheat in the Western diet.
If you find the restrictive diet too difficult, you could try desensitisation treatment (see pp. 210-13). This can work very well.
The patients who should avoid the culprit food indefinitely are those with Crohn’s disease and rheumatoid arthritis: a severe and irreversible relapse can occur otherwise.
The evidence
The evidence for idiopathic food intolerance is more substantial than its opponents would have you believe.
One very well-conducted and interesting study involved children with severe migraine who were investigated by a research team at Great Ormond Street Hospital in London. These are children who are very difficult to treat successfully by normal means. On an elimination diet, 88% of those children got better — an astonishing number. Not just their migraine, but all sorts of other symptoms as well, including aching limbs, runny noses, asthma, eczema, diarrhoea, wind, mouth ulcers and hyperactivity. Some of these children also had epileptic fits, and even this symptom cleared up on the diet, recurring when culprit foods were tested.
A notable feature of this study is that, of the five researchers involved, four were deeply sceptical at the outset. Their report notes that they ‘embarked on this study believing that any favourable response, such as that claimed to substantiate the dietary hypothesis, could be explained as a placebo response. The positive double-blind controlled trial… provides clear evidence that a placebo response was not the explanation.’
Other studies with good scientific credentials have demonstrated a role for idiopathic food intolerance in adults with migraine, and for sufferers from irritable bowel syndrome and Crohn’s disease. There are also good studies of individual patients with rheumatoid arthritis and palindromic rheumatism (an episodic form of inflammatory arthritis) who have responded dramatically to avoidance of a particular food. Some of these patients were given several double-blind challenges and showed changes in certain immunological tests, as well as joint symptoms, when challenged with the offending food. This suggests that the immune system could be playing some part in these food reactions.

Hayfever in Allergy

Foxtall grasses release their pollen - a potential source of hayfever symptoms.
`I gradually recognised that it was not an ordinary cold and that the symptoms were much worse on the

golf course or even during a nice day rowing on Loch Lomond.’ Dr John Morrison Smith, then a medical

student, began suffering from hayfever in the late 1930s. ‘At first I did not know what I had, and

neither did any other doctor I encountered in the next two or three years…’
All the classical allergic diseases (see box on p. 11) seem to be increasing, but none has exploded

quite so dramatically as hayfever. The physicians of Ancient Greece described asthma and food allergy,

and the Romans recorded allergy to horses, but there were no reports of hayfever. The only account –

and it is a doubtful one – comes from Persia in AD 925. Two hundred years ago, hayfever was unknown –

and careful research by medical historians has shown that this was not a case of it simply being

ignored, or misinterpreted as a cold.
The first case was reported in 1819, but even in the 1930s it was so rare that a succession of Scottish

doctors and medical students were baffled by Dr Morrison Smith’s symptoms. Today everyone knows what

hayfever is, since huge numbers of people sneeze and snuffle their way through the pollen season. There

are no certain explanations for this meteoric rise, but greater hygiene (21) may be an important

factor.
Symptoms of hayfever
The common symptoms of hayfever are well known:
• itchiness of the nose, mouth, throat and eyes – often the first sign
• a streaming and/or blocked nose
• frequent sneezing
• red, watery eyes (very rarely, hayfever affects the eyes only, with no symptoms in the nose).
Less commonly, there may be:
• dryness of the throat if the nasal blockage results in constant breathing through the mouth
• no sense of smell due to a blocked nose (but nasal polyps can also cause this – 30)
• a feverish sweaty feeling (but the body temperature is usually normal)
• swelling and inflammation of the eyelids, sometimes leading to blistering and ulceration: there

is a risk of blindness if this is not treated promptly
• recurrent sinusitis (30)
• earache, itching or a stuffy feeling in the ears, or ‘glue ear’ (29)
Some sufferers also experience:
• Oral Allergy Syndrome (an itchy tingling mouth) from certain fruits, nuts and vegetables (see

box on p. 63)
• a skin rash from pollen falling on the skin, direct contact with the leaves of the offending

plants, or with droplets of moisture from them – as when mowing a lawn or using a strimmer. If the skin

is cut or grazed, anaphylaxis can (rarely) result from direct contact with the plant (see pp. 58-9).
Even more rarely there can be:
• stomach upsets or even colitis (inflammation of the bowel) possibly due to pollen swallowed

with food or in the saliva
• irritation in the vagina
• migraine
• kidney inflammation (nephritis), leading to puffiness of the face and hands, and possibly other

symptoms
• joint pains.
The last two are probably caused by pollen allergens bound to their antibodies and carried in the blood

(13).
Diagnosis
The standard diagnostic tool here is the skin-prick test (see lo, 91). In diagnosing hayfever there are

three separate questions:
1 Is it actually hayfever?
2 Which pollen or pollens are responsible?
3 Are allergens other than pollen also involved?
Don’t be surprised if none of these questions is asked. In most countries, if you have hayfever-like

symptoms during the pollen season (i.e. when most hayfever sufferers have symptoms), the doctor will

conclude that you have hayfever - and that will be the end of that.
If hayfever seems plausible to you, and you respond to drug treatment, or manage well on pollen

avoidance (126), then -here is probably no reason to go further. Should you want a more thorough

investigation, you will need to be persistent. These are good reasons for requesting a full diagnosis:
• Your symptoms are worse in the pollen season, but they never really go away, suggesting that

you may be allergic to year-round allergens, such as house-dust mite or moulds, as well. It is worth

knowing which ones, so that you can avoid them. If you live in an area that is always warm (such as

California or Southern Australia) it may be that your culprit pollen is in the air all year round -

even so, knowing which pollen it is can help with avoidance. Around the Mediterranean, the pollen from

cypresses can keep hayfever going through the winter (or cause symptoms in winter only).
• Your symptoms are sometimes worse when they should be better, and vice versa. If you are

consistently worse indoors with the windows closed this could indicate that a seasonal indoor allergen

is the culprit - mould spores or cockroach perhaps (cockroach is often seasonal in regions with cold

winters - 118).
• Your symptoms begin before the pollen season begins, or go on long afterwards. Or the severity

of your symptoms does not match the daily pollen count for your suspect pollen. In Britain, the mould

Cladosporium herbarum produces spores in June, roughly coinciding with the grass-pollen season. Allergy

to this mould can easily be mistaken for grass-pollen allergy. You would need skin-prick tests for both

Cladosporium and grasses.
• You are much worse near home than elsewhere. It could just be a garden plant or tree. As one

California resident observed, ‘The worst offender was an olive tree on our front lawn. It’s been

removed.’
• You want to plan holidays free from the culprit pollen.
Moving house - especially to a region with different vegetation
- can be a spur to finding out exactly what your allergens are. If you are going for a full diagnosis

make sure it is done correctly. Don’t accept testing with ‘mixed tree and shrub pollens’ for example,

or ‘weed pollens’. The result tells you very little. Ask for tests with specific pollens.
Treatment
Too many people allow hayfever to spoil the summer months because they are anxious about taking drugs,

or feel that it is nobler to suffer. This book is not in any way complacent about the dangers from

drugs (see Chapter 5), but when it comes to hayfever there really is very little cause for concern. The

risks with drugs used for hayfever are absolutely minimal, and it is such a waste to miss out on the

best time of year.
Most hayfever responds very well to treatment with antihistamines (138). If they make you sleepy,

persist for a while, because this side effect often wears off - or ask for one of the new non-sedating

forms. The sleepiness is annoying, but it is only a minor side effect, and not an indication of the

drug causing any serious harm.
Cromoglycate drops (for the eyes or nose) do not work for everyone, but if they work for you, go for

them. These are absolutely the safest of the anti-allergy drugs. Steroid drops for the nose (144) are

also recommended. The dose of steroid involved is small, and very little gets into the bloodstream, so

there is no risk of serious side effects. If you suffer stinging, burning or dryness, it might be due

to preservatives in the drops, not the drug itself (see box on p. 33). Steroid drops for the eyes

should be used cautiously (144). Don’t use over-the-counter decongestant drops for more than three days

(29).
Immunotherapy is standard treatment for hayfever in many countries, but in Britain you will have a

struggle to get it (see pp. 164-8). Some hayfever sufferers feel they do well with homeopathy (215) or

acupuncture (214).
Pollen asthma
Some people with hayfever also have pollen asthma. Their asthma is worse in the pollen season but it

usually persists all year round (either because there are other allergens or irritants involved, or

just because the inflammation of the airways is self-perpetuating) whereas hayfever itself clears up.

Treating the hayfever fully with antihistamines helps considerably with the asthma symptoms.

 

In medical terms, this article covers a lot of ground.
First there are the classical allergic diseases
 such as hayfever and immediate food allergy, which are caused by the allergy

antibody, IgE .
Then there is non-IgE immune sensitivity, a category which includes a number of quite different

diseases, caused in a great variety of ways. They also vary in severity - there are serious lifelong

problems such as coeliac disease and minor short-lived problems such as contact dermatitis from garden

plants.
Finally the chapter looks at diseases where the immune system seems not to be involved, or

plays only a minor role: the intolerance reactions to food and synthetic chemicals. These are diverse

and rather mysterious in origin. They would not be described as ‘allergies’ by most doctors, though

they often are by complementary therapists (6).
These categories are not nearly as neat and tidy as they might sound. Some problems refuse to fit

anywhere, such as atopic eczema caused by food. A percentage of children with this problem have IgE to

the food concerned, while others do not - so where does it belong?
If you were expecting an answer to that question, you will be disappointed. Nor, quite often, are there

any certain and honest answers to questions such as ‘Has my baby really got asthma?’ or ‘Can you be

sure it’s irritable bowel syndrome?’ There are no answers to
such questions because most diseases do not exist in neat compartments, and the words we use to

describe them really denote rather abstract concepts.
This does not mean that the terms used to describe diseases are invalid - doctors and medical

researchers invent them to try to make sense of a complex, confusing and largely foggy reality. They

also argue over them, split them, unite them and redefine them. There is a constant desire to get the

medical picture of that foggy reality more precise and accurate (although medical politics gets

involved too - 7 -which is unfortunate).
Over time, thanks to huge amounts of research effort, things gradually get clearer. You’ll no longer

hear a doctor talk about ‘rheumatism’ or ‘arthritis’, because it was long since realised that these

categories were useless - they included a number of diverse diseases. And while doctors might say ‘food

poisoning’ or ‘heart attack’ or ’skin cancer’ to a patient, they use much narrower and more precise

terms when talking among themselves, and when ordering tests or prescribing treatment. Each of these

categories has been split into several well-defined sub-categories.
Ideally, this process of splitting continues until each disease category has a set of well-defined

symptoms (this set is known as a syndrome), plus a few simple and definitive diagnostic tests. This

will probably depend on the cause of the disease (the mechanism in medical jargon) being clearly

understood. Once the mechanism is clear, then a disease category is a truly satisfactory tool for

diagnosis and treatment.
Of the disease categories mentioned in this book only a few, such as coeliac disease and hayfever, have

reached that happy state. The majority are still somewhat arbitrary and debatable.
Some disease terms describe a set of symptoms with no clear underlying cause, for example, ‘irritable

bowel syndrome’. Others describe a well-defined response by the body, that can be caused in many

different ways - an endpoint that can be reached by various routes. This is true of ‘asthma’ or

‘urticaria’.
A third type describes a much less well-defined cluster of symptoms. Idiopathic food intolerance,

chemical intolerance and yeast overgrowth all come into this category. A few doctors don’t even see

some of these clusters as real diseases because the symptoms involved are so vague and so widely

encountered. Some of the arguments used to dismiss idiopathic food intolerance are dissected on pp.

74-7. A key point made against these diseases is that the symptoms they produce are non-specific -

common symptoms such as headache, fatigue and diarrhoea, which can arise in a great variety of ways.

Ever since Pasteur and the germ theory, medicine has been based on the idea of each disease having

specific symptoms and specific causes, and it has roared ahead on the basis of this assumption. This is

the prevailing paradigm of modern medicine, and like all
paradigms it blinds people to facts that don’t fit. Evidence is accumulating that there are diseases

which have multiple, non-specific and variable symptoms. Chronic Fatigue Syndrome (CFS - see box on p.

85) is one of these, and its recent transformation from a doubtful diagnosis to a reputable disease

recognised by conventional medicine suggests that the paradigm might be starting to crack.
To sum up, the business of identifying and naming diseases is a complex and uncertain process, in which

the concept of most diseases is only ever that - a concept, subject to change and refinement. This does

not make it worthless - quite the opposite. These concepts are the best we can do at the present time,

and accurate diagnosis is the key to getting the best treatment available now.
As regards both diagnosis and treatment, this book covers a very wide spectrum of medical opinion, from

the entirely orthodox to the frankly whacky. I have tried to give an objective view of these different

opinions and approaches, using the evidence currently available, in the hope that it will help readers

to improve their health while wasting as little as possible of their time or money. In using this

information, you should always try to work closely with your doctor (96), respecting the depth and

breadth of knowledge that conventional medicine has to offer.