Food Allergy: What are problem foods??

Food allergy is on the rise, and someone with food allergy can present to a skin specialist, physician, child specialist and sometimes even a surgeon. Urbanization, environmental pollution, promoting caesarian delivery, changing food habits, etc. contribute to sharp rise in food allergy in recent past. Being a less discussed entity, patient might be unaware of the actual cause of this distressing health issue.


What is food allergy!
Food allergy is an abnormal reaction to food, triggered by our immune system. Immune system is our body’s defense mechanism against harmful threats such as bacteria, viruses, etc. When this defense system reacts against certain food components, it manifests as allergy. Common symptoms of food allergy are stomach upset, pain abdomen, itchy skin rash, blood in stool, diarrhea, difficulty breathing, swelling of face, unexplained fatigue, irritability, etc.  Symptoms of food allergy usually begins in childhood, but can also start later in life.

There are range of delayed onset food allergies that appear as late as one week after food intake. It is difficult to point at the triggering agent in such situations. Moreover, some people show symptoms without an actual allergy. It is due to intolerance to certain food components. For example, intolerance to lactose component in milk, manifests as diarrhea within few hours of milk consumption. Also, some foods directly produce chemicals such as histamine, mimicking symptoms of allergy. Foods such as wine and pickles cause itchy mouth, sneezing or difficulty breathing promptly. This reaction is dependent on amount ingested. This is not exactly food allergy. Your doctor will be able to tell you precisely.


Foods associated with allergy
Common food allergens in our circumstance are cow milk, egg white, peanuts, fish, wheat, soy bean, dairy products such as cheese, etc. Other allergens are raw fruits and vegetables, tomatoes, chocolate, legumes, lemon, etc. Some foods such as meat, vegetables and fruits can be rendered harmless via cooking, because their allergenic components are destroyed by cooking. Food products such as preservatives, colorants, flavor enhancers such as cinnamon, menthol, vanilla, food additives, wine, dried fruits, pickles, strawberry, etc can directly stimulate symptoms similar to food allergy.


Who gets food allergy??
Small infants and children are more prone to food allergy. Some foods such as cow milk and egg white cause specific symptoms from early childhood. Early introduction of solid foods or formula milk products before six months of life has been associated with development of allergy. Children with history of allergy in family members are at more risk.
Adults can also commonly develop specific food allergies later on.
Generally, someone with one food allergy might also have other food sensitivity. Having said that, all potential food allergens do not cause symptoms in everyone.


COW MILK PROTEIN ALLERGY

Cow milk protein allergy is common in developed world, while it is rising in our part of the globe. It is not always diagnosed as we do not suspect food allergy frequently in our scenario.

It usually begins within first year of life, and occurs within a week of introducing foods containing cow milk protein. Children typically present to a doctor with diarrhea, vomiting, bad stomach ache or blood in stool within few hours of consuming cow milk or formula feed. Other symptoms are crying inconsolably, irritability, skin allergies, such as itchy hives and eczema, swelling of eyes and lips, shortness of breath, etc.

Children who are not exclusively breastfed for at least first four months of life are at more risk. Components of cow milk protein are present in common formula feeds available in the market, affecting children who are put on these feeds. Cow milk protein is also present in skimmed milk, butter, curds, cheese, yogurt, beverages, burgers, etc. Older children may have eating difficulties, avoiding certain foods, poor weight gain, etc. Do not force your child to eat foods he denies or refuses consistently. Children are often unable to express the discomfort or symptoms accurately.

A doctor makes a diagnosis based on patient’s complaint, previous episodes and careful examination of the patient. Tests such as skin prick tests, specific blood tests (IgE antibodies) help in confirming cow milk protein allergy. These tests are available in few hospitals and laboratories in Nepal. It is not always mandatory to have tests for the diagnosis.

Treatment is avoidance of the food trigger. Exclusive breastfeeding for at least 4 months, and preferably 6 months seem to be protective. In circumstances where exclusive breastfeeding is not possible, it is important to choose formula feed vigilantly. Common formula feeds are not recommended. Partially hydrolyzed infant formula or “hypoallergenic” formula milk should be chosen. Soy formula or litho can be a reassuring alternative in our scenario. However, 10-30% children with cow milk protein allergy also cross react to soy proteins. Replacing cow milk with goat or sheep milk isn’t recommended. On brighter side, cow milk protein allergy generally improves by 6 years of age. But there is no specific age for reintroducing cow milk in diet.

Other food allergies common in childhood are egg white and peanut allergy. While peanut allergy is a menace, children might develop tolerance to egg whites similar to cow milk. Doctors usually advice patients to avoid problem foods, however, a recent study showed that exposing young child with small amounts of culprit foods, eg peanuts, help them develop tolerance to that specific allergenic food.
Another aspect of food allergy is whether we can predict them before they happen. The answer is no, except in few instances, where parents or other family members have similar problems. Children with dry skin, reactive skin and asthma have increased likelihood of developing allergies as adults. But no one can exactly anticipate it before it happens. Parents have to be alert and cautiously follow their child’s relevant symptoms in relation with food intake.
Hence, food allergy is less commonly discussed, not so uncommon health problem.

Birth of a girl child...

After five beautiful years with my daughter, I was in operating room again, ready to bring my second borne into this bittersweet world.
He was borne at fifteen hundred hours, as the day was exhausting into soothing twilight...  An anesthesist friend brought him to me, as I lay in OT table. I noticed his nose, similar to mine. I smiled. My pediatrician husband then took charge of the baby.

I was taken to postoperative room for the night. Two patients were already there, I was placed on the third bed. I was well acquainted with pain, from my previous caesarian section. As a doctor, I also knew I could comfortably rely on analgesics.  However, other two ladies were winching, carefully fidgeting, so that any movement wouldn't throb their raw wounds.

Midnight passed. I was dozing off to sedative-induced drowsy sleep, when a wheeler rolled in. It carried a teenage newmom, after emergency operation. Her babygirl was put to her side. Some hospitals bring baby to mother's side immediately after operation, while others wait 24hours.

As the newborn started crying out of hunger, her mother didn't seem keen to feed her. At first, I thought it was probably because of pain and apprehension immediately atfer operation. Her mother in law was summoned for help. It was then, that I was astonished beyond words. Both women started cursing the newborn. They were so upset that it was a girlchild. They called her names, in harsh cruel offensive language. Mother-in-law angrily vanished out of the room into the darkness, blabbering all the while..... I sank in my bed in horrid disbelief. I found it brutal, close to barbarious. But it was kind of routine for caretaking nurses and obstetric staffs. They didn't react.

The baby was still howling, unaware of the harrowing cruel world she just came into. All she wanted... was her mom's suckle and granny's snuggle or her father rocking her to sleep.... :(

Nursing staff fetched the father in, hoping he could assist the new mom. This first time father was just a boy, perhaps in his late teens. He gently asked his wife to feed the child, but she started ranting again, vehemently. He seemed more level headed than both the ladies. He sat silently for few minutes. It seemed he wanted to help but had no idea what nursing or breastfeeding meant. Their first born was wailing all the time. But her mom was deafmuted to maternal emotions. After few requests, he gave up attempts of coaxing his wife and walked out of the room.

Meanwhile, baby seemed exhausted from crying. Her shrill screams became whimpers and then periodic sobs. Morning was less than hours away when she sobbed herself to sleep.

As the dawn pierced the gloomy dark night, bringing in pale yellow rays through the curtains, I woke up. To my surprise, my fellow mate was feeding her child. Even the granny had mellowed down a bit. She was spreading the light meal hospital allowed for the patient. It was as if the soft morning breeze had lightened their hearts. I understood they had finally amicably accepted the birth of a girl child. Then I heard the teenage mom talk to her child, a hint of tenderness in her voice. Love had sprouted amid the bitterness, anxiety and laments....

My heart crushed for them all. They were mere victims of a mindset, of social preference for a male child.

Why I didn't gain weight??

Everyone has been asking why I haven't gained weight after delivery or during pregnancy.
Its actually a long story, that I didn't wanna whine about in social media. Yes, our lives aren't exactly what we potray in facebook n instagram. We don't look as good as our pictures. I have dark circles, bags and perhaps much more. I haven't slept more than two hours in one stretch of a time in last two months, coz that's how frequently I need to feed my newborn.
Coming back to weight gain, my pregnancy and puerperium were more stormy than I ever imagined.
Pregnancy pukes were so horrible, I landed in ER and took IV drips. I had ketonuria, ie frequent vomiting made me pass glucose in urine. I had hyperemesis for first 4 months.
 During last 3 months, I had severe iron deficiency n anemia. In my final month, I was bedridden coz of my preexisting illness, fibromyalgia. I couldnt eat, I couldnt sleep.

At 36 weekd, a random ultrasound showed that my uterus was just about to erupt or dehisce. Uterine wall thickness was less than 4 mm.  I had to rush for emergency caesrian section. Operating gynecologist ma'am later informed that my uterus was plastic thin and baby's hair had already protruded out of the defect. I was rescued right before uterine rupture threatened both me and my baby's lives. Hubby told me later that day, that it was my second life.
But it was only the beginning of my countless sufferings....
My baby was taken to neonatal ICU for first 24 hours for TTN. My hubby informed me that my boy had heart murmur, a suspected VSD. I was petrified. Amidst so much pain,  all I could think of, was my little boy's VSD. I cried, whined, sobbed and prayed. An ECHO revealed that the defect was small, which would most likely, close spontaneously. But only time would tell.

On the 3rd night, while still in the hospital, I got fever from breast engorgement. Severely painful milk expressions, day and night, for 4-5 days, and it dwindled a bit, only to be followed by wound infection, urinary tract infection and uterine wall infection. There was fluid collection(seroma) at wound site, which was drained via syringe.
At the end of second week, my wound hurt so bad that I couldnt empty bladder or bowel. It went on for a week before a senior gynecologist at Grande Hospital detected the source of infection. I took my third course of antibiotics. I was so weak, I couldnt eat or sleep well.
Just when the wound infection abated, and I thought all was well, I woke up in the middle of the night with fever, rigors and excruciating breast pain. Next day, I was told I had second bout of breast engorgement involving entire lower zone and risked forming an abscess. There I was, getting IV antibiotics again, fourth course. Running to hospital four times a day, as I refused admission coz I couldn't risk exposing my baby to hospital acquired infections. I was five weeks postpartum by then.
As that episode subsided, I had vestibulitis along with aphthae and dental impingement. I couldn't eat, again. My dose of antibiotics were escalated, as they feared my nasal infection had risks of passing into the connecting brain linings. With treatment, my swollen nose and eroded tongue was beginning to wane, and I had severe gastritis, forcing me to stop all antiobiotics.
Between all this, my wound pain had revived. And my gynecologist said I had scar adhesions, probably connecting to the uterus. He was apprehensive that I might need laparoscopic surgery for breaking adhesions if my pain won't subside. Maybe after 6months or so. But for me, any more surgery sounded like death sentence. I had suffered so much, any surgical intervention scared me.
Thankfully the wound pain vanished. And now, my baby is two months old, thriving well, with remarkable weight gain. And his murmur has disappeare. He has embraced my genes wholeheartedly, his light brown eyes, sharp nose, full lips and the dimples that light my world when he smiles.

During all the chaos, my baby's healthy weight gain was my only pride. And I learnt two things, pain is a constant, yet nothing lasts forever. I survived and I conquered.

Happy Sixth

My dear daughter,
You are six now. You are this beautiful chirpy little thing that warms my heart and life.
Your shoes are getting bigger. And suddenly, I realise that one day you will out grow us and this house, to build your own shelter, or to find your own world. So I ask, why you can't be six forever?? Coz these are the best years of "you and me", coz you are innocent yet mischevious. Your pour your questions at us with utter amusement, and your little games add music to our souls.
Your father loves you, very deeply. As you will always fondly remember, he takes you places, shows you happiness and beauty. What you might not reckon, is that he subtly makes sure that sadness doesn't hover around you. He wants to protect you from the universe, from its chauvenism, judgements, patriarchy, etc. He acknowledges the charm of a girl child. At the same time, he understands the challenges of being a woman. and wishes so hard, that you don't encounter them. It makes him love you more everyday. That....  makes him the best father you could ever have. Happy Sixth Birthday.

So far.. in Nanjing

A petite brown-skinned woman in her early thirties, donning a blue long floral dress, has a backpack on her tiny shoulders, and an incubating pot-belly, protruding out of her rounded waist. She's at the airport, nervously fidgeting with her air-ticket, so uncertain of herself, for the first time in her life, daunted by fears of plausible upcoming challenges. At sixth month of pregnancy, she is traveling alone, to a place where English is an estranged language, where traffic signs, food menu and everything else is in Chinese. She can stutter few incoherent Chinese words, but her vocabulary is limited to countable ramblings. She looks at her five year old, one last time, shuddering at the thought of missing her desperately. Her daughter looks at her with piercing hopefulness, but in vain. With tearful sunken heart, she takes aching strides to the departure gate... "

This journey is a memoir I have to scribble about... too important a life event, too many memories to recount in years to come. I came to China for a training course of one month, all by myself, to a city I had never been to, without a single soul to call my acquaintance. It may not sound so unnerving, but my guts failed me because I was in vulnerable stage of life. I had lost my pace, recently overcame hyperemesis with ketonuria, and was regaining my health and stride back....

But the most striking part of my journey was the eager generosity people bestowed upon me. Be it random Chinese passerbys, handful Nepali students at the dorm or doctors at the hospital. I was greeted with exceptional kindness and love. Everyday I travel alone, to my faraway hospital, to shopping centers, electronic stores, groceries, and far off. I somehow find my way, without the google map, amid illegible Chinese signs, hoarding boards and bus routes. My full belly turns a lot of heads, and many helping hands too. Some instances are surreal and too-good-to-be-true. My beliefs of benevolence are reaffirmed very strongly in this presumed outlandish city...

... to be continued

DAYCATION

A trend has set in. Any employee working under someone else in Nepal, literally goes gaga over holidays during the weekend. Although it may sound bizzare to Westerners, for whom two days long weekend, isn’t a luxury but a norm. More than 40 hours of work week is overtime. But not in our country. So how do we handle this exhilaration of a stretch of 48 hour long break? We go crazy, we run to nearest staycation or daycation spot. And our facebook and instagram scroll busier than usual, with photographs and captions.... of outings and contemplations of life etc.

In such similar strive, we drove to Namobuddha, an outing closest to our abode. Beauty of this place cannot be confined to words. It’s enrapturing placidity mirrors peace, stillness, faith and warmth. It has an aroma of sophisticated mysticism and spirituality, as if an answer to all human frailties, gluttony and malice. However, the last few strides to reach this sanctuary is obnoxiously unpleasant. Our vehicle suffered bumps, curves, caves and thuds along with sheets of mud. My four month old belly cramped all along the unruly lane. We loathed the incompetence of our unstable government, which gobbles hefty taxes from us, but is unable to suffice its obligations. 

Just as we reach the destination, our disappointments of the stumbling journey mists into breezy air. The spotless restfulness ripples at Namobuddha. The yellow-capped hermitage rests at the hills of Kavre, various wings of the monastery is terraced along its stairs. This place wasn’t a stranger though.... We had hiked to this picturesque site, more than a decade ago, in first year of med-school. We were teenagers, freshly paired up with each other, and quite naïve about one another.... one of the fondest memories of maiden years of love. Time has taken its swift flight, and here we are, a family of three.

Our family trip was one of its kind this time, coz we had packed home food with us. Sausages, cheese, bread, juice, papadum, vegetables, etc were in the list. In a cozy nook of this peaceful hilltop, we spread our lunch-pack enjoying the beaming sunshine. Aaliyah was especially elated, as it was so refreshing. There were throngs of visitors from near and far off places, from cities and villages alike. All of them were amusingly busy, taking pictures of themselves, mostly selfies. Women and girls seemed more aware of their dresses and makeup, than the serene scenery. An irony. Changing times. Men on the contrary, were more self-reliant, absorbing the stunning backdrop contently.

The site-seeing lasted a brief hour, and we were heading back sooner than we had reached. Those sixty minutes were cleansing, purgatory and delightful. We were weary but content. Gleeful. Happy. And just like every tour, the journey back home seemed shorter. We were home before twilight guzzled the Dhulikhel sky. 

Vitiligo: The scourge and the stigma- how the battle can be won

Humans are enthralled by the concept of beauty. And in our pursuit of vanity, mankind has many a times, rebuked any contrary to the norm. Be it leprosy, syphilis or tuberculosis, diseases have been loathed and ostracized ruthlessly since primeval times. How could vitiligo escape this coercive subjugation. Since its first documentation in Egyptian medical papyrus in 1550 BC, vilitiginous white spots have been noted by Indians, Japanese and Latins alike. The journey of demystifying vitiligo traverses almost four thousand years in time. And the path to unfurl its scientific genesis is still in progress....  Vitiligo stood apart from other diseases due to its deceitful appearance, despite naive harmlessness. An innocuous disorder raised such harsh abhoration in communities in the eighteenth and ninteenth century! Hence baptized "historical curse of depigmentation"  Unlike our veteran vitiligans today, patients suffered despondent segregation from the society in the past. This stark stigma has aroused curiosity, resentment, distaste and sympathy across generations. Vitiligo patients are still divaricated from social throngs, as ugly ducklings. In our times, Michel Jackson catapulted the social standing of this disease to jolting acceptance. His unmatched contribution is etched in history. Vitiligans like Winnie Harlow, Lee Thomas further eased the battle by embracing their depigmented bodies, and shedding light on the disorder. Therefore, I believe that blemishes of vitiligo shall fade with time.
However, in developing countries like India and Nepal, the task of generating awareness about this disease is herculean. We lack vitiligo societies or foundations unlike in the West. It is still hurtful to disclose to a 10 year old that he/she has vitiligo, as it brings disgrace not just to the child, but the entire family. The prognosis maybe brighter in an adolescent, but the excruciating agony caused by the diagnosis, is hard to dampen, even with elaborate counseling. Hence, clarity about the disease and stupendous treatment efficacy will be the unwavering weapon against this discriminative illness.
The scientific task of delineating the etiopathogenesis has been arduous. Wide array of clinical causes have been postulated time after time, with newer theories emerging every now and then. As dermatologists, we are aware of the lists of various hypothesis. So lets take a brisk walk, down the lane of known etiopathogeneic factors. Autoimmunity, oxidative stress, cytorrhagia, traumatic, neural, genetic, biochemical factors are snippets of the dice we have yet to complete.  Oxidative stress and autoimmunity are the titans that have had paramount significance. Others fall out in the fringes. Recently genetic linkage and associations are surfacing as strong determinants of both the onset and severity of the illness. Various susceptibility genes have been identified. Unfolded protein response(UPR), melanocortin and Raper mason enzyme related genes, genome with linkage and association studies are rising as susceptibility indicators. More concrete impact of gene analysis on disease predictability and prognosis, is yet to be disclosed.
Coming back to autoimmunity, tremendous association of vitiligo with other autoimmune conditions such as thyroid disorders is unputdownable. Studies show thyroid association in quarter of the childhood cases, and more than half of adult vitiligo cases. A study conducted in our center, have also reaffirmed the coexistence of thyroid disorders with vitiligo. Newer studies reveal autoantibodies and T cells predomination in diffuse and localized vitiligo. CD8T cells were positive in lesional skin in localized vitiligo. Depending on whether the cellular or the humoral response is predominant, extent of the disease maybe predictable in future.
My concern for autoimmune association, is regarding thyroid autoantibodies. To me, thyroid disorders and their treatment guidelines, are biased against cutaneous disorders. Thyroid associations in the West, specifically advocate against treating mild thyroid alterations despite cutaneous manifestations. Their cut off for thyroxine supplementation is TSH>10. We frequently witness patients with vitiligo, who have moderately increased TSH and positive Thyroid peroxidase (TPO) antibodies. Will autoimmune vitiligo improve as long as TPO remains escalated? Does mild TSH alteration shift the balance of skin homeostasis? Do we wait for endocrine storm to abate or we intervene? These questions need to be addressed in order to find a solution for autoimmune skin conditions.
In regards to management, counselling has a tremendous role. It is encouraged to make intelligible leaflets in patient’s language. For me, it is heart-crunching to see patients willing for painful surgeries for this asymptomatic condition. Hence, generating awareness in our community should be our prime priority.
Treatment modalities in vitiligo have metamorphosed over centuries, as we unravel this enigmatic condition. Treatment guidelines have been simplified, and rendered more precise in recent times. Dichotomy of segmental and nonsegmental vitiligo, treatment modalities according to body surface areas and stability of lesions are primary considerations for choosing treatment modalities.
Conventional treatment modalities such as steroids, are the veteran warhorse that still reign supreme in vitiligo. Oral steroids are the most potent tool to halt disease progression. Immunomodulators such as azathioprine, tacrolimus and phototherapy are prevailing steroid sparing alternatives. Phototherapy is an irrefutable asset. NB-UVB is superior to PUVA, with excellent color matching and minimal adverse effect profile. However, we have found rewards in Bath PUVA, turban PUVA and bathing suite PUVA in our vitiligo patients.
Newer molecule Tofacitinib has grabbed limelight of late. Tofacitinib inhibits the IFN-Y signalling via Jak pathway, hence halting progression and maintenance of vitiligo. Multiple clinical trials hint towards excellent potential role of Janus kinase inhibitors in near future.
Adjunctive or alternative therapies are topical gingko biloba, levamisole, latanoprost, vitamin D analogues, topical ruxolitinib and antioxidants.
Selenium in the form of selenomethionine or sodium selenite, has shown promise in cutting off the TPO levels. Selenium improves TPO profile, and also directly quenches the oxidative surge. Hence, it might emerge as a robust tool in autoimmune vitiligo. Some studies have shown the linkage between vitamin D deficiency and vitiligo. Vitamin D accentuates photo-induced melanogenesis and hinders cytokines linked to vitiligo via immune-modulating properties. Vitamin D deficiency related vitiligo might be more important in our skin types, as some reports have shown significant role of Vitamin D induced repigmentation with NB-UVB. Role of micronutrients such as selenium, zinc and copper should be further extrapolated.
Interventional strategies have gained momentum for some time now. Experts are fanatic about surgical grafting in patients with stable lesions. However, surgery maybe double edged sword, because of debacle of stability. Scoring these lesions, serial photographs and performing test grafts may aid in warranting stability. In test grafts, unequivocal repigmentation beyond 1mm from the border of the test graft is said to indicate stability. Individual lesional stability is cardinal before holding a scalpel. Evidence based practice will further uplift the surgical results in vitiligo patients. However, the despairing fact of failure of surgical grafts should be counselled even in the most promising patient.
Punch grafts were the harbinger of surgical interventions in vitiligo, and mini punch grafting still remains one of the most common surgeries. However, threats of cobblestone, lopsided repigmentation and anatomic restraints limits its utility.
Epidermal suction blister grafts, split skin grafts and tissue grafts are met by their rewards and hindrances. At present, non cultured epidermal cell suspension and cultured melanocyte suspensions are at the heart of vitiligo surgeries, as they address large recipient areas, provide excellent response and admirable color matching.
Hair transplantation, excision of small lesions have all been done with variable results. Nonsurgical interventions such as lasers and home-based phototherapy may prove to have snowball effect, as they gain momentum among patients with localized disease. Neon lasers, fractional lasers, microfocused bioskin phototherapy are glimmering in the horizon as promising innovations. In recent past, Mosenson et al. showed that vitiligo can be reversed through immune targeting with mutant  Heat shock proteins(HSP70), given the evidence of association of Heat shock proteins (HSP) in depigmentation.
In conclusion, patient specific and lesion specific individualized approach in vitiligo management can defeat this colossal stigma. Unambiguous patient counselling at first patient visit should follow individual targeted therapy at achieving disease control and repigmentation. We stand at this glorious era in the history of vitiligo, where we have defined many uncharted spheres in etiogenesis and management. Future gleams in delight, as we discover newer prospects in battling this ancient disease.