by Lawrence D. Rosen, MD, founder of The Whole Child Center
Springtime brings us sunshine, flowers, and unfortunately for more than 60 million people in the United States, seasonal allergies.(1) As many as 40% of children are affected, and the cost to our society due to allergic rhinitis is now estimated at greater than $11 billion. Allergic disorders, including asthma, allergic rhinitis and eczema, are widely considered to be rising in prevalence at epidemic rates.(2)
A New Paradigm: The Iceberg Model
The iceberg provides a useful metaphor to understanding how allergies develop. The tip of the iceberg represents the observable clinical traits seen in children, including skin rashes (eczema), vomiting (reflux), runny noses (rhinitis) and coughing (asthma). What lies beneath the surface is a complex matrix of genetic predisposition and resulting immune and metabolic dysregulation, all triggered under certain environmental conditions. These triggers include airborne, food and water contaminants (tobacco smoke, pesticides, heavy metals, pet and pest dander, food allergens), infectious agents (viruses, molds), and stress.(3-8) Under these conditions, cracks in the ice develop, as certain immune cells are over stimulated relative to others, resulting in an imbalance between Th1 dominant and Th2 dominant immune responses.(9) Even prenatal factors (mothers’ nutrition and other environmental exposures) can greatly affect this immune balance, making certain babies more likely to develop allergies than others.(10,11) Perhaps, then, we can intervene prenatally, or even pre-conceptually, to prevent the inevitable sequence of events. Th2 dominance leads to an immune dysregulation marked by a heightened allergic response and a proliferation of inflammatory cellular mediators (e.g. cytokines, interleukins, leukotrienes). Inflammation involves excess mucous production and other clinically-observable phenomena we call “allergies.”
The Hygiene Hypothesis and the Allergic March
The “hygiene hypothesis” is a popular current theory to explain why we are experiencing this great increase in allergy prevalence.(12) According to this theory, our environments are now too “clean” – we are not exposed to as many infectious agents as previous generations. The reasons proposed for such a change include the eradication of infectious agents by vaccines, antibiotics, and “super-clean” living conditions. There is some evidence that children raised on a farm or exposed to certain livestock may in fact develop fewer atopic symptoms.(13) Once the cascade of immune dysregulation is triggered, allergic symptoms often develop and multiply; this is known as the “allergic march” – once you develop one allergic trait (eczema), others are likely to follow (food allergies, asthma and allergic rhinitis).
An Integrative Approach: Prioritizing Prevention
One of the core principles in integrative medicine is the belief that prevention is preferable to treatment whenever possible. It is almost always safer, more effective and less expensive. Unfortunately, the U.S. health care system currently does not “incentivize” preventive/wellness care. If we are to truly improve health, we must shift towards valuing wellness care and prevention. Of note, the use of complementary and alternative medical (CAM) therapies is rising among both adults and children. One reason for this trend is the dissatisfaction with both the efficacy and safety of conventional allergies treatments. Research on the safety and efficacy of CAM allergy therapies is limited but can be one tool to guide us in integrating natural remedies in practice. Various approaches will be discussed below, including nutritional modulation, botanical medicine, Traditional Chinese Medicine, mind-body therapies, homeopathy, and manual therapies. Some of these therapies have not been specifically studied in patients with allergic rhinitis, but when applicable, research related to asthma or other atopic conditions will be referenced.
As Hippocrates famously noted, “Let thy food be thy medicine.” Perhaps the factors with the greatest effect on modulating atopic expression are nutritional in nature. For those at risk, exposure to certain foods may contribute to severe, life-long asthma or food allergies. Other foods, rich in anti-inflammatory antioxidants, may in fact ameliorate allergic responses to environmental stimuli. It is unlikely to be one factor that is solely responsible for unlocking genomic tendencies toward atopy. For example, contaminants in food and water, not just the proteins in these foods, play a role in allergic disease expression. There are clear links between seasonal allergies and food allergies. In some individuals, allergic rhinitis due to specific pollens (i.e. birch) is connected to oral allergy symptoms due to certain fruits and vegetables (i.e. apples and carrots). Interestingly, organic versions of these same foods may be tolerated by patients who experience reactions with conventional produce. It may be that the pesticide stimulation of the immune system is responsible for this difference, or it may be that the level of antioxidant nutrients in organic foods is more concentrated. Scientific studies compiled by the Organic Center (14) support this latter hypothesis, suggesting that increased levels of vitamins A, C, D – all of which have been associated with protection against atopic disorders – may make those who ingest organic foods less likely to experience allergic symptoms. Vitamin D in particular is of increasing interest in atopic prevention and treatment. A growing number of studies have consistently demonstrated that a majority of children are vitamin D insufficient or deficient, and these children may be at increased risk for the development of asthma and other atopic conditions. (15,16)
Pregnancy and Breastfeeding
Advice on what pregnant mothers should eat or not eat changes has varied over time. There is concern that limiting groups of foods, most commonly dairy, soy, eggs, nuts, wheat and shellfish, may create nutrient deficiencies (folic acid, calcium, iron) that will play a negative role in neonatal development. Of note, maternal vitamin D intake in pregnant women is inversely associated with the development of asthma and allergic rhinitis in offspring.(17) General antigen avoidance for the population as a whole is not supported by current data.(18) In families at highest risk (parents and/or siblings with significant atopic history), avoidance of these most highly-allergenic foods, especially peanuts and tree nuts, should be considered during pregnancy and during duration of breastfeeding. Maternal lactation diets are covered by the same general guidelines, with one exception. Based on the same data, two international groups advocate different strategies. The American Academy of Pediatrics’ advises avoiding peanuts and tree nuts during lactation, while the European Society for Pediatric Allergology and Clinical Immunology (ESPACI) does not recommend this approach.(19)
If done, one must take great care to ensure proper compensatory intake of vitamins and minerals. Even the choice to breastfeed or not is thought to influence the expression of atopic disease. Both the U.S. and European agencies support breastfeeding as a means to reduce allergic disorders, and this advice seems supported by current research studies. Exclusive breastfeeding for 4 to 6 months (depending on the study) is associated with a lower risk of developing atopic dermatitis, food allergy, allergic rhinitis and asthma.(20-23).
If exclusive breastfeeding is not possible, U.S. and European experts are in agreement regarding the use of soy formulas for atopic prevention in high risk infants; they are both solidly opposed.(19) A recently updated Cochrane Database Systematic Review (SR) concurs (30). What both groups recommend for these high-risk babies, again supported by a recently updated Cochrane SR(31), are hydrolyzed protein formulas(19). These formulas may contain extensively- or partially-hydrolyzed cow’s milk proteins (casein or whey), and there is debate about whether they are both equivalently effective in preventing atopic expression.(32) Most experts currently recommend extensively-hydrolyzed products, but cost (more) and availability (less) issues often factor in as well.
Some children will exhibit such severe atopic symptoms, even on these formulas, that they may need elemental amino acid formulas. Although often digestively well-tolerated compared with cow’s milk, it is generally advised to avoid other animal milks (goat, sheep) in infants at high risk for atopic disease.
Solid Food Introduction
There continues to be much debate about the optimal time to introduce solid foods to infants, for the general population and for those at high risk. With increasing prevalence of allergic disorders, some experts are advocating for delayed solid food introduction in all babies until 6 months, with the introduction of highly allergenic foods as follows: dairy products at 12 months, eggs at 24 months, and peanuts, tree nuts and shellfish until 36 months. This group, the American College of Allergy, Asthma and Immunology, concludes in its published consensus document, “Pediatricians and allergists should cautiously individualize the introduction of solids into the infants’ diet.”(33) These guidelines are also recommended by major U.S. and European groups, but only for infants at high risk.(19) Early solid feeding (prior to 4 months of age), particularly of gluten-containing products, does seem to be associated with atopic disease as well as celiac disease.(34-35) Some have postulated a similarly negative role for gluten with respect to increased risk for other autoimmune and neurodevelopmental disorders. The introduction of fruits and vegetables at 4-6 months, prior to grain introduction, has been adopted by an increasing number of U.S. pediatricians. Foods rich in specific anti-inflammatory phytonutrients, such as quercetin and bromelain, may provide protection against the development of atopy. There have also been several studies looking at treating atopic disorders, particularly eczema (36-37) and asthma (38-39) with various nutritional interventions. Avoiding specific food allergens and encouraging particular nutrients (e.g. magnesium, zinc, PUFA’s) does seem to benefit a significant subset of atopic children.
Essential Fatty Acids
More recent studies have looked at the role of essential fatty acids in reducing allergic disease. The evidence is very good for prenatal prevention of atopy when mothers ingest higher amounts of omega-3 polyunsaturated fatty acids (PUFA’s).(24) It also appears that babies who ingest breast milk relatively richer in omega-3 are less likely to develop allergic symptoms.(25-26) This effect is most prominent in those babies at highest risk genetically. Interestingly, the results of directly feeding infants PUFA’s are not as clear. Some studies of dietary modification with omega-3’s PUFA’s in children at high risk demonstrated reduction in atopy(27-28), and another study showed improvement with supplementation of evening primrose oil, an omega-6 PUFA(29). Perhaps it is the balance of the two that is most important, and one must also take into account pre-existing dietary deficiencies and genomic factors. More research is clearly needed in this realm before universal recommendations can be made.
Prebiotics and Probiotics
Probiotics, the billions of symbiotic organisms that live in our gut, have long been known to play a role in immunomodulation.(42) It is precisely this role that suggests probiotic supplementation and support can be used for atopy prevention and treatment.(43-44) Several fascinating studies have, in fact, demonstrated that probiotics given prenatally to women and then postnatally to either breastfeeding mothers or directly to formula-fed infants can reduce the incidence of atopic dermatitis by half in those infants at high risk.(45-46) These effects, noted in randomized, controlled trials of lactobacillus GG, have held up to 4 years out postnatally. Prebiotics, special oligosaccharides that act as nutrients for probiotic growth, have also been shown to prevent eczema in a vulnerable infant population.(47-49) Treatment studies have been generally encouraging, as well. One study demonstrated a significant airway anti-inflammatory effect of lactic-acid bacteria, supporting the idea that probiotics can suppress allergy-induced inflammation.(50) This study has remarkable implications for asthma treatment. Several randomized controlled trials have pointed towards a positive effect of probiotics and probiotics on the course of atopic dermatitis.(51-54) One recent publication found no such effect.(55) It is likely that we will need to more clearly elucidate which strains and doses of probiotics and prebiotics have the greatest effect for specific atopic conditions.
Many botanically-derived products have been used to treat atopic conditions. One of the most promising herbals for allergy treatment is butterbur. Butterbur and purified petasin have been demonstrated to decrease concentrations of histamine and leukotrienes while down-regulating mast cell response to contact with allergens. A specific butterbur leaf extract (Ze 339) has been shown to effectively and safely treat allergic rhinitis.(56) Two other botanical products, Boswellia serrata gum resin and French maritime pine bark (pycnogenol), have been shown to improve asthma symptoms.(57-58). Given concerns about long-term steroid treatment, it would make sense to carefully examine these and other promising therapies as adjuncts in the integrative treatment of asthma and other atopic disorders.
Traditional Chinese Medicine
Traditional Chinese Medicine, or TCM, is a complete system of healthcare which integrates several therapies we, in the West, consider complementary or alternative. Acupuncture in particular has been singled out as a “CAM therapy” with great promise for use in specific conditions, like asthma, when, in fact, TCM considers acustimulation one potential part of the care of children with atopic conditions. Also incorporated are usually botanical remedies, nutritional modulation, tui na (massage), gua sha (scraping), cupping and mind-body therapies. Kielczynksa has written a wonderful case description about the use of Traditional East-Asian Medicine in the treatment of a child with asthma(59), which gives a flavor of the holistic nature of the TCM approach to atopy. There have been promising trials of TCM for allergic rhinitis(60-62) and a Cochrane Database SR of Chinese herbal medicine for eczema.(63)
Among the most popular, widely-studied, safe and effective treatments for the stress component of atopic disorders are mind-body therapies. Any therapy, including self-hypnosis, guided imagery, biofeedback, mindfulness-based stress reduction, and meditation, which acts to reduce immune hyperstimulation via psychoneuroimmune pathways(64), and which teaches self-care and control, has the potential to be quite effective. This fact has been demonstrated for children with asthmatic dyspnea(65) and for those with severe eczema.(66) Yoga, with its blend of breathwork, relaxation training and movement, is quite well-matched for children and adolescents with asthma.(67)
Manual therapies include, but are not limited to, chiropractic, osteopathic manipulation and therapeutic massage. Various theories abound regarding the mechanism for manual treatment of atopic disorders, most commonly for asthma. Some contend there is an anatomical effect on respiratory musculoskeletal function, while others regard these therapies as a method of rebalancing sympathetic and parasympathetic neurological tone. A large Cochrane Database SR concluded, not surprisingly, that more research is needed in all areas(68); these therapies, in fact, are not comparable to each other and deserve specific trials for each and every one. Despite the publicity surrounding the negative findings of a New England Journal of Medicine article on chiropractic treatment for childhood asthma(69), this modality continues to be perhaps the most widely utilized CAM treatment in children for all atopic disorders. Therapeutic massage trials for asthma and atopic dermatitis have been published, both with positive results.(70-71) Osteopathic manipulative therapy has been studied as well, with one randomized trial demonstrating a positive effect in asthma treatment.(72)
Homeopathy, as with TCM, is a holistic, whole branch of medical care. Dr. Edward Shalts, in his book, “The American Institute of Homeopathy Handbook for Parents,” writes about the rich history of homeopathic treatment of allergic disorders, noting that “homeopaths pioneered both the research and treatment of allergies.”(73) For as many children with allergies, there are homeopathic treatment regimens. One of the beauties and challenges of classical homeopathic therapy for atopy is that one must individualize the remedy for each child’s constitution and presentation. When it works, as it often does (despite the difficulty of explaining the mechanism in conventional medical terms), it works wonderful quickly and safely, for a long period of time. Studying homeopathy is difficult, but one published trial found homeopathy significantly superior to placebo for treatment of allergic rhinitis(74), and another case series found an 87.6% success rate for treatment of respiratory allergies.(75)
Clearly, with a great allergic epidemic upon us, the challenge to medicine is not to develop more aggressive and costly treatments but to devise and implement more effective prevention strategies. Integrative medicine practitioners are well positioned to advocate for such a paradigm shift. Our holistic integration of CAM and conventional strategies coupled with our dedication to evaluating and alleviating environmental triggers allows us to help families best avoid the allergic march to life-long atopic disorders. This integrative approach is well represented by the results of the Canadian Childhood Asthma Primary Prevention Study; this study has already proven that a balanced, integrative approach can yield dividends. Following nearly 500 children over seven years, researchers have demonstrated that avoidance of house dust, pets, and environmental tobacco smoke along with encouragement of breast-feeding and delayed introduction of solid foods significantly reduced allergic disease.(76) This is the place where research meets real life. While it is important to demonstrate safety and efficacy of specific therapies, it is often the practical combination of several approaches (e.g. nutritional modification, environmental trigger avoidance, stress coping skill training) that make the most sense, and the biggest difference.
Tips for Families to Prevent Allergies
Our environment is loaded with potential allergy triggers. While avoiding the outdoors entirely in springtime is not feasible, one should aim to limit exposure to pollen and other common airborne triggers (e.g. tobacco smoke). Wash off pollen from hands and other exposed areas in peak allergy seasons.
– Keep windows and doors closed during high pollen count times and stay inside on the driest, windiest days to minimize exposure to seasonal allergens.
– Use high-particulate air (HEPA) filters inside to reduce most airborne contaminants, especially in bedroom locations.
– In humid areas, use a dehumidifier to limit mold development.
– Buy allergy-proof bedding, including mattress and pillow case covers, to reduce allergy symptoms, and regularly wash sheets, blankets and pillow cases in hot water.
– Stuffed animals and real animals alike can contribute to allergic rhinitis, so wash them frequently.
– Consider removing carpeting in bedrooms or use area rugs which can be cleaned regularly. Vacuum all carpets and floor surfaces weekly with a HEPA-filter equipped appliance.
– Limit lawn mowing and other gardening activities at peak allergy times; avoid use of chemical pesticides and outdoor products.
– Use environmentally- and health-safe household cleaners.
– Eat healthy, whole organic foods with plenty of anti-inflammatory antioxidants
– Avoid use of herbal products and foods that can cross react with seasonal allergens; for some people this may include Echinacea species and certain fruits and vegetables (this is known as the “oral allergy syndrome”).
– To prevent allergic disease in babies, consider perinatal avoidance of known food allergens, especially if there’s a family history of atopic disease; breastfeeding is known to be protective as well.
– Try a saline rinse device called a “neti pot” to clear pollen from the nasal cavities. Even children as young as 2 or 3 years old can be taught how to use one.
– Look into using specific natural health product supplements, like probiotics and essential fatty acids, which may lower your risk of developing allergies.
– Think about taking up a stress-coping technique, like yoga or meditation.
(Adapted from Rosen LD: An Integrative Approach to Atopic Disorders in Children. Altern Complement Ther 13: 71-77, 2007)
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