Posts for: February, 2013
The parents of, 4 year old Sally are concerned about the stuttering they observed a few months ago in their daughter. The stuttering hasn’t improved despite efforts to correct and help the child overcome the stutter whenever it arises.
Language and Speech problems in the pre-school age group have become one of the most common problems we face in primary care pediatrics. There is a garden variety of potential neuro-developmental problems that may manifest as different forms of speech or language disorders. This post is intended to address one of the common concerns we’ve encountered in our experience and we caution our readership about the gross simplification introduced here since these concerns are seldom simple. We will address, Sally’s stuttering in this post.
Stuttering, typically occurs as the young child begins to make the transition from two word utterances to more complex sentences. This usually happens between ages 2 and 5 years. It is estimated that ~ 5% of all children experience stuttering at some point in childhood lasting for more than 6 months. The condition is characterized by dysfluencies within words. The medical criteria for diagnosing stuttering as a speech disorder is met when a patient like Sally has dysfluencies like “W-w-w-what is this? Or “Wwwww what is this? Affecting more than three words in a 100 word sequence. These may be accompanied with signs of increased physical tension like increased blinking and facial tension or hand movements. A family history of stuttering in a first degree relative such as a parent or sibling is often found in many cases. At least ¾ of affected patients improve spontaneously without any medical intervention within the first 12 - 24 months of symptom onset. The temptation to interrupt and “help” these children complete the words they are struggling with mid-speech has been shown to increase time pressure on them that adversely contribute to the dysfluency and reinforce the negative responses to stuttering. Parents are advised to avoid this practice. Speech therapy and audiologic evaluation may be warranted in some cases. Boys tend to be affected by stuttering more often than girls and tend to have a more severe disease course.
Children with other forms of concern accompanying their stuttering like sharp audible intakes of breath before the dysfluency occurs or facial tension or body, head or extremity movements have a moderate risk of developing anxiety as a co-morbid condition and would benefit from specialist evaluation in addition.
Female patients who develop these symptoms, especially at ages less than 4years at onset have good prognosis and we are happy to report that, Sally required no form of medical intervention and improved within a year of symptom onset with complete resolution and normal speech fluency today.
For more information, visit: http://www.asha.org/default.htm
Diverse symptoms ranging from an infant “spitting up” to overt vomiting or diarrhea or colic are very common in newborn infants. Abdominal pain, flatulence and constipation tend to be more common in older children. All these symptoms often bear a timed relation to the ingestion of the suspected food item when parents notice them and the perception of a probable allergy or food intolerance is made as a result. The diagnosis of food allergy is beyond the scope of this article, however once the diagnosis is established, strict avoidance and elimination of the culprit food item becomes medically necessary. The Food Allergen Labeling and Consumer Protection Act of 2004 mandates food packaging companies to identify products containing milk, egg, soy, wheat, peanut, tree nut, fish and shellfish on the packaging label. This allows parents to make an informed choice to avoid known allergens and exclude these from the diet of their children.
Do allergies last a lifetime once established?
Food allergies as with other disease processes affecting the immune system can vary widely in their clinical courses over time. Most studies however posit that 70%-80% of patients outgrow milk and egg allergy, 60% to 70% outgrow soy and wheat allergy, and 10% to 20% outgrow peanut and tree nut allergy. Repeat assessment by your physician or allergy and Immunology specialist may be necessary with an updated patient history before conclusions about ‘outgrowing” a specific allergy can be made with certainty. These can be done yearly, but it is noteworthy even from above numbers that peanut, tree nut and fish along with shellfish are less amenable to “outgrowing” and repeat testing may need to be less frequent in these cases.
What do I do, if I’m accidentally exposed to a known food allergen?
The approach to care would depend on the appearance and severity of symptoms. Immediate reactions or those that occur within a few minutes or delayed reactions occurring many hours later are both common. They may be mild and benefit from comfort measures that often include anti-histamines. Anaphylaxis is a medical term used when severe allergic reactions involve multiple body systems after exposure to a known or unknown allergen. These reactions may affect, the skin, the gastrointestinal or respiratory systems commonly. Indeed any body system of tissues and organs can be involved in a severe allergic reaction like anaphylaxis. They are life-threatening emergencies. The epinephrine auto-injector comes in two strengths for different patients depending on their weight. These are administered via injection into the muscle through clothing in an emergency. Every child or adult with a known food allergy should carry one or have immediate access to one at all times. Observation in a medical facility after use of epinephrine is necessary and activation of the emergency medical service afterwards is recommended in our practice.
Food allergies have become extremely common in our collective daily experiences. I recently got my turn to buy snacks for my daughter’s kindergarten class and was impressed by the lengthy allergy list, as I kept glancing at it furtively for compliance while I raced through the snack aisle at the store.
8% of US children are currently affected by food allergies and recent epidemiologic trends reveal a progressive rise. In keeping with this quasi rule of 8’s, largely just 8 food groups cause this rather impressive prevalence of food allergies. These are milk, egg, peanut, tree nuts, wheat, soy, fish and shellfish. There has always been a hasty approach by parents to designating children as having food allergies. We need to remember that allergy have a very specific immune mechanism and that not all adverse food events are truly allergic. Some are more appropriately food intolerances. The distinction is important because it’ll help our understanding of the intriguing world of immunology and how diagnostic testing for immune mediated (allergy) diseases however enchanting can fall short of correctly identifying true allergies. The quality of life issues and fall out that follow an incorrect food allergy designation can last a lifetime and affect socialization and frankly gustatory delights that’ll make the Travel Channel’s, Anthony Bourdain jealous.
How are food allergies diagnosed?
The medical history is very important and providing your healthcare provider with a good run of events preceding and surrounding the sentinel allergy event is a great start. We encourage the use of a diary and conscientious documentation of food items ingested. The importance of this chronicle of foods eaten, was it cooked? baked or eaten raw? and reactions observed cannot be overstated. How soon after exposure did the symptoms occur? What symptoms were observed? Because often, the careful identification and informed elimination of the likely culprit(s) may be all that’s necessary. Diagnoses of food allergies or intolerance can be made this way and when done appropriately fall into the very high pedigree of statistical accuracy called “ a trial of 1”. Specific blood testing looking for presence of antibodies to food allergens by measuring the levels of the antibody most commonly associated with allergies, called IgE are common in everyday clinical practice. When this is combined with a skin-prick test, the diagnostic accuracy improves. It would be fine if the immune system were as simplistic as that. A system that’s so uniquely adapted and continually evolving to memorize every invader that’s ever breached its defenses and program itself to make antibodies or get cells battle ready to stop that invader or others related to it next time they get lucky enough to get inside while maintaining surveillance for cancer cells and preventing the body from turning its own more than a billion troop of soldiers on itself surely would be more complicated. It is! There are food allergy mechanisms that by-pass the process above, termed non- IgE mediated or use some combination of it with other mechanisms. Blood or skin-prick testing would not readily detect these. It is also possible to find a positive test as described above to food a child is eating presently without any difficulty. This is where a careful patient exposure and observed reaction history is truly worth its weight in gold. This eliminates indiscriminate testing and optimizes the physician’s chances of correctly making the food allergy diagnosis.
To be continued next week…