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·THE MANAGEMENT OF CHILDHOOD ASTHMA

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·THE
MANAGEMENT
OF
CHILDHOOD
ASTHMA
by
FREDERIC SPEER VD
ant Cn al P ofe or of Peda
The Uni y of lansas Shool of Med
Deo of Peda 1 xy Cin
The Un oy of Xan as aled ai Cene and
D of 4 g Clic
Ch Id en Mercy Hop al
+nd ng Peda an B thany HOD
Podne Hooal and $ Ma gre Но p al
Aan a C
Fe ow of he me on A od my of Peda
Felou of the Ama an Col eg of Aeg
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BOKS
CHARLES C THOVIS. PUBLISHER
Springfeld
Illinois
.
USA
SYMBOL
LEADERSEY

·CHARLLSC IHOVAS • PUBLISHER
BAN VERSTONE HOUSC
301 327 East Liwrence Avenue, Springfield, Illinois USA
Published simultancously in the British Commonwealth of Nations by
BLACK HELL SCIENTIFIC PUBLICATIOV3, LTD, OXFORD ENGLAND
Published simultaneoush in Canadla by
THE RYERSON PRESS, TORONTO
This book is protected by copyright No part
of it may be reproduced in any manner with
out written permission from the publisher
Copyright 1958 by CHARI FS C THOVAS
PUBLISHER
Library of Congress Catalog Card Number 58 8134
Printed in Cape Girardeau, Mo,
in the United States of America

·PREFACE tion What is childhood asthma? Is it a mysterious syn drome for which there is little hope and no specific treat ment? Is it a more or less harmless childhood problem which will eventually be outgrown? Is it some sort of neurosis with roots in the mother s emotional life In spite of the fact that allergic management of asthma las proved uniformly effective questions like these continue to be asked or implied In Burtons The Anatomy of Melancholy is found this abbreviated account of a Sixteenth Century consulta in Reinerus Solenanders counsels he and Dr Brance both agreed that the patient s disease was hypo chondriacal melancholy Dr Matholdus said it was asthma and nothing else Taking his cue from the forthright dissenting consultant the allergist of today might add it is an allergic disease and nothing else! With an increasing number of physicians becoming interested in the allergic approach to childhood asthma a need has arisen for a text which would include the methods essential to the proper establishment of allergic control It is to meet this need that this manual has been prepared Neither this book nor any other can hope to çıve all the information that every physician will require in every case but if with its use the reader can develop a sound basis for an attack against the disease it will have fulfilled the purpose for which it was written FREDERIC SPFER VI

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·ACKNOWLEDGMENTS Since this manual is the outgrouth of the teaching program of the pediatric services of the Unnersity of Kan sas and The Children's Mercy Hospital, the writer would like to acknowledge the cooperation of the three who made the establishment of the pediatric allergy clinics possible Dr Herbert C Miller, Cluef of Pediatrics, Dr Orval R Withers, Chief of Allergy, and Miss Elizabeth Martin, R N, former superintendent of Mercy I or suggestions and assistance in the atid of the manuscript, thanks are due Dr Alex Roth, Dr Thorhal Jensen, Dr Antoni Diehl, Mr Il'illiam V VcGre, BS Chief of the Photography Service, and Virs Jo Ann Clif ford medical artist For giving the benefit of her professional experience as a writer to a revers of the manuscript, thanks are due my mother, Mrs Clara Ailen Speer for her and in pre paring the scction on Allergic Cookery and for her pa tience during the preparation of the bool, special thanks are due my wife, Mrs Jeannette Hylskmann Speer FS

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·CONTENTS Preface del nowledgments Pace V Chapter | The Asthmic Child and His Fimits Asthma and the Child The Fimily The parents feelings Parent education 3 3 4 5 te 7 8 2 The Diagnosis of Asthm The Clinical Picture Vodes of onset Systemic Allergy Arsal allergy Eximining the nose The nasal smear The shin The nervous systemi The gistrointestinal sistem The genitourinar sistem Viscellancous systemic minfestations Diferential Diagnosis 12 13 15 16 12 18 IY ·Contents Chaptei Page 21 3 Ltrology of Isthmi Inha ints Pollens Compositie Grisses Chenopouls (goosefoot fimily) Amirintis (pigweeds) Trecs Other plants Which pollens tre importit Vold Allergens Import in molds Other molts Itmospheric Surches Vaterials counting technique \onseasonal Inlaints House (lust Inimal epithelials Viscellancous inhalings less common inhauts 21 23 25 20 26 26 27 28 28 29 30 92 30 39 40 12 12 12 4 Etiology of Asthmi Foods Drugs Inxect Bites Non specific Factors Foxx Allergens Il buch fixols tre important The biological relationslup of ſouls Food fimiles $333 293.gslos Foxxls without relaties Vineral Kingdom 15 ·Contents 11 Chapter Pnge 16 Sources of foods Drug Allergens Allergy to Insect Bites Nonspecific Causes Infection Primary inhalant irritants Physical factors Psychic factors 18 49 49 49 51 52 53 53 55 55 58 58 61 62 62 62 5 Tinding the Cruses of Asthma History Taking in Asthma The history form Skin Testing Intracutaneous test Scratch test Significance of skin reactions The Clinical Testing of Foods 11 hen to test foods Selection of foods for testing Teclinique of clinical food testing (ase Study Working out the Cause of Asthma in Infancy Case Sturly Infantile Asthma 6 Treatment of the Asthmatic Attack General Management Drugs Epinephrine Iminophylline Other drugs Dcluydration 63 fi 71 7) 75 75 76 76 77 77 78 ·Contents Chapter Page Infection Status Asthmaticus What Not to do in Asthmatic Attacks 79 79 80 82 82 7 Specific Treatment Ivoilance of Inhalants loidince of rood Allergeois Hyposensituation Preparation of treatment set Hyposensitization schedule Precautions in hyposensitization Treatment of reactions How long is hyposensituation continued 45 86 89 89 91 92 198 93 8 V in igement of Problem Cases Fature in family cooperation Incomplete asowance Slow response to hyposensitization Act sensitivities Psychic fictors Hichelen food allergens 91 95 (W) Wergic (ookery Mill Free Dicts Egg Frec Diets Corn Free Diets Ihcat Free Dicts Tomuto Frec Diets Citrus Free Ducts Food Dye Frec Diets Vetrec Diets Referenres Inder 9) JON) 102 102 109 103 10% 101 103 113 ·THE MANAGEMENT OF CHILDHOOD ASTHMA ·It is one of the wonders of pediatric al lergy practice that the mother of the asthma. tic child is typically patient, devoted, obserı ant, and wise To this typical mother this book is dedicated She openeth her month with urdom, and in her tongue is the lau of kindness- -Proverbs XI.X7 26 The asthma doctor inust and dare not for get that his own quiet, deliberate and reassur ing manner and his absolute conuition that almost all cases of astiuma can be cured, con stitutc one of the most apportant prere quisites for success -I'RSACH ·Chapter 1 THL ASTHMATIC CHILD AND HIS FAMILY ASTHMA AND THE CHILD N matter lon poor a inedical term may be, once it be comes arrached to a disease entity it is not likely to be replaced Thus ss true of malaria and angina pectoris, and it is true of astua An attempt to improve the term and differentiate it from cardiac dyspnea has been made by speaking ot bronchial astma but this is of little help as all astıma is bronchial it might better be called bron chal allerg) or allergic bronclutis but these terms have little baching and no official sanction Asthma may be defined as an allergic clisease of the bronchioles and small bronchi characterized by edema of the mucosa muscle spasm, and hypersecretson of mucus The outstanding clinical manifestations are dyspnea heezing and cough These phenomena cut in attacks, separated by inten als of more or less relef Although spontaneous remission is not unknown in asthma 1t45 essentially a chronic disease which if untreated usually leads to progressive loss of uita capacity and employsema It is a common disease of childhood and is found at all ages Isthma seldom if ever occurs as an isolated allergic minfestation The patient is allergically speaking 'sich all over asthm representing only one of many allergic manifestations For uniformly successful results in this $ ·4 The Management of Childhood Asthma disease the physician must identify all allergic manifest ations and all responsible allergens The young child does not seem unduly disturbed by Ius asthma He is an are of his hearing chest and can hear his wheezing, but it does not seem to occur to him that everyone is not affected in the same way As he grons older he begins to see that he is different, that he is under certain restrictions, and receives special consideration from others With this neli auareness comes the urge 10 get well It is a source of continual surprise to allergists to note hon early in life their little patients accept the re strictions and discomfort of allergic management in watching their diets they are often more alert than their anothers, and where liyposensitization is given, they accept their shocs with remarkable cheerfulness and fortitude THE FAMILY 4 surgeon repairing a hernia does not invite the family in to assist lum A physician dealing with an asth matic child, hon cier, must do just that, and fuis success clepends very much on lus ability to gain the confidence of the parents and enlist their cooperation 1o gain their confidence he must understand how they feel about their shuud, and to cnlist their cooperation he must clucate them in the fundamentals of allergy and asthma The Parents' Feelings The most significant reaction of parents on becom ing aware that their child has astlıma is ſcar They have probably known of asthma among their acquaintances and they think at once of the most serious case in their experience The "asthma' they have known inay sell have been any one of a number of other chest diseases, but the word still strikes fear to the heart and often lends ·The Asthmate Child and Hus Fomily 5 to dismay and panc With the passage of time the attacks are inclined to become increasingly sesere and the desire to escape from so frightening a situation is ofren over powering leading to the urge to flee to some supposedly ideal climate Such Right not infrequently takes place often at the price of famıly disruption and financial run The child then is often the center of a taut emotion al situation and no matter hos calm the surface it is well to proceed on the assumption that all is not well within The mother is certain to have had extensive and gratui tous ad ce from all sorts and condnions of people and has almost certainly been assured by someone that the *hole problem stems from the fact that her child is un wanted and rejected In ker unhappy and bewildered con drtion she may half way accept this cruel judgment and with her original problem complicated by guilt and fresst ration her misery may have been heightened to an almost unbearable extent Is the physician sees that he is dealing wsth a famh whose integrity 15 threatened by the emotional by pro dutts of asthma he has an opportunity to do much to re store x When the parents learn that he is fully an are of their feelings and looks upon them unth sympathy and understanding the way is clear for their self confidence and poise to return If he then proceeds to embark on a tireless campugn against the childs disease esen though progress be slow and uneven he can look for patience and trust in huis relations issth the family Parent Education The allergist works mainly with the mother of the asthmauc child and he should teach her all she is capable of learning about allergy and asthma ishlolding noth in that will make for bester management of the disease

·6
The Management of Childhood Asthma
She should know something of
(1) The theory of allergy
(2) The nature of asthima
(3) The common causes of asthma
(4) How the causes are detected
(5) The unitations of skin testing
(6) What to do in case of an attack
(7) Hou long it will probably tale to achievc con
trol
18) Special factors applicable to her chuld
Much of this information slie can pass on to her lus
band and all of it to lier growing child No fear need lye
felt that the mother till go off on her own in treatment
Some women do this anyway and the better she under
stands allergy and asthma the less tempted she will be to
experiment with irrational methods
In excellent booklet for family education Allergy in
Children is nos avnilable through the American Founda
cron for Vlergic Diserses Inc 271 Vladison Avenuc New
York 16 Vers York

·Chapter 2 THE DIAGNOSIS OF ASTHMA 1 is impossible to exaggerate the importance of careful diagnosis in the child with dyspnea, wheezing, or cough It is the responsibility of the allergist to determine if each case is really asthma and only asthma The three essentials in diagnosis are (1) The presence of the typical clinical picture (2) The presence of associated allergic traits (3) Differential diagnosis THE CLINICAL PICTURE An attack of asthma characteristically begins with sneezing, nasal discharge and a dry cough As the attack develops the cough becomes steadily more severe and fre quent, and wheezing and dyspnea rapidly set in It is soon apparent that the distress of the child is great This is re flected in huis anxious expression, labored breathing and pale clammy skin In severe attacks the lips may be cyano tic, especially in young children, and further evidence of oxygen want may include restlessness irritability and even clelirium The patient's efforts are soon concen trated on breathing, and this, with his frequent inability to take fluids, leads to progressive weakness and dehydra tion Vomiting is common and may, as Ratner has point ed out, bring a measure of relief If it is prolonged how ever, it further interferes with respiration and greatly aggravates delıydration and fatigue 7 ·8 The Janagement of Childhood Asthma Examination of the chest at the height of the attack reveals evidence of more or less emphysema, with the chest distended and the amplitude of respiratory moie. mnents lessened The percussion note is tympanitic, and cardiac dulness is obscured drost obvions of all are the classic asthmatic rales These are best described as squeals, and excurring as they do over side areas of the chest and with variations in pitch might be compared to the squeak ing of a chorus of mice In prolonged attacks these rales may become coarse, Bet it shoukl be emphasized that the truc astımatic rale is aluays expiratory It is true that moist inspiratory rales may occur in asthma, but their presence usually indicates infection atalectasis, or bronchuectasis Betscen attacks the child may present no chest find ang but in severe cases, more or less wheezing inay tisual ly be found at almost any time If it is not heard during ordinary breathing it may be brought out by the method of Iineman " The examiner holds one hand on the front of the chest, the other on the back The stethoscope is held between the thumb and palm of one hand and during ex piration the exammers hands are pressed firmly together so as to empty the chest of air In this way, wheezing can often be produced when it is otheru isc absent In an occasional case there will be euidence of clc fornity of the chest in chuldren around the age of 2 years, the sternum is often depressed, while m older children, changes resembling the pigeon breast of rickets are scen (Fig 1) Although less coinmon, the typical barrel chest of chronic emphysema may be found Modles of Onset of fundamental importance in the management of astlima is an understanding of the various ways an attack ·The Diagnosis of Asil ma 9 Figure 1 Changes in Rib Cage in Childhood Asthma (a) Early changes in six year old boy Note slight prominence of sternum and upper costal cartilages (6) Advanced changes in nine year old boy More marked forward thrust of sternum faring of ribs and Harrisons grote Picture taken during inspiration 50 accentuate these findings 25 to may be initiated Belons are listed five distinct mechan isms Vore than one may be operatne in any case and there may be mixing of types but if the patient is carc fully folloned his particular way of reacting will crent ully become apparent (1) Simple Exposure In cases of marked sensitivity exposure to the allergen is sufficient to bring on in at anch familiar eximples are patients sensitive to animal ·10 TIe Vanagement of Cl illt ood Asthma epithelials or to such ingestants as aspırın or shrimp If there is no other sensitisity the patient is entirely symptom free betseen attacks If simple exposure were the only mechanism or even the usual mechanism in allergy the management of asthma would be far simpler than it is (2) Exceeded Tolerance Vany if not most asthmatic chuldren have some degree of tolerance to allergens to which they are sensitive and develop a franh attack only when this tolerance is exceeded A child sensitive to house dust for example may have an attack only when helping with house cleaning and another sensitne to chocolate inay flare up only when as his inother says He mahes 1 pig of himself Vany of these patients have some ev? dence of asthma betus een attacks (3) Triggered Attacks Allergic children especially young children often show little if any endence of asthma mul their allergic balance is upset by 7 trigger mechan xsmn The most important of these is respiratory infection" and mothers commonly feel that their children are aller IC to colds Isthma attacks are especially likely to ap pear during the incubation period of measles and certain other infectious diseases * Also of importance as a trigger mechanism is thermai dinge especially chilling and this at Icast partially 10 counts for the fact that some children are upset by sucidien ucuther changes It should be remembered honever that the chief cause of weather change is wind and sind often brins high mold and pollen (ounts (1) Allergens dating Together Certain allergens are relatively or entirely harmless klien acting alone but may initiate attachs lien acting synergistically with an other such allergen Thus phenomenon is found common ly in asthma of combined lood and inlialant origin An example is the patient ulio tolerates oranges at any time ·The Diagnosis of Asthma II except the ragweed season or to put it another way toler ates ragweed quite well except when he eats oranges It is important that allergens of this type be identi fied as failure to do so is an important source of failure in the treatment of inhalant allergy Parents of children being given pollen or mold hyposensitization should be advised that failure in such treatment may call for in vestigation of foods as synergistic allergens (5) Cyclc Asthma Asthma at times shows a ten dency to occur in cycles with no apparent initiating factor In some cases the periodicity of attacks is remarkably con stant and mothers can predict almost to the day when an attack will occur This type is most commonly found in young children with food allergy There is a seasonal fac tor in many cases as attacks often do not occur in hot weather It is interesting to note that this tendency for the manifestations of food allergy to appear in cycles and be worse in winter has been reported in the Northern Hemi sphere by Rone and in the Southern Hemisphere by Briedahl. SYSTEMIC ALLERGY Essential to a proper understanding of childhood asthma is an awareness that these children are highly aller gic individuals who commonly present widespread evi dence of systemic allergy When confronted with a multi tude of these complaints related by an anxious mother the physician may be tempted into the old concept of the neurotic origin of asthma but if he proceeds to deal with them as bona fide somatic disorders he will find that they will help him establish the allergic nature of suspected asthma and help him find the cause If he then proceeds to relieve them he will find that he has relieved a con stitutional allergic problem uluch represents far more ·12 The Vanagement of Childhood Asthma than a simple bronchial disorder Nasal Allergy A common but not inariable accompaniment ol asthma is nasal allerg, Parents of asthmatic children often show surprisingly little interest in this problem, so great is their anxiety over asthma It is often the duty of the allergist to point out that nasal allerg) is a first rate prob lem in its onn right As in asthma, the outstanding findings in allergy of the nose are mucosal edema, hypersecretion, and obstruc tion of the airway Itching and sneezing in nasal allergy are analogous to the wheezing and cough of bronchial allergy The symptoms vary considerably from patient to patient in degree and severity Frequent colds are a com mon complaint, and although many of these are allergic flares others are indeed infections Examining the Nose The pluysician creating allergic children should form the labit of looking in the nose of every respiratory case at every visit until the case is controlled Whatever shilled examinations belong cyclusively to the rhinolaryngolog ist, the use of a head mirror and a nasal speculum should be familiar to all In nasal allergy the chief finding is edena The inferior turbinates are coinmonly tremen dously swollen and may be the only structures seen Thur color is usually blush gray. and an excess of clear or oprque mucus is a regular finding There are often large crusts of dry mucus Tlie writer has formed the habit of making a diagramatic sketch of the degrec of snelling of the inferior turbinates on the childs chiatt at cach visit These shecbes become itseful in charting the progress of the case

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·The Management of Childhood Asthma asthma, but not uncommonly the tro diseases occur at the same time In infants, the face, especially the cheeks, is most likely to be ini olved, but in severe cases, virtually the entire body may be affected in older children, the sites of predilection are the skin folds of the extremities but patchy involvement of the face, nech, and trunk are common It is not at all unusual for eczema and astlımı to be on the same etiologic basis Urticaria and Angioedema If the patient is sensitie to a substance which causes urticaria or angioedema and develops asthma from the same cause the asthma is likely to be very severe One gets the impression in these cases that the child develops urticaria of the bronchus' rather than ordinary asthma The Nervous System Tension Fatigue A beliavior pattern marhed by ex tremes of mental and physical activity is commonly found in asthmatic children “ As infants they are overactive tense and sleepless In older childhood, tension takes the form of irritability and such patients are inclined to act spoiled," to be quarrelsome, pees ish and resentful Also with increase in age the tense behavior is accompanied by periods of listlessness, acluness and fatigue It is most gratifying to find that this type of behavior tends to dis appear as the allergic problems of the cluld are solied Migraine It often comes as a surprise to those not acquainted with childhood ills to find that children not uncommonly suffer from migraine in discussing the problem with adult sufferers, one often learns that they have had "sich lieadaches' as long as they can remember There have been numerous reports' as to the allergic origin of this syndrome in children and the impression is growing that allergy is the outstanding cause Since young ·The Diagnosis of Isthma 15 children cannot easily express themselves it often is re vealing to ask the child with cylic vomiting if he hurts anywhere Many times the child will reply that his head liurts! Convulsions When anaphylaxis and allergy were new there was high hope that epilepsy would be found to be a disease of hypersensitivity This lias not come to pass but at times convulsions will be found to be of aller gic origin The atithor has three asthmatic children under his care who have had generalized convulsions All are ex tremely allergic children and in two cases foods have been shown to be the source of the convulsions Chocolate is the cause in one egg in the other The Gastrointestinal System Foods which cause asthma often cause gastrointestin al disturbances as well Where such complaints appear without other cause they are to be considered of possible allergic origin and their source carefully sought Diarrhea No bowel complaint is more likely to be of allergic origin than recurrent diarrhea Allergic diar rhea often begins in early childhood and many times the history will implicate the offending foods When the mother reports that a particular food caused diarrhea in infancy but the child has outgrown it this food should be considered very seriously as a possible cause of otlier allergic complaints including asthma Abdominal Pain Any ailing child may complain of stomach ache much as an adult may complain of head ache and does so almost as commonly Where there is per sistent discomfort the trouble may often be traced to a food Constipation The common expressions Boiled milk is constipating and That makes the cheese more ·16 The Management of Childhood Asthma binding, 'gre a clue to a food which is a common cause of constipation It may be argued that the nature of the curd of cou's mull rather than allergy to this food causes constipation, and that may be true, but it is not an un. common occurrence to find other foods responsible for the production of liard stools Flatulence is a common com paniment of allergic constipation and other intestinal allergies Foul Breath A common finding in childhood allergy is loul breath In some cases this seems to depend on poor masal function, but in others, it seems to be a direct result of food allergy It commonly causes great concern to par ents and it should be marked as a symptom to watch dur ing the course of management of the more serious allergir mamlestations It is at least partly because of thus finding that anorexia is so common in allergic chuldren Other Gastrointestinal Manifestations Occasional findings in allergic chuldren are somuing bloating, geo graphical tongue, and aplitiae or canler scres l'omiling is confined largely to infants the older chuld usually cither ngons' this manifestat or learns to avost the of kandling agent Bloating is often mistaken for obesity bue ulicn the waistline rapidly diminishes during food clımın Tuon 11 is often found that relief of distension is the cor ret explanation Geographical tongue, Izle other distur vances of the digestile tract often disappears during the course of allergy treatment (anker sores often are caused In foods, toothpaste, or other sulxstances taken into the mouth The Genitourinary System Ilthough genitourinary allergy is not of outstandmg importance, there are several annoying symptoms worthy of note Vany allergic girls are given to a irritation ·TIe Diagnosis of Asti ma 17 and pruritis Frequency of urination is a common com plaint and enuresis may be present as well Probably most enuresis in allergic children has nothing to do with al lergy but the possibility that it is due to allergic bladder irritation is to be considered Foods which are most com monly found responsibile for enuresis are citrus fruits tomato milk food dyes and black pepper Miscellaneous Systemic Manifestations The Blood As is well known eosinophilia is very coinmon in allergic individuals According to Rinkel Randolph and Zeller " the leucocyte level in patients with food allergies is inclined to be labile and chronic leucopenia is common Anemia does not seem to be a symptom directly attributable to allergy Hyperhidrosis Bowen has spolcn of certain asth matic cluildren as Het sleepers When mothers become aware of the fact that hyperludrosis can be a specific aller gic reaction to foods they will often note that the erung of a certain food will invariably be followed by heavy sweats Muscle Pains Pains in tlie large muscles especially those of the thugh and leg are common in allergie chuleni The pain is characteristically worse at night w Ix rather severe Allergic Facies Where constitutional allery is wille spread poor color is common Patients often se on pale and listless with infriorbital discoloration and prillo ness Fever Although drug fever is fairly well known !! 15 often overlooked that other allergens may j ruc acute or chronic fever" Acute fever is most comm , in infants and may be as lugh as 106 F or more Tir alle gist sees several patients each year with fever door to 2 ·18 The Vanagement of Childhood Asthma lergy to foods ation DIFFERENTIAL DI IGNOSIS It is surprising hon closely a number of other diseases may resemble asthma and it is the duty of the physician 10 rule out all conditions capable of producing a similar clinical syndrome He must be especially on lus guard if the child has a history of asthma In this section the most common conditions inch may be confused with asthma will be discussed (1) Foreign Body m the Bronchus Tlus accident is a leading source of confusion in the diagnosis of asthma," and because of its peculiar dangers deserves first consider I history of clioking on a particle of food or other object is often obtained, and there may have been subse quent coughing, difficult breathing and perlaps cyano $18 Localized, unilateral expiratory wheezing is often heard and associated atelectasis or emphysema my be Identified by physical examination and roentgenogram The latter may slou an opaque foreign bully (2) Bronchiolitis in infectious process much like asthma and variously termed broncholotis, spasmodic bronchitis, asthmatic bronchitis, or capillary bronclutus oc curs not uncommonly in mfants it may, at least in some cases, represent the asthmatic response to infection and the possibility of later asthma should be kept au mind it is characterized by dyspnea, wheezing, cough, lever, and prostration As in asthuna the wheezing is generalızed, but 1t is usually much louder and coarser than that of asthima In infants, broncluelous us undoubtedly the descase most frequently confused with asthuma, and in many cases a definite diagnosis must be deferred (3) Pneumonia coarse vype of expiratory wheci ing is sometimes found in bronchiopneumonly, and, ·The Diagnosis of Asthma 19 especially if there is a previous Instory of asthma confus ion may arise A useful early sign commonly appearing before the typical physical and roentgenological signs be come manifest is flaring of the nostrils on inspiration IE tliere is any doubt as to the presence of pneumonia it is an excellent plan to initiate prelimonia therapy (4) Bronchiectasis Generally speaking the asth matic wheezes while the bronchiectatic rattles but Field reported wheezing in 33 per cent of a series of cases of bronchiectasis Where there is real doubt a bronchogram may be indicated (5) Croup In infants it is not always easy to differ entiate croup from astlima In both conditions respir ation is labored but in croup the loud hoarse breathing wall usually betray its laryngeal origin Where a childs airway threatens to become dangerously narroned what ever the suspected cause no time should be lost in con sulting a laryngologist (6) Fibrocyshc Disease of the Pancreas The infant with severe food allergies and the infant with fibrocystic clisease of the pancreas may act very much alike both be ing given to digestive and bronchial difficulties (7) Congental Laryngeal Sindor This condition is ordinarily detected easily but when accompanied by nasıl allergy it may produce a picture not unlike asthma (8) Congenital Heart Disease Trequent attachs of bronchial infection with cough are seen in certain cases of congenital heart disease in which there is increased pui inonary flow there a murmur is not obvious as in occas ional cases of atrial septal defect these recurrent episodes may siggest asthmi (9) Thymic Asthma Althouglı the thymus gland is Currently considered of little if any importance in obstruc tion of the air ny Glaser" warns It is desirable to heep

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·Chapter 3 LTIOLOGY OF ASTHMA: INHALANTS MOS rost substances finely enough divided be carried in the air may act as inhalant allergens These may ap pear seasonally as is strikingly true of pollens and largely true of mold spores Others may be encountered at any cime, and in this category are found ammal epithelium, house dust, insecticides, and other household inhalınts In adults there is scarcely any limit to the possibilities in this type of allergen, but children as a rule are exposed to relatively few inlialant contacts The inhalınts commonly encountered in childhood practice are molds, pollens and house dust, and the relative importance of each us in dicated in Figure 2 and Table I POLLENS Any plant which is wind pollinated (as opposed to inscct pollinated) is a potential source of respiratory al lergy In practice, however, only those pollens which coin bine the following characteristics will be found inport ante (1) Buoyancy Corn pollen, for example, is of little clinical importance because it is so lieavy that is does not travel over 200 feet from its source" (2) Antigenıcı) (Toxicity) line is a heavy pro ducer of buoyant pollen, but is apparently incapable of sensitizing (3) Productivity Although cralgrass pollen is pre- ·23 The Vanagement of Childhood Asthma sumably buoyant and toxic, it is released into the air in sich sconiy quantity that it is of no importance in allergy This section will be devoted to a discussion of pollens tuulutulestie FURINN MILK 406% 676% ALTERNARIA ராயALLENINNAI CHOC - COLA 197% RAGWEED 42 9% HITACHI NA JEGO TURK EGG 11 7% HOUSE DUST 381% Iru11111/JruJi LEGUME 98% HELMINTH 22.5% MILITANTE GRASS 17B% NINNI CORN 79% WHEAT 29% MONIL SIT 9,8% TE! TOMATO 29% 67 % CATTLE SIAN CITRUS 2 9% HORMODEND 6 7% WYMI PORK 26% ELM 54% ASA 26% COTTONSEED 51% E WALNUT 17% CAT 41% INHALANTS 17% FOOD DYES INGESTANTS Figure ? Incidence of Food and Inhilant Allergens in 515 Cases of Chulthool Asthni Data on less common causes are given in Table 1 ·Etiology of Asthma Inhalants 23 TABLE I INCIDENCE OF SENSITIZATION TO ALLERGENS A Yoyo $15 CASES OF CHILDHOOD ASTIA Inhalants Cases Per Cent Allernaria Ragweed House Dust Ilelminthosporium Grass Monila Satophia Cattle Hair Hormodendrum 213 13 120 77 56 31 21 21 17 16 13 11 8 7 6 67 6 429 381 22.5 17.8 98 67 67 54 51 Elm Cottonseed Cat Hair Pyrethrum Western Water Hemp Feathers Dog Hair Russian Thistle Rabbit Hair hochita 1forse Hair Sulk OTTIS Root 36 25 2.2 17 1.6 1.3 07 3 4 2 Ingestants Vilh 128 406 Chocolate Cola 62 197 Fgs 37 117 Legumes 31 98 Com 25 79 Wheat Tomato Citrus 9 2.9 Pork I SA A 25 Fuox! Dyes Halnut Pecan 6 17 Apple Fish Porato Cinnamon 16 Bech Plum Family Grape 4 1.3 Cabbage Foods Barley Oat Onion 3 10 Vinc Fans Bect spinach Bananas Lamb Pineapple . 07 Cantaloupe Shrimp 0.3 "Does not grow in Kansas City area incidence is very high among patients frutta halutat 5 ·24 The Vanagement of Childhood Asthma which have proved significant in allergy They will ap pear in their approximate order of importance Compositae The composite famıly includes such beautiful flowers as asters, zinnias, and crysanthemums, and such attractive needs as goldenrod, dandelion, and daisy Since all these are insect pollinated they are not hay fever plants Hou ever, many composites lave degenerated into wind pollin ation and in the process have become the allergic scourge of North America Included in this category are the num erous types of ragweed and sage There is considerable cross sensitivity among these plants Ragu ceds The term raglieed applies particularly to members of the genus aluch livs been fantistically mis named Ambrosia Included uncler this heading are small (comnion) ragnice giant ragweed, sestern raguced, southern ragneed and others of less importance Ilthough there are some who dissent, these plants are probably from a practical therapeutic standpoint antigenically identical Theu importance rests on the fact that their pollens are remarkable for their buoyancy, 104city, and productivity They particularly infest area of extensive agriculture, but one type or another is likely to be found almost anywhere There are several otlier meinbers of the ragweed tribe which are so closely related to the truc ragweeds as to be cuther antigenically identical or nearly so Among these are burneed marshelder (prairie sagtecd), rough marsliclder, the false rags eeds, and cochlebur. Buruecd marslı cider is in some dry areas the dominint ngneed, and should recerle special attention where thus is truc. Cochlebur is a poor pollinator and is seldom considered of importance ·Etiology of asthma Inhalants 25 Artemisia To the artemisia famıly belong the sages sagebrush and worms oods and where these abound they should be given individual attention In areas where rag weeds are the dominant composites however Brier" feels that sage is probably of academic interest because it in teracts with ragweed pollen Grasses The most widespread source of pollen allergy not only in the United States but in the world is the grass family of the thousands of species a comparatively small number possess the qualities necessary to make them im portant Their pollens are quite antigenic but fortunate ly are not as buoyant as those of many needs and trees and do not usually appear in the air in heavy concentra tion To the great simplification of the allergist s tash inost grasses cross react more or less perfectly for example the common lawn and pasture grasses blue grass timothy orchard grass and redtop are scarcely to be distinguished antigenically and some allergists use timothy exclusively for testing and treatment Two exceptions to this satis factory stite of affairs are Bermuda grass and Johnson grass which interact poorly with other grasses" Chenopods (Goosefoot Family) The most important of the chenopods is Russian thistle a tumbleweed This great pest of the plains and Rochies is responsible for a tremendous amount of severe respiratory allergy wherever it is found A close relatie is burning bush (kocha scop3111) and although its pol len is app irently less untigentic than Russian thistle 10 is nevertheless an important antigen Another common need of this family is lumbs quarters but in children at ·26 The llanagement of Childhood Asthma least, it is of dubious importance Amaranths (Pigweeds) Thus family furnishes a wide variety of prolific and noisome seeds Although much mentioned in the hay fever literature, shin reactions are rarely found, at least in the Kansas City area. The one exception is restern water lemp, and since it flowers at about the same time as the ragweeds, failure to consider it may lead to poor re sults in late summer pollinosis Trees In view of their side distribution and large pollen production, it is surprising that trees are not of more allergic importance than they are This may be because of their short seasons, or because they pollinate mostly in the early spring before houses are open Where the season is long, as is the case with oals in certain mountain areas," they may be of considerable importance In cities where elms are plentiful, thus pollen appears in enormous volume in late winter (fig 4) and not uncommonly is responsible for severe respiratory allergy Mountain cedar hias Jong been known as a source of severe pollinosis in parts of the Southwest Other trees whose prollens appear on atmospheric slides are maple (and box elder), sycamore, pine, poplar (and cotton 1:00.). pecan, mulberry, walnut, luckory, Escach birch and others Yone of these inc heen found important in the Kansas City area Other Plants Among plants occasionally suspected 111 respiratory allerhy are plantain, beet, doch, prnet, rhubarb, acacia, buch ubieat and mesquite Where the allergist finds these ·Et olngy of Asth na Ini alants 27 pollens on his atmospheric slides he is justified in testing patients for them no matter how little attention they have caused in the hay fever literature On the other hand if lie tests with them when they are eitlier absent or none of his patients have symptoms at the time of their flowering he will confuse luimself and waste much time and effort An interesting liay fever plant is hemp (marijuana Cannabis) Over most of its distribution it is too scattered to be a significant factor but in the Omaha Nebraska area where it was once grown as a source of rope it lias escaped from cultivation and become an important local pollen" A baffling problem in extensive areas of the Soutlı is hay fever X * It occurs throughout the coastal plain and at last reports efforts to determine its etiology have been unsuccessful Unfortunately for its victims it is a common type of hay fever Which Pollens are Important? Although the whole subject of pollen allergy is com plex the local situation in any ghen area is relatiely simple It is the responsibility of each allergist to find out what his own problem is and to lielp him in this task fe may draw on many excellent sources of information He often can get this inforination from allergists working in lus area or he may consult Sumpter and Durhani s Region al Allergy" a very useful book which combines the col lectate experience of allergists working in all sections of Vorth America He will learn much by looking about liim and finding for himself the plants present in his commun ity In excellent help in this endeavor is Hay Fever Plants hy Wodehouse™ Further information may be obtained from county iced control officers and from books on 11 ecels grasses and other plants wluch these officers can ·28 The Vanagement of Childhood Asthma furnish or recommend For example the writer las found the folloning books of the greatest interest and assistance II ceds of the lorth Central Stales a publication of the University of Illinois Igricultural Experimental St71101 Urbana and Il eeds m kanses and Grasses m hansas by Trank C Gates published by the Kansas Surte Board of Igriculture Topel? Il atching the plants about him is one hobby the busiest physician cu culun ate and enjoy VOLD ILLERGES The discovery that soil fungi or molds are important inhulant allergens has been the most noteworthy develop ment in recent allergy history These organisms will grow in almost any place where there is sufficient moisture but their great reservoir is the soil They ire important en vironmental allergens in ırcas of extenske agriculture in older houses in poorly drained areas and near bodies of water The allergenic factor of most importance in moll allergy is the asexual spore or conduum but it has recent ly been demonstrated that the niycelium or vegetative portion of the fungis is antigenic as well * These or 711 isnis kould be of limited interest if they acted only is en vironmental allergens Their real importance lies in the fact that their spores inuade the uur in force and during larni months constitute 1 sersonal allergic problem of the first magnitude Important Volds Alicrhana There is general greement liat ller narın is the most iinportant fungus allergen in the United States ** It is a vigorous organism thriving under condi tions which discourge other molds In most arcis it is active throughout the greater part of the yer becoming ·Ftiology of Asthma Inhalants 29 clormant only in the coldest weather in the South it may be present throughout the entire year Alternaria has an interesting seasonal incidence (Tig 4) In the Midwest it begins to sporulate at the first sign of that in the late winter and continues to be a source of trouble from March through November Spores appear in the air at any time wlien the ground is not frozen, saturat ed with rain, or covered with snow Although prolonged dry weather lias a tendency to inhibit this fungus even conditions of extreme drought do not stop its activity, and, in the Midwest, dry weather tends to give higher counts than rainy w catlier Since Alternaria grous rapidly on vegetation, espe cially grasses, harvest time (June for hansas wlicat) and hay cutting time are occasions for high counts Tlie com bination of dead vegetation and fall winds makes Oct ober another favorite time for high counts Hormodendrum Hormodendrum is closely related to Alternaria and similar in habit and growth It is espe cially prevalent in the spring, and on wet dlays it may ex ceed Alternira in activity It is considerably less import ant in allergy than Alternaria Other Molds Of the tliousands ol species of soil molds, only a few apperr in sufficient strength to be clinically significant I common bread mold, Monilia sitoplula is very active antigenically and is a common reactor Probably because their relationship to Alternaria is very close Helmintho sporum, Spondylocladium, and Curvularia are common shin reactors, but, except for occasional showers' their spore counts are los Also worthy of mention are Asper gillus, Penıcıllıum Fusarium, Rhusopus, Absidia, Phomi, Vucor, Chaetomu, and Pulullaria Balers yeast and D C ·90 The Vanagement of Childhood Asthma brewers yeast are of occasional importance in children One of the writer's mold patients has developed severe symptoms from stirring hot roll mix and from inhaling fumes from yeasty' beer Mold patients do not tolerate the drinking of beer or the eating of certain cheeses or other foods which contain fungi It should be noted that many present day cheeses are processed and do not con tain) molds ATMOSPHERIC STUDIES To obtain the best clıcal results in pollen and mokl allergy and to non one of the real pleasures of thic prac tice of allergy the allergist will want to do lus onn air studies He may use a simple technique consisting of the daily study of greased slides which liave been exposed cach 24 hours in the open air, or he can use more highly perfected techniques suitable for research studies The 1111er s method wluch nul be gnen belos is a simplified ndipration of the standard method Vaterials The necessary materials for atınospherz study are (1) pollen slicker (2) glycerin jelly, (3) microscopic slicics The Shelter (Fig 3) The slichter used is modeledi closely after the device designed by Durham It consists Guelly of tho disks of galvanized sheet iron or other rust resistant material, 9 inches in diameter, hell 3 mches apart by three bolts In the center of the lower disk a painted block of 100d is fastened It is I inch high and ins tlie dimensions of a glass slide Tho thuin metal clips hold the slide in place on the block The shelter is sup ported on a vertical pipe with a lise or may lic placed on a bracket The pipe is fastened to the lower Jisk and to a ·Etiology of Asthma Intialants 31 Figure 3 Pollen Shelter base with floor llanges, obtainable from plumber s supply stores Tlie most accurate counts are obtained if the shelter i placed on the lughest point of a tall building, but the practitioner is more likely to be faithful in his counting if it is placed outside a convenient window Glycerin Jelly This material is prepared at follows Soal come gelaun for 2 or 3 hours in cold water pour off the superfluous water and heat until meleed To 1 part of this add 192 parts of glycerin anit while 51111 hot filter through spun glass pressed into the lower part of a heated funnet Add ? or 3 per cent phenol still keeping the mixture hot and Nuul add drop by drop a satiiralel solution of methyl green in 50 per

·$2
The Management of Childhood Asthma
cent alcohol until the glycerin jelly becomes fully as dark as green ink
(the method guen here is that of Brandt The writer has succecded in
Motering with filter paper instead of spun glass)
Preparation of Slides A drop of melted glycerin jelly
is placed on a slide and smeared to a thin film 4 number
of slides may be prepared at one time and stored in a
covered slide box Lach morning a slide is labeled with
the date and placed in the shelter
Counung Technique
The method of counting spores and pollen grains is
much like that of the blood count" Instead of counting
A

·1 ABLE II Pot AND VOI VENDAR hansas City, 1930 Februar March 1lay June Jun1 Ultcmaria Viernarin Ilicinaria Venaria \ltraาแa Iftc112113 1 maciendrum Hormolendrum Hormouendisini tormoulandum Ilorineienclum Hormodendum Im Fim Maple Vuple Himmthospoumlic Imithosporium Ile Imunthoporum Oak Pine (258 Willow Grass (henpol ninth Celar Doch Rusts I tiology of Asthma Inhalants ON Hallow Cedar Ponlar Rusts Poplar line Studis not Pine TWalnut done in Walnut SycNone January GUS 33 ·31 ISBEE 11 (Continued) POMPIN AND VIOLD CALENDAR Aansas (1h 1956 fugust September October مرا (م : ۱ Drimbit Alternaria Scrari. \lernaria Tlcernaria Ormondenium Ulternaria Ilutenowlendrum Ilorinodendrum Hormodendrum elminthesporium Helminthesporium Thelminthosponium Grass Grass The llanagement of Childhood Asthma (hennpol amaranth Ragweed Chenopol amaranth Raguced (henopod amaranth Rigueel Rust Rusts Hemp (nposites Composites licinp

·Fhology nf Asthma Intılants
35
Jan Feb Mor Apr May Jun Jul Aug Sept Oct Nov Dec,
>
LTERNARIA
HORMODENDRUM
A2
ongs
Jon Feb Mar Apr May Jun Jul Aug Sept.Oct Nov Dec
Figure + Alold Polien Count, h insts (ny 19.6 Weekly Ascrages
Distance between borironal fines represents 10 pollen grains or
spotes For Calendar shomg 1%83097 pollens and spores see Table II
elements in squares, loneler the pullen mold count in
(ludes all elements found in the low power field during
file trips across the short dimension of the stude The ex
aminer places the shade in the stage with one end under
the objective He begins the count at the upper edge and

·36 The Management of Childhood Asthma completes it at the lower He moves a short distance along the slide and repeats the same process in the opposite direc ton After a total of five such trips across the slide the count is complete The total of each type of grain or sporc seen mahes up the mold and pollen count for the day Pollen counts are tabulated and hept in grapluc form as shown in Figure 4 For a more complete list of seasonal allergens, sce Table II Identification of Pollens and Spores There is 110 better way for the beginner in air studies to become familiar with air borne substances than to acquire known specimens and mount them in glycerin jelly In Figures 5 and 6 microphotographs of common pollens and spores are slıonn Further material on thus subject may be ol) tained from the work of Durham and Mchay," Wode house, Bronn," Christiansen and Swacbly," or the stand ard textbooks of allergy NONSEASONAL INJAL INTS Innlants to such a patient may be exposed at any time are known as nonseasonal inhalants. This is not a strictly accurate designation, as there is some difference in cxposure according to the time of the year, but in this group we do not find the striking periodicity characteristic of pollens and molds Included under tlus hicading are farm and industrial inhalants and such householl aller gens as animal furs, house dust, and insecticides This sec tion will be devoted to a discussion of this class of anti gens House Dust Aremarhably potent allergen is produced as a result of the aging and degeneration of cotton and other organic materials for want of a better term, tliis sulystance, a fine ·Etiology of Asthma Inhalants 37 b Perry d Figure 5 Common Vold Spores (a) Alternaria The spores are often seen in dai of two to four or more but are usually scen singly as in (b) (c) Fformodendrum Spores are usually in groups usually some fre to sen to the group Spores vary considerably in (d) Helminthosporium small size (6) Tielminthosporium usual size Spondylocadium The spore shown in (d) is from a culture all others are from a mosphenc slides (vG10) sne

·The Alanagement of Childhood Asthma
20
O
b
:)
OR
og
Figure G Common Pollen (brains (1) Raguced (b) Hemp (Can
naby) (1) Grass (d) Russiin tusle (e) Pine (1) Vaple (g)
Oak (h) lim (1) Hickory () Cedat (k) Sage (1) Popiar
(x610).

·Choing) of Astl mat Inhalants 99 gray ponder is called house duse It occurs in all fouses to a greater or less extent and has been found in all chi mates It is a very common offender in adults and al though less commonly seen in chuldien it is salt an att gen of considerable importance House din sensititity is Sery pret alent in lower income groups tecluse of greater exposure to old furniture and old living quarters In kiss ter when locises tre closed and furnaces are busy it * especially important It is produced in abundance from mattresses pillon s stuffed furniture and to a consider ably less extent from souffed toys hint ind books Animal Epithelials Among the most potent inhalant allergens are the epithelia of mam5337ls includmg ass and «ander The feathers of birds are less actose allergens but are of defi nite importance Becanse dogs and cats are such common house pets these two sources are of first importance in childhood Source of pathells The child who is sensitie in cats and dogs will have difficulty not only from sharing a house with them but some cases may lze symptoms from lair arched to the clothing of playmates or react to the presence of these inimiis on outdoor contact Form conmice accounts for most cases of allergy to borses <ule and other sock but clothing of those landing 2mals my affect extremely sensite children Rug pads made of cattle hur are an exc?$101]} but important source of cattle Huur allergy Feather pillons comforters and feather beds are both epithelial and linuse dust contacts Rabbits are sufficiently common as pets to constitute a minor allergic problem Because of itse fact that ilicy are carefully cican ed before use sool (in fibrics) and horse liar (in furni ture) do not seem to be acute antigenicilly ·40 Tle Vanagement of Chillhood Asthma Miscellaneous Inhalants Pyrethrum Pyrethrum un insecticide is 1 common and active allergen It is manufactured from thic flower of a plant closely related to the ragn ceds and since the commercial product contuns pollen it is i common of ſender i ragweed sufferers Coltonseed Ilthough cotton fiber is nonmiyeni the seed my (zust the most scsere allergic reactions Sen sitive patients have symptoms from sleeping on unpro tected mattresses and from contact with certain (attle feeds Cottonsecd merl is sometimes used m the mim facture of candy and in biking and is a ment to pruents highly sensitive to this antigen Cottonseed oil on the other land is considerad antigenic ally inert les most ller osts Orris Root This active allergen wis lormerly much tised in cosmetics but less patients now reut to it It source is the rhizome or root stock of an Ital1111 iris Sulk The return of silk to common use is bringu, ibus intigen back into prominence It is used in scarics Japanese jachets suits und in many other was Silh is of insect origin ind allergy to it iniy be related to ulergy to moths Vzy flies etc In the vicinity of large bodies of water such as the Great Lakes insect eminations may be important schonal inhalınts Wergy to these inliams is detected and treated in the same way is with pollens and molds Tobacco Smole Vany children complain wlicn es posed to hery concentrations of tobacco smolc In most rises the smole probably acts 15 7 primary irritint but in otliers it acts as a true antigen" It is probably never grec essary to completely exclude asthmatic cluberen from the presence of tobacco smoke but it 15 lise to see to it that ·Etiology of Asthma Inhalants 41 they are not exposed to the lieavy concentrations often found at parties, in closed cars, etc Less Common Inhalants Other inhalants which have been reported are ha raya gum, goat hair, hog liair, insect emanations, flaxseed derris root (rotenone), smuts and rusts guinea pig hair white rat and mouse hair, wheat flour, Lapok gum acacia fish glue, castor bean dust, coffee bean dust wood shay ings, saw dust None of these is common in pediatric prac tice, but in puzzling cases or special situations, these and others may need to be considered ·Chapter 4 ETIOLOGY OF ASTHMA TOODS, DRUGS, INSECT BITES, NONSPECIFIC FACTORS rood ILLERGENS In wens of the fact that allergic children become sensitive to inhalints on the basis of relatiely casual contact it is not surprising that their heriy exposure to foods leads to a great deal of food allergy Thuis exposure to foods is 01c1whelming in infines For example 7 15 pound baby ishing 1 egg yolk and I quart of mulk duly (18 many do) may be compared to 1 180 pound min on 1 claily intake of a dozen egg yolks ind i gallons of milk! When we further consider the endence that the gastrointestinal trict of infunts is permeable to a foreign protein se my well wonder that food allergy is not more common and importint than it is Il luch foods are Important? Any food seems to be capable of sensitizing but there are several which are encountered thi especnl frequency Generally speakmg the leading allergens vre common foods lilc milk gruins legities and cogs but certain others like chocolne pits 771cl crustaceans seem to one their importance to high inlcrcnt itigem City In Tigure 2 und Table I thic relaine importance of foods in 3$t11mntic children is shou n cinni2017 12 ·roods Drugs, Insect Bites orspecific Factors 43 The Liological Relationship of Foods Nothing has clarified our understanding of food allergy more than the discovery that foods which are mem bers of the same botanical or zoological family tend to in teract antigenically ** In this section the various food families and their members are listed It will be noted that allergically speaking the terms fruit vegetable protein, greasy food, seafood rich lood starchy food' spicy food, etc have little or no place As allergens foods are classified according to their place in the plant and animal kingdom only In the next chap ter we will see how this relationship becomes useful in determining which foods are important in asthma The following Food Families list is the one which the writer gives to the mothers of children with a food allergy problem sweets Food Families Allergy to one member of a famuy of foods often means allergy to other members This is especially true of many families (per family citrus famtly) but less w of others (nammal family) Apple Family Apple pear quince Aster Family Lettuce is most common Others are chicory endise escarole artichoke dandelion sunliower seeds tarragon (Ragwced and sige belong to this family also the insecticide pyrethrum) Beet Family Beet spinach chard lamb s quarters (Has fever plants in this family arc Mexican firexecd and Russian thistle) Blurberry Family Blueberry hucklebern cranberry Bucku heal tamil Buckwheat shubarb garden wortel Case Family Cashen pistachio mango Chocolate Family Chocolate (Cocoa) and cola ClTus Family Orange lemon grapefruit lime tangerine kumquat (tron Fungus Family Vushtoom and seast (Ihc molts that cause in halang allergy belong to this family Also antibiotics ) Cinger Fornly snger cardamon turmeric ·44 The Management of Childhood Asthma Gooseberry Family Current and gooseberry Grains (Cereal or Grass Fanih) li heat corn rice oats barley re Also wildrice cane millet sorghum bamboo sprouts (The hay fever grasses belong to this family ) Iaurel Famın Avocado cinnamon bay lcance sassafras Hallou Famih Cottonseed and olta Selon (Gourd) Famih Iatermelon (itemunher cantaloupe ptimp Lin Squash and other melons Imt Famih Vint peppermint spearmint thyme sage horchound marjoram basıl sasori rosemary balm (melissa) catnip vustard Family Mustard turnip radish horse radish watercress and varieties of cabbage The varietics of cabbage are cablage chinese cabbage broccoli Brussel sprouts collards lalc cauliflower Lohtrabı and rurabaga Vyrtle Family Allspice guava clove pimento (not pinnento) Onton Family Onion garlic asparagus chines leche sarsparılla Palin Famih Cocontit and date Parsler Family Carror parsnip celers partes ccleric Also the fol louing spices anise dill fennel angelica celery sced cuma contander carawas Pea (I cur or Clorer) Family Peanuts l'eas (green field black eved) Neans (navy lima pinto string soy etc) I ess important are lic rice acacia tragacanth 7 fun Family Hum cherry peach apricot nec trine will cheer almond Polato Family Potato tomato se plant peppers This family uder all foods called pepper except black and white pepper such as Toen pepper red pepper cui pepper paprika puniento cayenne (apsiani (Tobacco telladonna stranionum and hoxyamus belong to this family) Rose Family Stranberry raspberry blackberry Joubern and sucht deeksped berries as loganbern youngherry frysenberry etc Il all Family English nalmur black waluut precau hickory nur buticut Animal hingdom Vollust Family Oystet clam abalone musc! Crustacean Family Crab lolkier slump Fish family ! trtte fusht either fresh water or salt warcr such as ulmon [uin sardine catfish crappie cic etc (tisli seristic pilienus often cannot handle or offeruise come in contact with fish glue lite Lerages) ·45 roods, Drugs, insect Bites, Nonspecific factors etc Berd Family All fowl and game birds chicken whes duck goose guinca, pigeon, quail pheasant etc Although egg belongs to this famils it does not seem to be related to chichen allergy except the meat of laying hens may cause trouble in egg sensitive cases Reptiles These are eaten very little but it is interesting that both turtle and rattlesnake meats are available The frog an Amphibians not a common food Nammal Family Beef pork lamb rahbut suurtel venison Cows milk is of the same animal origin as beef and there is a slight ten dency for those who are milk sensitie to be allergic to beef Vost per sons allergic to cons milk cannot take the milk of other animals such as the goat Foods Without Relatives The following foods are the only members of their botanical family which are commonly used as foods in the lited States Iron root ban ana black (white) pepper Brazil nut capers chestnut chicle coffee clderleiry lig grape hazelnut (filbert) hones juniper flaxseed harava gum maple sugar lew Zealand Spinach nutmeg imace) one oregano papaya pincapple persiminon poppy seed saffron sesame seed sucet potato tapioca tea vanilla wintergreen water chestnut Mineral Kingdom Many favors coloring agents medicines etc are of mineral origin Pop Roolade Popsichles Jello and candies are artificialls colored and Rasored Occasional trouble is caused by these agents Aspirin is the most important mechcine causing allergue reactions It is found (usually under the name of acetylsalicylic acut) in a wide var iety of preparations bike APC Anacin Bufterin Ilhascitzer The medicines used in allergic chuldren seldom cause allergic re actions but if any seem to cause trouble thes should be watched From thus outline you can see that there is no such thing as being allergic to all nuts seafood fonts starches greasi foock spices etc notice that these are not related tuna and shrimp white potato and sweet potato wheat and buckwheat black and red pepper crab and clam raisin (grape) and prune (plum peanut and other nuts almond and other nuts ·-16 The Management of Childhood Asthma coffee and tca ginger close and cinnamon Totice that these foods are related apple and pear peach and plum pea bean peanut whcat corn other grains beet and spinach chocolate and cola drinks onton garlic asparagus cucumber and melons walnut and pecan Carrot and celery Sources of Foods A number of workers fase patiently and efficiently compiled detailed lists of food such are the source of various common antigens These lists are very useful for adults who must eat in restaurants but in childhood prac tice the writer las found it more practical to give the inother 1 general list of sources and encourage her to lear to read labels on food pachages Since mothers are experts on foods they can be very easily taught to Icep a child on a diet sluch is safely free from the food being asonded and of the allergist makes certain that she tinderstands that thuis avoidance must be total he will find that lic nced Inve no fear as to her role in die studies General fists of food sources are to lie found under food Testing" pige 61 DKUG ALLERGENS WIthough drug allergy is not of outstanding inipor tance in childhood asthmi, the possibil that either pre scribed drugs or patent medicines may act as allergens is to be lept in mind lastly the outstanding drugs to watch in the asthmatic child are aspirin and prenicillin As is true of allergy to insect bites («ce belou), allergy to drugs often acts more like anaphylaxis or serum sich ness than ·Foods Idrigs Insect Biles Tonspec fic Fa to 47 68 clinical allergy or atopy. That is to say drugs are more likely to produce urticaria rashes arthralgia or fever than asthma eczema rhinitis or migraine Aspırın Aspirin has the distinction of bem, 11 e 1st common drug in modern use but it also is the inos com mon childhood poison and in asthma at least the most common drug allergen Aspirin asthma is invariably severe and since the drug is routinely given for childhood colds attacks due to aspırın are commonly thouglit be a result of the cold It is wise to discourage aspirin il astlimatics and where its use is alloned it should be cure fully watched The writer routinely forbids it in severe cases Penicillin Penicillin has become a very importint allergen especially in dermatology Bronchial reactions are by no means rare however and the asthmatic who gives a hustory of any type of allergy to penicillin should not be given this drug **** Other Drugs Brown lists the following drugs 25 those most commonly associated with bronchospasm ac ICTH anesthetic agents antiinstamını agents argyrol the arsenicals atophan atropine asthma powders cocaine cortisone dertis toot demerol digitalis emeune heparın insulin odides ipecic curare gum liver extract lycopodium the mercurials morphine pan topon para aminosalicylic acid penicillin pollen extracts privine pyromen sera streptomycin sulfonamdes taha dustase tunic acid tetraethylanmonium bromide tua mine and sarcines 1lthough the introduction of diplı theria and tetanus toxoids has greatly reduced the indic ations for its use horse serum remains an extremely din Gerous agent in suscepuble children in stlmt patient of the writer died in another city minutes after being guten intitetinic serum In history is talen prior to acia aspirin ·48 Iello rigenet Child/ 90 / {stl ma injection and no shin itst is made The physician who is spring and cautious in his use of drugs will sale fus famils ind lunself a great deal of trouble Vay drugs in overdosi, ire pousons and all are potential lor,cus lisenze deserves speani mencion be cause of its current use as a specific 111 ustimmt and its dangers need the strongest cmpliasis *** ILLERGI TO INSECT BITES Is Loreless and lucher lase pointed out sensiti ziuion to insect inoms in more in the ture of anaphy laxis or serum sickness than stopy This me ins that the normil imendurl is probably is likely to buconit sensit azed as tlic allergi mencuri und tut the rene tion will be one of sciere cdum rither than true 15tım?' The asthmatic chuld nith luis senisins foncr respiratory rul however would seem more likely to rent with ecem of the glovus or 12th pulmoury cem ud such a case should be venca nith the greatest iespcct ind cum Prevention. The principle of nodance upplies strongly in the field of ilergy 10 unisex t stings in cluzka who gives euidence of my type of lyperscusitivity 11. sects should be taught to zvenel prices fiere liees and 11 75ps abound It is wise to nou the plante, of ourdon flowers floti ering shrutx ind closer in the yards of p? tients with bee sensitiuty The chuld should also lie pre vented from playing about old sheds muddy places bise ments and other trens frequented by 11 35pps Treatment of the Reachon The treatment of a sicre insect reaction is identical with that of the management of a constitutional reaction to fiyposensitization (pige 91) Desensıtı ation True desensitization is possible in insect allergy Glaser * in a modification of the method of Vueller und Hill" recommends beginning uuh 11 ·Foods Drugs Insect Bries Conspcciſc Cactors 49 1 000 000 dilution and working up cautiously to I to 10 He recommends 3 years treatment Suinn;" whose expet rence is extensive advises prolonged follow up of patients to make certain that there is not a gradual return in sen Sitzity NONSPECIFIC CAUSES Infection Easily the inost important nonspecific factor in cuild hood asthma at least in infants is infection " Its role is so important in fact that it has been argued that bacteria act is specific antigens in asthma It is true as ve me seen in Chapter 1 that infection 15 ? Very coinion trigger mechanism and it is also true tljat asthmanc children are oſten much given to colds and other respiratory infections but attempts to demonstrate the specific etiologic role of bacteria in asthma are not conclusne Any child with an infection amenable to treatment should be treated for it of course and this is eminently true of a child already itt with asthmı If the physician wishes to use bacterial vac cines he may justify lumself with the contention that they may be nonspecific stunulators of the immune mec Janism Crump has reported good results in resistant cases from the use nf vaccines made from bronchoscopic cul fure * It has long been suspected that focal infection may play a role in childhood asthuna and this point of view has found a strong advocate in Chobot 'However most workers find that surgical removal of lymupliord cissue or other tissue in an effort to remove facal infection is not effective" There is in fact a suspicion that removal of tonsils and adenoids may act as a stimulus to the de clopment of respintory allergy in susceptible children Primary Inhalant Initants Iny sulosince which is irritating to the normal ·20 The Ilanagement of Childhood Asthma respiratory MILOSA may act as a nonspecific factor in childhood asthma "* Of particular importance are ma. terials used in interior decoration such as paint, varnish, shellac, lacquer, linseed oil, turpentine and other thin ners, ammoma, and paint remouers 1 hese and a long list of sunlar substances can contribute to the development of an attack of asthma It would be impossible to list all the other sources of irritation, but among them are soap powder and detergents, insecticides, mentliol, camphor ether, tobacco smoke and other smoles, sans dust. per fumes, sulfur trioxide and diode," hydrogen sulfide. cleaning fluids flowcr odors, food odors,” Acrosene, gasoline, formalın and alluminating gas Some of these act as allergens rather than as simple irritants, and in any given situation it is often impossible to say which nicchanism prevails It is remarhable hon often primary irritants combine with allergens to upset allergic balance Cases like the following, a hypothetical one, are not uncommon child sensitive to house clust, ternur11, and the ragheeds is well controller! During the Labor Day sock end his father undertakes to redecorate the living room In the process of removing wall paper and hammering on mop bourds he stirs up a large volume of house clust and molds He uses ammonia to clean Woodwork and with a sander ruses a cloud of wood dust and old paint He uses a punt remover to loosen a heavy layer of sarnısh from a door and uses fish glue to repair it The punt, an un usually odoriferous product, is thinned with turpentine and stretched with linseed oil while at work the imateur decorator solices himself with large, blach cigars By the time the job is finished the air has been sufficiently pollut ed to fill iny allergist s heast sitli horror, and being done at the height of the ragreed and Alternaria season, the child is exposed far beyond his tolerance and goes ·Foods, Drugs, Insect Bites, Nonspecific Factors 51 into a severe attack of asthma A case of this type shows not only the importance of inhalant and irritant avoid ance, but the necessity of thorough indoctrination of the families of asthmatic children Physical factors Thermal Factors An important factor in childhood asthma is temperature change Many children are especial ly intolerant of chilling, and at the first visit, the mother may object to the child being disrobed for examination and testing An occasional patient reacts similarly to be ing overheated Whether thermal reactions are actually allergic phenomena (plıysical allergy) or nonspecific fac tors is not settled, but since the patient who is properly controlled tends to gain tolerance to thermal factors, the latter view seems more probable" An interesting form of thermal intolerance is seen in the patient who theezes after laughing, exercise, crying or other activity which increases the respiratory exchange In some cases this is a result of the extra load on the limit ed vital capacity, but in others it seems to be a result of a large volume of cold air being drawn into the bronchi Humidity Humidity has often been suspected of be ing a deleterious factor in asthmatics and it often proves to be According to Markow and Reicher " however, most patients apparently intolerant of damp neather are so be cause in the rainy season in the East the mold count is often high Dry climates are often docated for asthma, brut according to Perlman, Very lon relaun e humidities can be harmful in a more subtle way because of the dry Ing of the mucous membrane' Probably the best ansser to the effect of moist air and dry air lies in the unexplain cd fact that some patients best tolerate humidity, others aridity ·51 11e llanagement of Child! oo! Isthma whose asthma begin early and whose attacks are ses crc and frequent will of course by likely to have muluple allergies ind react slously to treatment Possible Allergens It the beginning of 1 survey of allergens ilıc motlıer is asked if slic suspects any food of causing asthm Ilthough the allergist is seldom fortun atc cnouglı to get such a history it is well worth the ash ing Thic infancy luistory is of the greatest importance as the allergic baby oſien reacts solently to food allergens and 11) of these are permanent sensitizations Instory of eczen? feeding problems and new born breathing citiculties (nasal or bronclul) may be of the greatest hielp in identifying such offenders as milk cgg citrus fruits and others Careful questioning alout housing conditions liouse pets type of beelding and reactions to house dust smoke and other inlulints is in order If the physician knows the seasemal incidence of pollens and molds for the pro vious year he can often correlite the listory with pollen and mold peaks It will help the mother remember the date of llure ups if she is asked Ion uns he on his birth day on Vicmorul Day on the fourth of July Hallone en might the Christmas holidays? Ilis birthday for example may huic happened to coincide with the pork day of the Ilternati? season and his mother may reply He had in attich uluch ruined his birthday party Clare ups during the Christmas season raise the question of allergy to ever greens housc dust (on stored decorations or 7 result of careless lioliday house cleaning) or 1 scasonal treat lilc cliocolate or pecins Systemic Allergic Vanifestations Careful investiga tion of systemic minifestations does tho things First it gnes information which wll help in finding the causes of asthma For example of the investigator finds that the ·50 Furling the Causes of Asthma child has a history of diarrhea from mill he may later find that the child has a larent sensitivity to thus food which becomes manifest as a cause of asthma wlien he has 2 cold Second it gives him the chance to relieve other allergie complaints Parents who have become resigned to minor eczema leadache or behavior problems are glad to see that the physician is very much interested in these problems as well Non allergie Manifestations While the child is under the close observation coincident to the minagement of asthma an excellent opportumty is presented for the dis covery of other pathology The allergic history should in clude non allergic factors in its scope The History Form Since no one will rememler all points of an allergic hustory a prepared Hustory sheet 15 tised Not only is this necessary for completeness but as an important record to which the plrysician can refer at any time \othing will shale the familys faith in the allergist (shtch after many false starts and lost hopes as often shaly enough alreacly) than for lum not to be instantly aware of all important phases of the fustory It is a mistake to keep a precise re cord of skin tests and laboratory tests many of which may be of no valute thatever and lude in important point in the lustory in 2 miss of record The fustory sheet used by the writer is shown in Figure SHIN TESTING The selection and number of shin tests depend on geography and the playscian s preferences Perli aps no tko allergists not sliving the same office tise quite the same selection in Figure 8 the shon test form used by ·50 The Vanagement of Childi ood Asthma Encircle outstanding findings Underline other significant findings Infancy Colic I czema Blocked nose omifing Diarrhet Constipation ose Blocking Dewburge Jil FEB VIR VPR 11 JU Sneezing Freq URI JUI ILG Ser OCT TOT DFC Cough Isthimi JU FEB VAR IPR MX1 JUN Pneumonia ( roup JUL IUG SET OCT NOV DEC Chest (I rorexia lomiting Pan Constip Eczema Diarrlen Foul breath Shin Urticaria (NS Iension Headache Fatigue Visc Enuresis Hyperludrasis Inhalants House Dust Cat Dog Volets Smoke Insecticides Foods Apple Ipricot Aspirin Banana Birley Bein Bett Beer Bect Broccoli Cabbage Carrot Cauliflower Celer Cherry Chicken Chocolate Cinnanion Coconut Coffee Coli Corn Cucumber Egg Fish Food colors Grape Grapefruit Lemon Lettuce Velons Vilkuts Oat Onion Oringe Pea Pennut Peach Petr Pecan Pepper (green) Pepper (black) Pineapple Plurn Pork Potato ce Shrimp Spinach Strouberty Sweet potato Tomato Halnut Wheat Figure 7 Allergy Plastory Record ·Finding the Causes of Asthma 1 Cattle Hair Car Hair Dog Hair Featers xed Horse Hair Rabbit Hair 2 Cottorisees Parakeer Feathers House Dust kapok P's rezhrum Silk Orris Root Aspergillus Alccrnaria Chaetonzum Fusarium Grın Dust Tobacco Helminhosporium Hormodendron Monilia Sucophila Pencilium Vincor 5 Burweed Varsh Elder Elm Vine Crosses hoclia Johnson Grass Bermuda Grass 6 Red Oak Russian Thistle Raguced mixed Hestern Water Hemp Ipple Bunan 7 Bect Binck Pepper Nai y Bean Cabunge Carrot Clunkers 8 Cashew Chocolate Egy Grape Corn M:31 9 On07 Orange Tenut Peach l'ork Potro Peran Slirimp Tuna cost Halers Tomato Figure 8 Shih Test Form ·58 The lanageinent of Childhood Asthma the writer is shown), and this may be discl as a guide in selecting extracts Extracts should be arranged in thic rach so as to correspond with their order on this shect In allergic skin testing. the extracts may be injected into the skin (intradermal or intracutaneous test) or applied to a superficial scarification (scratch or cutancois test) There are advantages to both methods, but in pediatric practice at least, the scratch test is preferred In ini estigative worh, the skin of a donor who has beci gncn intracutancous injections of scrum from an allergic pa tient is sometinics tested (passive transfer test) but this is of ro practical value in the study of childhood asthma' Intracutaneous Test The shiter uses the intracutaneous test very little Although it sometimes is more accurate than the scratch test it is also considerably more painful, and has been the cause of constitutional reactions leading to death *** It must never be used unless a preliminary scratch cest 1175 shoun the particular anugen to be a reactor of very low intensity, and it should be remembered that the tradition al 0 10 cc of the tuberculin test and other intracutaneous tests is far too much Only cnough to blanch a tiny area of the skin (about 002 cc) should be used Scratch Test Experience has taught that the most reactre and accessible areas for shin testing are the upper back and the lateral aspects of the upper arms The area to be used is gently washed with alcohol or Zephiran (If the skin is rubbed roughly it may temporarily reduce its reactivity) As nearly as possible the child should be handled in a manner least likely to frighten him, because a frightened child often reacts poorly, probably because of an increase ·Finding the Causes of Asthma 59 in circulating epinephrine Many times the child must be tested repeatedly unul he overcomes has fear of the pro cedure The scratch may be made sith any sharp instrument from a common pin to a small lancet The scratch should not cause bleeding but should be deep enough to be vis ible For several years the writer and lus associates have used the Morrison microscratcher" exclusively and its consentence and painlessness and the uniformity of its scarifications make it the instrument of choice It con sists of two main parts a rotating core with two sharp points at the end and an outer casing (Fig. 9) The core rotates by spring power and the device is cocked by so tating i knurled knob at the end opposite the scratching pourts When the cocked scratcher is pressed against ilze skin the points rotate sharply maling the scratch After the child is prepared for testing the MICTO scratcher is adjusted so that the possis are first visible as the plıysician sights across the end of the instrument Ex perience will show whether this is the correct setting and In any event the first scratch should be observed for a moment to see if the scratch is the correct depth in in fants and others with thin sensitive skins special care Feast be observed to avoid too deep a cut lfter the te quired number of scratches 171 e been made a small amount of extract (a large drop is wasteful and likely to run ) is applied to each scratch according to its place in the rack Twenty to thirty tests are sufficient for one sit ting, and in infants a dozen is often enough After 10 to 20 minutes depending on when the re actions seem to be at their peal the tests are read The reaction produced by the allergen is a sleal or bue SIIT rounded by an arei of erythem? There is trually con şiderable itching it a small shçal appears which definite-

·60
Pe lanageinent of Child) oor Astlima
Tigure 9 Morrison Microscratcher in Use (a) Setting depth of
ed by turning knurled end clockwise (c) Vaking the scratch by
pressing scratcher against skın Askın marking pencil or ballprint
pen is used to mark location of scratch

·61 Fin ling the Causes of Asti na dy extends beyond the circular scratch the reaction is re corded as ) plus If there is a large whea} 1 cm sr more in diameter the reaction is recorded 4 plus Intermediate wherls are labeled 2 plus and 3 plus accordin, to their intensity Although erythemi and achung curroborate the reaction it is the wheat that determines the reaching Significance of Skin Reactions Inhalaul's Feu tests in insecticine are more ccurate than skin tests for inhalant allergens Illergy to pollens molds and the various epidermals and dusts may be de tected accurately by esther scratch or sntracutaneous tests A test need not be strong to be significant If the firstory is positive for this antigen a borderline reactor may usua! ly be tentatively regarded as a factor in the case it is here that an intracutaneous test may be of help There are occasional exceptions to tire sul that 1.1 halants are dependable shin reactors False posities 1235 be obtained at times because of an ouerrerctive shin these can be detected by comparing the reaction with that of other anugens or a contro! It times the patient may fase deseloped respiratory allergy before the skin be comes reactive Buſfum fuas pointed out that this is com man in infants Another exception to the rule that all ants are good reactors is dog har" For some reason it is often negatise in chuldren definitely (soun in be do sensittle Foods as Sin Reactors in tren of their great poriince in allergy it is most unfortunate that foods are poor shin rectors" Lot only do knoun offenders com monly ful to react im quite innocent foods often gue false positie rerctions One is tempted to gre up shin testing for fooxls altogether but not infrequently the salut tion of 2 rase of asthma is greatly listened in the prens ·62 The Itanagement of Childhood Asthma ance of good skın reactions to foods Slin testing for foods Is somewhat more efficient in eczema than in respirator) allergy, and the chuid with associated eczema descries thie lielp that this method of testing may bring TIE CLINIC IL TESTI G or FOODS Thic failure of skin testing to furnish an accurate means of identifying fo«xl allergens hos forced the de velopment of clinical or dietary methods of testing There are several techniques, but all are based on the clinical response to food elimination and refeeding When to Test Foods In sei cic asthim the writer begins food testing at the first visit In milder cases especially where the history suggests pure inhalant sensitivity, testing is delayed until it appears that mhalant treatment is not adequate for complete relief It is often necessary to test common loods several times One reason for this is the difference in food colerance in the various seasons and another is the fact that astlima in the early weeks or months of management is occasionally so severe that a mmor food allergen may escape detection Selection of Foods For Testing There are several consulerations which gouern the choice of foods to be subjected to clinical testing The following criteria are useful in making the choice (1) A food with a luistory of causing any type of al lergic reaction at any age should huse first consideration For example a child who goes a luistory of prolonged colic or other feeding problem' should be suspected of milk allergy * while an cirly history of vomiting egg places tlus food under heavy suspicion ·Finding the Causes of Asthma 63 (2) A marhed craving for a particular food may be evidence of allergenicity" (3) Marled antipathy to a food in all forms sugges allergy to that food" (4) Sensitivity to a particular food may be a family trait" and when the mother remarks none of us can ent eggs or none of us can stand milk the mentioned food is under some suspicion (5) A strong skin reaction to a food allergen calls for clinical corroboration False positives in foods are com mon (6) If none of the above clues to food sensitivity proves useful foods should be tested in the order of their incidence as allergens in childhood allergy (Fig 2) It is of course a waste of time to test a food which the child seldom or never eats Technique of Clinical Food Testing The method of food testing used by the writer is a modification of the Rinkel Individual Food Test · Foods are usually eliminated for four days but any foods giving especially suspicious histories may be eliminated for 3 or 4 weeks while minor suspects are given 4 day studies in feasible the child is examined shortly before the test gain on the last day of abstinence and finally on the day following the return of the food to the diet The mother lias the responsibility of maintaining the dietary restric tions and of observing the chuld s symptomatic response to food manipulation The form shown in Figure 10 is given to the mother marked with the symptoms to be observed and foods to be eliminated Its use is explained in the opening paragraph of tlie form She is also given + diet diary form (Fig 11) so that a record of foods and symp toms may be kept ·61 The Vanagement of Childhood asthma Future 10 Ilimintuan Diets Eliminate the fornis marked blou for a period of days During the last two days of the dret clumination see if the symptoms winch are underlined bxley disappear or improve On the last tlay or two of the diet elmmunition I will want to see him and again a day or two following the return of the food Symptoms (ough wheezing laring the thront blocked nose rumny nose heud clue musk jclies 1CESSAC she iting constipation diarrhca stomach the foul breath tension fit, uc bed setting 1 Talk Wilk buttermilk RC (Ilimshierbet ces cheese cottage Clipesc custruind all creamed tools such is crean grasics soup potito dishes (reameel vegetables burier oleo and most baked fools including breu (Most culeren are not so allergic to mill that slight trices such as Coar in butter will cause trouble but during testing the diet should be completely free of milk 2 Chocolate and Cola (hocolate cocon cont col Pepsi oli and il carbon uted drinks containing cali cutricts 3 Grams (a) Wheat Breuils bredeal fools breakfast cereals cream stuce tlour muruni spaghetti noodles crickers vokies kc ero im cones pancules waffles brun pretre che dou, hnuts and mything in de siti flour Rie Isread un com bread contain wheat and occisionally heat is found in chili canned meats or fried meses to (1») Corn met corn syrup (most candy roolics cinned (ruut cougl syrup chewing bum) citieil corn corn on cob popcorn crackerjichs homın beer grits fritos corn cercals tamales tor ullas und miny other Venic in loods (c) Onts (d) Rice (e) Rye (1) Barley (Includmg malt) are used! mostly in brezkfast cereals 4 Egg Ice cream (some brindis) some nooilles noodle soup mer ingue custard meat lorf French toast jonnuse frostings some sulad dressings croquettes icings some cindtes fritters 1 most all baked goods are mule sath egg exceptions being ordinary bread buns crackers and buls cookies Be on your gurd for foods containing even the sliglatest trace of egg beciuse it must be completely eliminated 5 Beans Peas and Peanuts Remember to the way peanut butter chuli and candics nude with pernuts or peinut butter 6 Potato Tomato [gg Plant Peppers Tomto is found in many such micd disles 7 chili suures salads silid dressinge c1tsup pork and beans etc llatch for potito in soups and is potuto chips and sticks ·Finding the causes of Astma Figure 10 Continues 7 Cirrus Truits Orange lemon lime grapefruit langerne tiron kumquat 8 Apple Family Apple cider cider vinegar apple pectin jellies) pear quince 9 Plum Family Plum prune cherry peach apricot nectarine almond CASE STUDY The following case study is presented to illustrate the procedure used in working up a case of childhood asthma Since the sucessful soling of an asthma problem calls for the collection of a great deal of informaron this will be a rather losg report Houerer none of the find ings listed are without salut in a proper understanding of the case The hustory is gnen in the way given by the mother in conversational fwguage and in the present tense History AG year old boy first seen July 7 1953 has as his chef comp) uint asthma The apparent age of onset nas 31/2 yers Allics occur the year round but are more sciere and frequent in cold wenilier and are becoming more scrcre ind luard to relieve with the passige of time Infanc, The patient was started on breast feeding and guined weight satisfactorily However he was sa fussy that it was felt that he was not satisfied and he was seart ecl to an esaporated milk and corn syrup formula The baby s fussiness became korse when he was wennel and the formula upset lum in ilmost every way There were Freqitent forceful vomiting constipation and a mild fice rash Numerous feedings were irjest all of uinch were based on cows mulk (dried ex aporated or fresli) fruit There 175 Battle difference among them Thic vomiting

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Childhood Asthma
Lunch
The Management
Brealfast
60)
Date

·Tinding the Causes of Asthma 07 ceased at about 6 weeks but colic persisted up to about the seventh month During the first year there were sev eral attacks of diarrhea which although not severe were inclined to resist treatment As nearly as his mother can re member, he has never been entirely free of nasal stuffiness even as a new baby Nose for most of his life especially during the win ter the child has suffered with colds sore throats and ear infections Even when apparently free of a cold lic often rubs his nose and is compelled to brenthe for the most part through his mouth His tonsils and adenoids were Temoved at the age of 4 and for ses eral months fuis mouth breathing was somewhat improied Last year he develop ed typical hay fever beginning about the middle of Aug ust and lasting until frost Chest Asthma has been perennial but worse in win ter Comparison of the time of summer attacks shows that they correspond to known Alternaria peaks The attacks are almost always severe and may last as long as 5 or 6 days Oral medication including cortisone has seemed to be of little help Coughing is confined largely to isthma attacks but at times there will be a troublesome night cough without obvious asthma Inhalants The mother suspects Houst elust largely because she herself sneezes when cleaning house and be cause when the chuld is in the cellar the shrring up of dust causes sneezing and coughi The child gives a suspicious mold history He alwuys sneezes when his father cuts the grass and he has had a similar reaction to raking lenses and playing in dirt Once during a visit to a firm he came down with severe asthma after playing in a grain bin There are no pets in the home and he is not in con tact with other birds or animals He has used a foam rubber pillow for the past year and a half He always sneeres when his mother uses either 1 moth spray or mosquito spray ·69 The Flanagement of Childhoo l Asthma Castrointestinal system Ifit chill is a poor caler but iras been somewhat bciter the last scir lle crucd mill during his second ycar of life and got to the point 11lcre lic rould like lutle else Thuis did not concern inis mother because she felt that mulk was the perfect food and that is long as fie drink plenty of it he needed nothing else At about the indholl the fimily doctor foume the chill to be quite inemic and suggested that he be cu bick on his mulk in the Since then the child has honn less and less interest in inild but his mother in sists that he toke i gliss it ech meil The child frequenils i us foul breith especulls in the morning His mother thunks perlu upus fuis is counts for Ius poor appetite for bretheast Ski The child his no present skin allergies is 1101 al there 175 ppruns mild ficul cczenii tire first months of life During tus second and third winter there 1475 muli cxcmt of the fore arm and arm lolls Head 1 sacre ittick of hans it the age of four but the cause 1175 not letermined Terrous System The «lules mother states that he is cry nerous He is inclined to be cross and mood and If he dousn t get his 125 he will huic cantrums some ol wbuch are rather severe At ismes especially mornings he is listless and compluns of tiredness and log ache Tihen he w7s 2 or 9 yeirs old he would often have sciere leg pains it might It the same stage le 1175 n very poor sleep er and much of this seems to have been because of leg ache Miscellaneous The patient 1175 always been 7 heiny $cater but this is less noticeable in the past yerr or two Hc is inclined to urigare frequency and is guon to occ15 con il cnuresis Physical Findings The general appearance of the patient is one of chronic ill heuth He appears listless and irritable The ·rinding the causes of Isthma face is pale with dark circles of discoloration below the eyes He is of asthenic liabitus and has 1 slouching os ture Head The tonsils are absent The nasal mucosi I pale and of a grayish hue The inferior turbinates ue se swollen as practically to fill the anterior nusul cavity Both tympanic membranes are lusterless ud retracteri Chest The rib cage is normal On ordmary breath ing no abnormal sounds are heard but on forced expir ution diffuse wheezing is heard There are no definite signs of emphysema Abdomen and Extremities negative Laboratory Tindings 11 BC 6800 56 polys 37 lymphis 5 cos 1 mono Hb 13 gm Urine negative Tuberculin negative Chest Roentgenogram Negative except for slight in crease in peribronchial markings Nasal Smear Scattered throughout the smear are numerous cosinoplules about 15 per cent Differential Diagnosis Nothing was turned up in history physical examin ntion or laboratory to suggest disease other than asthm A probable diagnosis of asthma was made and an allergy study conunued Shin Tests The significunt rectors were Alternaria ragisced elm cat rur pyrethrum navy beins peinuts when Be cause of bor erline reaction to house clust in intra dermal test was done which is negative Clinical rood Tests In view of the patients stormy infancy milk #15 withilraun for a period of 1 month Bcaause of positie ·70 Tle Vanagement of Childhood Asthma shin tests to legumes (peinuts and beans) and wheat these loods were subjected to fourclay elimination tests 11 heat was negative Ilhile off legumes the patient scem ed to feel better in every way slept better and coughed less 11 lule abstaining from legumes fuis nose 135 less congested and had better color All findings became worse on a return to pernuts and beins The test was repeated with the same result At the end of 7 month milk was returned to the childs dict During abstinence he was unquestionably better Ils nose was less congested! he ate better and felt better On the night of returning to mill he descloped a rather severe attack of asthma His parents have refused to allow a refccding of this food and the child himself shares their feeling Treatment and Follow Up (Strictls speaking these tsso phases of manigement belong to Chapters 7 and 8 but they are so inextricably bound to ctiologic diagnosis they will be discussed is the case report continues ) Hyposensitization Treatment with Alternaria rag mood and clm extracts was begun injections being given 11ice weekly the first 2 months wechly unul December monthly through deep sinter and then bich to weekly injections Minor reactions necessitated temporary cut backs in treatment twice during the early stages of treat ment Avoidance Milk and legumes were to be avoided strictly The mother was carefully instructed in the sources of both categories She was also carefully instruc ted in the avoidance of all common inhalants including those giung a negative skin test Calcium wafers Here prescribed Follow up After the first 2 months or so there were no attacks of asthmi Nasal stuffiness came tinder con trol much more slowly and there was more or less reseci ·finding the Causes of Asthma 71 ual congestion throughout the first year During the sec ond year ol management nasal symptoms continued to improve to the point where there was no significant nasa! blocking After 3 years of treatment the child was dis missed as controlled WORKING OUT THE CAUSE Or ASTHMA IN INFANCY The management of asthma in infancy does not differ radically from the management of the disease in older children but there are a few points that justify special consideration In infants for example there must be moje care in differential diagnosis Asthma often acts more like bronchitis or whooping cough' tfian asthma while other diseases like foreign body in the bronchus or fibrocystic disease of the pancreas mimic asthma Also the small air way and mucus producing tendency of infants mahes for pecularly severe attacks Finally the dominance of food allergy in infancy colors the working out of the etiology of the case" Most asthmatic infants later develop inhal ant sensitivities and thus calls for frequent retesting in such cases Since infants are worked up in the same general way as older children much the same routine of history taking and skin testing is used but in the following case study the differences in the work up are illustrated Case Study, Infantile Asthma Present Hoston A 9 month old infant boy is brought in because of frcquent spells of choking up coughing and wheezing His mother states that he always 1778 7 rattling in the throat and that about escry two or three weeks he chokes up and wheeres (or two or three drys at a time At times these attacks are preceded by a coll it other times they come on without warning usually at night Two attacks have been so sesere that the childs ·The Management of Childhood Isthma lips become blue and he had to be taken to the hospital for ircitment in an oxygen tent There secms to be no change in intensity of attacks at trious seasons Prelous Histon Delnery was uncientful ind the infant #35 i norint! full term infint lle ad no obvious difficulties with his formula but his mother siss that he Inas ningys been 1 fussy snfant At about the age of 1 months le socmed to be more irritable than fic loud been prevousliind luis mother thought he might be hozung stom ich nche from cerculs Sie trial changing cereals und lound that lic ns less irritable on rice mod oats and she felt that mixa cercal (especialls) ind burley upset luni llis stools were frequentls loose for several as 71 7 time Besides cereals the child has been feel all vegetables fruit egg yolk mashed binın baby cookies and beel His mother docs not feel that any al tliese inile hun urrit able Inhalants The finuly are living m 7 new house anul there ire no house pets The infant sleeps on a plastie covered in uttress and he has no pillon or stuffeul 101He is seldom out of doors and is no worse after being taken out Physical frammation At tlie time of cinnation the chuid did not line ictive asthim The nose «cemerl blocked but very luile mucus 175 obtained on ispir ation and in the smeır there were neither eosinophils nor other cells The chest "negative Skin Tests The infint uns tested for house churst Alternut Hormodendrum mixed grasses monced milk egg oits rice whert burlei apple peach green beans peus carrot sheet potato egg orange and chocol nte All shin tests were negatie Diet Vanipulation from the fuistory there was doubt as to the compatibility of milk and cereals Because of thus these foods were eliminted in an effort to volite other possible causes vegetables and fruits were gnen on ·Finding the Causes of Asthina 78 separate clays on a 3-day rotation The child is given soy milk formula sweetened with cane sugu The mother Was instructed to keep a diary of foouls given anal associ ated symptoms Progress Four days after being placed on his dit tlic child was entirely frec of asthma None of the loods of frus rotated diet seerned to cause trouble and rotation was clus continued after 9 days and at the end of weeks he was returned to milk He remained free of asthm7 until being gren weat in the form of crackers and whicit cereal He was hept ole wheat for 7 wceh and at the end of that time was given barley cercal The giving of barley was also follouced by asthma in the succeeding 6 wcehs it is found that he was un ible to eat any of the cereals (whent corn rice onts and barley) Follow up The child deycloped a persistent cough at the age of 18 months Skin tests were negative but when the cough persisted and the child leveloped ? nasıl discharge he was re-examined At this visit he was found to live eosinophiles in hos nasal smear and a shin test was positive for Alternaria He has been kept on 41 ternının layposensitivation for the past year and has re mained well He has 1 permanent intolerance to wheat and corn Comment This case demonstrates how much the working out of 1n 18tlımı problem depends on follow up At first glance it apperrel that milk was 7 factor but it happened that cereals were taken out at the same time 18 milk It sliould be remembered that although mill is the great offenders in childhood food allergy beans in cluding soy berns are not infrequent sources of trouble (Tug 2) If the infint had continued to Inze difficulty alter 1 cliunge 10 7 305 mill mert base formula woull have been indiciled A beel base formult is available commercially or it can be prepare as follows **

·The lanagement of Childhood Asthma
SIRAINED Vest hokve
Strained frect pork lamb chicken 1 cup
Corn oil
344 tablespoon
(ranulated sugar
2 tablespoon
Tapına starch or flour
21/2 tablespoon
Calcium carbonate (buy + oz)
teaspoon
Table sali (not rolurcel)
tcapion
Water
quart
Hout water in the top of 1 double boiler until the water
in the outer boiler starts boiling Add the salt sugar and
calcium carbonnit Vix the search to a paste in 1/3 cup
of * iter and stir into the water in the top of the double
boiler Cool mixture for 10 minutes stirring constantly
Then add the struince me it and oil Vox thoroughly and
cool ten more minutes

·Chapter 6 TREATMENT OR THE ASTHMATIC ATTACK GENERAL MANAGEMENT A child in an attack of asthma represents much more than a problem of simple bronchial obstruction He is often dehydrated and weary he may be ill with infection and he is almost certainly very much afraid It is well for the physician to proceed on the assumption that all these factors are present or impending and to gre direct at tention to each if he proceeds to do so in an optimistic and confident manner the child and his parents will sense that relief is in sight and the aura of anxiety surrounding the case will greatly diminish When first seen the young patient will often be found to be breathing rapidly and jerhily This type of respiration represents the hyperventilation of fear and the chulds first need is gentle reassurance The writer has found the following maneuver tiseful The child is asked to watch the doctor who then proceeds to breathe slowly and not too deeply with plenty of time for expiration He is directed to breathe in this more deliberate way and to take plenty of time in emptying his lungs The slower rate is more efficient and by avoiding deep inspiration the child avoids the trapping of ur resultant emplıysema The child is then ready for therapy directed toward re lieving the obstructed airway Whether the patient is treated at home in the fros 75 ·76 The Management of Childhood dsthma pal, or in the doctors office, he is placed at rest 117 a quiet place Such sources of inhalant allerg) or irritation as tobacco smoke, house clust, menthol and camphor ſumes from vaporizers, etc, are eliminated Hot liquids lihe ica and broth visually have a relaxing effect, and if the chuld is not somiting these are to be encouraged Com mon allergens such as milk, choxolate, aspirin cola drinks, and egg are ljest withheld even though they are not known offenders in the particular case The cry fact that the Chuld is in an attach is presumpte evidence that all fac tors have not been identified' In enemy often is bene ficial perhaps because it remores intestinal gas which may interfere with contraction of the diplıragı DRUGS Epinephrine I he dose of epineplırme for a 150 pound man is 05 1, and hence it is proper to give 0 10 cc for cach 80 pounds of body weight This should, in fact, le considered the maximum dose and often half or the thirds as much is fully as effective By using smaller doses the physician is free to repeat injections as often as every 20 1o 30 minutes for tio to four injections So as to allow for precisely accurate dosage, a tuberculin syringe is used for admimstration and the use of a 26 needle will almost entirely olvate pain The home administration by a member of the family is recommended by Bonen,' froun exi on by Segal 'The writer has found thus practice wise in an occasional case Most patients have a nurse neighbor who will be glad to accommodate in the task It is not a bid plan to gue the patient a note or card on uunch lus dose is written This will allow aclministration by an emer gency room fouse physician without the danger of over closage ·Treatr rent of the Asthmatic detack 77 It is important that overdosage be avoided as in im proper doses there is likely to be very distressing tachy cardır ind tremor Aminophyllıne The physician will lase no trouble remembering how much epinephrine and aminophylline to give a chuld if he remembers that the adult dose of 11 000 aqueous epinephrine is 05 cc and the adult dose of aminophry? line is 05 gm Here however the resemblance encës Epinephrine is given subcutaneously and may be repeated rarlier frequently lule aminophylline is best guen in travenously or rectally and must not be repeated at fre quent intervals The physician who has given aminophryl Ime intramuscularly is not likely to do so again as the pain is intense It is poorly absorbed when given by mouth buat 1$ used occasionally for minor symptoms intravenous administration must be sloss Like epinephrine aminophyllsness overdosage is dangerous " and it is well to adhere to the dosage of 100 mg lo cach 30 pounds of body weiglut It must also be re membered that the drug has 1 cumularne action and it is wise to space closage at 12 hour inter als Other Drugs Cphedrine Ilthough Iery useful for os asthma tic symptoms ephedrine has luzie of any place in a severe attack. It is not effectise in severe asthma and it may lead to numerous unpleasant side effects particularly ex citement sneals and indigestion Levin* has mentioned ils occasional rendency to produce depression It may be gren zone or in combination with aminoplazłlıne autt histamshitcs or barbiturates The adult dose is 23 mg Jodides Potassium soddle occasionally finds tise is in ·TA The Vanacement of Childhood Asthma cxpectorant Il probably is inost uscíul following the more sciere stages of the attich The dose recommended by Overall is three curly doses of the saturated solution of potassium 10xlıle cach dose cqueling in drops the age in cirs Serlatives It is tlic writer s feeling that the only seda Inc nccdeel in asthma is the comforting presence of soli Chtous aculis The chuld needs an awareness of what is going on so that lie may understand and cooperate The barbiturates are more likely to cxcite than calm lum and if the physician secs tlie nocl of securion he may use Bena dryl or chloral Vorphine is the most dingerous of all drugs which line been used to bring rest in astlina being a respiratory depressant * The writer 117s not used atarec (1c (tranquilizing) Irugs since seeing one of lues asthma patients develop sciere shock after rectal chlorpromazine Talr or Drt (5 rp IN ASTIA Dose 10 IH Cholet Frequency Fpinephrine I 1 000 (10 cc sulicut 9 20 30 min for 3 or closes Iminophyllinc olgm 11 9 12 hr as long as needed SSKI S drop bs mouth tad as long as needed plcarine img by mouth 4 4 hr Pro Cortisone 25 75 mg by mouth 910 or 5 days ICTII Get 10 10 units IV dails or days Drug DEHIDRATION Since persistent somiting is a regular complication of severe asthma, dehydration and acidosis must often be given serious consideration Many times the 'toucap pearance of the patient depends more on dehydration and fatigue than on the asthma itself, and fluids may be the child's greatest need As Lesin" las pointed out, the de hydrated cluid inay have diminislied glycogen stores, and since chlorides are depleted by comiting, the appropriate ·Treat ent of the Istimat c Attack 79 solution for routine use would appear to be 5 per cent dextrose in salıne or Ringer s lactate solution Segal' te ports excellent results with plasma in patients with severe peripheral vascular collapse Since aminophylhne must be given slowly an intravenous infusion makes an ideal vehicle for this drug INFECTION Infection is a common and treacherous problem in asthmatic attacks especially in infants It may be the pre cipitating factor a complication or a little of both At times especially in young children what appears to be asthma may turn out to be bronchiolitis or bronchopneu monia Since exact differential diagnosis may be imposs ible antibiotics should not be witliheld STATUS ASTHMATICUS In asthma of young children failure to respond to treatment usually indicates that infection is present but in older children uncomplicated asthma may prove re sistant and the term status asthmaticus is properly ap plied The real basis for success in these cases is proper application of the measures already disclissed but at times other treatment is indicated Oxygen lien it is seen that an attack of asthma is blely to be severe or prolonged oxygen will often greatly relieve the tiring patient Thuis is especially true in infants and if given in 1 Croupette the combination of oxygen and cold steam is often dramatically effective Thic adds tion of carbon dioxide 5 per cent seems to be of value as the gas is both an expectorant and respiratory stim ulant Segalrecommends that continuous oxygen not be used longer than 18 hours Gamma Globulm Bonen hy recommended the use ·80 The Janagement of Childhood Asthma of galima globulin in resistant asthma in doses of 5 cc every month Ilthough there is no evidence of lack in ganma globulin in allergy, many astfimatic children seem to respond to this treatment (TH and (ortisone It is aluays comforting to late sonicthing in reserve in the management of a disease whiclı may at times beconie very seiere, and ICTH and the adrenocortical steroids fill this need l'nfortunately thcy are widely used in lieu of specific treatment, a role for which they are poorly adapted They are limited not alone in efficacy, but in safety, and current thinking may be summarized in thus statement of Leun," Treatment with these hormones is never a substitute for thorough allergk study and search for specific etiologic factors with subsequent specific avoidance or desensitization For this reason we limit the rise of these drugs to short term ther apy of 3 to 5 days for acute asthmatic episodes when the incasines alreadly outlined have not been su cessful in terminating an attack 'He finds ACTH gel the agent most likely to gre prompt relief, and recommends the following closage for a child of 5 years 1st Day 2nd day Srd day 4th day 5th day In a recent paper, Rachemann“ states that the ste roids cannot replace niore simple and less dangerous drugs, and adds that once started they are liard to stop In speaking of prednisone and prednisolone he says that their total effect, both good and bad is not very different from hydrocortisone 30 40 units 20 units 10 20 units 10 units if necessary 10 units if necessary WHAT NOT TO DO IN ASTHMATIC ATTACKS A fer prolubitions that have been found tuseful in

·Treatment of the Isthmatic Attack
81
teaching are these
(1) Never use morphine
(2) Use the smallest effective dose of all drugs
(3) Do not use Cole syrup to control vomiting in
allergic children
(4) A calm manner on the part of attending adults
is the best sedative
(5) Penıcıllın allergy is common in adults unusual
in children rare in infants When in doubt as to infection
in infants penıcıllın should be given but if there is no
reasonably good indication in older patients do not use it
(6) Dont criticize the parents of their failure to fol
low directions brought on an attack The allergist who is
patient and tolerant in his dealings with the family will
find the family patient and tolerant with him
(7) Don t overlook dehydration

·Chapter 7 SPECIFIC TREATMENT The treatinent of the asthmatic attack as discussed in the last chapter is non specific and should be part of the therapeutic equipment of every pliysician who treats buldren In thus chapter 11c usill be concerned with specific allergic treatment a type of therapy in which the play SK171) udio undertakes the permanent relief of the disease must le proficient l'he specific treatment of asthm is duided into two phases avoidance and hyposenstization Where complete avoidance is possible (as in foods and certain infinlants) no other treatment is required Where inlulint avoidance 15 impossible (as in pollen house dust, and inold allergy) lıyposensitization is indicated AVOIDANCL Or INHILANTS Avoidance of Almospheric Inhalants rlie allergic in de dual is to a large evient at the mercy of atmospheric inlialants, and unless he is able to retire to a climate de soud of the guilty pollens and spores, the best that he can hope for is partul asosdince At times it is practical for an individual to move from an area where a particularly toxic pollen such as rigweed is prevalent, but it must be lept in mind that lie my very well des elop a serisitivity to another pollen in huis new home Even if it were com monly successful, the practice of children being moved to an area where counts of all pollens are low has the serious 82 ·Specifc Treatment 89 disadvantage that the child is from then on a prisoner of climate and may not in adult life be free to ine where he tyishes Lven when being hyposensitized the patient with a lergy to pollens and molds should not expose hunself lo any greater concentration of the offending antgen tlian necessary Remaining indoors is of considerable ha lp to such patients and where efficient air conditioning is avail able tlus is quite practical if it does not too greatly limet the patients duties and recretion The chuld who sleeps in relatively pollen and mold free bedrooms and spends some of bus dayume hours indoors will better tolerate the lord of antigen le must contend with at other times Avoidance of Household and Other Environmental Inhalants The writer Leeps 7 copy of the picture shown in Figure 12 hanging in lus ollices and clinics This car toon was clesigned to demonstrate clearly to patients and families the sources of environmental inhalants It will be seen that sources of house dust molds and other allergens and primary respiratory irritants are illustrated in the basement are seen wet moldy walls sop por der sati dust moldy and dusty pipers (picked up by chuldren in paper draes) in old style furnice uith its cold air shaft and lieut pipes 15 shoun so that the parents may see for is should be kept clean in the room above are shown the dust formmg mattress stuffed toy pullous and stuffeci furniture I trions dust caschiers are shown including shelios drapes cornices books and rugs Primary irrit ints illustrated are paint perfume istion!! ridles etc Other anugens included are doc cat feathers pyrethrum tobacco smole hapok cotton seed and cruile hair mg prd Inging on the wall ss 1 form scene in which Tre sllustrated ſtarse and cattle und such sources of mold as strun hy lens churchen llouses etc Thus illustration insect

·87
rie Vlat agement of C) Idlond Asti na
ha
ht
F gure 12 Con mon Household Inhaly is For scussion see text

·Specific Trealment 35 has been found seful in indoctrmaung families in the mysteries of unlialant allergy and is kept hanging in plain view as a reminder of the importance of continued uigil ance in avoidance ALOI INCE OF FOOD ILLERGENS As in inhalant allergy avoidance of tood allergens is a part of both treatment and prophylaxis Ilhen a lood luas been identified 78 a definite allergen it is good prac tice to order its complete removal from the diet for one month As Rinkel has found abstinence from al lood tends to sncrease tolerance and after i munth some children can tolerate the food every 4 or 5 days If tuler ance has not been gained the fact is quire obvious to the parents and often to the child and the food 11111 be recogs nized as a food for much the child has permanent intuler ance The duty of the allergist extends to the use idance of future sensitizations Our Inon ledge of the biological re lationship of tools teaches is in encourige ciution in allowing a patient to eat foods closely related to those to ulisch he is sensitne Por eximple the child found sensi me to corn is fell aslysed in mod excessite use of other grains It is also well to caution against the excessite use of toods and drugs touch scem indigentc by nature stich 2 chocolate citrus fruits egg fish nuts aspirin and pens HI POSENSITIZITION Theoretically the degree of clinical sensiently quy Inhalınt allergen may be reduced bs the parenteral tc ministration of extracts of the oſtendig substance In prictice this procedure is largely tumited to house dust molds and pollens but it is of Occision Il tsse 11 other in ·86 The Management of Childhoorl Asthma halants such as dog hair. Physicians beginning to work with allergic people are commonly confused by discussion of low dosage, high dosage, titration, etc is to dosage and serial clution tests or litrations, most allergiste sull agree with Peshkin' in lciresing such tests have nou been shown to test on fundamental and scientific cudence and scrie only to add confusion 31 faise assurance in any cicnt, the way of knowing when the patient is sulle iently hyposensitized depends on the clinical «perience with trcatment of the patient in his particular evronment In practice most allergisis begin with a dose Wirele is lou enough to be safe, and proceed with caution to reach 'maximum tolerated dosage within the bounds of com fort and safety for the patient Is Withers once pointed out to the writer, the patient who has constitutional re actions may have no positive skin reactions at all the il riter once attempted hyposensitization in the case of a dental assistant with a positive raquecd lustory and a com pletely negative shin test Tven with the most extreme dilutions the prtient produced frightening consututional reactions Preparation of Treatment Set There is a great deal of variety in the methods of pre paring extracts for use in hyposensitization To avoid con fusion, the writer will present only his own method but those interested in other techniques including those in volung preparation of concentrates from crude materials may consult one of the standard textbooks of allergy Tlie pollen extracts used are the standard 1 10 con centrates obtainable through firms marketing allergic extracts The mold extracts are "Type 33," developed by the Association of Allergists for Mycological Intestigation and obtainable from the Hollister Srier Compiny The house ·Specific Treatment 87 TIRLF 111 DSLUTION OF ALTER EXTRACTS 1 Pollens (110) Tolce of concentrate ad !9 of saline This is 150 Poice of 1 100 ad } 40 slane Thusis I 500) Tole of 1 350 a Id cc salıne This is 1 2.500 To I re of 1:00 ack! 4 cc saline This ss} }2300 2 Ty} }} Volds (1 100) Tolec of concentrate add 9 cc salme Thus is 1 1 100 Tolce of 1 1000 adet ts saline This is 1 5000 To icc of 1 5000 add 4 cc saline Thssss : 25000 Tolecol? 21000 ad ! 4 cc saline This is 12100 3 Efro: H (140) Tool cc di concentrate add sal ne This is 1 000 To ce of 1 4000 adet ce salate This is ? 20 000 roi cc of 2000) adli«salite This is 100 000 Tocculto add 48 saliste 7h55 18 1 500 000 dust concentrate is that developed by Efron and obtun able from the Endo Conpany The strongest dilutions itsed in our offices and clinics are pollens 1 100 Type 33 molds 1 1000 and Ffron dust 14 000 The writer las not found stronger shelations of advantage although ciuldren can usually colerace aller gic extracts in the greatest concentration In Table Ill the method of diluting extracts is out lined Dilucing is done with a sterile syringe and the diluting extrict is ordinary buffered saline The indoned 1138 domng the difuting should be so a tocim to himself so ·88 The Management of Childhood asthma MIVEDRIGU EED (1 12 500) MIVED RIGH FED (1 2 500) 09 MI\LDRAGNEED (1 500) 333 MI\RIGHEED (1 100) Figure 13 Labeling of Pollen Treatment Set that there is no chance of a mistahe being made because of clistriction or interruption It is important that the sals be labeled carefully and since treatment may be grcn not only by the allergist, but boy fuis assistants refer ring doctors Other doctors assistants etc it is kise 10 label the vials so that there is scarcely any chance of the dosage being misunderstood although the strongest del uhon is the first dolution, it is not giren first' It is our practice to libel the wals according to wien they are used and therelore the weakest is mumber 1 We use to further spleguards se libel the bottle with the actual strength and to give emphasis that bottle 4 is the strongest four numerals are used Three are used for bottle 3 tuo for bottle ? und one for bottle 1 For example 7 ragneed set is labeled as shown in Figure 13 The bollles may be labeled according to anis 53slem that urll make certain that the relatue strengths of the dilutions uill be understood by the least experienced in dividual into whose hands these potent extracts may fall The metliod given here has pros ed practical and safe but ·Specifc Treatment any method wluch will make certain that there is no con fusion in dosage may be used Hyposensitszation Schedule Patients are begun on 003 uc of the weakest dilution and are treated with doses representing increases of a proximately 50 per cent until a maintenance dose is reach ed (Table 1) This is usually 0 25 cc of the stronges dilution but if the child exhibits persistent intolerance (local or constitutional reaction) at a louer dose the usual maintenance dose is just belon the dose wluch is not tolerated Injections are best ghen tu ke weehly until control is achieved but where this is not practical they may be guen weehly When the maintenance level us reached ille pacient is irented once a week during the period when the anngen to which he is sensitive is acre and every 3 tot weeks at other times It is n15e to cut the dose of potent pollens Ithe rigueed and Russian thistle in 1:all during the height of the season 15 full doses may cause reactions or accentuation of symptoms Precautions in Hyposensitization Allerg) extracts are potent agents and the playsıctın needs to be familiar sith their dangers As 7ll orseful drugs Tre potent honeser he should not be vfraud of them in occasional pruent reiets violently to injections and 1 knowledge of prevention and trertment of these reactions 1 very important The causes of reactions tre (I) oies closage mud (2) accidental entry of 1 sein I ocal Reactions it the site of the injection there will often be more or less itching ? sinoll heal and muid erythem? Thus is not to lic considered an intonard re action iſ an area of edema ? e or more in cameter pjeirs however this is to le considered a mikl tocit rc ·90 The Vanagement of Childhood Asthma TRIE IRPATMENT SCHEDLIFIY Hirost SITIZATION Bottle (1 12500 pollen 112000 Type 33 mold 100000 Endle house dust Ist dose 003 2nd dose 00> 3rd donc 007 cc fth dose 0 10 cc 5th dose 015 cc Gth done 0.25 cc Bottle 32 (1 2500 pollen 1 ?»,000 Type 35 molt I 100 ONI Fado house dust) 7th dose 005 cc and work up to irth doxe 0-25 cc Boltle 333 (1 500 pollen 1000 Type 33 mold 1 20 000 Endos house dust) 12th dose 00.cc and work up to 16th dose 025 cc Bottle 4141 (1 100 pollen 11000 Type 35 mold 11000 Bndo house dust) 17th dose 00cc and work up to 0.2, cc top dose Note in patients who cannot take the full dose of 0.2) cc of the strong est dilution the highest dose they can tolerate becomes the maintenance dose action In severe local reactions, the entire lateral aspect of the upper arın may suell Constitutional Reactions This alarming reaction, lucl is fortunately uncommon, may tale sei eral forms The patient may develop asthma or there may be multiple areas of urticaria, itching under the chun and betueen the scapulae, sneezing, pallor, cold sweats and prostration Coma and death are not unknown Prevention of Reactions To prevent reactions the physician attempts to avoid (1) exceeding tolerance (?)

·Specific Treatment 91 accidental overdosage and (3) accidental entry of a vein (1) Avoiding Exceeding Tolerance Especially if doses are being increased the patient or his parent is asked about any previous reaction After the injection the pa tient should remain in the vicinity of the office or clinic for about 20 minutes (2) Avoiding Accidental Overdosage The old rule Lised in eye medication may be applied here Check dose and dilution before drawing in into syringe before in jection and immediately after injection (3) Avoiding dccidental Entry of I ein This acci dent should be carefully avoided The precaution of draw ing back on the plunger of the syringe should be followed It is wise to use a 24 or 25 gauge needle as a smaller needle may not allow reflux of blood It is a good practice to keep on hand a pachage of red adhesive stars to affix to the treatment record of any pa tient who has any type of untoward reaction Once a pa tient has had a treatment reaction of any type drop back to two or three steps below the point where the reaction Occurred and increase thereafter with caution Treatment of Reactions Treatment is usually not necessary for local reactions but patients so reacting should be kept in the office for about 20 minutes to be certain tliey are not in an incipient constitutional reaction If there is doubt it is best to proreed as if a constitutional reaction is present The patient having a constitutional reaction is made to lie down and a liglit tourniquet is placed above the site of the injection He is given epinephrine (aqueous 1 1000) 0 10 cc for each 30 pounds of body weight in the injection site and the same dose in the other arm An antihistaminic is given by mouth The patient is lept in ·92 The Management of Childhood Asthma the office until Icovered Turther treatment, if necessary, is grion along the lines of management of the asthma at tach, page 75 How Long is Hyposensitization Continued> There is no easy answer to this question Generally speaking, mold and pollen treatment should be continued I full year after control is adequate In the case of house dust, most patients become so careful in avoidance that 1 or 2 years of treatment are considered adequate In poor environments, especially where asthmia is severe house dust treatment may have to be gisen indefinitely ·Chapter 8 MANAGEMENT OF PROBLEM CASES I". the management of childhood asthma as in such fields is orthopedics and orthodontia success depends to a large extent on efficient follow up in most cases this involves little more than proper attention to stundurd allergic routine but in others it may be very dificult and tedious and these problem cases call for all possible skill and perserverince This chapter will be devoted to the important sources of treatment fulure and to the methods indicated for correction Failure in Family Cooperation In spite of the most careful attention to fimily edu cation there will be an occasional case where the parents are unable or unwillmg to cooperate Ar umes as when the family is broken or a parent is mentally incompetent the physician may face an impossibile situation but in the great majority of cases a relationship can be establish ecl wuch will make successful management of the case possible la is well to remember that the lamıly very like ly has other problems besides the chills 75to17 prol lems perhaps of even greater importance It is seldom that a family willful tlie physician when he makes it clear that he has a genuine interest not only 11) their child but in their problems in general He is especially likely to be successful in wimuing their confi dence if his fees do not impose un induc burden on the 93 ·91 The faringement of Childhood Asthma Camily budget! Vany allergists huc found it kise to treat all asthm on the basis of 7 flat fce covering all services rendered during a stated period of time Tlus not only allous the parents to budget the allergy fee but encour iges them in fyring the child in often enough and long enough to insure proper control Incomplete Avoidance Since isoidance is of the utmost inportilice 11 asthi in it is necessary that the follows up include frequent checks of this phase of treatment as the asthma becomes quiescent it is only natural that the child and those about lm become lax in asordance It may be found that one child has been gren a house pet beciuse he didnt react to the skin test that another sensitzie to egg kas been eating a new and egg containing brand of ice cream or candy that mother is using a ferther pillon on top of his loam rubber pillou The more the allergist shares his understanding of allergy with mothers and the less he relies on involved prepired lists the better will allergens be avoided The mother who really understands what is being avoided and hy suah restriction is necessary may be depended on to see to it that this important phase of treatment is success fully carried out Slow Response to Hyposensitization Although some cluldren respond to liyposensitization with remarkable promptness others respond very slowly Thus is notably true in mold allergy especially in cases of long standing In such cases the allergist is well udvised ļo inform the parents in advance that although there should be constant improvement good control may be delayed for a year or so Having the mother watch daily ·Management of Problem Cases 95 fluctuations in the mold count is of great help in cases uliere results of mold treatment are slow It helps her determine when outdoor activities need to be restricted and makes it possible for her to see increasing resistance to concentrations of spores which have in the past brought on severe asthma New Sensitivities Although cluldren with asthma are perfectly capable of developing new sensitivities at any time they are for tunately not especially inclined to do so This is particu larly true when the mother has been properly instructed in allergic prophylaxis 11 hen however the youngster enther fails to respond to treatment of relapses from ade quate control the possibility of neu sensitization is to be considered Among inhalants pollens are especially likely to appear well after other allergens have been identified and controlled At times a food which has not pie lous ly been eaten is introduced into the diet with resultant relapse Among the many which may react in this way are chocolate legumes cinnamon black pepper food colors shrimp walnut cettonseed meal mint and strawberry Psychic Factors Althouglı allergists in general dissent from the theory of the psychogenic origin of asthma unustial psychic stress is i recognized contributing factor in certain cases A pr tient of the writer a very allergic girl of 6 years whose Sather regularly expressed bus franh hatred for fier 195 much relieved of asthm following his stilden death An other little girl also known to have widespread sensitivi ties was openly rejected and neglected by both parents who were do orced shortly after the child was first seen In her case there 1 75 7 less obv 10115 relationshup between ·OG The Manngement of Childhood Asthma hier unhappy situation and her asthma, but certainly the Iroken home made inipossible proper attention to lier allergic needs Whatever the role of psychic factors in asthma, the allergist is first of all a plıysician and will be certain to do all he can to free any of his young patients from the trag edy of an unhappy childhood He must not, on the other hand, tise the psychosomatic theory as a convement excuse for hus failures Hidden Tool Allergens The problem in intractable astlima which is at once the most important and difficult is that of hidden or latent food allergies It is a difficult problem because Iudden food allergens may become manifest only when the child is under stress It is an important problem because failure to recognize guilty foods is certain to lead to poor results if not outright failure When the child is carrying a heny load of inhalant allergy, or is under nonspecific stress as from infection or chulling, these subtle offenders become of the greatest possible significance At times the presence of hidden food allergens can be picked up by repeated individual eliminations However, thus has the disadvantage of being an extended process and the patience of the family (and the futh of the neigh bors) is sorely tried With the use of the follos ing diet the writer has had excellent results This diet called the 8 day diet because of its duration, eliminates all cominon offenders while rotating all others A record of foods and symptoms is hept on a food diary slieet (Fig 11) If asth matic and other allergic symptoms clear remarkably dur ing the 8 days of the diet, one of the foods which was com pletely eliminated is suspected If he clears on certain days and flares on others, one of the foods or food families be ·97 Management of Problem Cases ing rotated is suspected Many times at the end of the diet the child is relieved, but the cause is unknown In this case, the rotation is continued and eliminated foods are returned to the diet in turn until the culprit is found Often the diet cannot be used as shown because it contains known food allergens but it is not difficult to mahe sub stitutions The 8 day diet as gnien belor includes the instruc tions given to the patient s mother LT DAY DIET Thys diet eliminates all cominon foods and rotates the rest You may cook with vegetable oil and shortening sugar and salt Although butter and oleo contain traces of muk they can be used m moderation The child does not have to eat any particular food and since this is a very strict det it as wise to allow him to eat when he wants and as nuch as he wants Note on fruits 11 hen a fruit is allowed it must be esther fresh dietetic (water pack) or dred It must not contain either food dye or corn syrup Tirst Day Reet (hamburger breah fast Ixecf dried beef ro ist steal ctt) I olan potato chips Tomato tomato juice lush (han fresh pork ba Lalud ctc ) Jirst 01 Second Days Banana (inge ile Beet Sprach Date 1 apioca Cucumbei pickics Lettuce Cantaloupe Yuash 11 terinenn (ranberr Current ( xeberry Rhubarb נlנון 1 Second Day Third Day Blars pets peinuts Apple stoler apple vinegar Pear Chicken (nut hem) Grape pe price raisin isli (salmon tuna fresh fish etc) Onion Ispani, us run rune peach cherry Almond Third or Tourth Days (artof Celery Broccoli Cabbage Catift *er 1 urip Brussel splits One Tea Radush l'armp Sweet Potato Pineapy le Fig lourth Day ·09 The Vanarment of Childhood Isthma Ifter following this dict for four days the chill repeats the wme schedule for an additional four dans keep a record of all foods dooks and medicines taken during this perial on the diet diars street 115c male note of any allergic simptomis that occur during the eight days - ·Chapter 9 ALLERGIC COOKERY The great majority of mothers faced with the task of re stricting the diet of their allergic children quickly ad just to these restrictions and, even with little if any in struction, learn to prepare well balanced and palatable diets However, they will learn to do so much more quick ly and satisfactorily if they start with certain fundamentals of food avoidance and substitution which have been learn ed by others It is the purpose of this chapter to outline these fundamentals A few recipes will be given all of which have been brought in by mothers who have actually put them into use, but for the most part discussion will be devoted to fundamentals and basic principles These will be discussed according to the food to be avoided MILL-FREE DIETS Since cow's milk is a universal food in infants and Chuldren, mill substitution is a real problem in infants the most practical solution is the use of one of the soy milks' The product with which the writer has had the most experience is Mullsoy It is palatable, and num erous reports have shown it to be equal to cow's milk nutritionally In older children unable to take milk, the intake of animal protein should be high, and the eating of meat, fowl, egy, and fish is encouraged Useſul calcium supple Calcets (Walker), Syrup of Neocalglucon Inents are 99 ·100 The Management of Childhood Asthma (Sandoz), calcium lactate, calcium wafers, or even cal ciun carbonate powder Strice chuldiren almost always are very fond of ice (ream and other frozen desserts, most mothers of children with milk allergy arc glad to non of ways of making sub stitutes Delicious ices may be made with fruit pulps and juices Soy milhs or the coffee crem substitute Mocha Vii* may be used as a base for ice creain The latter is also liscful as a substitute for milk on cereals but it must be pointed out that unlike soy mills it does not have the mutritional value of cow's milk Raspbern Ire 1 package raspberrs flavored gelating 1/2 cup sugar 11/4 cups hot water 14 cup lemon juice pichages froren rispberries thanel siesed Other fruits and gelatine flavors may be used ) Dissolve gelatine and sugar in hot water and cool Adu lemon juice and fruit pour into refrigerator tray freeze Break up bcat smooth and refreeze 3 hours In cooking, most mothers find at best to learn to cook without creiming foods, using water in gravies and sauces Vegetables may be buttered in most cases, as crcamery butter contains very little milk protein EGG-TREE DIETS Egg is used in cooking for its flavor, binding qualities and (by trapping air in whipping) as a leajening agent It also makes Laked goods lighter and moister There is no efficient substitute for egg in cooking, but by exercis mg sufficient ingenuity, the mother can do very well with out it By local inqmry, ice creams and sherbers can be found which are made without egg Most children are very fond of canned noodle soup which contains eng * Acrated Products 2714 Cherry Kansas City Vo ·Allergie Cookery 101 noodles and probably hen, but mothers can make their own noodle soup with egg free noodles and friers It is in baling that a Inowledge of egg sulostintes is especially valuable Since even the baling ponder may contain cgg, the mother is directed to itse euther KC Dr Prices, or Royal baking powders Fruit pulp is useful as a moistening and binding agent Wacky Cakc Start heating oven to 310' Sift together 11/2 cups sifted all purpose flour 1/2 tsp salt lahlsp cocoa 1 tsp baking soda and 1 cup sugar Vahe 3 hoks in mngredients in first hole put ispegar second I tæp pure vanilla extract in third 5 tablsp salad ml Over whole thing pour 1 cup water Mix well Bake 30 min or unus tester comes out clean This cake is mixed 113 the same pan in which it is baked Eggless Cake 2 cups cake flour 2 11p ceg Iree baling powder 1 tsp salt 1/3 cup shortering 1 cup sugar 1. tup Vocha fix (ot water) 1 tsp tanilla Sift fou once and baking powder and salt Soft agun (ream Sugar and shortching dd lour mixture and Marlia Vix and cat well Bale in No 8 inch cake pans of loaf pans Sef oven at 375 and bake 20 minutes (i mashed banant or a pinch of soda mas lx added) Chinese Almond Cookies ? cups flour SCP sugar Isp almond extract 1 cup shortening at least falf hutier si ale Mix shortening and favor thoroughly Arul lor and sugar hircil until rolls Slice Balc al S.' 10 minutes ·102 The Management of Childhood Asthma COR TREE DICTS rhe chuc problem in corn allergy is the produce of corn syrup often one of the worst corn offenders Suice corn starch is not widely used in commercial foods or in home cooking it 15 not ? 1112jor problem and most aller Ists feel that corn oil and corn sugu are not antigenta Sur honey brown sugir ind maple sugar (and syrup) (in hc usccl where fruits desserts candies and baked goods are to be succtened Children who get hun ry for popcorn my be given peanuts (or other nuts as toler 710) salteel non corn breakfast cerents various <rchers pointo chips and pretzels WIC IT TREE DIETS Tothing is more cricting than the norance et Whent and since sheet oncs its excellent biking ques to gluen other flours are far from sausfactory Two ryc products Ry Krisp and canned rye bread are taken nell by many chuldren especially if tliey are toasted rous used in place of wheat flour are taploci flour soy flour arrol root flour and potato flour Because of their close biological relation to a fent flours made from gruns such is corn rice out and ſe although not forbulden te not to be encouraged for general use Peanut Butter Cookies (Contain no grains) 42 cup brown sugar 3 cup sugar 1 cup vegetable shorten ng 1 cup peanut butter 1 cup tapioca flour legg beaten 2 tsp soda 44 tsp vanilla 1 tsp salt ·Allergic Cooker) 103 Bahe 1 to 15 unutes at 400 Yules al ott! (rs Joren Vacaroon15 (Centally no grains) Beat Tul still 1/2 cup egg wl ile Beat in 11 cup sugar 14 Isp salt 1 tsp vanilla and 1 cup brolen nut mcats not too fue Diep ro in leul tsp ? 1 ches apart on ungrease wrapp ng paper 01 l ak ng sleet Bakc ntil set and le cately brown conut "15 rups may be used in place of nuts TOVATO TREE DIETS Although tomato is widely used in cooling it is surprising how easily it may be avoided for example a delicious combination salıd may be made with lettuce carrot cauliflower pepper radıslı celery and other rau vegetables plus an appropriate salad dressing Soups cluli and stens will be found to lose little from the elimination of tomato In the making of chili sugar and vinegar sur ply much of the sour sueet character of tomato CITRUS TREE DIETS Children we cannot take citrus juices may use as substitutes grape juice pineapple juce tomuto je apricot nectar apple juce etc For eating betti con meals most children like grapes plums apples pears bananas and peaches Many chuldren lile raisins prunes and other dried fruits as is FOOD DYE FREE DIETS Children who must 71 od food dyes and flors must avou pop Popsichles frankfurters Jello hoolide olco colored ice cream and several other foods In place of colored carbonated drinks they can be given the clear mixers like ginger ale and lite soda Gelatine desserts may be colored and flavored with frut jilices Sensitivity to food dyes does not necessarily extend to all colors Ix perience will shou huch of these inust be 7 oided ·101 The Slanagement of Childhood Asthma VCAT-TREE DIETS The child sensitive to porh inay be given lamb par lics, breakfast beef (in place of bacon), liamburger fishi cluchen, and egs The child with beef allergy often tales pork stcals, lamb parties and chops and other meats very well The cluid sensitive to fish may be able to eat shrimp and vice versa Chicken allergy is rare, and when there is doubt as to the other meats it is very useful as a source of anunal protein ·REFERENCES 1 Adrianı ) Anesthesr ind allergy Ann Allergy 1519 1951 2 Baker J Allergy in children as related to alutude Ann Allergy 6 33 1948 S Balyeat RM and Rinkel HJ Allergic migrune in children Am J Dis Child 4 1126 1931 4 Bedford P D Idiosyncracy to aureomycin Butish NI ] 1 140. 1951 5 Berly M Z Jr Considerations of special interest to the allergist on the composition of production of poliomyelitis vaccine Ann Allergi 14 349 1950 6 Black I Ravin Turman VII Foreign body in Tespiratory tract simulating bronchial asthma Ann Al lergy 11 40 1933 7 Bowen R Some practical suggestions in the management of asthmatic children 11 Rec v Ann 39 1189 1915 8 Bowen R The Achilles liecl in allergy South A1 ] 47 163 1951 9 Bowen R Gimma globulin and the astlimatic child | Allergy 26 87 1955 10 Briedlahl HG Syndrome of cyclic attacks of allergy in childhooil i Australia = 961 1990 11 Brier A J in Sampter N and Purham O G Regional Alle gy of the Unted States Canada Yerico and Cuba Springfield Thomas 19.30 12 Brown I. A Drug alleig tart Rer Allerg - Applied Immuno! 751 1903 13 Bronn td anel Columbo The 1stlunogenic effect of olors smells me lumics Inn Allerg) 13 14 1951 ·106 1 he Vanagement of Chuldl vod istina 11 Brown GT Pollen Slide Studies Springfield Thomas 1919 15 Buftum 11 P Isthmi in infunci Anu Allergy 11 175 1953 16 Bullum lr The dignosis of asthma in infunts and children dam | Dis Child 93 231 1957 17 Catzort AG inel Johnston TG in Simpter 11 and Durham ( Regional Allergy of the muted States Canada Verica and Cuba Springfiell Thomas 1955 18 Chobot R Pediatric Allery Sex Torh lfcGris Hill 1951 19 Christensen (Vind Snachly in Sheldon J V Lovell R 6 Vulietis krd Vannal of (cal Al lers Philadelphin Stunders 1953 20 Clan 1 Cols mill allergs in infint l'ediat Chin North america 1 919 193 1 21 Crump I liccne treatment in allergk respiratori con ditions Pediat Chin Vorth America 1 987 1951 22 Curpley T Tatal anaphylaxis in bronchial zsthma fol lowing «ministration of penicillin tuo cises with autopsy findings Vew York į Med 53 1107 1953 23 Deumer 11 C in Ratner 1 Allein in Relation to Pediatrics St Paul und Minnerpolis Bruce 101 p 169 21 Decs SC Development and course of asthma in child ren MVA Am I Dis Chld 93 228 1997 25 Dees SC The use of aminophyllene rectal suppositor ses in the trentment of bronchial 1stlun Allerg) 14 192 1913 26 Derles V J Wenser Nk and Cotton IL Complı citions of bronchial asthm im Sc 222 88 1951 27 Durham O Cind Vchay F L in Shelilon J 1 Lor ell RG Vathens IPA Manual of Climcal Allergy Philadelphia Saunders 1953 28 Editorial | Allerg), 24 187, 1953 29 Field C Bronchuectasis in children cmical suri ey of 160 cases Pediatrics 1 21 1919 ·References 107 30 Feingold BT The influence of infection on the course of allergy in childien J Pediat 14 515 1919 31 Fineman HA The pressure test as an and in the clinical diagnosis of bronchial asthma AI & Rec, 135 425 1932 32 Foreign I etters England Sulfur chief cause of fog deaths TATA 156 785 1954 33 Glaser 1 Vigraine in pediatric practice Observations with special reference to migraine of allergic origin AMA Am I Der Child P8 92 1954 34 Glaser Allergy in Childhood Springfield Thomas 1956 35 Halpern SR and Hilpern D Reactions from dpt immunization and its relationship to ulergic children Pediat 47 60 1955 36 Hansel FK Clinical Allergy St Louis Mosby 1993 37 Hansen Pruess OC Arsenic in the treatment of asthma Ann Allergy 131 1935 38 Hurris C and Shure N Sudden death due to allergy tests | Allergy 1 208 1930 39 Horesh A J Allergy to odor of white poruto (Irish potato) | Allergy 15 147 1944 40 Leun s į Management of the acute asthmatic attack in childhood Pediat Chin North America 1975 1994 41 Loveless MH and Fachler JR Wasp venon and immunity Ann Allerg 14 347 1956 4. 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96 Wodehouse RP Pollen Grains New York McGraw
Hill 1935

·re Management of chill on 1 {sti na ficid Thomas 1935 77 Schaffer uncl Sercmon LP Vold content of air clinical aspects | Soc leu Jersey 51 68 1991 78 Segal VS Seiere Bronchal Asthma Springfield Thomas 1930 79 Sheldon ) Vind Losell RG Asthma due to halogens A Pract 13 1919 80 Sherman 1 B Drug allergy Ann | Ved 3 509 1917 81 Sulier AS ind 110man PI (hironic arsenic poi soning following use of asthma remedy containing Fowl er s solution (potassium arsenite) 1 322 1952 82 Sobel G Adenotonsillectomy ind its relation to asthma ann allergy 11 583 1993 83 Speer FTlie allergic tension fatigue syndrome Pediat Clin North America 1 1029 1931 81 Swineford 0 }r and leaser V Histori taling in allerg) an Int Med 20 293 1914 85 Swinelord o Jr Don I do this in allergy Ann Int Wed 20 293 1993 86 Swinncy B Severe reactions from insect stings Texas 1 Med 46 639 19.0 87 Unger L Bionchial Asthma Springfield Thomas 1945 89 Urbach L Analysis of 152 ward cases of asthma In Ternat Chin #89 1910 89 Vaughan T Food allergens I A genetic classifica tion with results of group testing / Allergy 1 385 1930 90 Vaughan 11 Tand Pipes D V Correlation between food dislikes ind food allergy ) Allerg) 8 257 1937 91 laterhourse 1 T Bee stings and anaphylaxis Lancet 2 946 1914 92 Wiseman JR anul VcCarthy Brough MP Skin sensitivity in the aged futality following intracutaneous tests J Allerg) 16 200 1915 93 liithers OR Tood allergens a statistical study of 43 cases relative to the genetic classification of foods South ·INDEX etiolology 21 2 mosle of onset 8 physical finding 8 thymic 19 treatment of attack 7) 81 treatment specific 82 98 Atmosphcuc studies 30 36 Avoidance failure in 94 food 85 Inhalant 82 8 A Abdomen distension 16 pain) 15 Acetylsalicylic acid 1) 47 ACTH 80 Adrenalin 76 Air conditioners 83 41r studies 30 36 Allergens food 42 46 62 inhalant 21 11 Allergic cochery 99 Allernarta 23 28 7 Altitude 52 Amaranths 26 $8 Ambrosio 24 38 Immophyllme 77 79 Ingioedema 14 Animal enianations 99 61 Aphthae 16 Artemasın 25 38 Aspirin 447 Istina attack 7 7 treatment 73 80 what not to do 80 Asthma cardiac 20 clinical picture 7 cyclic 11 definition 3 diagnosis 7 18 B Beer 29 Behaviour 14 Bloating 16 Blox in asthina 17 Bronchrectasis 19 Bronchiolitis 18 Bronchitis astmatic 18 Bronchopneumonta 18 Bronchus foreigti bods 18 Burning bush 2 Burkced marsh elder 21 с Calendar pollen mol 33 15 Canalis 37 38 Canker sores 16 Cardiac asthma 20 Case studies 671 Cat haur 39 Cattle hair 39 113 ·114 Index Dye food 43 103 Dyspnca sighing - Colar mountain 26 98 Chenopouls 25 Chcst dcformity & 9 Chilling 1D 51 Chocolate 22 23 43 Citrus fruits tos Climate 51 Clmical picture 7 (Actite 2 Cola 243 81 (olds 12 49 Color food f 103 Compositae 24 Constipation 15 Constitutional allergy 11 54 Convulsions 15 Cookery allergic 99 Cor 102 Corticotropin 80 Cortisone RO Coutonsced 40 Croup 19 Cutaneous test 58 Cyclo comiting 15 E Ecrema 13 Education familo 5 89 Egg 45 103 Elm 26 38 Emotional factors 5 2 9) Emphysema 8 Fnuresis 17 Fosinophilia bloodt 17 nasal 13 Ephedrine 77 Epinephrine 76 Fpithelials 39 Etiologic diagnosis 53 74 Etiology of asthma 21 52 Extracis preparation 86 D Dehydration 7A Dermatoses allergic 13 Desensitization 83 Diagnosis asthm. 7 differential 18 etiologic 53 Diarrhea 15 Dict diary 66 96 eight (lay 96 elunination 61 96 Dog har 39 61 Drugs as allergens tv in treatment 10 Must house 36 83 86 F Hacies allergic 17 Family of asthmatic child IAI 93 Fatigue allergic 14 Feathers 39 Fetor oris 16 Feier allergic 17 Flatulence 16 Foods 49 62 99 antipathy to 63 acordance & 99 crasing 63 distahes 69 dies 103 families 43 hidden allergens 16 important 22 23 12 preparation 99 shin tests 61 63 sources 46 tolerance & Foreign body on broncus 18 ·Index 115 Foul breath 16 Fungi 28 30 37 43 G Gamma globulin 79 Castrointestinal allergy 15 Genitourinary allergy 16 Ceographic tongue 16 Glycerin jelly 31 Glue fish 41 Coosefoot 25 Crasses 21 38 important 22 23 27 irritants 49 51 molds 28 37 non seasonal 36 41 pollen 21 28 3. 39 scasonal 21 30 shin testing 53 62 Insect allergy 40 48 Insecticides 40 41 Intracutaneous test 58 loclides 77 Irritants inhalant 1951 4 Jelly glycerin 31 h kochia scoparia 2) L Lambs quarters 2) Laryngeal stridor 19 Loeffler s sindrome 20 H Hansel stain 13 Hay fever 12 Ha feser Y 27 Headache 14 Heart disease congenital 19 Helminthosporu 29 37 Hemp 27 88 History foro 556 History taking 53 Hori odendrum 2) 37 Horse dander 39 serutn 4/ House clust 36 83 86 Humidity 51 Hyperhidrosts 11 Hyposensitizauon 899 dosage 89 extract preparation 86 87 how long continued 92 precautions 89 reactions 89 schedule R9 slow response to 91 Marihuana ! 38 Veat base formula 14 Veat free diet 104 Microscratcher Vorrison 59 60 Magrane 14 Vulk 16 23 45 99 substitutes 74 99 Molds 28 30 37 Yon la sito hela 9 Vorphine danger of 78 Vother of asthmatic child + RI 98 Mountain colar 26 Muscular pain 17 1 Infanc asthma in 71 Infection 10 49 79 Inhalants 21 41 61 82 alondance 82 epithelials 50 Vasal allerg) 19 cognophilia 15 ·116 Index tumatto 12 olystructoti 20 $133 13 Versos sistemi! 0 Oak 2018 Orange 103 Orris rewt 10 (wigen 70 Sughing dyspnca 20 Silk 10 Shin allergy 13 Skin lots 5567 form 57 intracutaneous 59 passic transfer 54 scratch 8 Smoke tobacco 40 Spondylocladom 37 Spores mold 39 37 Status asthmaticus 79 Stridor lanngeal 19 Sucating erressnc 17 Sustemic allergy 11 31 Pallor allergic 17 Purcas broxstic discare 19 Parents 1, 81 95 Penicillin 46 47 81 Perspiration excessive 17 l'iguceds 26 Physical allergy al Playstal crammation 8 Plant in 26 Puc tuinonia 19 Pollen 21 28 9 94 Polleni shelter 1032 Prednisone 80 Problein cases 99.99 Psychic factors ) 19) Pyretlim 10 T Tension allergic 14 Thermal facters 10 51 Thymnis 19 Tolacca 40 Tomato 103 Tongue geographic 16 Trees 26 U Urinary manifestations 16 1 rticaria 1+ R Rabbit hair 39 Ragweed 24 38 Reactions to treatment 89 Rug pads 39 Russian thistle 25 58 Vomiting 7 14 15 16 78 Tulsa irtinuon 16 S 11 eculs 2119 Il estern water hemp 26 Ihcat 102 11 oris ocul 21 Sage ? 98 Scratch test 58 Seclaties 78 Serum horse 48 Yeast 29

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