Eczema News – Non-Celiac Gluten Sensitivity

Around end November 2014, I ran a blog series on Children Food Sensitivities, explaining there are various types of gluten-related food sensitivities, namely:

GLUTEN SENSITIVITY

Various types of gluten-related conditions

Celiac disease – Immune system attacks the villi in the esophagus when exposed to gluten protein gliadin, found in wheat, barley, rye, and sometimes oats. This lead to intestinal inflammation, flattening of the villi and long-term damage to the small intestine.

Non-Celiac Gluten Sensitivity (NCGS) – Diagnosis is not straightforward with no proven medical test. It is typically diagnosed after elimination of other similar conditions (for instance, wheat allergy, Irritable Bowel Syndrome) and after observation and further consultations.

Wheat Allergy – Involves an immune Ig-E mediated reaction to the wheat protein, can be diagnosed via allergy test.

It was debatable in 2014 then as to whether non-celiac gluten sensitivity (NCGS) even exists as (i) it is difficult to diagnose NCGS, and (ii) some studies concluded that it is actually sensitivity to FODMAPs rather than NCGS. (Gluten-containing grains are high in FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols) which are sugars/ carbohydrates that tend to be poorly digested, e.g. frutose.

Almost a year later in 2015, we want to examine (i) whether non-celiac gluten sensitivity (NCGS) is a clinical entity (ie we are sure there’s such a medical condition) and (ii) its impact on eczema or skin rash.

September 2015 Study – Cutaneous Manifestations of Non-Celiac Gluten Sensitivity: Clinical Histological and Immunopathological Features

Methods: 17 patients affected by NCG, median age 36, 76% females, with itchy rash similar to  eczema, psoriasis or dermatitis herpetiformis; wheat allergy and celiac disease tests were carried out to confirm that these 17 patients were not suffering from these.

Finding: Skin improvement noted after a month of gluten-free diet

July 2015 Paper – Non-celiac gluten sensitivity: Time for sifting the grain

In this paper, non-celiac gluten sensitivity is stated as a clinical syndrome characterized by both intestinal and extraintestinal symptoms, which are responsive to gluten (wheat) withdrawal from the diet.

Its estimated prevalence is 3% to 5% and a syndrome from multiple factors.

July 2015 Case study – Gluten Psychosis: Confirmation of a New Clinical Entity

In this case study, a 14-year old girl recovered from psychotic symptoms, after eliminating gluten. Other conditions linked to NCGS included:

  • Gastrointestinal symptoms: Abdominal pain, bloating, diarrhea or constipation
  • Systemic manifestations: “Foggy mind”, depression, headache, fatigue, and leg or arm numbness
  • Neuro-psychiatric disorders: Autism, schizophrenia and depression

June 2015 Study – Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity

From this paper, a diagnosis pathway was suggested to determine if one suffers from NCGS. The blind gluten challenge remains a ‘gold standard’ for diagnosis; if going on a strict gluten free diet, it is maintained for at least 3 weeks to observe if symptoms improve.

Non-Celiac Gluten Sensitivity Diagnosis

NCGS Diagnosis; copyright of World Journal of Gastroenterology, June 2015; 21(23); 7110-7119; Figure 1

June 2015 Study – Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria; The criteria is similar to above, with varying guidelines on the duration of gluten free and introduction of gluten diet.

Various research had linked NCGS to female gender and adult age.

It seemed from recent studies that NCGS remained a syndrome without an easy way of diagnosis. The latest study that noted an association between gluten and skin rash would likely be considered as being on a small scale. However, the possibility of skin rash linked to gluten cannot be dismissed and more collaboration between dermatologist and gastroenterologist would increasingly be seen as more patients suspect gluten as a source of their skin problems.

Update on 17 October 2016 – A new study showed the possible group of proteins found in wheat – amylase-trypsin inhibitors (ATIs) – to trigger an immune response in the gut that can spread to other tissues in the body. From MedicalNewsToday

ATIs only make up a small amount of wheat proteins – around 4 percent – yet the immune response they induce significantly affects the lymph nodes, kidneys, spleen, and brain in some people, causing inflammation. ATIs have also been suggested to exacerbate rheumatoid arthritis, multiple sclerosis (MS), asthma, lupus, and nonalcoholic fatty liver disease, as well as inflammatory bowel disease.

What’s your experience with gluten? Do you think your child has gluten sensitivity? Share in the comments and we can all learn from it!

Eczema News – Abdominal Pain and Allergy, Sensitization in Kids?

We’ve been looking at eczema research news for the past 2 weeks and this week, I came across an interesting study looking into the correlation between abdominal pain and allergy-related disease. My child sometimes complain of tummy ache and now I’m wondering if it got anything to do with her eczema. Let’s check out this study!

Study title: Allergy-related diseases and recurrent abdominal pain during childhood – a birth cohort study

Study objective: Examine the association between allergy-related diseases or sensitisation during childhood and abdominal pain at age 12 years.

Study method:  2610 children in Sweden, using questionnaires. Parents answered questions regarding asthma, allergic rhinitis, eczema and food hypersensitivity and children answered questions on abdominal pain at 12 year old. IgE blood tests were taken at ages 4 and 8. Celiac disease and inflammatory bowel disease excluded.

Why focus on Abdominal Pain?

Recurrent abdominal pain affects 8% of children in western countries and often leads to school absence and lower quality of life. Multiple factors contribute to it, including irritable bowel syndrome (IBS). It’s also related to low-grade gut inflammation and the link to asthma, eczema and rhinitis had also been studied (with no conclusive result).

Abdominal Pain Allergy Disease

What’s the Possible Link between Abdominal Pain and Allergy?

As written in the study,

Children with multiple allergy-related diseases may have a low-grade inflammation in the gut, resulting in barrier defects in the gastrointestinal tract, thus increasing the risk for disturbed motility and pain sensitivity. IBS patients with an allergic background have demonstrated increased IBS symptom scores, colonic permeability, mast cell counts and tryptase release or increased gut permeability compared to IBS patients without an allergic background.

Conclusion: Among 2610 children with complete follow-up, 9% reported abdominal pain at 12 years. All allergy-related diseases were associated with concurrent abdominal pain at 12 years and the risk increased with increasing number of allergy-related diseases. Asthma at 1 and 2 years and food hypersensitivity at 8 years were significantly associated with abdominal pain at 12 years. There was an increased risk of abdominal pain at 12 years in children sensitized to food allergens at 4 or 8 years, but in stratified analyses, this was confined to children whose parents had not reported food hypersensitivity at time of sensitisation.

My take: It’s not causal and admittedly, associations are not accurate. As pointed out in the study, it could be allergy kids already go to clinics more often or have increased anxiety and stress that lead to the recurrent tummy aches. But I do believe in benefits of a healthy gut – an area where increasingly gut influences more than just gut! Eat a low oxidation diet, fruits, vegetables and probiotics.

What’s your healthy gut diet? Do you monitor the foods for your child with allergy, asthma, eczema or rhinitis? Do share in the comment so that everyone can hear from each other!

Children Food Sensitivities – Confusing Gluten

There’s so much about gluten-free these days – it’s an industry in itself and marketing ‘Gluten-Free’ is seen in menus and food packaging. We hear of sports celebrities performing better after cutting gluten and we hear of celebrity moms choosing gluten-free diets for their children. But what is gluten and what happens when you eat it? As the 4th part of this series, today’s post explores the different types of gluten sensitivities.

TOP 5 Facts You Need to Know to Differentiate Your “Gluten Sensitivity Type”!

Gluten refers to the proteins found in wheat, barley, rye and triticale (a cross between wheat and rye). Gluten gives elasticity/stickiness to the dough.

GLUTEN SENSITIVITY

GLUTEN SENSITIVITY TYPE #1 – CELIAC DISEASE (CD)

CD Fact #1: Involves immune system, BUT not IgE-mediated reaction to the gluten.

CD Fact #2: Immune system attacks the villi in the esophagus when exposed to gluten protein gliadin, found in wheat, barley, rye, and sometimes oats. This lead to intestinal inflammation, flattening of the villi and long-term damage to the small intestine. Associated with high intestinal permeability whereby bacteria, antigens and undigested food ‘leaked’ through the gastrointestinal barrier.

CD Fact #3: Symptoms include diarrhea, abdominal bloating/pain/cramps, bone/joint pain, bruises, constipation, depression, failure to thrive for children, mouth sores, infertility/miscarriage, malnutrition, weight loss, chronic fatigue, anemia, blood or fats in stool, nausea, joint pain, tingling on hands/feet, Dermatitis Herpetiformis or no symptom. Related to malabsorption of nutrients due to the intestinal villi being compromised.

CD Fact #4: Diagnosis is straightforward with tests to detect AGA (Antigliadin) and EmA (Andomysium Antibodies). Cutting gluten before testing will affect results. Small intestinal biopsy is an accurate test for celiac disease.

CD Fact #5: Treatment is strict avoidance of gluten in order for the villi to heal. Note that oats can be tainted with gluten and some common medications, vitamin supplements and cosmetic products also contain gluten. Untreated gluten has been linked to intestinal cancer, liver disease, small bowel ulcers and other inflammation-related diseases of the digestive tract, heart, joint and even brain.

GLUTEN SENSITIVITY TYPE #2 – NON-CELIAC GLUTEN SENSITIVITY (NCGS) or GLUTEN INTOLERANCE

NCGS Fact #1: Does not involve immune system and is not celiac disease. However, patients clearly experience discomfort and symptoms after ingesting gluten.

NCGS Fact #2: No intestinal inflammation and not associated with high intestinal permeability, unlike celiac disease.

NCGS Fact #3: Symptoms are gastrointestinal symptoms like abdominal bloating, diarrhea, gas, cramps, headaches and fatigue.

NCGS Fact #4: Diagnosis is not straightforward with no proven medical test. It is typically diagnosed after elimination of other similar conditions (for instance, wheat allergy, Irritable Bowel Syndrome) and after observation and further consultations.

NCGS Fact #5: Treatment is avoidance of gluten ONLY after confirmation of this course of action by doctors. Doctors will eliminate the possibility of celiac disease, wheat allergy or other diseases before advising on treatment for NCGS.

GLUTEN SENSITIVITY TYPE #3 – WHEAT ALLERGY (WA)

WA Fact #1 : Involves an immune Ig-E mediated reaction to the wheat protein

WA Fact #2: The increase in IgE antibodies trigger chemical release that lead to allergic reactions, that can either be manifested via the skin, respiratory or gastrointestinal systems and other behavioral issues.

WA Fact #3: Wheat is one of the common food allergens in children and symptoms include eczema, rhinitis, asthma, urticaria, conjunctivitis, abdominal pain, diarrhea and angiodema. These symptoms could be immediate (swelling or hives) or be delayed, including low weight gain in children. There’s also exercise-induced anaphylaxis to wheat.

WA Fact #4 Diagnosis is via allergy testing.

WA Fact #5: Treatment is avoidance of wheat. There is no need to avoid barley and rye which contains gluten but not wheat.

There is recently studied that people with non-celia gluten sensitivity may actually not be sensitive to gluten, but instead to FODMAPs. FODMAPs stand for fermentable oligo-, di-, and mono-saccharides and polyols, which are sugars, carbohydrates that tend to be poorly digested, e.g. frutose. It could be that gluten-containing grains are high in FODMAPs and thus avoiding gluten makes one who is sensitive to FODMAPs feel better. (see this study conducted as double-blind cross-over trial).

Update on 17 October 2016 – A new study showed the possible group of proteins found in wheat – amylase-trypsin inhibitors (ATIs) – to trigger an immune response in the gut that can spread to other tissues in the body. From MedicalNewsToday

ATIs only make up a small amount of wheat proteins – around 4 percent – yet the immune response they induce significantly affects the lymph nodes, kidneys, spleen, and brain in some people, causing inflammation. ATIs have also been suggested to exacerbate rheumatoid arthritis, multiple sclerosis (MS), asthma, lupus, and nonalcoholic fatty liver disease, as well as inflammatory bowel disease.

Hope this 4-part series clarify! it did for me and I have a clearer picture and better appreciation of the complexities involved in understanding and diagnosing one’s gluten-related (or suspected!) condition.

For other posts in this series, do check out

Allergic, Intolerant or Hyper?

Top 10 Kids’ Food Sensitivities Myths

Outgrowing Food Allergy

Sources:

MedicineNetFODMAP studyMayo ClinicWebMd

Children Food Sensitivities – Outgrowing Food Allergy

This blog has always been focused on eczema, rather than allergy. However, I came across a very good book by Dr Wayne Shreffler and Dr Qian Yuan on ‘Understanding your food allergies and intolerances‘ and found that it clarified many food allergy concepts. Thus, this 4-part series is to share that knowledge with you!

For the past 2 weeks, we’ve covered

This week, I’m doing something totally unscientific – I’m compiling all statistics I find online on outgrowing allergies to lay out in a graphical representation of  WHAT AGE will a CHILD (likely!) OUTGROW FOOD ALLERGY! It’s definitely not scientific because each study/report has a different focus but just to save time for you (paranoid moms and dads who would try to do the same), I figure I might as well make an attempt!

Age your Child will Outgrow Food Allergies

While reading up on outgrowing food allergies, I’ve found some interesting food allergy facts!

Fact #1 Shellfish allergy onset later in life (6 years and older) and usually lifelong. Same for fish allergy.

Fact #2 Shellfish allergy IS NOT THE SAME as fish allergy.

Fact #3: Shrimp, lobsters and crabs are more allergic than mollusks such as scallops, oysters, clams and mussels.

Fact #4: Allergy to one type of (fin)fish does not mean allergic to another BUT study in 2004’s Journal of Allergy and Clinical Immunology found that 30% of children and approximately 66% of adults reacted to multiple types of fin fish.

Fact #5: More women than men are allergic to fish (0.6% vs. 0.2%).

Fact #6: Egg allergy is most closely associated with eczema, among the other food allergens. (Does not mean that egg allergy is most likely the trigger for your child’s eczema, as house dust mite is the more likely suspect for older children)

Fact #7: You can be allergic to either egg white or yolk or both but avoid the whole egg as it’s not possible to ensure clean separation.

Fact #8: Eggs and Milk cooked under intense heat (say baking cakes) seem to be more well-tolerated but don’t experiment without doctor’s advice (study here).

Fact #9: Soy allergy tend to be mild

Fact #10: Highly refined soybean oil (not cold pressed, expeller pressed, or extruded oil) and soy lecithin is usually tolerated by people with soy allergy.

Fact #11: Food allergies developed from young (except peanuts, tree nuts, shellfish and fish) are more likely to be outgrown versus food allergies developed as a teenager or adult, which tend to be lifelong.

Fact #12: 26.6% of children outgrew their allergies by age 5.4.

Fact #13: The more severe the allergic reaction, the less likely to be outgrown.

Fact #14: Mean age of tolerance for egg allergy was age of 7.2; Milk 6 years; Tree Nut 9.6; Shellfish 11.6; Soy 7; Fin fish 9.3; Peanuts 8.4

Fact #15: Boys are more likely to outgrow allergies than girls.

When researching for this post, I actually found quite a number of websites carrying misinformation or unclear information where it’s either proven wrong in later studies (for instance, to delay introduction of foods) or information relating to intolerance being grouped as food allergy information (such as only larger amounts of food trigger a reaction).

Another ‘sad’ news is that there is a study that children can develop a second (different) reaction to foods that they have outgrown. This is a study on Eosinophilic Esophagitis or EoE where it was found that 17 out of 1,025 patients in the study had initially outgrown IgE-mediated reaction to the foods but now suffer from EoE reaction (see AllergicLiving.com for their interview with the researchers of the study). EoE is an inflammation at the esophagus due to increase of eosinophil cells, leading to narrowing of the esophagus.

Hope whatever age your child is, your family is managing the food allergies well. Share your outgrowing age below!

Sources:

  1. ACAAI
  2. RaiseHealthyEaters (post by Dr Joneja)
  3. FARE
  4. Mayo Clinic
  5. Medscape
  6. Studies (egg) here and here

Children Food Sensitivities – Top 10 Kid’s Food Sensitivity Myths

Top 10 ids food sensitivity mythsThis blog has always been focused on eczema, rather than allergy. However, I came across a very good book by Dr Wayne Shreffler and Dr Qian Yuan on ‘Understanding your food allergies and intolerances‘ and found that it clarified many food allergy concepts. Thus, this 4-part series is to share that knowledge with you!

Last week, we clarified Food Allergy vs Food Intolerance which gave an overview of the differences between the two. Today we can put this to test by tackling these Kids’ Food Sensitivity Myths!

Myth #1: This Food Doesn’t Agree with Me, I’m Allergic to It!

This actually reminds me of my hubby (lol), most times we don’t agree (that is when we actually talk!) but no, I’m not allergic to him (hopefully he thinks the same!). As explained in last week’s post, food sensitivity can be either in the form of allergy or intolerance. Some doctors also allow for a 3rd category of food sensitivity, when they can’t classify it as either an allergic reaction or find the chemical the body is intolerant to.

However, these days, there’s almost a ‘cool’ factor to say you’re allergic to something. So while it is possible that more people think or say they have an allergy than they really have, food intolerance/sensitivity may also be underestimated as they are hard to diagnose. Do note too that adults can also have an onset of allergy at an older age, esp for certain allergy like shellfish.

Myth #2: Food intolerances can be tested using IgG antibodies test

There are many IgG tests available online and generally the medical community is against this test for identifying food sensitivity. The main reason is that elevated IgE implies an exposure to the food rather than an allergy to the food. Also while 80% of the foods are the common suspects in allergy, IgG test may test hundreds of foods and with false positives, lead to harmful elimination diet.

Myth #3: You are either Allergic or Intolerant

For some individuals the same foods can trigger both food allergy and intolerance. For instance, there can be an allergy to the milk protein while also lacking lactase digestive enzyme to break down lactose. This is why it is important to consult a specialist as it is not easy to figure it out on your own.

Myth #4: You can eat JUST A LITTLE of the sensitive food

This falls back to last week’s explanation of food allergy and intolerance. For severe food allergy, smelling the food can trigger a reaction, and it can be fatal one like anaphylactic reaction (that’s why there is so much debate about peanuts on plane!). However, for food intolerance, some people can eat certain amounts or in certain forms, e.g. food cooked with milk (I tried this fish recipe before, tasted horrible!) may give a different reaction to drinking milk.

Myth #5: I feel Bloated, I’m Allergic!

Bloating is more closely related to food intolerance but eating gassy foods cause bloating too. Pregnant women suffer more from bloating and constipation due to pregnancy hormones leading to relaxation of gastrointestinal wall muscles, thus foods stay in the tract longer.

Myth #6: I didn’t eat the food, how can I be allergic to it?

Food sensitization is when the body first comes into contact with the food protein and the body then ‘tag’ it as an enemy. The next time even small amounts of the food (in some cases, touched or smelled) can trigger an allergic reaction. So smelling peanuts on plane, touching or shaking hands with another child with peanut butter trace on hands can lead to an allergic reaction.

Myth #7: Delaying food introduction to a child can prevent the food allergy

Based on updated studies, the recommendation to delay introduction of common food allergens (usually peanuts, tree nuts, shellfish) is now revoked. The studies were contradictory – some showed late introduction helped as the child’s immune system is stronger while others showed early introduction helped as the child builds an immunity to it earlier. Thus the current recommendation is Just Eat (Whatever) a Balanced Diet. An update on a study on early introduction of eggs done in August 2015 showed that the elevated immune responses to egg were established prior to egg ingestion at 4 months and were not affected by whether eggs were introduced early.

Myth #8: Allergy testing is 100% accurate

Allergy testing (skin prick and IgE) is fairly accurate but not 100%. The only gold standard in food allergy testing is the oral food challenge. However due to the difficulty of conducting the oral food challenge (involves hospital stay), doctors form a diagnosis based on corroborated ‘evidence’, for instance the test results, parents’ observations and doctor’s knowledge of food allergens, family history.

Myth #9: Organic Foods are Safer

Organic foods (only the properly certified ones) may be safer in terms of free from pesticides but not safer in terms of allergic reaction to the food protein. Organic or not, the food protein is still present. For some people, peeling the fruit’s skin or cooking in a different way may help.

Myth #10: Allergy test can tell how Allergic you are

Allergy testing only tells you if you have an allergy, but it cannot predict the severity of the reaction. For instance, (see this previous post), the size of the wheal from skin prick test does not correlate with the reaction you will have.                                                                                                   

Children Food Sensitivities – Allergic, Intolerant or Hyper?

This blog has always been focused on eczema, rather than allergy. However, I came across a very good book by Dr Wayne Shreffler and Dr Qian Yuan on ‘Understanding your food allergies and intolerances‘ and found that it clarified many food allergy concepts. Thus, this 4-part series is to share that knowledge with you!

Each week is a different concept de-mystified, so let’s get started!

Kids Food Sensitivities – What is Sensitivity?

What does it mean to be sensitive to a food? In layman’s term, it could mean a range of symptoms from headaches to tummy upset, but medically, it covers two main terms:

Food Allergy and Food Intolerance – both have similar symptoms but the cause and treatment is different, which is why it is important to differentiate the two.

Food Allergy Food Intolerance
Direct immune system’s response to food protein Not a direct immune response but different causes (not all known), e.g. lack of specific enzymes to digest the food (not necessarily a protein)
Cause is the reaction to food protein, can be tested with fair accuracy with allergy tests Cause is not always known and not easy to test a food intolerance
Symptoms can be immediate (few hours) or delayed, and include

Itch, hives, breathing difficulty (including anaphylaxis), eczema, runny nose, coughing, vomiting, diarrhea, abdominal pain, swallowing difficulty, chronic chest pain, heart burn, constipation, weight loss, swelling of facial features

Symptoms can affect the skin, intestines, respiratory tract and cause behavior change

Symptoms may take place gradually – nausea, stomach pain, gas (bloating)/cramps/bleeding, vomiting, diarrhea, heartburn, headache or migraine

 

Symptoms typically affect intestines.

Happens every time May not happen for the tolerated amount or in certain forms; the more you take, the more severe the symptoms and symptoms may differ in each incident
Small amount triggers Certain amounts may be tolerated (trial and error process to figure out)
Common food allergens: Milk, soy, egg, wheat, peanuts, tree nuts, fish and shellfish Common food intolerances: Frutose, Sucrose, Lactose, MSG (monosodium glutamate), sulfite, tyramine, histamine
Except for peanuts, tree nuts, fish/shellfish that are harder to outgrow, other food allergens tend to be outgrown at older age May actually onset at older age
Genetics play a role Genetics play a role

As seen above, there are distinct differences between food allergy and food intolerance although the symptoms of both are similar. However, to be concerned that there is indeed a food sensitivity issue, there has to be a reproducible reaction with the food – i.e. not referring to a one-time stomach upset after eating prawns in the past year (that might be food poisoning!).

The diagnosis of food intolerance is generally difficult, except for lack of digestive enzymes lactase, frutase and sucrase. The lack of the digestive enzymes result in lactose, fructose and sucrose not being broken down and result in pain, bloating, spasm and diarrhea.  Even stress or anxiety associated with a certain food can cause an intolerance.On the other hand, symptoms such as swelling are closely associated with allergic reaction.

The diagnosis of immediate food allergy is more straight forward than delayed food allergy, with allergy testing and blood test to detect elevated levels if immunoglobulin E (IgE). The common food allergens differ in different country (taken from allergyuk.org)

  • Worldwide – milk, egg
  • USA, UK, Australia – peanut and tree nuts
  • France – mustard seed
  • Italy, Spain – peach, apple, shellfish
  • Israel – sesame
  • Spain, Japan – fish
  • Japan – buckwheat
  • Singapore – birds’ nest, shellfish

For those in Singapore, it is interesting that fish isn’t on our list of common food allergens possibly due to it being so much part of our diet. Birds’ nest on the other hand is given as ‘tonic’ to children early and may actually trigger an allergy!

Treatment wise – for both food allergy and food intolerance, avoidance is key. For food allergy, children can undergo another allergy test to see if they have ‘outgrown’ it. For food intolerance which usually does not result in fatal reaction, small amounts of food can be re-introduced in different forms to see which form/amount can be tolerated. There is no cure for allergy or intolerance; however, for certain food intolerance, enzyme supplements can be taken beforehand to digest the food to be ingested e.g. lactose.

Here’s a graphic for recap!

Is it Food Allergy or Food Intolerance? Graphical representation

Is it Food Allergy or Food Intolerance?

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