Naturopathic Approaches to Care of Children and Adolescents with

Naturopathic Approaches to Care of
Children and Adolescents with
Asthma and Allergies
Darin Ingels, ND, MT(ASCP)
Ingels Family Health
2425 Post Road, Suite 100
Southport, CT 06890
dingels@gmail.com
Who has allergies and asthma?
  According to the American Academy of Allergy, Asthma
and Immunology, more than 50 million people in the U.S.
have some form of allergy.
  Allergic diseases affect more than 20% of the population.
  Allergies are the 6th leading cause of chronic disease in
the U.S.
  According to AAAAI, more than 10% of children under
the age of 17 have allergic rhinitis and 8% have food
allergies.
  According to the CDC, 7.1 million children have asthma
in the United States (9.5% of all children).
  The incidence of asthma and allergies continues to rise
each year.
Pathophysiology of Asthma
Asthma is defined as a chronic disease that involves
inflammation of the pulmonary airways and bronchial
hyperresponsiveness (bronchoconstriction) that results
in lower airway obstruction.
Gross pathology of asthmatic airway shows lung
hyperinflation, smooth muscle hypertrophy, lamina
reticularis thickening, mucosal edema, epithelial cell
sloughing, cilia cell disruption and mucus gland
hypersecretion.
Microscopic pathology shows increased numbers of
eosinophils, neutrophils, lymphocytes and plasma cells
in the bronchial tissues, bronchial secretions and mucus.
Pathophysiology of Asthma
Activated CD4 T-cells recruit leukocytes from the
bloodstream to the airway and direct the release of
proinflammatory cytokines, including IL-1, IL-4, IL-5,
IL-6, IL-13 and TNF-α.
IL-4 with IL-13 signals the switch from IgM to IgE
antibodies, triggering mast cell degranulation and
release of histamine, leukotrienes and other mediators
that perpetuate inflammation and bronchoconstriction.
IL-5 recruits and activates eosinophils which
additionally perpetuate the inflammation.
Histamine is the biggest factor in the acute phase of an
asthma attack due to bronchoconstriction as well as
increased vascular permeability.
Pathophysiology of Asthma
Prostaglandin D2 elicits further bronchoconstriction and
vasodilation (which can potentially lead to
hypotension).
The late phase reaction (4-8 hours later) is mostly
mediated by the presence of leukocytes which release a
second wave of chemicals that continue to cause
inflammation and bronchoconstriction.
The presence of IgE in the acute and late phase
reactions explains the often prolonged nature of asthma.
Repeated inflammation of the airway causes structural
damage and long-term remodeling of the airways,
which may lead to further complications.
Types of Asthma
Extrinsic asthma (493.00)
a.  Atopic (Allergic): most common type of asthma
triggered by environmental allergens such as dust,
mold, pollen, foods, etc.
b.  Occupational: chemical inhalation
c.  ABPA: aspergillus spores
Intrinsic Asthma (493.10)
a.  Nonreaginic: URI
b.  Cold or exercise induced
c.  Pharmacologic: drug-induced reactions, such as
aspirin-induced asthma
Asthma vs. RAD
Reactive Airway Disease (RAD) is a term used to describe a
multitude of obstructive airway symptoms, but is not
necessarily asthma.
RAD tends to be transient in nature, where asthma is a
chronic condition.
RAD does not necessarily need to have the inflammatory
component and may only involve bronchoconstriction.
Most children under the age of 5 are diagnosed with RAD as
ascertaining a diagnosis of asthma is prohibitive.
Only 30% of children under the age of 3 who wheeze will
go on to develop asthma1
1. Medscape : http://emedicine.medscape.com/article/800119-overview
Symptoms of childhood asthma
•  Wheezing (whistling sound) when breathing
•  Coughing, often worse at night or lying down
•  Tachypnea: be aware of norms for children
Newborns: 30-60 bpm
Toddlers: 20-40 bpm
•  Labored breathing
•  Complaints of chest hurting
•  Reduced energy
•  Feeling weak or tired
Diagnosis of Asthma
1.  Medical history: when symptoms occur, family
history, other allergy symptoms, known triggers,
pets, school exposure
2.  Physical exam: wheezing, allergy signs, eczema
3.  Spirometry is the gold standard test for
diagnosing asthma, but not reliable for children
under 5. Reduced FEV1, FVC which improves
with bronchodilator.
4.  Peak Flow Meter: reduced PEFR
What Triggers Asthma?
  Allergens: inhaled (pollen, mold, dust, animal
danders, etc.), food, sulfites/preservatives/MSG,
medications, chemicals
  Infections
  GERD
  Tobacco smoke
  Exercise
  Cold
  Anxiety or emotional stress
Differential Diagnosis of Asthma
  Asthma
  Croup or other viral
infection
  Bronchiolitis/Bronchitis
  Epiglottitis
  Aspiration of foreign body
  Tracheo- or bronchomalacia
  Cardiac failure
  Pertussis: more than 25,000
cases in US
Asthma: When to Refer to ER
  Cyanosis
  Dyspnea that does not respond to conservative
treatment
  Tachypnea or tachycardia
  Change in mental status (hypoxia)
  Grunting
  Absent breath sounds on auscultation
Drug Therapy for Asthma
1.  Short-acting beta-2 agonist: albuterol (ProAir,
Proventil, Ventolin), levalbuerol (Xopenex).
Relaxes smooth muscle in airway and causes
bronchodilation. Used as “rescue inhaler”.
2.  Low dose inhaled corticosteroid: fluticasone
(Flovent), budenoside (Pulmicort), mometasone
(Asmanex), beclomethasone (Qvar). Inhibits
inflmmatory cytokines and reduces inflammation.
Drug Therapy for Asthma
3.  Long-acting beta-2 agonist: not generally
recommended for children. Have many side
effects. Not used as solo therapy, but always in
conjunction with steroid inhaler. Salmeterol
(Serevent), formoterol (Foradil). Newer inhalers
have combinations of low dose steroids and
LABA’s such as fluticasone and salmeterol
(Advair Diskus, Advair HFA), budesonide and
formoterol (Symbicort), and mometasone and
formoterol (Dulera).
Drug Therapy for Asthma
4.  Leukotriene receptor antagonists: monteleukast
(Singulair), zafirlukast (Accolate). Selectively binds to
leukotriene receptors, blocking the proinflammatory
action of certain leukotrienes. However, many
neuropsychiatric symptoms have been reported with
children on monteleukast, so caution is advised.
5.  Oral corticosteroids: prednisone, prednisolone (OraPred).
Inhibits inflammatory cytokines.
6.  Immune modulator: omalizumab (Xolair). SC injection
given 2-4 times a week. Inhibits IgE binding to mast cells
and basophils. Anaphylaxis is common, so rarely used.
Drug Therapy for Asthma
7.  Theophylline: methylxanthine that antagonizes
adenosine receptors which leads to
bronchodilation. Also has mild antiinflamatory
effects. Has narrow therapeutic index and many
side efects, so rarely used today.
8.  Chromones: cromolyn sodium (Intal). Mast cell
inhibitor. No longer commercially available in
US, but can get in Canada. Can be compounded
for nebulized treatment.
Drug Therapy for Asthma
Papadopoulos NG, et al. International consensus on (icon) pediatric asthma. Allergy
2012; 67: 976–997.
What is Allergy?
  Allergy is defined as a harmful, increased susceptibility to a
specific substance , also known as hypersensitivity.
  Typically used to describe type I or immediate hypersensitivity
reactions, mediated by IgE, but may include types II, III and IV
hypersensitivity.
  However, this definition does not encompass the breadth of immune
reactions to substances.
  Anyone presenting with recurrent infections or multiple endocrine
dysfunction should be evaluated for allergies.
Common Allergens
  House dust mites
  Pollen (trees, grasses and weeds)
  Mold
  Animal danders (cat, dog, rabbit, etc.)
  Insects
  Foods (children): milk, egg, peanuts, wheat, soy, tree nuts
  Foods (adults): Peanuts, tree nuts, fish, shellfish
Less Common Allergens
  Food components: histamine, tyramine, MSG, phenolics
  Food dyes, especially tartrazine (yellow #5)
  Chemicals: perfume, formaldehyde, phenol, petroleum,
preservatives, tobacco smoke
  Medications
  Hormones, neurotransmitters? Do some of the body s proteins
stimulate immune reactions?
Classification of Hypersensitivity
Adapted from Johansson SGO et al. Allergy 2001;56:813-24
Hypersensitivity
Allergic hypersensitivity
(Immunologic mechanism defined)
IgE mediated
Atopic
Classic allergy
Nonallergic hypersensitivity
(Immunologic mechanism excluded)
Non-IgE mediated
T-cell
Non-atopic
(contact dermatitis, Celiac disease)
Insect sting
Parasites/Infection
Eosinophillic reactions
IgG-mediated
(allergic alveolitis, food allergies?)
Drugs
Idiosyncratic
Others
Classification of Hypersensitivity
Adapted from Johansson SGO et al. Allergy 2001;56:813-24
Hypersensitivity
Allergic hypersensitivity
(Immunologic mechanism defined)
Enzymatic Food Intolerance
(i.e. Lactose intolerance)
Nonallergic hypersensitivity
(Immunologic mechanism excluded)
Pharmacologic Reactions
(i.e. caffeine)
Psychological Reactions
(i.e. aversions to foods)
Classical Allergy Symptoms
  Allergic rhinitis (hayfever)
  Sinusitis
  Allergic conjunctivitis
  Otitis media/Otitis interna
  Asthma
  Eczema
  Contact dermatitis
  Hives (urticaria)
  Gastroenteritis
Other conditions that may suggest allergy
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Arthritis
ADHD
Bladder infections
Candidiasis
Canker sores
Celiac disease
Chronic infections
Colic
Constipation
Depression
Diarrhea
Fatigue (Chronic)
Gallbladder attacks
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GERD
Glaucoma
Hypertension
Hypoglycemia
Hypothyroidism
IBS
Inflammatory Bowel Dz
Irregular menses
Migraine headaches
Obesity
PMS
Psoriasis
Ulcers
What Affects Allergies?
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Frequency of exposure
Duration of exposure
Dose of exposure
Genetics: allergy has strong familial disposition
Prenatal factors (smoking, alcohol, diet)
Diet
Lifestyle: Smoking, obesity, excessive alcohol consumption
Underlying infection
Stress
Occupation: nail technician, mechanic, dental hygienist, etc.
What Affects Allergies?
Season (in most of U.S.)
  Winter: House dust mites, indoor mold, animal danders
  Spring: Tree pollen, outdoor mold
  Summer: Grass pollen, weed pollen, outdoor mold
  Fall: Weed pollen, outdoor mold
  Perennial: Food, animal dander, mold, house dust mites
Physical Signs of Allergy
  Allergic shiners
  Dennie s Lines
  Allergic salute
  Eczema
  Runny nose
  Post-nasal drip
  Serous fluid accumulation in middle ear
Allergic Shiners
Allergic Salute
Dennie s Lines
Diagnosis of Allergies
Skin Tests:
Blood Tests:
  Prick/Puncture Test
  Intracutaneous Test
  Patch Test
  Total IgE
  RAST: Specific IgE
  IgG4 tests (foods)
  IgA (selective IgA
deficiency)
Diagnosis of Food Allergies
1.  RAST (ImmunoCap®): specific IgE antibody test for a specific
food. Most useful for diagnosing anaphylactic food allergies.
2.  IgG antibody tests: specific IgG antibody test for a specific food.
More likely to detect delayed reaction to a food or food
substance. Better for diagnosing food intolerances or food
sensitivities.
3.  Oral challenge: Eliminate suspected food allergy for two to three
weeks and then challenge the food back and look for symptoms.
4.  Esoteric testing: EDS, muscle testing, NAET, AAT. These
methods are NOT diagnostic, but may provide insight to how the
body reacts to certain foods.
Diagnosis of Allergies
  Provocation/Neutralization: Intradermal method of
using serial 1:5 dilutions to provoke symptoms with
one dilution and turning the symptoms off with the
neutralizing dose. Used for foods.
  Serial endpoint titration (SET): Used for inhalants.
  *Esoteric Testing: Electrodermal screening (EDS),
kinesiology, NAET, AAT.
* These methods are not FDA approved as diagnostic
methods, but may provide insight into one s allergies.
Prevention of Allergies
Clean Up The Home!
1. 
Dust mite protection: protective covers for mattress, pillows. Vacuum mattress
regularly. Wash sheets weekly and other bedding regularly. Remove carpet from
home.
2. 
No animals in bedroom.
3. 
Ventilate home frequently, especially bedroom.
4. 
Do not smoke in home. Wash clothes soon after exposure to smoke or other
chemicals.
5. 
Use air purifiers: HEPA filter (with UV light if mold allergies). Change filters in
furnace as often as needed.
Tsitoura S, et al. Randomized trial to prevent sensitization to mite allergen in toddlers and preschoolers by allergen
reduction and education: one-year results. Arch Pediatr Adolesc Med 2002;156:1021-7.
Morgan WJ, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med
2004;351:1068-80.
Clean Up The Home!
Reduce exposure to mold:
•  Eliminate sources of water leaking into home
(especially basements). Fix water damaged areas
appropriately. Test home for stachybotrys (toxic
mold).
•  Clean mold in bathrooms, etc. with 10% bleach
solution. Clean clothes with Borax if mildew.
•  Use dehumidifiers in areas of home that are over
saturated. Home humidity should be ~ 40-50%.
•  Remove carpet and padding. Padding harbors
mold more than carpet, especially if carpets have
ever been steam cleaned.
Clean Up The Home!
Reduce exposure to chemicals:
•  Counsel patients on cleaning up their home and
work environments. Home Safe Home by Dadd.
•  Lowering the exposure to chemicals reduces the
load on the immune system.
Safe cleaners to use in the home
1) 
2) 
3) 
4) 
Arm and Hammer Baking Soda
Bon Ami cleanser or Borax
Water and white vinegar
70% isopropyl alcohol
Clean Up The Diet
  Consume whole foods. Avoid foods that are canned, processed,
refined. These foods may contain additives, preservatives, dyes.
  Eat organic when possible and available.
  Eat organic foods and foods that do not contain hormones or
antibiotics. Our Toxic World by Rapp.
  Avoid known food allergens.
  Mind the gut. Changes in gut microflora may regulate immune
responses in the lungs1. Overuse of antibiotics and chronic intestinal
inflammation may predispose to microflora imbalances.
1 Noverr
MC, Noggle RM, Toews GB, Huffnagle GB. Role of antibiotics and fungal microbiota in
driving pulmonary allergic responses. Infect Immun 2004;72:4996-5003.
Clean Up The Lifestyle
  If overweight,
lose weight. Obesity predisposes to allergies and asthma in
1
2
children and losing weight reduces hypersensitivity .
  Reduce stress. Stress
decreases secretory IgA, which may increase risk of
3
mucosal infections .
  Get off the phone? Study found one hour of continuous cell phone use had a
significant increase in the allergic skin response to dust and cedar pollen,
compared with those who did not use a cell phone4.
1O
Connell EJ. Pediatric allergy: a brief review of risk factors associated with developing allergic disease in childhood. Ann
Allergy Asthma Immunol 2003;90:53-8.
2Stallone
DD, et al. Decline in delayed-type hypersensitivity response in obese women following weight reduction. Clin Diagn
Lab Immunol 1994;1:202-5.
3Bosch
JA, et al. Differential effects of active versus passive coping on secretory immunity. Psychophysiology 2001;38:836-46.
4Kimata
H. Enhancement of allergic skin wheal responses by microwave radiation from mobile phones in patients with atopic
eczema/dermatitis. Int Arch Allergy Immunol 2002;129:348-50.
Conventional Treatment/Prevention
  Antihistamines: H1 receptor antagonists. Cetirizine
(Zyrtec®), diphenhydramine (Benadryl®), loratidine
(Claritin®), fexofenadine (Allegra®).
  Decongestants: pseudoephedrine (Sudafed®).
  Nasal sprays: oxymetazoline (Afrin®), cromolyn sodium
(NasalCrom®).
  Steroids: nasal, inhaled, topical. Triamcinolone (Nasacort®),
fluticasone (Flonase®), budesonide (Rhinocort®),
hydrocortisone (Cortaid®).
  Leukotriene inhibitors: montelukast (Singulair®).
  Immunotherapy: weekly or monthly allergy shots.
Conventional Treatment:
Good News, Bad News
Good News
  Will often control symptoms
rapidly.
  Can prevent life-threatening
situations.
  Do not require frequent
office visits, unlike
immunotherapy.
Bad news
  Many side effects.
  Can interfere with ones daily
activities.
  Does not address underlying cause or
immune dysfunction.
  May cause further immune
suppression or dysregulation
(steroids).
  Masks triggers that might be
identifiable and avoidable.
  Risk of anaphylactic reaction.
  Frequent office visits if doing allergy
shots.
Treatment of Allergies and
Asthma
Treatment Goals for Allergies
and Asthma
Treatment Goals:
1.  Identify the allergen. Avoid or minimize substance
exposure.
2.  Reduce the total load. Eliminate other factors that
influence the immune system.
3.  Improve immune function with non-suppressive means
(nutrients, herbs, homeopathy, etc.).
4.  Detoxification
5.  Immunotherapy: non-injection, isopathy. Can alter the
way the immune system responds to an allergen.
Cromolyn sodium
  Semi-synthetic bioflavonoid that inhibits degranulation of
mast cells.
  Can be used intranasally (NasalCrom®), inhaled (Intal®)
or orally (Gastrocrom®).
  Used to treat allergic rhinitis, asthma and food allergies.
  Excellent safety profile. No known drug interactions.
Ratner PH, et al. Use of intranasal cromolyn sodium for allergic rhinitis. Mayo Clin Proc 2002;77:350-4.
Meltzer EO, NasalCrom Study Group. Efficacy and patient satisfaction with cromolyn sodium nasal solution in the treatment of
seasonal allergic rhinitis: a placebo-controlled study. Clin Ther 2002;24:942-52.
Seo SB, et al. Disodium cromoglycate inhibits production of immunoglobulin E. Immunopharmacol Immunotoxicol
2001;23:229-37.
Other Nasal Treatments
  Alergol®: petrolatum-based cream applied to outside of1
nose reduces allergic rhinitis symptoms by almost 75% .
Appears to block pollen, dust from entering nose.
  Reduced glutathione (GSH): 600
mg per day nasally
2
significantly improved rhinitis . GSH in nasal fluid is
often low in those with rhinitis.
  Saline irrigation. Used in traditional Indian medicine.
  Euphorbium nasal spray: homeopathic preparation.
1Schwetz
S, et al. Efficacy of pollen blocker cream in the treatment of allergic rhinitis. Arch Otolaryngol
Head Neck Surg 2004;130:979-84.
2Testa
B, et al. Glutathione in the upper respiratory tract. Ann Otol Rhinol Laryngol 1995;104:117-9.
Magnesium
  Small study showed children have lower RBC magnesium levels
during an acute asthma attack, but not plasma magnesium and the
RBC magnesium level return to normal after treatment1. The
severity of the attack was directly proportional to the degree of
hypomagnesemia.
  Oral magnesium supplementation 300 mg/day in 37 children in
inhaled fluticasone (and salbutamol) reduced bronchial reactivity to
methacholine, diminished allergen-induced skin responses and
provided better symptom control than those on medication alone.2
  Magnesium may have mild anti-histamine effects, so possible
benefits for allergic rhinitis.
1 Amin
2
M, et al. Magnesium concentration in acute asthmatic children. Iran J Pediatr 2012;22:463-7.
Gontijo-Amaral C, et al.. Oral magnesium supplementation in asthmatic children: a double-bilnd
randomized placebo controlled trial. Eur J Clin Nutr 2007;61:54-60.
Magnesium
  IV magnesium sulfate (25 mg/kg with max 2g) was found to be
useful when administered to children within the first hour of an
acute asthma attack.3 The number of children requiring mechanical
ventilation support was 4% in the treatment group compared with
33% in the control group.
  Nebulized magnesium sulphate and salbutamol significantly
increased peak flow, compared with those treated with nebulized
saline and salbutamol in the treatment of acute severe asthma.4
3
Torres S, et al. Effectiveness of magnesium sulfate as initial treatment of acute sever asthma in children,
conducted in a tertiary-level university hospital: a randomized controlled trial. Arch Argen Pediatr
2012;110:291-6.
4 Ahmed
S, et al. Comparison of salbutamol with normal saline and salbutamol with magnesium sulphate
in the treatment of acute sever asthma. Mymensingh Med J 2013;22:1-7.
Vitamin E
  Vitamin E appears to have mild leukotriene inhibition1.
  112 adults with allergic rhinitis had significant improvement in
nasal symptoms after taking 800 IU/d of vitamin E for 10 weeks2.
  A diet high in vitamin E decreases the risk of developing hayfever3.
1
Centanni S, et al. The potential role of tocopherol in asthma and allergies: modification of the leukotriene
pathway. BioDrugs 2001;15:81-6.
2
Shahar E, Hassoun G, Pollack S. Effect of vitamin E supplementation on the regular treatment of
seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2004;92:654-8.\
3
Nagel G, Nieters A, Becker N, Linseisen J. The influence of the dietary intake of fatty acids and
antioxidants on hay fever in adults. Allergy 2003;58:1277-84.
Vitamin E: Set The Record
Straight
  Vitamin E does not thin the blood at recommended doses.
Studies show anticoagulant effects occur at > 3,200 IU per day.
Caution still taken with those on blood-thinners.
  Supplementing with high doses of vitamin E (> 400 IU/d)
DOES NOT increase mortality. Recent study in Ann Intern
Med had serious flaws. Most of the studies analyzed used
synthetic vitamin E and many people in studies taking vitamin
E had other serious comorbid conditions. Many other studies
show benefit of taking supplemental vitamin E to prevent heart
disease.
  Use natural vitamin E (d-alpha tocopherol) or mixed
tocopherols, not synthetic (dl-alpha tocopherol).
Omega-3 Fatty Acids
  Diet high in EPA decreased risk of developing hay fever in adults1.
  Children given 184 mg of fish oil per day from 6 months to 3 years old, in addition to dust mite
control, had a 10% reduction in cough and a 7.2% decrease in dust mite sensitization2.
  Introduction of omega-3 fatty acids during pregnancy and early post-natal period may modulate
immune system and decrease risk of developing allergies3.
  Some studies show benefit of fish oil in reducing severity and frequency of asthma.
1
Nagel G, Nieters A, Becker N, Linseisen J. The influence of the dietary intake of fatty acids and antioxidants on hay fever in adults. Allergy
2003;58:1277-84.
2
Peat JK, et al. Three-year outcomes of dietary fatty acid modification and house dust mite reduction in the Childhood Asthma Prevention Study. J
Allergy Clin Immunol 2004;114:807-13.
3
Prescott SL, Calder PC. N-3 polyunsaturated fatty acids and allergic disease. Curr Opin Clin Nutr Metab Care 2004;7:123-9.
Vitamin C
  Vitamin C has demonstrated in-vitro anti-histamine activity.
  Preliminary in-vivo studies found vitamin C helped reduce symptoms of
hayfever1 2, but a controlled study found 2,000 mg per day of vitamin C
had no benefit3.
  Few in-vivo trials were short-term (few days). May need to supplement
with vitamin C for longer period of time to see benefits.
  May have other immune-modulating effects.
  Recommend 1,000-3,000 mg per day. Warn patients of loose stool (bowel
tolerance). Unlikely at these doses.
1 Holmes HM, Alexander W. Hay fever and vitamin C. Science 1942;96:497.
2 Ruskin SL. High dose vitamin C in allergy. Am J Dig Dis 1945;12:281.
3 Fortner BR Jr, Danziger RE, Rabinowitz PS, Nelson HS. The effect of ascorbic acid on cutaneous and nasal response to histamine and allergen. J Allergy Clin Immunol 1982;69:484-8.
Other Nutrients
  Vitamin B6: 100-200 mg per day.
  Vitamin B12: 1000 mcg oral daily or IM once per
week.
  Vitamin D: 1200 IU per day with food.
  Selenium: 200 mcg per day with food.
  Vitamin B3 (niacinamide): 200 mg qid.
  IV Myers cocktail
Thymus Extract
Thymomodulin® is a special preparation of the thymus gland from calves.
  Studies show thymus extract helps improve symptoms of hay fever and allergic
rhinitis1 2, food allergies3 4, and infection1.
  Has modulating effect on T-cells.
1 Kouttab NM, Prada M, Cazzola P. Thymomodulin: biological properties and clinical applications. Med Oncol Tumor
Pharmacother 1989;6:5-9.
2 Marzari R, Mazzanti P, Cazzola P, Pirodda E. [Perennial allergic rhinitis. Prophylaxis of acute episodes using thymomodulin].
Minerva Med 1987;78:1675-81.
3 Cavagni G, et al. Food allergy in children: an attempt to improve the effects of the elimination diet with an immunomodulating
agent (thymomodulin). A double-blind clinical trial. Immunopharmacol Immunotoxicol 1989;11:131-42.
4 Genova R, Guerra A. Thymomodulin in management of food allergy in children. Int J Tissue React 1986;8:239-42.
Probiotics
Beneficial bacteria part of normal flora of the gut, including Lactobacillus sp. and Bifidobacter sp.
  Probiotics improve digestion by limiting the absorption of food allergens and/or by changing
immune responses to foods1 2.
  Probiotics may also be important in non-allergic food intolerances3.
  Not all probiotics are created equal! Lactobacillus GG one of the more reliable strains. One
unpublished study found only 1 in 20 probiotic products contained exactly what was stated on the
label.
1 Kirjavainen PV, Gibson GR. Healthy gut microflora and allergy: factors influencing development of the microflora. Ann Med 1999;31:288-92.
2 Salminen S, Isolauri E, Salminen E. Clinical uses of probiotics for stabilizing the gut mucosal barrier:successful strains and future challenges. Antonie Van
Leeuwenhoek 1996;70:347-58.
3 Hunter JO. Food allergy-or enterometabolic disorder? Lancet 1991;24:495-6[review].
Digestive Enzymes
Pancreatic enzymes: trypsin, chymotrypsin, lipase, amylase. May break large, allergenic
proteins into smaller non-allergenic proteins. Bromelain and papain also useful.
  Preliminary research showed benefit in pancreatic enzymes as a treatment for food
allergies1 2.
  Use of enteric coated pancreatic enzyme preparation reduced severity of food allergy
symptoms in 10 patients (non-anaphylactic reactions)3.
Potential benefits using betaine/HCl/pepsin for protein degradation, but no research
supporting its use yet.
1
Oelgoetz AW, Oelgoetz PA, Wittenkind J. The treatment of food allergy and indigestion of pancreatic origin with pancreatic enzymes. Am J
Digest Nutr 1935;2:422-6.
2
McCann M. Pancreatic enzyme supplement for treatment of multiple food allergies. Ann Allergy 1993;71:269 [abstract #17].
3
Raithel M, et al. Pancreatic enzymes: a new group of antiallergic drugs? Inflamm Res 2002;51(Suppl 1):S13-4.
Pycnogenol
Extract of French maritime pine bark (Pinus pinaster)
containing bioflavonoids. Inhibits release of histamine
from mast cells and inhibits leukotriene production.
  In-vitro study showed Pycnogenol equal to cromolyn
1
sodium in blocking mast cell histamine release .
  RDBPC study found 3 months of Pycnogenol treatment
in young adults with asthma led to improved asthma
symptoms and pulmonary function, decreased use of
rescue medication and decreased urinary leukotrienes2.
1 Sharma SC, Sharma S, Gulati OP. Pycnogenol inhibits the release of histamine from mast cells.
Phytother Res 2003;17:66-9.
2 Lau BH, et al. Pycnogenol as an adjunct in the management of childhood asthma. J Asthma
2004;41:825-32.
Nettles
Preliminary study showed that freeze-dried capsules of
nettles (Urtica dioica) reduced sneezing and itching in
those with hay fever1. Use 600-900 mg t.i.d.
Nettles has a historical use in botanical medicine for treating
cough, TB and arthritis. In-vitro studies suggest it may
have anti-inflammatory effects and inhibit prostaglandins.
1
Mittman P. Randomized, double-blind study of freeze-dried Urtica dioica in the treatment of allergic
rhinitis. Planta Med 1990;56:44-7.
Butterbur (Petasites hybridus)
Open label study with 580 patients with seasonal allergic rhinitis took 2
tablets a day of Butterbur extract Ze339 (containing 8 mg petasines per
tablet) for two weeks. Symptoms of rhinorrhea, nasal congestion, itchy
eyes and nose, red eyes and skin irritation improved in 90% of the
patients compared with baseline.1 Use 50-75 mg bid. Is mild leukotriene
inhibitor. Found to be as effective as 180 mg of fexofenadine.2
Butterbur contains pyrollizidine alkaloids, so should be used with caution
or use PA-free extract.
Butterbur is in the ragweed family so should be used with caution in those
allergic to ragweed.
1
Kaufeler R, et al. Efficacy and safety of butterbur herbal extract Ze339 in seasonal allergic rhinitis: postmarketing surveillance study.
Adv Ther 2006;23:373-84.
2 Schapowal A.
Treating intermittent allergic rhinitis: a prospective, randomized, placebo and antihistamine-controlled study of
Butterbur extract Ze339. Phytother Res 2005;19:530-7.
Herbs Traditionally Used In Treating
Asthma and Allergic Rhinitis
  Ma Huang (Ephedra sinica)
  Marshmallow (Althea off.)
  Eyebright (Euphrasia off.)
  Mullein (Verbascum thapsus)
  Eucalyptus (Eucalyptus globulus)
  Plantain (Plantago lanceolata)
  Red Raspberry (Rubus idaeus)
  Elecampane (Inula helenium)
  Elderberry (Sambuccus nigra)
  Coltsfoot (Tussilago farfara)
  Sage (Salvia off.)
  Ivy leaf (Hedera helix)
  Slippery elm (Ulmus fulva)
  Lobelia (Lobelia inflata)
  Tylophora (Tylophora indica)
Homeopathics Used In Treating
Asthma and Allergic Rhinitis
1. 
Allium cepa: copius acrid discharge from eyes and nose, burning, < indoors, < warm room, > open air.
2. 
Euphrasia: copius watery discharge from eyes and nose, < sun, < warm room, > open air, sneezing, < lying
down.
3. 
Arsenicum album: acrid lacrymation, excoriating discharges, intense photophobia, thirsty for cold drinks
(sips), < after midnight, < wet weather, > heat, < 2-3 am.
4. 
Blatta orientalis: asthma remedy (follows ars well). Asthma associated with bronchitis. < night, < lying
down, > expectoration. < exertion and damp environments.
5. 
Tuberculinum: hard, short, dry cough. > open air. < milk. Yellow/green discharge from nose. < evening.
6. 
Phosphorus: tickling cough which is < lying on back, epistaxis. Dry, burnt feeling in chest. < lying L side.
Stitching pain in chest.
7. 
Calc carb: dyspnea with exertion, < ascending. < stooping forwards. Clear/bland discharges.
8. 
Silica: violent cough which is < lying down. Thick yellow expectoration, < lying L side, > warm wraps to
head, < new moon/night.
9. 
Pulsatilla: clingy, desire to be carried, thirstless, air hunger from asthma. < warm room, > open air, > gentle
motion.
Other Modalities Used In Treating
Asthma and Allergic Rhinitis
1.  Yoga: many studies showing yoga can help reduce frequency and
severity of asthma attacks.
2.  Exercise: especially in overweight children.
3.  Constitutional Hydrotherapy: can do home version with hit and cold
towels. Easy for parents to do to their children.
4.  TCM: Gua Sha: It involves palpation and cutaneous stimulation
where the skin is pressured, in strokes, by a round-edged
instrument, that results in the appearance of small red petechiae.
Sublingual Immunotherapy
(SLIT)
  Treatment concept same as injection; different route of
administration. Allergy drops taken under tongue and then
swallowed.
  Used in Europe more widely than in U.S. More than 30
years of clinical use.
  Proven safety record. No risk of anaphylaxis. Safe to use
with children.
  Can use same diagnostic techniques to determine
neutralizing dose (endpoint).
  More than 200 published clinical trials showing SLIT
effective in treating inhalant and food allergies. Potential
to treat other allergies/sensitivities (chemicals,
autoimmune conditions)?
SLIT: How Does It Work?
Dendritic cells (DC) within the sublingual and buccal
mucosa capture and process the antigen efficiently and
are programmed to elicit IFN-γ and IL-10 which have a
suppressive function in naïve CD4+ T-cells. DC also
induce higher expression of toll-like receptors (TLR 2,
4,5,7) in other lymphoid tissues which have
immunoregulatory effects.
Mascarell L et al. Oral dendritic cells mediate antigen-specific tolerance by
stimulating Th1 and regulatory CD4+ cells. J Allergy Clin Immunol 2008; Sep
(133): 603-9.
SLIT: How Does It Work?
In vivo study with 10 children with house dust mite allergy
treated for 12 months with SLIT showed a significant increase in
IL-10, reduction of IL-12 and reduction of CD86 expression
(necessary for T-cell proliferation and IL-2 production) in mature
dendritic cells.
Angelini F et al. Dendritic cells modification during sublingual immunotherapy in children with
allergic symptoms to house dust mites. World J Pediatr 2011; Feb (7): 24-30.
SLIT: How Does It Work?
The sublingual mucosa contains a limited number of
pro-inflammatory cells, such as mast cells.
Therefore, there is little likelihood of having an
adverse reaction when administering the drops
under the tongue.
Sublingual Immunotherapy
The Research
More than 50 RPCS and 5 meta-analyses show that SLIT is a safe,
effective treatment for allergic rhinitis. There are more than 600
studies mentioned in the medical literature. Many of these studies
also include asthma.
The biggest factor determining clinical outcome is dose. Optimal
dosing for SLIT has not been established and individual doses of
allergen have varied tremendously, with a 30,000 fold difference in
antigen dose ranging between 10 ng to over 300 mcg and differing
dosing schedule from daily to a few times a week. Higher dosing
regimens have generally been shown to be more effective.
Sublingual Immunotherapy
The Research
Review of five meta-analyses, all involving children being treated for
allergies to house dust mite, grass pollen and other various allergens
showed a 32-95% improvement in symptoms of allergic rhinitis and
a 33-76% reduction in use of allergy medications. Studies showed
that the magnitude of SLIT therapy was higher in patients with more
severe symptoms during grass pollen season (10%, 33% and 34%
respectively) based on low, moderate and high severity symptom
scores. No significant adverse effects with SLIT.
Incorvaia C et al. The current role of sublingual immunotherapy in the treatment of allergic
rhinitis in adults and children. J Asthma Allergy 2011;4:13-17.
Sublingual Immunotherapy
The Research
Meta-analysis of nine studies including 232 children between the
ages of 3 and 18 years old with mild to moderate allergic
asthma compared with 209 controls. SLIT was initiated for
allergies to dust mites, grass pollen and tree pollen for 6 to 32
months. Significant reductions is asthma symptom scores and
use of rescue medication were observed on those receiving
SLIT.
Penagos M et al. Metaanalysis of the efficacy of sublingual immunotherapy in the
treatment of allergic asthma in pediatric patients, 3 to 18 years of age. Chest
2008;133:599-609.
Sublingual Immunotherapy
The Research
113 children aged 5 to 14 years old with allergic rhinoconjunctivitis
limited to grass pollen were treated with either SLIT plus
medication or medication alone for 3 years. No significant
differences were observed in the first year of treatment, but in the
the second and third years of treatment, there was a significant
difference in hay fever symptom scores and use of medication.
Development of asthma was 3.8 times higher in the control group
than the SLIT treatment group.
Novembre E et al. Coseasonal sublingual immunotherapy reduces the development of
asthma in children with allergic rhinoconjunctivitis. J Allergy Clin Immunol
2004;114:851-7.
Sublingual Immunotherapy
The Research
Review article using SLIT for treatment of Alternaria alternata, a
common outdoor mold, found that children and adolescents
treated with specific Alternaria IT had fewer respiratory
symptoms and used less medication. No change in IgE was
noted between treatment and control groups, but a significant
increase in IgG4 was observed in the group receiving
Alternaria IT. Is IgG4 a major player with mold allergy?
Martinez-Canavate Burgos A, Valenzuela-Soria A, Rojo-Hernandez A. Immunotherapy
with Alternaria alternata: Present and future. Allergol et Immunopathol
Sublingual Immunotherapy
The Research
SLIT for the treatment of food allergies is relatively unknown as
there are only a few studies (peanut and peach). One study
treated 18 children with peanut allergy for 12 months (6
months of dose escalation and 6 months maintenance) using
SLIT. The treatment group safely ingested 20 times more
peanut protein than the control group and had a decrease in
wheal size on skin prick testing. IgE levels initially increased
and then decreased whereas IgG4 levels rose during the course
of the treatment.
Kim EH et al. Sublingual immunotherapy for peanut allergy: clinical and immunologic
evidence of desensitization. J Allergy Clin Immunol 2011;127:640-6.
Sublingual Immunotherapy
SLIT: Lasting Results
Open controlled study of 59 adults with house dust mite allergy
matched with 12 controls found that those receiving SLIT for
3 years, the clinical benefit lasted 7 years. In those who
received SLIT for 4-5 years, the clinical benefit lasted 8 years.
New sensitizations occurred in all control subjects and in less
than a quarter of those receiving SLIT (21%, 12%, 11%
respectively).
Marogna M et al. Long lasting effects of sublingual immunotherapy according to its
duration: A 15-year prospective study. J Allergy Clin Immunol 2010;126:969-75.
Sublingual Immunotherapy
SLIT: High compliance and cost effective
Meta-analysis of SLIT in children showed that compliance of therapy
was very high (84%) and better than SCIT (61%).
SLIT is significantly cheaper than SCIT. The average annual costs of
SCIT in France was €2672 ($3900) before SLIT initiation and €629
($918) after SLIT therapy.
Marseglia GL et al. Sublingual immunotherapy in children: facts and needs. Italian Journal
of Pediatrics 2009;35:31.
Sublingual Immunotherapy
What can be treated with SLIT?
1. Food allergies/sensitivities
2. Molds/Yeasts
3. Pollens (trees, grasses, weeds)
4. Dust and dust mites
5. Animal danders: cat, dog, horse, etc.
Sublingual Immunotherapy
Studies show SLIT is effective 75-90% of the time. The
effectiveness of the treatment is based on quality of antigen,
dose of antigen and duration of treatment. This is equal or
superior to conventional injection immunotherapy.
The duration of treatment can be short (6 months for food) up to
many years (mold, pollens).
Advantages of Sublingual
Immunotherapy
1.  Non-invasive. Drops are administered under the tongue or
on the wrist. No needles or injections.
2.  Excellent safety record.
3.  No weekly doctor s visits to get treatment. Able to
administer at home.
4.  More control over dose. Treatment can be easily tailored to
response.
5.  More effective than conventional immunotherapy?
Disadvantages of Sublingual
Immunotherapy
1.  Not covered by most insurance plans, despite its excellent
safety record and cost effectiveness. No CPT code for SLIT.
2.  Varying dosing regimens. Must be tailored to individual
patient.
3.  Works best with divided dosing schedule, often 3 times a
day. With children, I recommend before school, after school
and bedtime.
Treatment Pearls
1.  Alkalinize the body: sodium bicarbonate works well. 1/8-1/4
tsp bid-tid can help reduce allergy-like symptoms and
wheezing.
2.  Steam inhalation for wheezing with or without essential oils,
such as eucalyptus, lavender or wintergreen oils. 1-2 drops in
boiling water with head covered. Watch not to burn child.
3.  Nasal irrigation daily.
4.  Euphorbium homeopathic nasal spray for allergic rhinitis.
5.  Homeopathic histaminum/luffa/euphorbium 30C for hayfever.
6.  Nebulized glutathione: 60 mg/cc (2 cc ampules). Daily for
one month for recurrent asthma.
Contact Information
Darin Ingels, ND
 203-254-9957 (office)
 dingels@gmail.com
Jessica Tran, ND
 949-612-6371
 drjessicatran@gmail.com