Diagnosing Food Allergies in the Old Days

Dr. Paul Ehrlich
The best thing about 35 years of practice is also the worst thing. Young patients come through the door who are related to patients I had decades ago, and I get to catch up on their older relatives. To the extent that I made a difference in their lives these encounters are very gratifying. Unfortunately, they also remind me how long I’ve been practicing.

Recently a little Hasidic boy came to see me with his mother. He had terrible allergic rhinitis that his pediatrician couldn’t stop. His mother told me that her mother said, “It’s time to see Dr. Ehrlich.” Twenty-five years ago, the little boy’s uncle, then about 10, was also a patient. He had been diagnosed by his pediatrician with milk allergy, and the Mom, being conscientious, eliminated it from his diet.

This was not a stretch for a Hasidic mother. Restricting diet is routine: meat from dairy, no grain or legumes and a separate set of dishes for Passover, not to mention a permanent ban on pork and shellfish. In fact, Hasidic patients understand the restrictions better than most other people for the simple reason that they have different prayers for different foods. For example, they never confuse an allergy to peanuts with allergies to tree nuts because they have different prayers for legumes such as peanuts and for tree nuts, like almonds. This results at Passover in a distinct improvement in the incidence of eczema, by the way, because Ashkenazic Jews, including Hasidim, are avoiding those legumes, to which many are allergic.

Returning to the case of the now-grown uncle of my current young patient, Mom doubled up on fish to make sure the growing boy got enough protein, but unfortunately he didn’t get better. We went through an exhaustive history and tracked the timing of his reactions after mealtime. In time the answer revealed itself: the boy was allergic to fish, not dairy. When the grandson’s nose started to run and wouldn’t stop, I was the medical Rabbi they consulted.

The essential point here is that there is no substitute for a good history and sound clinical judgment in diagnosing and treating food allergies. Now, 25 years later, despite all we know, diagnosis is frequently no better than it was then, and of course, we can only manage food allergies, not cure them. Knowledge of the best practices is spotty. This timetable is an old story in medicine. There’s a rule of thumb, if I remember it correctly, that it takes an average of 17 years for a new clinical breakthrough to find its way into half of medical practices in this country. The information age hasn’t changed that. Somewhere in Brooklyn there’s another child whose doctor thinks his patient is allergic to milk, not fish. Call me for an appointment.

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