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The main drug in this group is ipratropium (Atrovent) which is taken by inhalation. Side-effects are rare except at high doses. They include dry mouth, difficulty in passing urine and constipation. Other anti-cholinergics include butethamate and atropine. Anti-cholinergics help to reduce the amount of mucus present in the airways as well as relaxing the muscles,

and may be useful where asthma and bronchitis occur together.

Sympathomimetics, such as adrenaline and ephedrine, are sometimes combined with anticholinergics in inhalers. Atropine is combined with adrenaline and a muscle relaxant in Brovon and Rybarvin. Butethamate is combined with ephedrine in CAM, which is taken by mouth. Ipratropium is combined with the bronchodilator fenoterol in Duovent.

Other bronchodilators

Sympathomimetics were once the main drugs used for bronchodilation, but they are much less specific for the bronchial muscles than the drugs described above. They produce side-effects more easily than modern bronchodilators and are much less used now. They include adrenaline, ephedrine and phenylephrine. Typical side-effects include nervousness, anxiety, tremor, irregular heartbeat and dry mouth.

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For anyone with multiple food sensitivities, avoiding all their culprit foods can be very difficult. And it may mean that they eat too much of other foods, with die attendant risk of developing new sensitivities. Even those who are intolerant of just one or two foods may find it difficult to avoid them, especially if they eat away from home a lot. So there have been many attempts to develop alternative methods of treatment.

Given the lack of knowledge about how food intolerance arises, these attempts are largely a ’suck-it-and-see’ exercise: trying out treatments and seeing if they work. No treatment has yet been devised which is 100 per cent effective for all patients, and there are some on offer from ‘alternative’ practitioners that are quite ineffective and even potentially dangerous (eg urine therapy). However, there are two methods currently being tried out by some doctors, known as neutralization or desensitization treatments, that are worthy of further investigation.

In some studies, these treatments have performed quite well, but in others they have been less successful. Consequently such techniques are controversial and many doctors feel that they should not be used until there is more evidence that they work. But given the complex nature of food intolerance, and the evidence suggesting that it is caused in several different ways (see Chapter Twelve), perhaps it is not surprising if a treatment gives varying results – it might be expected to work for some patients and not for others. Our own experience suggests that such methods are effective for a proportion of people with food intolerance. But they are probably not worth trying unless there is no reasonable dietary alternative.

These methods have also had some success in treating classical allergies, and in this context they may be very useful. The traditional method of desensitization, once widely used for hay fever and other allergies, cannot now be given by family doctors in Britain. This method involved injecting minute, but gradually increasing, doses of the allergen over a period of many months. There is a risk of collapse, due to anaphylactic shock, with this method, and a few patients have died as a result. Such desensitization treatment can now only be given in hospital, where resuscitation equipment is available.

Other uses claimed for these techniques include desensitization to environmental chemicals, such as exhaust fumes, and desensitization to Candida, where there is a sensitivity to the yeast’s products as a consequence of candidiasis.

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Most of the cross-reactions that are seen (or suspected) in patients do not match so well with the biological classification. For many foods, the use of the family group to predict cross-reactions is more a matter of faith than science, but it is still the most useful guide we have. There are also some unexpected cross-reactions, which do not tally with classification schemes.

If you have reason to suspect any food before starting on your elimination diet (because you eat it in large amounts, for example) you should check the food-family list to discover which family it belongs to. All its relatives should be excluded during the first phase of the diet, along with the food itself. The food families may also be useful later, in interpreting your reactions to tested foods, and in planning your diet afterwards – just as you should not eat too much of any one food, you should not eat too much from any one food family either.

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For the older baby, early weaning may be the answer, although it involves the risk of sensitizing the child to even more foods or – if all the high-risk foods are avoided – failing to give the child an adequate diet. Early weaning is only recommended if the baby is suffering quite badly and you have exhausted all other possibilities. It would not be appropriate, for example, in the case of a colicky baby who was otherwise well and growing normally. If you decide to try early weaning, remember the following points:

1. Certain foods seem to contain more potent allergens than others. Do not give the child eggs, fish, chocolate, wheat, oranges, peanuts or other nuts for at least the first six months, and preferably for the first year of life. If you introduce them before a year old, do not give them every day. Test out beef and chicken cautiously, as these can cross-react with milk and eggs respectively. If they seem to cause no problems, you can include them in the child’s diet.

2. Formula feeds commonly contain maize (corn) and tapioca, as well as cow’s milk, so your child may have become sensitive to these. Avoid these foods for at least six months and then try them out carefully. Maize comes in many guises, including cornflour, cornflakes, corn oil, corn syrup, sweetcorn, corn-on-the-cob and popcorn. Some medicines contain corn syrup: ask your pharmacist for advice if you are concerned about avoiding all corn products.

3. No food should be eaten in very large quantities, and it is best not to give any one food every day. This means using your imagination and buying some fairly unusual items. Foods such as millet and sweet potatoes make a good basis for baby foods, and if the baby does become sensitive to them, at least they are no trouble to avoid in later years.

4. Do not force the child to eat any food that is obviously disliked. Most children reject new foods the first time they are offered, but if your child clearly finds the food disagreeable, even after trying it three or four times, then don’t serve it up again. A dislike of the taste is sometimes an early sign of sensitivity.

5. If a child is not eating eggs, milk or fish, there is a risk of protein being in short supply. Make sure that you include other protein-rich foods, such as lamb, pork and other meats. Beans are a good source of protein, but they are also rather indigestible and cause wind; chickpeas (p303) are less of a problem, and have a milder taste.

6. Your child will probably need a calcium supplement, and the overall diet should be checked by a paediatric nutritionist to see if it contains enough of other minerals, as well as vitamins. Ask your doctor to arrange this for you.

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Anyone who lives in a town or city will have been kept awake, at some time or another, by the sound of a burglar alarm ringing endlessly in an empty shop or house. The alarm is only meant to ring if someone breaks in, but it is triggered off by some other quite innocent event, such as a strong wind or the vibrations of a passing lorry. This is more or less what happens in the case of allergies. The mast cells, which are meant to respond to invasion by parasites, are triggered off by an innocuous substance such as eggs or cow’s milk. But why should this happen?

The answer is that the body misguidedly makes IgE antibodies that fit the antigens in these substances. A very complex and intricate set of controls normally prevent the body from making IgE in response to such harmless materials, but in the allergic individual something goes awry and the control mechanisms break down.

In the case of Jane, her body had mistakenly made IgE antibodies to an antigen in peanuts, probably a protein. The strange symptoms that she experienced on eating peanuts were all produced by mediators released from her mast cells. Mast cells in the tissues of the mouth were triggered as soon as the food came into contact with them, producing symptoms almost immediately. Her lips and tongue swelled up because tiny blood vessels inside them became leaky, allowing fluid to seep out into the surrounding tissues.

The cause of Jane’s collapse (anaphylactic shock) when she ate peanuts again was a sudden drop in blood pressure, likewise produced by the mediators. This time, it seems, more IgE was present and far more mediators released. By making the blood vessels all over her body expand, and at the same time become more leaky, the mediators left her without enough blood pressure to keep the vital organs functioning.

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