Food Allergies – PediaCast 259

Dr Rebecca Scherzer and Dr Peter Mustillo join Dr Mike in the PediaCast Studio for a comprehensive look at food allergies. We cover the bases: from why food allergies occur… to the symptoms, diagnosis, treatment, and prevention of this common problem.

Topic

  • Food Allergies

Guests

Links

 

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It’s Episode 259 for July 17th, 2013. We’re calling this one ‘Food Allergies.”  I would like to welcome everyone to the program.

We have another nuts — literally — and bolts show for you today. This time on a topic that affects lots of kids and many adults as well — food allergies. Now, as I typically mention at the onset of our topical programs, this one’s a little different from our Answers to Listeners’ Questions and our News Parents Can Use editions of the program. And I realize a fair number of you out there do not suffer from food allergies, nor do your children have food allergies. But at the same time, nearly everyone knows someone with food allergies. And if you expand those you know from family and neighbors and co-workers, if you expand that out to include people in your social media circles, then I’m confident that you touch the lives of many people dealing with food allergies in their lives or the lives of their kids.

And so, I would ask this, if you could share this program with your social media family and friends, by sharing the episode on Facebook and Google+ and retweeting on Twitter and repinning on Pinterest. And by the way, we make it easy for you to share on social media sites because PediaCast does have a presence on Facebook, Google+, Twitter and Pinterest. So, even if you aren’t personally affected by food allergies, please consider sharing so we can get the information into the hands of moms and dads who need it but who may not know about the program.

02:12

So what food allergy information will we be covering while in usual PediaCast fashion? Pretty much everything. We’re going to talk about how food allergies occur, what symptoms to expect, what else could cause the symptoms. In other words, what the differential diagnosis? How does one go about diagnosing a food allergy, how are they treated, can they be prevented, is there a cure, what’s the long-term outlook? And what is the latest and greatest in terms of food allergy research?

And to help me cover these questions, I have a couple of great studio guests lined up for you today — Dr. Rebecca Scherzer and Dr. Peter Mustillo, both pediatric allergists here at Nationwide Children’s Hospital.

Before we get to them, I do have a couple of reminders for you. If you or someone you know is dealing with insulin dependent, so Type 1 Diabetes, be sure to check out our brand new Nationwide Children’s Diabetes Calculator For Kids. This is truly a first of its kind for the pediatric patient. Basically, you input a bunch of numbers regarding your child, including their age, their insulin carbohydrate ratio, their glucose correction factor, also known as the sensitivity factor, and their target blood glucose. So you input these numbers and the calculator spits out a convenient insulin bolus dose chart which allows you to cross-reference your child’s current blood glucose with the amount of carbs you expect your child to eat. So that you can determine the number of units of rapid-acting insulin that your child needs prior to his or her meal.

So the chart is personalized for your child and it can be printed or emailed to caregivers who need it. Now, you may be saying “I don’t know my child’s insulin carbohydrate ratio.” Or “I  don’t know what a glucose correction factor is.” Or “What in the world is my child’s target blood glucose?” If you don’t know these things, you should. And, in all cases, we recommend that you collaborate with your child’s diabetes doctor prior to inputting the numbers and using the chart.

0:04:01

Of course, collaborating with your child’s diabetes doctor is something you should do anyway. And by collaborating, you’re also informing your doctor about the calculator and he or she can share this great resource with his or her other diabetic patients.

So if you’re dealing with diabetes or you know someone who is, be sure to check out the Nationwide Children’s Diabetes Calculator for kids and I’ll put a link in the Show Notes for this episode, 259, over at pediacast.org so you can find it and share it easily.

OK, speaking of brand new, the Diabetes Calculator isn’t the only brand new thing to tell you about. Nationwide Children’s has a great new blog for moms and dads. It’s called 700 Children’s and you’ll find it at 700childrens.org. I’ll put a link to that in the Show Notes as well. Yours truly is a regular contributor. Some recent topics — How Fireworks Affect Hearing, Gluten-free Summertime Recipes, Lawnmower Safety Tips and Sunscreen Cause Skin Cancer. That’s what I put together. There’s a recent post on food allergies and another on medication poisonings in young children and another on kangaroo care.

So, lots of great information for moms and dads, direct from the experts at Nationwide Children’s Hospital. The address is easy — 700childrens.org. So be sure to check it out.

And finally, a reminder that PediaCast is your show. We have lots more Answers to Listener Questions episodes lined up. So, if you have a question you’d like answered, just head over to pediacast.org and click on the Contact link.

Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and a hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

All right, let’s take a quick break and I will be back with our studio guests and we’ll chat it up about food allergies, right after this.

[Music]

0:06:25

Dr. Mike Patrick: All right, we are back. Dr. Rebecca Scherzer is a pediatric allergy specialist at Nationwide Children’s Hospital and an associate professor of pediatrics at the Ohio State University College of Medicine. She serves as associate director of the combined Ohio State Nationwide Children’s Allergy and Immunology Fellowship Training Program and has a clinical interest treating children and teenagers with allergies, asthma and immunodeficiency disorders.

This is Dr. Scherzer’s first appearance on PediaCast and we welcome her warmly to the program. Thanks for joining us, Dr. Scherzer.

Dr. Rebecca Scherzer: Thank you. Thanks for having me.

Dr. Mike Patrick: Really appreciate you stopping by.

I do want to point out that Scherzer’s husband, DJ, I guess you could call him a regular on the program. He’s been here a couple of times. We talked about anaphylaxis with him, which is a severe life threatening allergic reaction back in PediaCast 178. And he’s also a member of the PediaCast foodies along with another allergy doctor, Dr. Amber Patterson. And back in PediaCast 227, we covered topics like hyperdosed corn syrups, transfats, food colorings and dyes, natural and artificial flavors, aluminum, bovine growth hormone. And we do have plans to get the foodies back together, so be sure to send in your food related questions by using the contact page over at pediacast.org.

So PediaCast 178 “Anaphylaxis”, 277 “Food Ingredients”, both a great shows for folks with an interest in food allergies, so be sure to check those episodes as well. But I don’t mean to steal your thunder, Rebecca.

[Laughter]

Dr. Rebecca Scherzer: I’m going to share it with my husband.

Dr. Mike Patrick: Dr. Peter Mustillo who is another first-time guest on PediaCast, he too is a pediatric allergist at Nationwide Children’s Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine. Dr. Mustillo serves as physician director of the Infusion Clinic at Nationwide Children’s and like Dr. Scherzer, treats kids and teens with allergies, asthma and immunodeficiency disorders.

0:08:16

So a warm welcome to Dr. Mustillo as well. Thanks for joining us.

Dr. Peter Mustillo: It’s great to be here. Thank you.

Dr. Mike Patrick: It’s great having both of you in the studio.

So, Dr. Scherzer, let’s start with you. If you could just define for moms and dads out there, what is meant by food allergy?

Dr. Rebecca Scherzer: So, the definition of a food allergy is an adverse health effect, arising from a specific immune response that occurs reproducibly upon given exposure to a food. I think there’s a couple of things in this definition that we should point out.  One of them is that this is an immune-mediated response. As we’ll talk about later, there’s lots of different responses people can have to food, but a food allergy is related to an immune response. It also occurs reproducibly upon given exposure to any specific food.

Dr. Mike Patrick: So this is a little bit different than a food intolerance where you may have a set of symptoms related to a food, but if it doesn’t involve the immune system, then it’s not really a food allergy.

Dr. Rebecca Scherzer: True. And even within the topic of food allergy, there’s different immune mechanisms than can lead to it. And we’ll talk more about that later. But yes, a food allergy is an immune-mediated response.

Dr. Mike Patrick: Great. Now, how common are food allergies?

Dr. Rebecca Scherzer: So, we see food allergies in about 6% to 8% of children and 3% to 4% of adults. So it definitely is a higher prevalence in children when compared to adults.

Dr. Mike Patrick: Now, sort of like asthma, it seems like there’s more and more food allergies being diagnosed. Do you think that’s because we just are recognizing it more, or is there really an increased incidents of food allergies over the last few years?

Dr. Rebecca Scherzer: I think it’s actually a combination of food. I definitely think there is an increased incidents of a lot of atopic diseases. But I also think food allergies are recognized more and these children are getting more and more to allergists to get the proper diagnosis.

Dr. Mike Patrick: Yeah. One of the numbers I came across was like one in 25 to 30 children have a peanut allergy. So if we take a classroom of kids, pretty much there’s going to be at least one kid who has a peanut allergy in that group.

0:10:08

Dr. Rebecca Scherzer: Yes, yes.

Dr. Mike Patrick: Now, do we see much difference in terms of age groups. So, do we see like more younger kids, more school-aged kids? Or is it more prevalent in adults? How does it break down in terms of age?

Dr. Rebecca Scherzer: It is definitely higher. There is a higher prevalence in children compared to adults and certainly in younger children, we see it more frequently.

Dr. Mike Patrick: Sure. Well, what about males versus females? Pretty much equal between the sexes?

Dr. Rebecca Scherzer: Yes. Yes.

Dr. Mike Patrick: And race and the ethnic groups, pretty much everybody sees it the same?

Dr. Rebecca Scherzer: Yes. Really, the biggest risk factors you have for food allergy are if you come from a family of food allergy, because we know that a lot of atopic disease is inheritable. But if you yourself have atopic disease such as asthma or eczema, that put you at higher risk of having food allergy.

Dr. Mike Patrick: Sure. So there is a genetic component to food allergies as well?

Dr. Rebecca Scherzer: There is, and to atopy in general.

Dr. Mike Patrick: Yup.

Dr. Mustillo, what foods are commonly involved? Is it pretty much any food can cause a food allergy or just a certain group of foods?

Dr. Peter Mustillo: Sure. So someone can be allergic to any food. Although, there are some that are much more common than others. In children, the top three foods that are responsible for approximate three-fourths of food allergy reactions are due to milk, egg and peanut. And of those three, milk is most common. About  2 1/2 percent of children are allergic to milk at a younger age.

And then, they have what we call the Big 8 which are responsible for causing up to 95% of the reactions in children. And they are due to milk, egg, peanut and tree nuts, soy, wheat, shell fish and fin-to-fish, which is basically fish with a backbone. And in adults, shellfish is actually the most common allergen.

Dr. Mike Patrick: Now, I hear this term tree nuts quite often. What is actually is a tree nut? How’s that different from a peanut?

0:12:08

Dr. Peter Mustillo: So a peanut is actually a legume that grows in the ground and its related in the same family as peas and beans such as soy beans. Tree nuts actually grow on the tree and they include almond, pistachios, walnuts, hazel nuts, Brazil nuts, macadamia nuts, among a couple others.

Dr. Mike Patrick: Yeah, like cashews. Those are my favorites. Add that in there.

[Laughter]

Dr. Mike Patrick: What about chocolate and strawberries? As I recall in my training, it was like “Don’t give kids chocolate or strawberries until they’re a year old.” Do you see much chocolate or strawberry allergies?

Dr. Peter Mustillo: So, as far as chocolate goes, it’s not impossible but it’s unusual to be allergic to the actual cocoa and chocolate itself. Most of the time, if people have reaction to chocolate, it’s related to either the milk contained in it or peanut or some tree nut.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: Now, strawberry, I’ve had a number of people who actually have mentioned that they feel their child is allergic to strawberry. That if this is the case, it’s typically not the classical IgE-mediated allergic reaction. And, most of the time, if the parents retry the strawberry, the children actually tolerate it. So a true allergic reaction to strawberry is also very uncommon.

Dr. Mike Patrick: Now, why do you think these Big 8 are the Big 8? What about those foods make them more allergy-provoking?

Dr. Peter Mustillo: So, that’s a question that I think the true answer is not clearly known. But these foods seem to, for some reason, contain a protein that the immune system is more likely to react with and this portion of the protein or the series of amino acids is called an epitope. And this is the protein that gets recognized by the immune system, typically in the case of food allergy, it’s the IgE antibody. But in some less common form of food allergy, it can be recognized by T-cells and it serves to actually augment in immune response.

0:14:33

Dr. Mike Patrick: Sure. One of the interesting things that I came across as I was doing some research for this topic is this concept of a pollen food allergy syndrome where you can have cross-reaction of… So someone has environmental allergies to certain pollens but then they can have cross-reactions. It’s a little bit more likely that they’ll be allergic to certain foods. Do you see that very often? I’ve not really heard of that before.

Dr. Peter Mustillo: It is a fairly common condition. If you think about where pollen comes from, it’s in some way part of a seed. And so, if you have some food such fruits like something in the Rosacea family — peach, nectarine or cherry — they can cross-react with the pollens.

Dr. Mike Patrick: Yeah, interesting. One of them I saw and it’s sort of a common one, ragweed, that it has cross-reactivity with bananas, melons such as cantaloupe, honeydew and watermelon, and tomatoes. So if you’re allergic to one of those foods and have environmental allergies with ragweed, don’t be surprised.

Dr. Peter Mustillo: That’s exactly right.

Dr. Mike Patrick: So, let’s kind of dig down to the cellular level. You talked about IgE antibodies. Kind of walk us through what causes food allergy down there at the cellular level. What’s going on?

0:15:55

Dr. Peter Mustillo: Sure. Well, what happens is there are allergy cells that are sort of present throughout our mucosal system and skin and in our GI tract. And these mast — they’re called mast cells — and they store histamine. Histamine is the chemical that when it gets released is what tends to cause the itching and other symptoms of allergic reactions. And there’s an antibody called IgE which is bound on the outside surface of these mast cells.

And then, if someone is allergic, when the food that they ingest winds up being absorbed, it binds to the IgE and it cause the IgE to cross-link. So basically, several IgEs will bind to that portion of the food protein and that will cause a signal to the cell to go ahead and release histamine and other mediators or cytokines that also might contribute to the allergic reaction, which includes the itching and the swelling and the redness and sometimes, the respiratory symptoms.

Dr. Mike Patrick: Right. And that’s why, and I think parents can understand this because when kids have those symptoms, they talk about taking an anti-histamine, something that’s going to counteract what the histamine is doing.

Dr. Peter Mustillo: Exactly.

Dr. Mike Patrick: Now, how much food exposure really is required? I mean, does it take… You have to eat a lot of the food in order to have an allergic reaction or can it just be a speck? You know, like they’re talking about peanut dust causing a problem. Is that really going to be such a small amount?

Dr. Peter Mustillo: So, yeah, the amount of protein exposure necessary to induce an allergic reaction in a person, varies actually across different individuals. So, for some people, that can be a minuscule amount. There are reports of people who if, say they’re in a family and one of the siblings ate a peanut jelly sandwich, used the serrated butter knife in order to spread the peanut butter. And then, it gets washed by hand or dishwasher, but there’s just a tiny little amount of that peanut butter still present between these serrations. And then, the next person who’s allergic to peanut, for example, goes and uses that same knife, there is some chance that can cause an allergic reaction.

0:18:23.7

There are some reported cases of kissing someone also who have previously eaten peanut butter. In rare cases, that can cause a severe allergic reaction. But they’re more the exception than the rule. Most of the time, you need to have a higher amount of exposure in order to induce an allergic reaction. And some people will have a threshold, so they’ll be able to consume a small amount but beyond that, then they can have allergic reaction.

Dr. Mike Patrick: Do you find after you’ve had an allergic reaction due to a specific food, would it then take less of the food the next time to cause it or not? Or however much it’s going to take is how much it’s going to take for a given individual?

Dr. Peter Mustillo: Yeah, it’s can be variable and we don’t really know why sometimes it takes a little more or sometimes it take a little less in order to elicit allergic response.

Dr. Mike Patrick: Sure. Speaking of the allergic response, Dr. Scherzer, what are the typical signs and symptoms that would point someone to this could be a food allergy that’s causing this?

Dr. Rebecca Scherzer: So signs and symptoms of an acute allergic reaction can vary. They can be in the skin, so you can have hives or urticaria. You can have swelling or angioedema. Or sometimes people just describe a lot of itching. Angioedema which is swelling, you can have it at the face, the lips, the tongue and the throat, or any other part of the body.

The lungs can also be affected. So people can have wheezing. You can have difficulty breathing. Some kids we see have a lot of nasal congestion and sneezing. So, again, it can be very varied. You can go along the path of more life-threatening anaphylaxis, which would be that angioedema or swelling of the lungs or the throat.

0:20:02

You can also have low blood pressure which is very dangerous and this can lead to shock. You can have a very rapid pulse or you can have dizziness or light headedness, or even loss of consciousness associated with an acute allergic reaction.

Dr. Mike Patrick: Now, what about in the GI tract itself? So things like abdominal pain, vomiting, diarrhea, would that be seen in a food allergy, in an immune-mediated response? Or is that going to be more of a food intolerance if you saw those kind of symptoms?

Dr. Rebecca Scherzer: So it could  really be an either. You certainly see kids who have what we call GI anaphylaxis. So they have repetitive vomiting usually with an IgE-mediated reaction if they’re going to have GI symptoms. And just like other forms of anaphylaxis, that can be treated with self-injectible epinephrine.

So it’s very important to keep that mind, if somebody’s having GI symptoms and you think they’re having an allergic reaction, that certainly can be sign of an anaphylaxis.

Dr. Mike Patrick: Sure. What about blood in the stool? And particularly in infants, if they have milk protein allergy, sometimes we see blood in the stool. Is that just confined during the infant period that you would see that? Or even in older kids, could blood in a stool be a sign of food allergy?

Dr. Rebecca Scherzer: So, in young children, you see it. In very young children, in infants, you can see blood in the stool, which is a sign of food protein hypersensitivity, which is usually not IgE-mediated. That’s in young children.

In older kids, you can see usually it’s not visible blood, but there might be quite positive blood in their stool if their GI tract is very affected by food allergies. You can see that probably less with just eosinophilic oesophagitis but other eosinophilic diseases could probably lead to not visible blood in the stool. But, when we see it, it’s mostly in the very young children, the kids in the first month or two of life.

Dr. Mike Patrick: And then, a lot of folks who suffer from migraines, I know histamine release can be a trigger for migraines. Do you see migraine headaches very often in the population of kids with food allergies that you treat? Or is that pretty rare?

Dr. Rebecca Scherzer: That’s pretty rare. Usually, the kids who have any kind of headache associated is a lot of times it’s allergic rhinoconjuctivitis. So it’s where we see it associated with food allergy.

0:22:12

Dr. Mike Patrick: And then, one of the things that I wanted to mention here — although we are going to have an episode of PediaCast coming up that’s going to be dedicated to celiac disease — but in terms of celiac disease and gluten which is a protein that’s in wheat and some other grains, is that considered a food allergy or above and beyond?

Dr. Rebecca Scherzer: Yeah, it’s definitely not an IgE-mediated response. So it won’t fall into the category that you think about with your typical kids of food allergies.

Dr. Mike Patrick: Right. So the immune system is involved but not in the same way when folks have a severe food allergy with hives and wheezing and that sort of thing.

Dr. Rebecca Scherzer: Right, right, right. And the treatment is — though avoidance is what you would use for both gluten-hypersensitivity or celiac disease and IgE-mediated food allergy to wheat — somebody with gluten hypersensitivity, they won’t need to have self-injectable epinephrine. Whereas, if you have an IgE-mediated wheat allergy, you would need to have available to you self-injectable  epinephrine.

Dr. Mike Patrick: Now, and this another interesting thing I have come across and maybe it’s not again something that you see very often because you know, you come across little details of things and it’s like one person in every state has ever experienced this. And not being an allergist myself, I don’t know how often someone comes in for these things. But I came across an exercise-induced food allergy. Have you ever heard of such a thing? Can either of you?

Dr. Peter Mustillo: Sure. There is a condition called exercise-induced anaphylaxis. And what happens is, if somebody eats a food and then exercises shortly after — usually within about two hours — they can actually develop anaphylaxis. If somebody eats that same food and doesn’t exercise within those couple to few hours afterwards, then they actually have absolutely no signs of any type of reaction.

0:24:13.6

Dr. Mike Patrick: Yeah. It really takes some detective work to figure out what exactly was happening because sometimes eating that food, you have to figure out that, “Oh no, I had to eat it and then exercise to have the reaction.” And I can see that becoming difficult to tease through.

Dr. Peter Mustillo: Right. And some foods are more common than others as far as being attributed to that exercise-induced anaphylaxis. Celery is actually one of the ones and wheat is another one also.

Dr. Mike Patrick: And you could see folks who exercise more might eat more celery.

[Laughter]

Dr. Peter Mustillo: That’s right.

Dr. Mike Patrick: So if we look at this set of symptoms that folks come in with, with food allergies, Dr. Scherzer, what other disease processes could cause similar signs and symptoms? So we suspect that maybe it’s a food allergy based on the symptoms but are there some other things that could cause those hives and swelling and that sort of thing?

Dr. Rebecca Scherzer: Well, part of the differential would be really based kind of on the symptoms when we think about things that can cause a lot of symptoms that we associate with food allergy. There’s a list including food intolerances. So there’s a lot of people that have different kinds of intolerances.

So, I think many people out there knows someone who’s lactose intolerance. And patients with that disease actually can get very ill upon exposure to dairy, but it’s not an immune-mediated mechanism. So it’s not a true allergy. Galactosemia would be another example of that.

There are pharmacologic responses. Things like caffeine or tyramine and aged cheeses can lead to responses that would be an adverse reaction to food, but not again an immunological response. Even food poisoning could fall under the toxin category. Again, not true food hypersensitivity reaction.

Even when you talk about food allergy and mediated responses, there’s different ways your immune system can respond. So,  patients can have IgE-mediated responses or non-IgE-mediated responses, which are most frequently cell-mediated immune responses. And then, just to keep things confusing, you can have a mix picture of non-IgE mediated and IgE-mediated. And you see that in things like in eosinophilic esophagitis and/or eczema.

0:26:15

There is one non-IgE mediated food hypersensitivity disorder which I think is important for people to keep in mind. Most patients when they’re having IgE-mediated responses to foods have the signs and symptoms within three minutes to two hours after the reaction. Well, there is something called food protein-induced enterocolitis syndrome or FPIES as I will call it for better ease. And this is a non-IgE mediated food adverse reaction.

And these kiddos, we usually see them in younger children within the first year of life. When they’re exposed to the specific food somewhere around four to six hours later, they can get very ill. They can have significant vomiting and diarrhea. This can lead to hypovolemia. They can have hypotension. They can look very, very ill.

And sometime, it takes awhile to diagnose because it doesn’t fall within the realm of what we expect from a food allergy response. The foods that most commonly cause FPIES are dairy and soy. But there’s also solid foods that can be involved and when you think about solid foods, the grains are usually the most likely culprits.

It’s a little different than IgE-mediated specific food when you look at grains. When you think about which grain is most allergenic from an IgE-mediated standpoint, it would be wheat. When you talk about FPIEs, you think more about things like rice. And so, they’re a little different. Again, they can both make kids very ill.

Dr. Mike Patrick: Whether it’s IgE-mediated or cell-mediated, this is just really a differential for us, clinical folks, to know which pathways ultimately causes the symptoms. But from the parents’ perspective, they ate a food, there’s a problem, “I want to try to figure out what’s going on.”

Dr. Rebecca Scherzer: Right. And that’s why getting them to someone who’s trained in food allergy really can be helpful to tease this picture out.

Dr. Mike Patrick: Sure. And I do want to point out, too, that there is the potentials we talked about for this to spiral into anaphylaxis which can be serious and life-threatening. So if you’re concerned about a food allergy in your child, you really do need to see your doctor and not just say “Well, this cause some hives in my kid and I’m going to avoid that food from now on.” I mean, you really need to see someone and try to figure out what’s going on.

0:28:17

Dr. Rebecca Scherzer: It is. It’s crucial, because if you have someone who has an IgE-mediated food allergy, you want to make sure that they have an  epinephrine auto-injector with them at all times, because that very much can be lifesaving. And so, it was discussed earlier, just because you had an reaction this time that maybe just as hives, that doesn’t mean the next reaction cannot be life-threatening anaphylaxis. So, really, having that medication, the self-injectable epinephrine is critical.

Dr. Mike Patrick: Right.

Dr. Rebecca Scherzer: So yes, seeing your doctor, seeing someone who specialize in food allergy is very important.

Dr. Mike Patrick: Yup. And we’re talking EpiPen is kind of the brand name, but that’s the device that we’re talking about.

Dr. Rebecca Scherzer: There’s other ones out there now. There’s something called Auvi-Q, which is also used out there  and Adrenaclick. So there are other ones, other than just EpiPen, but that is the one that I think has been around the longest.

Dr. Mike Patrick: Yeah, kind of like Kleenex and Frisbee and…

[Laughter]

Dr. Rebecca Scherzer: Right, right.

The key thing is making sure that if you have a child with an IgE-mediated food allergy that you have one. And that, you, your child — if they’re old enough — and anyone who takes care of that child knows how to use the medication.

Dr. Mike Patrick: So, even if, let’s say mom or dad see your primary your primary care doctor and they say, “Yes, I agree that there’s a food allergy here and it’s IgE-mediated. They have hives and that sort of thing and I want to see an allergist.” Really, the primary care doctor should be prescribing an EpiPen along with the referral to see the allergist.

Dr. Rebecca Scherzer: That would definitely be the safest road to head down, is to make sure that immediately that child would have epinephrine available to them if they would have a reaction. Because you’ll never know when another accidental reaction may occur.

Dr. Mike Patrick: Sure. So, Dr. Mustillo, how then do you go about diagnosing? So if there’s different things that can cause it and you’re trying to tease things out, how, as an allergist, do you go about diagnosing a food allergy?

Dr. Peter Mustillo: So, the key parts in diagnosing a food allergy involve the medical history and also the diagnostic testing. Obtaining a detailed history remains a mainstay in establishing the diagnosis of food allergy. So questions regarding what was the specific reaction, what was the timing related to the food that is potentially implicated — was the food cooked, uncooked, how much did they ingest, did they previously react to it or is it just a first exposure — are all key components in determining the likelihood of an allergic reaction.

0:30:33

For IgE-mediated reactions which are sort of the classic and most common type of allergic reaction, both the skin prick tests — which are the skin test typically done on the back and sometimes the arms — and also blood test called serum-specific IgE, they actually have similar sensitivities and specificities. There are advantages and disadvantages to both.

The advantages of the skin prick testing include that you get immediate results visible to the patient and family. So, you can establish a diagnosis at the initial visit and come up with the treatment plan at that initial appointment while the patient is present. And the cost is actually lower than the serologic test. It’s about a third of the cost on a test-for-test basis.

Some disadvantages to the skin test involve that antihistamines need to be held for at least a few days prior. If someone has diffused extensive eczema or another condition called dermatographism where just pressure leads to hives, then the skin test can be more difficult to interpret.

Now, going to the blood tests, the serum-specific IgE to the various foods, advantages are that it’s not affected by antihistamines. Typically, the primary care doc can go ahead and order it. But at the same time, there are disadvantages including that you need to obtain blood. The child’s results are delayed rather than immediate. And the cost is higher.

0:32:10

The sensitivity of both of these in terms of detecting an IgE-mediated food reaction is actually in the range of 95%. But it’s important to know that when the tests come back positive, the positive predictive value — meaning, the likelihood that the child is actually allergic to the specific food — is in the range of only 50%. So, basically, a positive test implies sensitization, but that does not always translate into a clinical allergy.

And that’s why ordering these tests, we try to target specific foods and not sort of order whole entire screening panels. Because then, it’s not uncommon to come back with a positive result and then the questions will now “What do I do with it?” especially the child’s been tolerating it in the past.

And the blood tests also, typically people regard negative as either less than .1 or .35. But there are a lot of people who have — like milk for example, if you get a serum-specific IgE to cow’s milk and the result comes back at 3 which certainly higher than what’s considered negative, only about 50% of those patients will actually have a clinical reaction upon exposure.

Dr. Mike Patrick: I think this is another reason that a kid with food allergies or suspected food allergies really do need to see an allergist, because it’s easy for primary care doc to order these tests, particularly the blood tests. Most primary care docs are doing skin testing in their office. And either you come back with “My kids are not allergic to anything,” or “There is a list of things that they’re allergic to.” And then, you get a kid avoiding foods that they might not need to avoid, that they might enjoy and has nutritional benefit for them.

0:34:07

So, I mean, really, you can get false-positives and false-negatives. And so, it’s not just a simple thing where you order the test and then you know. You really have to take lots of information and synthesize it to figure out what’s going on.

Dr. Peter Mustillo: That’s exactly right. So another key point of what you’re getting at is that someone can have a negative test by either the skin test or the blood test but they can still be allergic to that food. Because these tests pick up the most common form of food allergy being IgE-mediated. But these tests do not detect all the potential non-IgE mediated causes that  Dr. Scherzer refer to such as the FPIES,  the food protein-induced enterocolitis syndrome, the allergic colitis when the infants get blood on their stool, eosinophilic esophagitis. Some of those cases are not IgE-mediated well and there are others.

Dr. Mike Patrick: Right. Now, what about an oral food challenge? Of course, with medical supervision. Do you ever do that where you present the food and see if they have a reaction and then you know it was that food?

Dr. Peter Mustillo: Sure, we do that in fairly, routinely, in our clinic and the double-blind placebo controlled food challenge where the child doesn’t even know if they’re eating the food or not and then, monitoring them for reaction is actually considered the gold standard in diagnosing food allergy. Most of the time, we’ll go ahead and offer the food in its sort of normal visible form to the child. And we only  offer these tests when we think the likelihood that they’re going to react is low.

Dr. Mike Patrick: So, if this is a histamine-mediated response, there are other things that can cause mast cells to release histamine. And so, do you ever see folks who think they have a food allergy, but then it’s really just more of a psychological — you know, they get nervous about the food that they’re about to eat and then, that’s what causes the histamine reaction?

0:36:04

Dr. Peter Mustillo: Sure. So some of the studies actually have demonstrated that if a parent comes in and believes their child is allergic to a particular food, that is actually the case in only about half of the children. So, yeah, there can be other reasons why the patients can develop hives.

Dr. Mike Patrick: And so, that’s where the double-blind test where the kid doesn’t know what they’re eating and then seeing what the responses can be helpful.

Dr. Peter Mustillo: Correct, yes. Now, what about when you have folks who come in with the food allergy, is this something… We’re kind of moving to the treatment thing, the treatment part of this with Dr. Scherzer. When you do have a kid who you think has a food allergy, what sort of treatment path do you go down with them?

Dr. Rebecca Scherzer: So, really, right now, the only treatment for food allergy is avoidance of the food. There are things that are being researched now down the pipe that we’ll talk about a little bit later. But right now, really, no specific treatment is available except avoidance. Now, there are some key things to keep in mind. If you have a child with food allergies, you want to try to avoid places which may put them at high risk of being exposed to these food. So if you have a child who has a peanut or tree nut allergy, places like bakeries and ice cream parlors can be dangerous.

Again, you want to make sure that every single person taking care of that child and the child themselves, if they’re at the right age, know how to use their self-injectable epinephrine. Sometimes we recommend identification bracelets or necklaces that will allow people to know they have food allergy. And then, really clear communication with all the caregivers of the child — what is the child allergic to, what do they need to avoid.

There are also times where we take out secondary to food allergy one or two of the major food groups. And in those situations, we frequently consider, “I’m getting a dietary consult from our nutritionist here at Nationwide Children’s Hospital.”

Dr. Mike Patrick: Now, for breastfeeding moms, if the mom eats a food that the baby may have an allergy to, is it a problem of mommy, too? Can the allergen transfer to the breast milk?

0:38:06

Dr. Rebecca Scherzer: So most of the time, it is safe. There are certain situations. Again, every situation is different. Even that small amount of protein seems to elicit symptoms in the child. And most of the time, babies tolerate breastfeeding well.

Dr. Mike Patrick: But if it’s something that mom is recognizing “Hey, when I eat X, baby does Y,” you kind of pay attention to that.

Dr. Rebecca Scherzer: Yes. Yes. And you definitely hear that. That the baby’s flushing and they notice hives or some itchiness after mom, say, drinks a lot of milk or has a lot of dairy products. So again, you have to look at the specific situation. But a lot of times, breast milk is tolerated well.

Dr. Mike Patrick: Now, we talk about EpiPens and the auto-injectable epinephrine. What role does antihistamines — we kind of hinted at this earlier in the show — what role does antihistamines play in the treatment of food allergies?

Dr. Rebecca Scherzer: So, when you think about an acute reaction, anti-histamines can play a role in a very mild reaction. But if someone’s having a severe or life-threatening significant reaction, epinephrine is the medication that will save their life and that is the first medication they should receive and they should receive it immediately.

Dr. Mike Patrick: Is there a role for steroid medications?

Dr. Rebecca Scherzer: Again, steroids can play a role. They can help sometimes. Patients can have a late phase reaction — six, 10, 12 hours after their first reaction — and usually that’s equal to or less than the first reaction. But they definitely can have a second reaction. So the late phase reaction, the steroids might help mediate those responses. But during an acute allergic reaction, epinephrine is the medication that will save the child’s life and lead to the best outcome.

Dr. Mike Patrick: So if you have a kid who in the past, they’ve had a later reaction, then that might be someone when they have their initial reaction who says to the doctor, “Hey, you might want to think about giving me a steroid because every time this happens, a few hours later, I’m right back at it,” then that could help prevent the second one?

Dr. Rebecca Scherzer: I think a lot of children who have very severe reactions to foods end up getting a steroid course associated with that reaction. But again, I cannot stress enough the importance of epinephrine in as early as possible.

0:40:06

Dr. Mike Patrick: Yup. So some parents are really sort of afraid to use that pen. Because there’s a needle and they’re not a medically trained person and they’re really worried about it. And so, they may want to go for the antihistamine first because that’s something that they feel more comfortable giving. But what you’re saying is, “Hey, even though it’s a needle, even though you feel uncomfortable, you need to do this to potentially save your child’s life.”

Dr. Rebecca Scherzer: Yes. And that’s why teaching for the family, teaching for anyone who takes care of the child really is critical. There are great videos on the Web that you can see. Actually, DJ Scherzer, my husband, has a nice one at the Web, on YouTube, that really can show you how to use the EpiPen. The Auvi-Q which is the newer self-injectable epinephrine, it’s Auvi-Q because it actually talks to you and tells you how to do it.

But again, making sure that your patients are really comfortable with the use of this medication. They all have trainors, so you can train them. You can send trainors home with them. And then, here at Children’s Hospital, we have a very nice helping hand that will describe it. So if somebody is a caregiver but not at the appointment, then you can make sure that they get good instruction on how to use that medication.

Dr. Mike Patrick: Yup. And we’ll be sure to put links to those things in the Show Notes, so folks can find it early or find it easily. And this is Episode 259, if you’re looking for that in the Show Notes.

What about allergy shots? And I’m sure that you get asked this from parents a lot, “Can we just get my kid an allergy shot, then they won’t have the food allergy anymore?”

Dr. Peter Mustillo: Well, allergy in shots in terms of desensitizing someone to a food allergy can at times be helpful. The problem is that the risk of anaphylaxis is very high. So, the risk are just too high giving allergy shots for food. And that’s why it’s not recommended.

Dr. Rebecca Scherzer: It’s not standard of care for food allergy right now.

Dr. Mike Patrick: Yup. What about complications from food allergies? And I guess the first one that we think about, of course, is anaphylaxis. So it’s just that the IgE-mediated reaction has spiraled out of control, and now you can get lower blood pressure and the person’s life can be at risk. Are there any other complications you can think of that can be an issue with food allergies?

0:42:19

Dr. Rebecca Scherzer: So, there are some more localized food allergic responses that if the food allergies aren’t recognized, certainly, it will not be able to be treated without recognizing these food allergies. Things like eczema or eosinophilic esophagitis or other eosinophilic GI disorders are all things that you may not have the typical  picture that you expect from allergic response but can be driven by IgE-mediated food allergy. So, until it’s recognized, the food allergen is playing a role, their symptoms may not abate.

Dr. Mike Patrick: Sure. I think another complication too is sort of the psychological implication for kids. I mean, they have to be really careful when they’re eating out. They may not be able to eat at a friend’s house or can’t eat the same foods as their family or friends are eating. I mean, it’s really kind of like a chronic illness for these kids.

Dr. Rebecca Scherzer: It definitely is. And you know, again, I think having the child and the family comfortable with the diagnosis is very important. There is so much support out there for kids with food allergy. There’s the Food Allergy Network, There are lots of different networks, there’s these camps that these kiddos can go to. And again, they can lead a totally normal life.

The key thing is really making sure that they understand what their food allergens are. Their family does, every caregiver does. You know, again, I’ve said it multiple times now, having that epinephrine auto-injector with them at all times.

Dr. Mike Patrick: Yup, absolutely. I guess this is not really a complication of food allergies, but I think it is a consequence of food allergies that a lot of parents believe is out there, but may not be the case. And that’s when you think about egg allergies, and the kids receiving immunizations. So a lot of parents think “My kid can’t have immunizations because they have an egg allergy.” Dr. Mustillo, is that correct?

0:44:00

Dr. Peter Mustillo: So, if someone has an egg allergy, there are really three vaccines that need to be considered potentially an issue as far as avoiding them. The first one is the influenza vaccine. So, in previous years, the recommendation was that if someone had an egg allergy, the flu vaccine should be avoided. That has actually evolved over the past few years, because it’s been determined that most patients who have an egg allergy can actually safely receive the influenza vaccine.

The current vaccines, most of them, have such a small amount of egg protein that it’s considered insignificant in terms of… it’s so unlikely to elicit any type of allergic reaction. And actually just this year, there are two vaccines that are not grown in egg. So they are not an issue at all, but they’re approved for ages 18 and over, so not for the little kids.

Dr. Mike Patrick: Are these specifically flu vaccines that you’re talking…

Dr. Peter Mustillo: Yes. And one of them, for example, is called flu block. Just approved this year. But if you have someone who does have a definite allergic reaction to egg and they’re completely avoiding all egg in their diet, then the recommendation is that they actually are evaluated by an allergist, and then the determination will be made. Can they go ahead and receive the full vaccination or should it be avoided? Most of the time, like I mentioned, they actually will be able to safely receive it. But as a precaution, we typically monitor them in our clinic for a full 30 minutes after to make sure there’re no reaction.

The two other vaccines that are potentially an issue is the rabies vaccine. A simple answer to this, if this vaccine requires is that there is one brand called Imuvacs which is not grown in eggs. So it can safely be administered. And then, third one is the yellow fever vaccine. That’s not often an issue in the United States unless someone is traveling abroad. And that one, they should be evaluated again by an allergist to determine the necessity and the risk versus the benefits of receiving the vaccine versus not.

0:46:24

Dr. Mike Patrick: Sure. So parents who have kids with egg allergies, it shouldn’t really be an automatic “Yes, they can have flu vaccine every year” or an automatic “No, they cannot have a flu vaccine every year.” They really need to discuss this with their allergist for their specific situation to see if that’s something that should be done or not.

Dr. Peter Mustillo: That’s correct.

Dr. Mike Patrick: Now, the rabies one is a little bit, I guess, more concerning because with the flu vaccine, OK, you can wait until you’ve had your appointment. And you go in and you see the allergist and make the decision. And really, the same thing with the yellow fever vaccine before you travel. But with rabies, it may be a weekend, you may not be able to talk, maybe you’ve never  seen an allergist yet. So, I guess that’s where the parent and the doctor who’s treating the child has to look at risk versus benefit. But just keep in mind that if the rabies vaccine, and we don’t have the one that’s egg-free available, then the benefit may outweigh the risk but you really do want to kind of watch that child for a while after they get the rabies vaccine to make sure that they’re not going to have an IgE-mediated reaction.

Dr. Peter Mustillo: Yes, probably a minimum of 30 minutes after.

Dr. Mike Patrick: Great.

So, what about complications from the treatment? And I only include this because we try to be complete here on PediaCast. In any decision that we make, you have to look at risk versus benefit. And I suspect that in the case of an IgE-mediated allergic reaction which could spiral into anaphylaxis and be life-threatening, the benefit of any treatment is probably going to outweigh the risk. But what are the risks for using an epinephrine auto-injector that parents need to know about?

0:48:00

Dr. Peter Mustillo: There are some potential risks, albeit they’re extremely small. There’s never been reported serious adverse reaction in a child who’s received epinephrine injection. Typically, what happens is you have the initial discomfort of the shot itself. And then, it’s very likely to increase heart rate and some of the recipients of the vaccine will get a little bit jittery. That effect typically wears off within about 20 minutes, which is when the epinephrine often wears off, plus or minus that amount of time. But the rest are very, very small.

Really, our concern might be if you have an adult who has known heart disease and then they get the epinephrine and that sort of increases that heart rate, that is when we might be a little more hesitant to administer it. But otherwise, we really have no concerns.

Dr. Mike Patrick: Right. But again, if they’re having a severe reaction and on the ground anyway, and you’re worried that person’s going to die, then using the epinephrine still, even with the heart conditions, is probably a good idea. But each individual case is different.

Dr. Peter Mustillo: That’s right. There are actually about a 150 deaths on average in the United States due to food allergies. And the most common cause of that is they either delayed the use of epinephrine too long or they don’t have it at all.

Dr. Mike Patrick: Dr. Scherzer, what’s the long term outlook for kids with food allergies. Is this something that they typically outgrow or something they’re going to have their whole life?

Dr. Rebecca Scherzer: That’s a great question, a very common question. So unfortunately, kids with peanut and tree nut allergy or adults also only have about 15% to 20% chance of outgrowing it throughout the course of their lifetime. The good news is kids with berry, soy, egg and wheat allergy have somewhere around the 75% to 80% likelihood of outgrowing those food allergens during their childhood, sometime during their childhood.

Dr. Mike Patrick: So, how do you figure out if they’ve outgrown it or not? Is it something that you check for regularly, especially if it’s a food item that maybe the kid wants to eat?

0:50:08

Dr. Rebecca Scherzer: So, that can be very patient-specific on how often you check. But frequently, every year or two years, again, depending on that child and the clinical situation. We repeat the skin tests and/or food-specific IgE levels looking for evidence of waning hypersensitivity.

Dr. Mike Patrick: Now, do you ever see where the food allergy seems to have gone away and now, they’re not sensitive to that food anymore, but then it comes back?

Dr. Rebecca Scherzer: That has been reported. That has been reported in children who have been able to tolerate a food challenge for certain food — especially peanut is the one that comes quickest to mind — but then, down the pike ended up having a food sensitivity that resurface again. So yes, that is a possibility.

Dr. Mike Patrick: But each kid is different.

Dr. Rebecca Scherzer: Yeah, everyone’s different.

Dr. Mike Patrick: And you really just have to… Again, the reason you need to see an allergist is because there is not any cookie cutter treatment for these things.

Dr. Mustillo, can food allergies be prevented?

Dr. Peter Mustillo: That’s a little bit of a complicated question. I’m going to try and answer, I supposed, in parts as best as I can. So, some of the questions that we often get related to prevention are, you know, a mom who’s pregnant wondering about — during her pregnancy and also after birth — if she decides to breastfeed, is her diet going to affect the child’s risk for developing a food allergy. And right now, as it stands, there’s just insufficient evidence to suggest that the maternal diet during pregnancy or breastfeeding affects the development or the clinical course of food allergies.

So, because of this, restricting the maternal diet during pregnancy or breastfeeding as a means of preventing development of food allergies is not recommended. As far as breastfeeding goes, there’s actually been mixed information on this, but the most up-to-date information is that there’s no strong evidence that breastfeeding serves a protective role in preventing atopic diseases, including food allergies.

0:52:11

Nevertheless, it’s still recommended that, if possible, infants be exclusively breastfed for the first four to six months, unless it’s medically contra-indicated. Sometimes people will ask us about “Should I give my infant a hydrolyzed infant formula?”, which is sort of a broken down, shorter protein chain than your standard formulas or an elemental formula — which is basically just one or two amino acids — generally, they call it as hypoallergenic.

And there’s a limited number of studies that suggest that partially or extensively hydrolyzed infant formulas — so these are generally Pregestimil, Alimentum, Nutramigen — that they may reduce the development of cow’s milk allergy in at-risk infants who are not exclusively breastfed. Hydrolyzed infant formula, as opposed to the cow’s formula, may slightly reduce or delay the risk of development of eczema, atopic dermatitis, the cow’s milk allergy and wheezing in early childhood. But there really need to be more information gathered on this. And one of the negatives about the hydrolyzed and elemental formulas is that it costs two to four times the normal standard infant formula.

Then, another question is, as far as timing of introduction of potentially allergenic foods in children, up until about five years ago, the recommendation was that in children who are potentially predisposed at high risk for developing food allergies that they avoid all egg until the age two and avoid peanut, peanut butter and seafoods until age three. But that recommendation actually has been removed because it was based on inconclusive evidence. So there’s no longer recommendation to avoid administering these food groups at a young age based on decreasing the risk for allergy.

0:54:09

And then, as far as preventing, one of the big questions that we have is, “Why is the incidents of all allergies, including food allergies, increasing over the years?”  And there’s a significant amount of research being conducted right now to try and explain the rise of the allergies in the recent decades. Some of the current theories to explain the phenomena — but let me say that all these require further information because there’s again nothing conclusive on this — but there’s some limited evidence that hygiene hypothesis, so sort of very clean environments maybe contributing to food allergies, decreased vitamin D levels in utero and also in infancy, below normal folate levels, the effect of pesticides, chlorinated compounds, also plasticizers and altering the what’s called the gut microbiota.

The use of substances such as antibiotics early in life, so there is a couple of studies that suggest that if there’s an infant who received two courses of antibiotics in their first year of life that they may tend to have a higher risk for developing food allergy. Again, probably through this mechanism of altering the gut flora.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: And they’ve done study on mice, too, where they’ve raised them in a completely stellar environment where no bacteria, even in their GI tract, and they all develop food allergies.

Dr. Mike Patrick: It’s sort of makes it difficult to know what to tell people or to advice when to start certain foods because on the one hand, we know that if you’re exposed to an allergen, you’re more likely to become sensitized to it because you’re exposed to it. Yet, on the other hand, if you delay too long or don’t have small amounts of it, then it makes it more likely that you’ll be sensitized to it. So, like there’s this middle road but we don’t really know where that middle road is.

0:56:10

Dr. Peter Mustillo: That’s right. And one of the reasons why the recommendation was removed as far as avoiding peanuts for example to age three and those who were genetically predisposed was there was a study done where they took the same population of Jewish people, some living in England and some living in Israel. And the ones living in Israel, they administered peanut butter to them within their first year of life and the ones in England, they waited until they were three. And the ones who actually had the higher incidents of developing a food allergy to peanut was the ones who waited until they were three years old in England.

Dr. Mike Patrick: Yeah. So getting a small amount early may be kind of like getting allergy shots where you’re getting the small amount of the allergen and then, you’re tolerating the allergen because you’ve been exposed to small amounts.

Dr. Peter Mustillo: Potentially, yes.

Dr. Mike Patrick: Potentially.

Dr. Peter Mustillo: Yes, it may help in early development of oral tolerance.

Dr. Mike Patrick: Yes. But in the other hand, you could also be sensitized to it with those initial exposures.

Dr. Peter Mustillo: Correct.

Dr. Mike Patrick: Yeah.

[Laughter]

Dr. Rebecca Scherzer: I think that’s especially important to keep in mind for the high risk infants. So the atopic event certainly, I think, is their own category and you have to keep in mind that they would be at high risk for fatalities.

Dr. Mike Patrick: Yup. Yup. And that’s where really we have to look at the whole picture, including what’s the family history and the history of other types of, whether it’s asthma or other types of allergic type diseases in that same child.

So, can food allergies be cured? And I’m guessing this is no.

Dr. Peter Mustillo: Yes.

Dr. Mike Patrick: [Laughter]

Dr. Peter Mustillo: So, when we refer to can they be cured, that means are they able to develop a complete tolerance to it, eat it whenever they want and not whenever they don’t want to.

Dr. Mike Patrick: With no worry that it will never come back.

Dr. Peter Mustillo: That’s exactly what I mean.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: The closest thing there is to a cure is the oral desensitization where children are given initially very, very small amount of food, gradually increasing dose in over an amount of time. And a significant numbers of those patients do wind up becoming desensitized. However, they need to routinely ingest this food typically at least a couple of times a week and if there’s a period of avoidance where they don’t ingest that specific food whether it’s egg or milk or peanut for example, then it’s not uncommon for them to become re-sensitized.

0:58:36

And that’s one of the delays in sort of getting this oral desensitization approved for use across the board. Right now, it’s still just research.

Dr. Mike Patrick: So, when you talk about hot topics in food allergy research, this oral immunotherapy would be one of those.

Dr. Peter Mustillo: Yes, I think it’s at the top of the list.

Dr. Mike Patrick: Yeah.

[Laughter]

Dr. Mike Patrick: So, it’s really kind of like an allergy shot but we’re giving a small amount of the allergen, the food in this case. A small amount of it by mouth rather than injecting it in the skin.

Dr. Peter Mustillo: Right.

Dr. Mike Patrick: Yup. But in terms of… How do kids get involved? So there’s ongoing research in that. So if a parent wanted to be involved in that research, how do they find it out just who’s involved in the study.

Dr. Peter Mustillo: Well, I believe that after they travel outside of the state, of our state in Ohio here. Studies where some of these research protocols have been conducted are in North Carolina, at Duke. Also, I believe John Hopkins and there’s a handful of other places in the country.

Dr. Mike Patrick: Yeah. But, it’s probably more that allergist at those places are telling the parents, “Hey, you want to be involved in this study or not?” Parents saying, “Hey, I want my kid to be in this research.”

Dr. Peter Mustillo: And, you know, there’s actually very small numbers in this study that’s extremely hard to get into and a lot of them have closed at least for the moment.

1:00:06

Dr. Mike Patrick: So, please, folks, don’t start emailing Duke and saying, “Dr. Mike sent us here,” because I’ll get a nasty email from Duke and from Nationwide Children’s.

[Laughter]

Dr. Rebecca Scherzer: I think it’s important really to keep in mind, again, it is in a small number of places and it’s not… I always tell people it’s not ready for primetime. It is not something that’s standard right now, would not be considered standard of care.

Dr. Mike Patrick: Are there other current hot topics in the food allergy research to talk about?

Dr. Peter Mustillo: Well, I sort of alluded to earlier the incidents of food allergies and why it’s going up. So there’s a lot research being conducted in regards to that. And then, there’s also some research where they’re trying to actually alter the epitopes which are the allergic portion of the proteins. It’s pretty well known which specific portion of food — let’s take peanut, for example — it’s called Ara H1 and H2. That’s the allergenic part. And what they’ve done in some studies is they actually removed that portion of that protein and then, the person who was previously allergic to peanut is now able to ingest it.

So this is genetically modifying the food and there’s a lot of controversy as far as if that’s good or bad. But that’s another topic in research.

Dr. Mike Patrick: And we don’t know if that particular protein affects the taste. And could that be an issue? I guess it would have to be on a food-by-food basis to know.

Dr. Peter Mustillo: Sure.

Dr. Mike Patrick: What about blocking IgE? So if the antibody IgE mediates this whole response, is there any research going on to look at blocking IgE?

Dr. Peter Mustillo: Well, yes, there is. There is a medication that’s given by injection, generally once a month. And it has been studied now for more than 10 years. And given that the cases of anaphylaxis are IgE mediated, this medication actually binds to the IgE antibody itself and in some sense, it takes it out of action. So that if the person then ingest the protein such as peanut for example, they are much less likely to have an allergic reaction. And so, in some of the studies, this particular medication has been shown to allow the children to ingest up to eight peanuts, for example.

1:02:32

Dr. Mike Patrick: And this is really going to be more for those kids who are so allergic that their life is at risk if they come in to even a small amount of contact with it. Because I suspect that this is probably a pretty expensive medication. And if it’s just routine food allergies, it’s probably not something that you’ll be exploring.

Dr. Peter Mustillo: That’s right. And it’s still not a guarantee that it’s going to protect the children. And the cost are probably are in the realm of over $20,000 to $25,000 per year for the medication alone.

Dr. Mike Patrick: And probably, it would be difficult to get insurance to cover it and that whole business as well.

Dr. Peter Mustillo: Yes.

Dr. Mike Patrick: So, tell us a little bit about the allergy clinic here at Nationwide Children’s. So if a parent out there, you know, their child has a food allergy and they really do want an allergist to manage their care, do you guys take referrals to see new patients from all sorts of places?

Dr. Rebecca Scherzer: Yes, we actually get referrals from all over the states and multiple states, around Ohio and their borders. We have a very strong core faculty at Nationwide Children’s Hospital Allergy and Immunology. We’re also very lucky, there are several practicing allergist from Ohio State who spend time at Nationwide Children’s Hospital. And we have some terrific private allergists who also spends some time at Nationwide Children’s Hospital. So we are able to take care of really every disease that you find in the realm of allergy and immunology.

From a food allergy standpoint, we’re able to do the testing that’s necessary and the interpretation of the testing. And as Dr. Mustillo mentioned, we do a lot of food challenges in our clinic. So we are able to provide allergy and immunology care for whatever that child would need.

1:04:09.5

Dr. Mike Patrick: And really do it in a safe environment, because if something’s going to go wrong during that food challenge, you want it to be someone who isn’t going to panic and knows how to take care of the child who’s having that severe reaction.

Dr. Rebecca Scherzer: And we have really a wonderful whole team. We have wonderful nurses. And so, really, the whole team is geared at taking care of the kids and  geared at taking care of people with these diseases.

We also some multi-specialty clinics that we’re involved in. So we do a mix clinic with dermatology and nutrition. We have that which is an eczema clinic. We have a rhinology clinic which is Allergy along with ENT, and an eosinophilic esophagitis clinic which we do with the GI folks and dietitians. There’s also a high risk asthma clinic. And Dr. Mustillo is involved in the 22Q or DiGeorge Clinic.

So, really, we work with many other groups in Nationwide Children’s Hospital to provide the best care for patients.

Dr. Mike Patrick: Yeah. And we make it really easy. If you’re a mom or dad out there right now, and you’re interested in having your child seen in one of these clinics, it’s really easy to get connected. And if you go to the Show Notes, so pediacast.org, and find the Show Notes for this episode which is 259, you’ll find the link that say “Connect Now With A Pediatric Allergist At Nationwide Children’s”. And this is a special link just for you. It will take you to a page and you put in your contact information and someone from our allergy program will get back to you in whatever your preferred method of being contacted is. And then, they can help you set up the referral or the appointment.

Now, it may be depending on your insurance that your primary care doctor actually has to do a referral but the allergy folks here can help make that happen and connect with your regular doctor to help facilitate everything. So we just want to make it as easy as possible for folks to find you guys.

All right, we do have lots of links, in addition to the “Connect Now With a Pediatric Allergist” link. As I mentioned, at the beginning of the show, The Diabetes Calculator For Kids — we’ll have a link to that — The 700 Children’s blog, Allergy, Asthma, Immunology here at Nationwide Children’s. Also, there’s an article called “Food Allergies In Children” from the Nationwide Children’s Health Library and it also include some tips for dining out with food allergies. We have all that.

And Dr. Scherzer, you’d mentioned the EpiPen videos and the Helping Hand and the Food Allergy Network and we’ll put the links to all of those links in the Show Notes as well.

1:06:33

Well, it’s really been great to have you both stop by the studio, just really appreciate you sharing your knowledge with everyone.

Dr. Rebecca Scherzer: Thank you.

Dr. Peter Mustillo: Thank you so much.

Dr. Mike Patrick: All right, let’s go ahead and take another break. I’ll be back as I usually am with a final word, right after this.

[Music]

Dr. Mike Patrick: All right, for my final word this week, I want to give you a final reminder about the Autism Speaks 2013 National Conference for Families and Professionals. It’s right around the corner now, Friday, July 26th and Saturday, July 27th at the Hilton at Easton here in Columbus, Ohio.

It’s right around the corner but it’s not too late to register. The conference is sponsored by Autism Speaks, Nationwide Children’s Hospital, the Ohio State University Wexner Medical Center and the American Academy of Pediatrics. As the name of the conference suggests, it’s aimed at families and professionals with great information and educational programs for both groups. This year’s focus is treating the whole person with autism, care across the lifespan. And it will feature sessions and workshops focused on the most current guidelines for addressing medical issues, developing approaches to care that integrate behavioral and medical treatment across the lifespan and helping kids and teens with autism spectrum disorder to lead happy, healthy and successful lives.

Keynote speakers include Dr. Paul Carbone, associate professor of Pediatrics at the University of Utah — he’ll be speaking on understanding medical issues from childhood to young adulthood — and Dr. Steven Shore, an educator and author and assistant professor of education at Adelphi University in Garden City, New York and he’ll be speaking on creating a fulfilling life.

1:08:30

So, if you’re dealing with autism at home, elsewhere in the family or in the classroom, or if you’re a clinician or scientist interested in caring for kids with autism, be sure to check it out. Autism Speaks held this annual event in Columbus last year. And there’s a reason they’re returning to Columbus next week.

Again, it’s not too late to register. And I’ll put a handy link in the Show Notes for this episode at 259, over at pediacast.org. The link will take you to the conference homepage and you’ll find lots more information there, as well as a convenient sign-up sheet.

So, the Autism Speaks 2013 National Conference for Families and Professionals, Friday July 26th, Saturday July 27th right here in Columbus, Ohio. And that’s my final word.

All right, I want to thank all of you for taking time out of your day and making PediaCast a part of it. I also want to thank Dr. Rebecca Scherzer and Dr. Peter Mustillo, a pair of pediatric allergist from Nationwide Children’s Hospital for helping us understand food allergies a little better.

I also want to remind you, iTunes Reviews are helpful; as are links, mentions, shares, retweets, repins, all those good on your social media sites. PediaCast is on Facebook, Twitter, Google+ and Pinterest. And be sure to tell your family, friends, neighbors, co-workers about the program. And last but not the least, be sure to tell your child’s doctor, next time you’re in for a sick office visit or a well check-up, just let them know about PediaCast. We do have posters available under the resources tab at pediacast.org.

If you have a question, a comment, a show idea, head over to pediacast.org and click on the Contact link. And, of course, we do have that “Connect Now With the Pediatric Allergist from Nationwide Children’s” link over in the Show Notes.

All right, that wraps things up for today. Until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.

So long everybody!

[Music]

Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening! We’ll see you next time on PediaCast.

Join Dr Mike in the PediaCast Studio for more answers to listener questions! This week’s topics include mosquito bites & meningitis, the dangers of laxative use, obstructive sleep apnea & sleep studies, vaccine reactions, homemade baby food & botulism, and gluten-free summertime cooking.

Topics

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It’s Episode 259 for July 17th, 2013. We’re calling this one ‘Food Allergies.”  I would like to welcome everyone to the program.

We have another nuts — literally — and bolts show for you today. This time on a topic that affects lots of kids and many adults as well — food allergies. Now, as I typically mention at the onset of our topical programs, this one’s a little different from our Answers to Listeners’ Questions and our News Parents Can Use editions of the program. And I realize a fair number of you out there do not suffer from food allergies, nor do your children have food allergies. But at the same time, nearly everyone knows someone with food allergies. And if you expand those you know from family and neighbors and co-workers, if you expand that out to include people in your social media circles, then I’m confident that you touch the lives of many people dealing with food allergies in their lives or the lives of their kids.

And so, I would ask this, if you could share this program with your social media family and friends, by sharing the episode on Facebook and Google+ and retweeting on Twitter and repinning on Pinterest. And by the way, we make it easy for you to share on social media sites because PediaCast does have a presence on Facebook, Google+, Twitter and Pinterest. So, even if you aren’t personally affected by food allergies, please consider sharing so we can get the information into the hands of moms and dads who need it but who may not know about the program.

02:12

So what food allergy information will we be covering while in usual PediaCast fashion? Pretty much everything. We’re going to talk about how food allergies occur, what symptoms to expect, what else could cause the symptoms. In other words, what the differential diagnosis? How does one go about diagnosing a food allergy, how are they treated, can they be prevented, is there a cure, what’s the long-term outlook? And what is the latest and greatest in terms of food allergy research?

And to help me cover these questions, I have a couple of great studio guests lined up for you today — Dr. Rebecca Scherzer and Dr. Peter Mustillo, both pediatric allergists here at Nationwide Children’s Hospital.

Before we get to them, I do have a couple of reminders for you. If you or someone you know is dealing with insulin dependent, so Type 1 Diabetes, be sure to check out our brand new Nationwide Children’s Diabetes Calculator For Kids. This is truly a first of its kind for the pediatric patient. Basically, you input a bunch of numbers regarding your child, including their age, their insulin carbohydrate ratio, their glucose correction factor, also known as the sensitivity factor, and their target blood glucose. So you input these numbers and the calculator spits out a convenient insulin bolus dose chart which allows you to cross-reference your child’s current blood glucose with the amount of carbs you expect your child to eat. So that you can determine the number of units of rapid-acting insulin that your child needs prior to his or her meal.

So the chart is personalized for your child and it can be printed or emailed to caregivers who need it. Now, you may be saying “I don’t know my child’s insulin carbohydrate ratio.” Or “I  don’t know what a glucose correction factor is.” Or “What in the world is my child’s target blood glucose?” If you don’t know these things, you should. And, in all cases, we recommend that you collaborate with your child’s diabetes doctor prior to inputting the numbers and using the chart.

0:04:01

Of course, collaborating with your child’s diabetes doctor is something you should do anyway. And by collaborating, you’re also informing your doctor about the calculator and he or she can share this great resource with his or her other diabetic patients.

So if you’re dealing with diabetes or you know someone who is, be sure to check out the Nationwide Children’s Diabetes Calculator for kids and I’ll put a link in the Show Notes for this episode, 259, over at pediacast.org so you can find it and share it easily.

OK, speaking of brand new, the Diabetes Calculator isn’t the only brand new thing to tell you about. Nationwide Children’s has a great new blog for moms and dads. It’s called 700 Children’s and you’ll find it at 700childrens.org. I’ll put a link to that in the Show Notes as well. Yours truly is a regular contributor. Some recent topics — How Fireworks Affect Hearing, Gluten-free Summertime Recipes, Lawnmower Safety Tips and Sunscreen Cause Skin Cancer. That’s what I put together. There’s a recent post on food allergies and another on medication poisonings in young children and another on kangaroo care.

So, lots of great information for moms and dads, direct from the experts at Nationwide Children’s Hospital. The address is easy — 700childrens.org. So be sure to check it out.

And finally, a reminder that PediaCast is your show. We have lots more Answers to Listener Questions episodes lined up. So, if you have a question you’d like answered, just head over to pediacast.org and click on the Contact link.

Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and a hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

All right, let’s take a quick break and I will be back with our studio guests and we’ll chat it up about food allergies, right after this.

[Music]

0:06:25

Dr. Mike Patrick: All right, we are back. Dr. Rebecca Scherzer is a pediatric allergy specialist at Nationwide Children’s Hospital and an associate professor of pediatrics at the Ohio State University College of Medicine. She serves as associate director of the combined Ohio State Nationwide Children’s Allergy and Immunology Fellowship Training Program and has a clinical interest treating children and teenagers with allergies, asthma and immunodeficiency disorders.

This is Dr. Scherzer’s first appearance on PediaCast and we welcome her warmly to the program. Thanks for joining us, Dr. Scherzer.

Dr. Rebecca Scherzer: Thank you. Thanks for having me.

Dr. Mike Patrick: Really appreciate you stopping by.

I do want to point out that Scherzer’s husband, DJ, I guess you could call him a regular on the program. He’s been here a couple of times. We talked about anaphylaxis with him, which is a severe life threatening allergic reaction back in PediaCast 178. And he’s also a member of the PediaCast foodies along with another allergy doctor, Dr. Amber Patterson. And back in PediaCast 227, we covered topics like hyperdosed corn syrups, transfats, food colorings and dyes, natural and artificial flavors, aluminum, bovine growth hormone. And we do have plans to get the foodies back together, so be sure to send in your food related questions by using the contact page over at pediacast.org.

So PediaCast 178 “Anaphylaxis”, 277 “Food Ingredients”, both a great shows for folks with an interest in food allergies, so be sure to check those episodes as well. But I don’t mean to steal your thunder, Rebecca.

[Laughter]

Dr. Rebecca Scherzer: I’m going to share it with my husband.

Dr. Mike Patrick: Dr. Peter Mustillo who is another first-time guest on PediaCast, he too is a pediatric allergist at Nationwide Children’s Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine. Dr. Mustillo serves as physician director of the Infusion Clinic at Nationwide Children’s and like Dr. Scherzer, treats kids and teens with allergies, asthma and immunodeficiency disorders.

0:08:16

So a warm welcome to Dr. Mustillo as well. Thanks for joining us.

Dr. Peter Mustillo: It’s great to be here. Thank you.

Dr. Mike Patrick: It’s great having both of you in the studio.

So, Dr. Scherzer, let’s start with you. If you could just define for moms and dads out there, what is meant by food allergy?

Dr. Rebecca Scherzer: So, the definition of a food allergy is an adverse health effect, arising from a specific immune response that occurs reproducibly upon given exposure to a food. I think there’s a couple of things in this definition that we should point out.  One of them is that this is an immune-mediated response. As we’ll talk about later, there’s lots of different responses people can have to food, but a food allergy is related to an immune response. It also occurs reproducibly upon given exposure to any specific food.

Dr. Mike Patrick: So this is a little bit different than a food intolerance where you may have a set of symptoms related to a food, but if it doesn’t involve the immune system, then it’s not really a food allergy.

Dr. Rebecca Scherzer: True. And even within the topic of food allergy, there’s different immune mechanisms than can lead to it. And we’ll talk more about that later. But yes, a food allergy is an immune-mediated response.

Dr. Mike Patrick: Great. Now, how common are food allergies?

Dr. Rebecca Scherzer: So, we see food allergies in about 6% to 8% of children and 3% to 4% of adults. So it definitely is a higher prevalence in children when compared to adults.

Dr. Mike Patrick: Now, sort of like asthma, it seems like there’s more and more food allergies being diagnosed. Do you think that’s because we just are recognizing it more, or is there really an increased incidents of food allergies over the last few years?

Dr. Rebecca Scherzer: I think it’s actually a combination of food. I definitely think there is an increased incidents of a lot of atopic diseases. But I also think food allergies are recognized more and these children are getting more and more to allergists to get the proper diagnosis.

Dr. Mike Patrick: Yeah. One of the numbers I came across was like one in 25 to 30 children have a peanut allergy. So if we take a classroom of kids, pretty much there’s going to be at least one kid who has a peanut allergy in that group.

0:10:08

Dr. Rebecca Scherzer: Yes, yes.

Dr. Mike Patrick: Now, do we see much difference in terms of age groups. So, do we see like more younger kids, more school-aged kids? Or is it more prevalent in adults? How does it break down in terms of age?

Dr. Rebecca Scherzer: It is definitely higher. There is a higher prevalence in children compared to adults and certainly in younger children, we see it more frequently.

Dr. Mike Patrick: Sure. Well, what about males versus females? Pretty much equal between the sexes?

Dr. Rebecca Scherzer: Yes. Yes.

Dr. Mike Patrick: And race and the ethnic groups, pretty much everybody sees it the same?

Dr. Rebecca Scherzer: Yes. Really, the biggest risk factors you have for food allergy are if you come from a family of food allergy, because we know that a lot of atopic disease is inheritable. But if you yourself have atopic disease such as asthma or eczema, that put you at higher risk of having food allergy.

Dr. Mike Patrick: Sure. So there is a genetic component to food allergies as well?

Dr. Rebecca Scherzer: There is, and to atopy in general.

Dr. Mike Patrick: Yup.

Dr. Mustillo, what foods are commonly involved? Is it pretty much any food can cause a food allergy or just a certain group of foods?

Dr. Peter Mustillo: Sure. So someone can be allergic to any food. Although, there are some that are much more common than others. In children, the top three foods that are responsible for approximate three-fourths of food allergy reactions are due to milk, egg and peanut. And of those three, milk is most common. About  2 1/2 percent of children are allergic to milk at a younger age.

And then, they have what we call the Big 8 which are responsible for causing up to 95% of the reactions in children. And they are due to milk, egg, peanut and tree nuts, soy, wheat, shell fish and fin-to-fish, which is basically fish with a backbone. And in adults, shellfish is actually the most common allergen.

Dr. Mike Patrick: Now, I hear this term tree nuts quite often. What is actually is a tree nut? How’s that different from a peanut?

0:12:08

Dr. Peter Mustillo: So a peanut is actually a legume that grows in the ground and its related in the same family as peas and beans such as soy beans. Tree nuts actually grow on the tree and they include almond, pistachios, walnuts, hazel nuts, Brazil nuts, macadamia nuts, among a couple others.

Dr. Mike Patrick: Yeah, like cashews. Those are my favorites. Add that in there.

[Laughter]

Dr. Mike Patrick: What about chocolate and strawberries? As I recall in my training, it was like “Don’t give kids chocolate or strawberries until they’re a year old.” Do you see much chocolate or strawberry allergies?

Dr. Peter Mustillo: So, as far as chocolate goes, it’s not impossible but it’s unusual to be allergic to the actual cocoa and chocolate itself. Most of the time, if people have reaction to chocolate, it’s related to either the milk contained in it or peanut or some tree nut.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: Now, strawberry, I’ve had a number of people who actually have mentioned that they feel their child is allergic to strawberry. That if this is the case, it’s typically not the classical IgE-mediated allergic reaction. And, most of the time, if the parents retry the strawberry, the children actually tolerate it. So a true allergic reaction to strawberry is also very uncommon.

Dr. Mike Patrick: Now, why do you think these Big 8 are the Big 8? What about those foods make them more allergy-provoking?

Dr. Peter Mustillo: So, that’s a question that I think the true answer is not clearly known. But these foods seem to, for some reason, contain a protein that the immune system is more likely to react with and this portion of the protein or the series of amino acids is called an epitope. And this is the protein that gets recognized by the immune system, typically in the case of food allergy, it’s the IgE antibody. But in some less common form of food allergy, it can be recognized by T-cells and it serves to actually augment in immune response.

0:14:33

Dr. Mike Patrick: Sure. One of the interesting things that I came across as I was doing some research for this topic is this concept of a pollen food allergy syndrome where you can have cross-reaction of… So someone has environmental allergies to certain pollens but then they can have cross-reactions. It’s a little bit more likely that they’ll be allergic to certain foods. Do you see that very often? I’ve not really heard of that before.

Dr. Peter Mustillo: It is a fairly common condition. If you think about where pollen comes from, it’s in some way part of a seed. And so, if you have some food such fruits like something in the Rosacea family — peach, nectarine or cherry — they can cross-react with the pollens.

Dr. Mike Patrick: Yeah, interesting. One of them I saw and it’s sort of a common one, ragweed, that it has cross-reactivity with bananas, melons such as cantaloupe, honeydew and watermelon, and tomatoes. So if you’re allergic to one of those foods and have environmental allergies with ragweed, don’t be surprised.

Dr. Peter Mustillo: That’s exactly right.

Dr. Mike Patrick: So, let’s kind of dig down to the cellular level. You talked about IgE antibodies. Kind of walk us through what causes food allergy down there at the cellular level. What’s going on?

0:15:55

Dr. Peter Mustillo: Sure. Well, what happens is there are allergy cells that are sort of present throughout our mucosal system and skin and in our GI tract. And these mast — they’re called mast cells — and they store histamine. Histamine is the chemical that when it gets released is what tends to cause the itching and other symptoms of allergic reactions. And there’s an antibody called IgE which is bound on the outside surface of these mast cells.

And then, if someone is allergic, when the food that they ingest winds up being absorbed, it binds to the IgE and it cause the IgE to cross-link. So basically, several IgEs will bind to that portion of the food protein and that will cause a signal to the cell to go ahead and release histamine and other mediators or cytokines that also might contribute to the allergic reaction, which includes the itching and the swelling and the redness and sometimes, the respiratory symptoms.

Dr. Mike Patrick: Right. And that’s why, and I think parents can understand this because when kids have those symptoms, they talk about taking an anti-histamine, something that’s going to counteract what the histamine is doing.

Dr. Peter Mustillo: Exactly.

Dr. Mike Patrick: Now, how much food exposure really is required? I mean, does it take… You have to eat a lot of the food in order to have an allergic reaction or can it just be a speck? You know, like they’re talking about peanut dust causing a problem. Is that really going to be such a small amount?

Dr. Peter Mustillo: So, yeah, the amount of protein exposure necessary to induce an allergic reaction in a person, varies actually across different individuals. So, for some people, that can be a minuscule amount. There are reports of people who if, say they’re in a family and one of the siblings ate a peanut jelly sandwich, used the serrated butter knife in order to spread the peanut butter. And then, it gets washed by hand or dishwasher, but there’s just a tiny little amount of that peanut butter still present between these serrations. And then, the next person who’s allergic to peanut, for example, goes and uses that same knife, there is some chance that can cause an allergic reaction.

0:18:23.7

There are some reported cases of kissing someone also who have previously eaten peanut butter. In rare cases, that can cause a severe allergic reaction. But they’re more the exception than the rule. Most of the time, you need to have a higher amount of exposure in order to induce an allergic reaction. And some people will have a threshold, so they’ll be able to consume a small amount but beyond that, then they can have allergic reaction.

Dr. Mike Patrick: Do you find after you’ve had an allergic reaction due to a specific food, would it then take less of the food the next time to cause it or not? Or however much it’s going to take is how much it’s going to take for a given individual?

Dr. Peter Mustillo: Yeah, it’s can be variable and we don’t really know why sometimes it takes a little more or sometimes it take a little less in order to elicit allergic response.

Dr. Mike Patrick: Sure. Speaking of the allergic response, Dr. Scherzer, what are the typical signs and symptoms that would point someone to this could be a food allergy that’s causing this?

Dr. Rebecca Scherzer: So signs and symptoms of an acute allergic reaction can vary. They can be in the skin, so you can have hives or urticaria. You can have swelling or angioedema. Or sometimes people just describe a lot of itching. Angioedema which is swelling, you can have it at the face, the lips, the tongue and the throat, or any other part of the body.

The lungs can also be affected. So people can have wheezing. You can have difficulty breathing. Some kids we see have a lot of nasal congestion and sneezing. So, again, it can be very varied. You can go along the path of more life-threatening anaphylaxis, which would be that angioedema or swelling of the lungs or the throat.

0:20:02

You can also have low blood pressure which is very dangerous and this can lead to shock. You can have a very rapid pulse or you can have dizziness or light headedness, or even loss of consciousness associated with an acute allergic reaction.

Dr. Mike Patrick: Now, what about in the GI tract itself? So things like abdominal pain, vomiting, diarrhea, would that be seen in a food allergy, in an immune-mediated response? Or is that going to be more of a food intolerance if you saw those kind of symptoms?

Dr. Rebecca Scherzer: So it could  really be an either. You certainly see kids who have what we call GI anaphylaxis. So they have repetitive vomiting usually with an IgE-mediated reaction if they’re going to have GI symptoms. And just like other forms of anaphylaxis, that can be treated with self-injectible epinephrine.

So it’s very important to keep that mind, if somebody’s having GI symptoms and you think they’re having an allergic reaction, that certainly can be sign of an anaphylaxis.

Dr. Mike Patrick: Sure. What about blood in the stool? And particularly in infants, if they have milk protein allergy, sometimes we see blood in the stool. Is that just confined during the infant period that you would see that? Or even in older kids, could blood in a stool be a sign of food allergy?

Dr. Rebecca Scherzer: So, in young children, you see it. In very young children, in infants, you can see blood in the stool, which is a sign of food protein hypersensitivity, which is usually not IgE-mediated. That’s in young children.

In older kids, you can see usually it’s not visible blood, but there might be quite positive blood in their stool if their GI tract is very affected by food allergies. You can see that probably less with just eosinophilic oesophagitis but other eosinophilic diseases could probably lead to not visible blood in the stool. But, when we see it, it’s mostly in the very young children, the kids in the first month or two of life.

Dr. Mike Patrick: And then, a lot of folks who suffer from migraines, I know histamine release can be a trigger for migraines. Do you see migraine headaches very often in the population of kids with food allergies that you treat? Or is that pretty rare?

Dr. Rebecca Scherzer: That’s pretty rare. Usually, the kids who have any kind of headache associated is a lot of times it’s allergic rhinoconjuctivitis. So it’s where we see it associated with food allergy.

0:22:12

Dr. Mike Patrick: And then, one of the things that I wanted to mention here — although we are going to have an episode of PediaCast coming up that’s going to be dedicated to celiac disease — but in terms of celiac disease and gluten which is a protein that’s in wheat and some other grains, is that considered a food allergy or above and beyond?

Dr. Rebecca Scherzer: Yeah, it’s definitely not an IgE-mediated response. So it won’t fall into the category that you think about with your typical kids of food allergies.

Dr. Mike Patrick: Right. So the immune system is involved but not in the same way when folks have a severe food allergy with hives and wheezing and that sort of thing.

Dr. Rebecca Scherzer: Right, right, right. And the treatment is — though avoidance is what you would use for both gluten-hypersensitivity or celiac disease and IgE-mediated food allergy to wheat — somebody with gluten hypersensitivity, they won’t need to have self-injectable epinephrine. Whereas, if you have an IgE-mediated wheat allergy, you would need to have available to you self-injectable  epinephrine.

Dr. Mike Patrick: Now, and this another interesting thing I have come across and maybe it’s not again something that you see very often because you know, you come across little details of things and it’s like one person in every state has ever experienced this. And not being an allergist myself, I don’t know how often someone comes in for these things. But I came across an exercise-induced food allergy. Have you ever heard of such a thing? Can either of you?

Dr. Peter Mustillo: Sure. There is a condition called exercise-induced anaphylaxis. And what happens is, if somebody eats a food and then exercises shortly after — usually within about two hours — they can actually develop anaphylaxis. If somebody eats that same food and doesn’t exercise within those couple to few hours afterwards, then they actually have absolutely no signs of any type of reaction.

0:24:13.6

Dr. Mike Patrick: Yeah. It really takes some detective work to figure out what exactly was happening because sometimes eating that food, you have to figure out that, “Oh no, I had to eat it and then exercise to have the reaction.” And I can see that becoming difficult to tease through.

Dr. Peter Mustillo: Right. And some foods are more common than others as far as being attributed to that exercise-induced anaphylaxis. Celery is actually one of the ones and wheat is another one also.

Dr. Mike Patrick: And you could see folks who exercise more might eat more celery.

[Laughter]

Dr. Peter Mustillo: That’s right.

Dr. Mike Patrick: So if we look at this set of symptoms that folks come in with, with food allergies, Dr. Scherzer, what other disease processes could cause similar signs and symptoms? So we suspect that maybe it’s a food allergy based on the symptoms but are there some other things that could cause those hives and swelling and that sort of thing?

Dr. Rebecca Scherzer: Well, part of the differential would be really based kind of on the symptoms when we think about things that can cause a lot of symptoms that we associate with food allergy. There’s a list including food intolerances. So there’s a lot of people that have different kinds of intolerances.

So, I think many people out there knows someone who’s lactose intolerance. And patients with that disease actually can get very ill upon exposure to dairy, but it’s not an immune-mediated mechanism. So it’s not a true allergy. Galactosemia would be another example of that.

There are pharmacologic responses. Things like caffeine or tyramine and aged cheeses can lead to responses that would be an adverse reaction to food, but not again an immunological response. Even food poisoning could fall under the toxin category. Again, not true food hypersensitivity reaction.

Even when you talk about food allergy and mediated responses, there’s different ways your immune system can respond. So,  patients can have IgE-mediated responses or non-IgE-mediated responses, which are most frequently cell-mediated immune responses. And then, just to keep things confusing, you can have a mix picture of non-IgE mediated and IgE-mediated. And you see that in things like in eosinophilic esophagitis and/or eczema.

0:26:15

There is one non-IgE mediated food hypersensitivity disorder which I think is important for people to keep in mind. Most patients when they’re having IgE-mediated responses to foods have the signs and symptoms within three minutes to two hours after the reaction. Well, there is something called food protein-induced enterocolitis syndrome or FPIES as I will call it for better ease. And this is a non-IgE mediated food adverse reaction.

And these kiddos, we usually see them in younger children within the first year of life. When they’re exposed to the specific food somewhere around four to six hours later, they can get very ill. They can have significant vomiting and diarrhea. This can lead to hypovolemia. They can have hypotension. They can look very, very ill.

And sometime, it takes awhile to diagnose because it doesn’t fall within the realm of what we expect from a food allergy response. The foods that most commonly cause FPIES are dairy and soy. But there’s also solid foods that can be involved and when you think about solid foods, the grains are usually the most likely culprits.

It’s a little different than IgE-mediated specific food when you look at grains. When you think about which grain is most allergenic from an IgE-mediated standpoint, it would be wheat. When you talk about FPIEs, you think more about things like rice. And so, they’re a little different. Again, they can both make kids very ill.

Dr. Mike Patrick: Whether it’s IgE-mediated or cell-mediated, this is just really a differential for us, clinical folks, to know which pathways ultimately causes the symptoms. But from the parents’ perspective, they ate a food, there’s a problem, “I want to try to figure out what’s going on.”

Dr. Rebecca Scherzer: Right. And that’s why getting them to someone who’s trained in food allergy really can be helpful to tease this picture out.

Dr. Mike Patrick: Sure. And I do want to point out, too, that there is the potentials we talked about for this to spiral into anaphylaxis which can be serious and life-threatening. So if you’re concerned about a food allergy in your child, you really do need to see your doctor and not just say “Well, this cause some hives in my kid and I’m going to avoid that food from now on.” I mean, you really need to see someone and try to figure out what’s going on.

0:28:17

Dr. Rebecca Scherzer: It is. It’s crucial, because if you have someone who has an IgE-mediated food allergy, you want to make sure that they have an  epinephrine auto-injector with them at all times, because that very much can be lifesaving. And so, it was discussed earlier, just because you had an reaction this time that maybe just as hives, that doesn’t mean the next reaction cannot be life-threatening anaphylaxis. So, really, having that medication, the self-injectable epinephrine is critical.

Dr. Mike Patrick: Right.

Dr. Rebecca Scherzer: So yes, seeing your doctor, seeing someone who specialize in food allergy is very important.

Dr. Mike Patrick: Yup. And we’re talking EpiPen is kind of the brand name, but that’s the device that we’re talking about.

Dr. Rebecca Scherzer: There’s other ones out there now. There’s something called Auvi-Q, which is also used out there  and Adrenaclick. So there are other ones, other than just EpiPen, but that is the one that I think has been around the longest.

Dr. Mike Patrick: Yeah, kind of like Kleenex and Frisbee and…

[Laughter]

Dr. Rebecca Scherzer: Right, right.

The key thing is making sure that if you have a child with an IgE-mediated food allergy that you have one. And that, you, your child — if they’re old enough — and anyone who takes care of that child knows how to use the medication.

Dr. Mike Patrick: So, even if, let’s say mom or dad see your primary your primary care doctor and they say, “Yes, I agree that there’s a food allergy here and it’s IgE-mediated. They have hives and that sort of thing and I want to see an allergist.” Really, the primary care doctor should be prescribing an EpiPen along with the referral to see the allergist.

Dr. Rebecca Scherzer: That would definitely be the safest road to head down, is to make sure that immediately that child would have epinephrine available to them if they would have a reaction. Because you’ll never know when another accidental reaction may occur.

Dr. Mike Patrick: Sure. So, Dr. Mustillo, how then do you go about diagnosing? So if there’s different things that can cause it and you’re trying to tease things out, how, as an allergist, do you go about diagnosing a food allergy?

Dr. Peter Mustillo: So, the key parts in diagnosing a food allergy involve the medical history and also the diagnostic testing. Obtaining a detailed history remains a mainstay in establishing the diagnosis of food allergy. So questions regarding what was the specific reaction, what was the timing related to the food that is potentially implicated — was the food cooked, uncooked, how much did they ingest, did they previously react to it or is it just a first exposure — are all key components in determining the likelihood of an allergic reaction.

0:30:33

For IgE-mediated reactions which are sort of the classic and most common type of allergic reaction, both the skin prick tests — which are the skin test typically done on the back and sometimes the arms — and also blood test called serum-specific IgE, they actually have similar sensitivities and specificities. There are advantages and disadvantages to both.

The advantages of the skin prick testing include that you get immediate results visible to the patient and family. So, you can establish a diagnosis at the initial visit and come up with the treatment plan at that initial appointment while the patient is present. And the cost is actually lower than the serologic test. It’s about a third of the cost on a test-for-test basis.

Some disadvantages to the skin test involve that antihistamines need to be held for at least a few days prior. If someone has diffused extensive eczema or another condition called dermatographism where just pressure leads to hives, then the skin test can be more difficult to interpret.

Now, going to the blood tests, the serum-specific IgE to the various foods, advantages are that it’s not affected by antihistamines. Typically, the primary care doc can go ahead and order it. But at the same time, there are disadvantages including that you need to obtain blood. The child’s results are delayed rather than immediate. And the cost is higher.

0:32:10

The sensitivity of both of these in terms of detecting an IgE-mediated food reaction is actually in the range of 95%. But it’s important to know that when the tests come back positive, the positive predictive value — meaning, the likelihood that the child is actually allergic to the specific food — is in the range of only 50%. So, basically, a positive test implies sensitization, but that does not always translate into a clinical allergy.

And that’s why ordering these tests, we try to target specific foods and not sort of order whole entire screening panels. Because then, it’s not uncommon to come back with a positive result and then the questions will now “What do I do with it?” especially the child’s been tolerating it in the past.

And the blood tests also, typically people regard negative as either less than .1 or .35. But there are a lot of people who have — like milk for example, if you get a serum-specific IgE to cow’s milk and the result comes back at 3 which certainly higher than what’s considered negative, only about 50% of those patients will actually have a clinical reaction upon exposure.

Dr. Mike Patrick: I think this is another reason that a kid with food allergies or suspected food allergies really do need to see an allergist, because it’s easy for primary care doc to order these tests, particularly the blood tests. Most primary care docs are doing skin testing in their office. And either you come back with “My kids are not allergic to anything,” or “There is a list of things that they’re allergic to.” And then, you get a kid avoiding foods that they might not need to avoid, that they might enjoy and has nutritional benefit for them.

0:34:07

So, I mean, really, you can get false-positives and false-negatives. And so, it’s not just a simple thing where you order the test and then you know. You really have to take lots of information and synthesize it to figure out what’s going on.

Dr. Peter Mustillo: That’s exactly right. So another key point of what you’re getting at is that someone can have a negative test by either the skin test or the blood test but they can still be allergic to that food. Because these tests pick up the most common form of food allergy being IgE-mediated. But these tests do not detect all the potential non-IgE mediated causes that  Dr. Scherzer refer to such as the FPIES,  the food protein-induced enterocolitis syndrome, the allergic colitis when the infants get blood on their stool, eosinophilic esophagitis. Some of those cases are not IgE-mediated well and there are others.

Dr. Mike Patrick: Right. Now, what about an oral food challenge? Of course, with medical supervision. Do you ever do that where you present the food and see if they have a reaction and then you know it was that food?

Dr. Peter Mustillo: Sure, we do that in fairly, routinely, in our clinic and the double-blind placebo controlled food challenge where the child doesn’t even know if they’re eating the food or not and then, monitoring them for reaction is actually considered the gold standard in diagnosing food allergy. Most of the time, we’ll go ahead and offer the food in its sort of normal visible form to the child. And we only  offer these tests when we think the likelihood that they’re going to react is low.

Dr. Mike Patrick: So, if this is a histamine-mediated response, there are other things that can cause mast cells to release histamine. And so, do you ever see folks who think they have a food allergy, but then it’s really just more of a psychological — you know, they get nervous about the food that they’re about to eat and then, that’s what causes the histamine reaction?

0:36:04

Dr. Peter Mustillo: Sure. So some of the studies actually have demonstrated that if a parent comes in and believes their child is allergic to a particular food, that is actually the case in only about half of the children. So, yeah, there can be other reasons why the patients can develop hives.

Dr. Mike Patrick: And so, that’s where the double-blind test where the kid doesn’t know what they’re eating and then seeing what the responses can be helpful.

Dr. Peter Mustillo: Correct, yes. Now, what about when you have folks who come in with the food allergy, is this something… We’re kind of moving to the treatment thing, the treatment part of this with Dr. Scherzer. When you do have a kid who you think has a food allergy, what sort of treatment path do you go down with them?

Dr. Rebecca Scherzer: So, really, right now, the only treatment for food allergy is avoidance of the food. There are things that are being researched now down the pipe that we’ll talk about a little bit later. But right now, really, no specific treatment is available except avoidance. Now, there are some key things to keep in mind. If you have a child with food allergies, you want to try to avoid places which may put them at high risk of being exposed to these food. So if you have a child who has a peanut or tree nut allergy, places like bakeries and ice cream parlors can be dangerous.

Again, you want to make sure that every single person taking care of that child and the child themselves, if they’re at the right age, know how to use their self-injectable epinephrine. Sometimes we recommend identification bracelets or necklaces that will allow people to know they have food allergy. And then, really clear communication with all the caregivers of the child — what is the child allergic to, what do they need to avoid.

There are also times where we take out secondary to food allergy one or two of the major food groups. And in those situations, we frequently consider, “I’m getting a dietary consult from our nutritionist here at Nationwide Children’s Hospital.”

Dr. Mike Patrick: Now, for breastfeeding moms, if the mom eats a food that the baby may have an allergy to, is it a problem of mommy, too? Can the allergen transfer to the breast milk?

0:38:06

Dr. Rebecca Scherzer: So most of the time, it is safe. There are certain situations. Again, every situation is different. Even that small amount of protein seems to elicit symptoms in the child. And most of the time, babies tolerate breastfeeding well.

Dr. Mike Patrick: But if it’s something that mom is recognizing “Hey, when I eat X, baby does Y,” you kind of pay attention to that.

Dr. Rebecca Scherzer: Yes. Yes. And you definitely hear that. That the baby’s flushing and they notice hives or some itchiness after mom, say, drinks a lot of milk or has a lot of dairy products. So again, you have to look at the specific situation. But a lot of times, breast milk is tolerated well.

Dr. Mike Patrick: Now, we talk about EpiPens and the auto-injectable epinephrine. What role does antihistamines — we kind of hinted at this earlier in the show — what role does antihistamines play in the treatment of food allergies?

Dr. Rebecca Scherzer: So, when you think about an acute reaction, anti-histamines can play a role in a very mild reaction. But if someone’s having a severe or life-threatening significant reaction, epinephrine is the medication that will save their life and that is the first medication they should receive and they should receive it immediately.

Dr. Mike Patrick: Is there a role for steroid medications?

Dr. Rebecca Scherzer: Again, steroids can play a role. They can help sometimes. Patients can have a late phase reaction — six, 10, 12 hours after their first reaction — and usually that’s equal to or less than the first reaction. But they definitely can have a second reaction. So the late phase reaction, the steroids might help mediate those responses. But during an acute allergic reaction, epinephrine is the medication that will save the child’s life and lead to the best outcome.

Dr. Mike Patrick: So if you have a kid who in the past, they’ve had a later reaction, then that might be someone when they have their initial reaction who says to the doctor, “Hey, you might want to think about giving me a steroid because every time this happens, a few hours later, I’m right back at it,” then that could help prevent the second one?

Dr. Rebecca Scherzer: I think a lot of children who have very severe reactions to foods end up getting a steroid course associated with that reaction. But again, I cannot stress enough the importance of epinephrine in as early as possible.

0:40:06

Dr. Mike Patrick: Yup. So some parents are really sort of afraid to use that pen. Because there’s a needle and they’re not a medically trained person and they’re really worried about it. And so, they may want to go for the antihistamine first because that’s something that they feel more comfortable giving. But what you’re saying is, “Hey, even though it’s a needle, even though you feel uncomfortable, you need to do this to potentially save your child’s life.”

Dr. Rebecca Scherzer: Yes. And that’s why teaching for the family, teaching for anyone who takes care of the child really is critical. There are great videos on the Web that you can see. Actually, DJ Scherzer, my husband, has a nice one at the Web, on YouTube, that really can show you how to use the EpiPen. The Auvi-Q which is the newer self-injectable epinephrine, it’s Auvi-Q because it actually talks to you and tells you how to do it.

But again, making sure that your patients are really comfortable with the use of this medication. They all have trainors, so you can train them. You can send trainors home with them. And then, here at Children’s Hospital, we have a very nice helping hand that will describe it. So if somebody is a caregiver but not at the appointment, then you can make sure that they get good instruction on how to use that medication.

Dr. Mike Patrick: Yup. And we’ll be sure to put links to those things in the Show Notes, so folks can find it early or find it easily. And this is Episode 259, if you’re looking for that in the Show Notes.

What about allergy shots? And I’m sure that you get asked this from parents a lot, “Can we just get my kid an allergy shot, then they won’t have the food allergy anymore?”

Dr. Peter Mustillo: Well, allergy in shots in terms of desensitizing someone to a food allergy can at times be helpful. The problem is that the risk of anaphylaxis is very high. So, the risk are just too high giving allergy shots for food. And that’s why it’s not recommended.

Dr. Rebecca Scherzer: It’s not standard of care for food allergy right now.

Dr. Mike Patrick: Yup. What about complications from food allergies? And I guess the first one that we think about, of course, is anaphylaxis. So it’s just that the IgE-mediated reaction has spiraled out of control, and now you can get lower blood pressure and the person’s life can be at risk. Are there any other complications you can think of that can be an issue with food allergies?

0:42:19

Dr. Rebecca Scherzer: So, there are some more localized food allergic responses that if the food allergies aren’t recognized, certainly, it will not be able to be treated without recognizing these food allergies. Things like eczema or eosinophilic esophagitis or other eosinophilic GI disorders are all things that you may not have the typical  picture that you expect from allergic response but can be driven by IgE-mediated food allergy. So, until it’s recognized, the food allergen is playing a role, their symptoms may not abate.

Dr. Mike Patrick: Sure. I think another complication too is sort of the psychological implication for kids. I mean, they have to be really careful when they’re eating out. They may not be able to eat at a friend’s house or can’t eat the same foods as their family or friends are eating. I mean, it’s really kind of like a chronic illness for these kids.

Dr. Rebecca Scherzer: It definitely is. And you know, again, I think having the child and the family comfortable with the diagnosis is very important. There is so much support out there for kids with food allergy. There’s the Food Allergy Network, There are lots of different networks, there’s these camps that these kiddos can go to. And again, they can lead a totally normal life.

The key thing is really making sure that they understand what their food allergens are. Their family does, every caregiver does. You know, again, I’ve said it multiple times now, having that epinephrine auto-injector with them at all times.

Dr. Mike Patrick: Yup, absolutely. I guess this is not really a complication of food allergies, but I think it is a consequence of food allergies that a lot of parents believe is out there, but may not be the case. And that’s when you think about egg allergies, and the kids receiving immunizations. So a lot of parents think “My kid can’t have immunizations because they have an egg allergy.” Dr. Mustillo, is that correct?

0:44:00

Dr. Peter Mustillo: So, if someone has an egg allergy, there are really three vaccines that need to be considered potentially an issue as far as avoiding them. The first one is the influenza vaccine. So, in previous years, the recommendation was that if someone had an egg allergy, the flu vaccine should be avoided. That has actually evolved over the past few years, because it’s been determined that most patients who have an egg allergy can actually safely receive the influenza vaccine.

The current vaccines, most of them, have such a small amount of egg protein that it’s considered insignificant in terms of… it’s so unlikely to elicit any type of allergic reaction. And actually just this year, there are two vaccines that are not grown in egg. So they are not an issue at all, but they’re approved for ages 18 and over, so not for the little kids.

Dr. Mike Patrick: Are these specifically flu vaccines that you’re talking…

Dr. Peter Mustillo: Yes. And one of them, for example, is called flu block. Just approved this year. But if you have someone who does have a definite allergic reaction to egg and they’re completely avoiding all egg in their diet, then the recommendation is that they actually are evaluated by an allergist, and then the determination will be made. Can they go ahead and receive the full vaccination or should it be avoided? Most of the time, like I mentioned, they actually will be able to safely receive it. But as a precaution, we typically monitor them in our clinic for a full 30 minutes after to make sure there’re no reaction.

The two other vaccines that are potentially an issue is the rabies vaccine. A simple answer to this, if this vaccine requires is that there is one brand called Imuvacs which is not grown in eggs. So it can safely be administered. And then, third one is the yellow fever vaccine. That’s not often an issue in the United States unless someone is traveling abroad. And that one, they should be evaluated again by an allergist to determine the necessity and the risk versus the benefits of receiving the vaccine versus not.

0:46:24

Dr. Mike Patrick: Sure. So parents who have kids with egg allergies, it shouldn’t really be an automatic “Yes, they can have flu vaccine every year” or an automatic “No, they cannot have a flu vaccine every year.” They really need to discuss this with their allergist for their specific situation to see if that’s something that should be done or not.

Dr. Peter Mustillo: That’s correct.

Dr. Mike Patrick: Now, the rabies one is a little bit, I guess, more concerning because with the flu vaccine, OK, you can wait until you’ve had your appointment. And you go in and you see the allergist and make the decision. And really, the same thing with the yellow fever vaccine before you travel. But with rabies, it may be a weekend, you may not be able to talk, maybe you’ve never  seen an allergist yet. So, I guess that’s where the parent and the doctor who’s treating the child has to look at risk versus benefit. But just keep in mind that if the rabies vaccine, and we don’t have the one that’s egg-free available, then the benefit may outweigh the risk but you really do want to kind of watch that child for a while after they get the rabies vaccine to make sure that they’re not going to have an IgE-mediated reaction.

Dr. Peter Mustillo: Yes, probably a minimum of 30 minutes after.

Dr. Mike Patrick: Great.

So, what about complications from the treatment? And I only include this because we try to be complete here on PediaCast. In any decision that we make, you have to look at risk versus benefit. And I suspect that in the case of an IgE-mediated allergic reaction which could spiral into anaphylaxis and be life-threatening, the benefit of any treatment is probably going to outweigh the risk. But what are the risks for using an epinephrine auto-injector that parents need to know about?

0:48:00

Dr. Peter Mustillo: There are some potential risks, albeit they’re extremely small. There’s never been reported serious adverse reaction in a child who’s received epinephrine injection. Typically, what happens is you have the initial discomfort of the shot itself. And then, it’s very likely to increase heart rate and some of the recipients of the vaccine will get a little bit jittery. That effect typically wears off within about 20 minutes, which is when the epinephrine often wears off, plus or minus that amount of time. But the rest are very, very small.

Really, our concern might be if you have an adult who has known heart disease and then they get the epinephrine and that sort of increases that heart rate, that is when we might be a little more hesitant to administer it. But otherwise, we really have no concerns.

Dr. Mike Patrick: Right. But again, if they’re having a severe reaction and on the ground anyway, and you’re worried that person’s going to die, then using the epinephrine still, even with the heart conditions, is probably a good idea. But each individual case is different.

Dr. Peter Mustillo: That’s right. There are actually about a 150 deaths on average in the United States due to food allergies. And the most common cause of that is they either delayed the use of epinephrine too long or they don’t have it at all.

Dr. Mike Patrick: Dr. Scherzer, what’s the long term outlook for kids with food allergies. Is this something that they typically outgrow or something they’re going to have their whole life?

Dr. Rebecca Scherzer: That’s a great question, a very common question. So unfortunately, kids with peanut and tree nut allergy or adults also only have about 15% to 20% chance of outgrowing it throughout the course of their lifetime. The good news is kids with berry, soy, egg and wheat allergy have somewhere around the 75% to 80% likelihood of outgrowing those food allergens during their childhood, sometime during their childhood.

Dr. Mike Patrick: So, how do you figure out if they’ve outgrown it or not? Is it something that you check for regularly, especially if it’s a food item that maybe the kid wants to eat?

0:50:08

Dr. Rebecca Scherzer: So, that can be very patient-specific on how often you check. But frequently, every year or two years, again, depending on that child and the clinical situation. We repeat the skin tests and/or food-specific IgE levels looking for evidence of waning hypersensitivity.

Dr. Mike Patrick: Now, do you ever see where the food allergy seems to have gone away and now, they’re not sensitive to that food anymore, but then it comes back?

Dr. Rebecca Scherzer: That has been reported. That has been reported in children who have been able to tolerate a food challenge for certain food — especially peanut is the one that comes quickest to mind — but then, down the pike ended up having a food sensitivity that resurface again. So yes, that is a possibility.

Dr. Mike Patrick: But each kid is different.

Dr. Rebecca Scherzer: Yeah, everyone’s different.

Dr. Mike Patrick: And you really just have to… Again, the reason you need to see an allergist is because there is not any cookie cutter treatment for these things.

Dr. Mustillo, can food allergies be prevented?

Dr. Peter Mustillo: That’s a little bit of a complicated question. I’m going to try and answer, I supposed, in parts as best as I can. So, some of the questions that we often get related to prevention are, you know, a mom who’s pregnant wondering about — during her pregnancy and also after birth — if she decides to breastfeed, is her diet going to affect the child’s risk for developing a food allergy. And right now, as it stands, there’s just insufficient evidence to suggest that the maternal diet during pregnancy or breastfeeding affects the development or the clinical course of food allergies.

So, because of this, restricting the maternal diet during pregnancy or breastfeeding as a means of preventing development of food allergies is not recommended. As far as breastfeeding goes, there’s actually been mixed information on this, but the most up-to-date information is that there’s no strong evidence that breastfeeding serves a protective role in preventing atopic diseases, including food allergies.

0:52:11

Nevertheless, it’s still recommended that, if possible, infants be exclusively breastfed for the first four to six months, unless it’s medically contra-indicated. Sometimes people will ask us about “Should I give my infant a hydrolyzed infant formula?”, which is sort of a broken down, shorter protein chain than your standard formulas or an elemental formula — which is basically just one or two amino acids — generally, they call it as hypoallergenic.

And there’s a limited number of studies that suggest that partially or extensively hydrolyzed infant formulas — so these are generally Pregestimil, Alimentum, Nutramigen — that they may reduce the development of cow’s milk allergy in at-risk infants who are not exclusively breastfed. Hydrolyzed infant formula, as opposed to the cow’s formula, may slightly reduce or delay the risk of development of eczema, atopic dermatitis, the cow’s milk allergy and wheezing in early childhood. But there really need to be more information gathered on this. And one of the negatives about the hydrolyzed and elemental formulas is that it costs two to four times the normal standard infant formula.

Then, another question is, as far as timing of introduction of potentially allergenic foods in children, up until about five years ago, the recommendation was that in children who are potentially predisposed at high risk for developing food allergies that they avoid all egg until the age two and avoid peanut, peanut butter and seafoods until age three. But that recommendation actually has been removed because it was based on inconclusive evidence. So there’s no longer recommendation to avoid administering these food groups at a young age based on decreasing the risk for allergy.

0:54:09

And then, as far as preventing, one of the big questions that we have is, “Why is the incidents of all allergies, including food allergies, increasing over the years?”  And there’s a significant amount of research being conducted right now to try and explain the rise of the allergies in the recent decades. Some of the current theories to explain the phenomena — but let me say that all these require further information because there’s again nothing conclusive on this — but there’s some limited evidence that hygiene hypothesis, so sort of very clean environments maybe contributing to food allergies, decreased vitamin D levels in utero and also in infancy, below normal folate levels, the effect of pesticides, chlorinated compounds, also plasticizers and altering the what’s called the gut microbiota.

The use of substances such as antibiotics early in life, so there is a couple of studies that suggest that if there’s an infant who received two courses of antibiotics in their first year of life that they may tend to have a higher risk for developing food allergy. Again, probably through this mechanism of altering the gut flora.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: And they’ve done study on mice, too, where they’ve raised them in a completely stellar environment where no bacteria, even in their GI tract, and they all develop food allergies.

Dr. Mike Patrick: It’s sort of makes it difficult to know what to tell people or to advice when to start certain foods because on the one hand, we know that if you’re exposed to an allergen, you’re more likely to become sensitized to it because you’re exposed to it. Yet, on the other hand, if you delay too long or don’t have small amounts of it, then it makes it more likely that you’ll be sensitized to it. So, like there’s this middle road but we don’t really know where that middle road is.

0:56:10

Dr. Peter Mustillo: That’s right. And one of the reasons why the recommendation was removed as far as avoiding peanuts for example to age three and those who were genetically predisposed was there was a study done where they took the same population of Jewish people, some living in England and some living in Israel. And the ones living in Israel, they administered peanut butter to them within their first year of life and the ones in England, they waited until they were three. And the ones who actually had the higher incidents of developing a food allergy to peanut was the ones who waited until they were three years old in England.

Dr. Mike Patrick: Yeah. So getting a small amount early may be kind of like getting allergy shots where you’re getting the small amount of the allergen and then, you’re tolerating the allergen because you’ve been exposed to small amounts.

Dr. Peter Mustillo: Potentially, yes.

Dr. Mike Patrick: Potentially.

Dr. Peter Mustillo: Yes, it may help in early development of oral tolerance.

Dr. Mike Patrick: Yes. But in the other hand, you could also be sensitized to it with those initial exposures.

Dr. Peter Mustillo: Correct.

Dr. Mike Patrick: Yeah.

[Laughter]

Dr. Rebecca Scherzer: I think that’s especially important to keep in mind for the high risk infants. So the atopic event certainly, I think, is their own category and you have to keep in mind that they would be at high risk for fatalities.

Dr. Mike Patrick: Yup. Yup. And that’s where really we have to look at the whole picture, including what’s the family history and the history of other types of, whether it’s asthma or other types of allergic type diseases in that same child.

So, can food allergies be cured? And I’m guessing this is no.

Dr. Peter Mustillo: Yes.

Dr. Mike Patrick: [Laughter]

Dr. Peter Mustillo: So, when we refer to can they be cured, that means are they able to develop a complete tolerance to it, eat it whenever they want and not whenever they don’t want to.

Dr. Mike Patrick: With no worry that it will never come back.

Dr. Peter Mustillo: That’s exactly what I mean.

Dr. Mike Patrick: Yeah.

Dr. Peter Mustillo: The closest thing there is to a cure is the oral desensitization where children are given initially very, very small amount of food, gradually increasing dose in over an amount of time. And a significant numbers of those patients do wind up becoming desensitized. However, they need to routinely ingest this food typically at least a couple of times a week and if there’s a period of avoidance where they don’t ingest that specific food whether it’s egg or milk or peanut for example, then it’s not uncommon for them to become re-sensitized.

0:58:36

And that’s one of the delays in sort of getting this oral desensitization approved for use across the board. Right now, it’s still just research.

Dr. Mike Patrick: So, when you talk about hot topics in food allergy research, this oral immunotherapy would be one of those.

Dr. Peter Mustillo: Yes, I think it’s at the top of the list.

Dr. Mike Patrick: Yeah.

[Laughter]

Dr. Mike Patrick: So, it’s really kind of like an allergy shot but we’re giving a small amount of the allergen, the food in this case. A small amount of it by mouth rather than injecting it in the skin.

Dr. Peter Mustillo: Right.

Dr. Mike Patrick: Yup. But in terms of… How do kids get involved? So there’s ongoing research in that. So if a parent wanted to be involved in that research, how do they find it out just who’s involved in the study.

Dr. Peter Mustillo: Well, I believe that after they travel outside of the state, of our state in Ohio here. Studies where some of these research protocols have been conducted are in North Carolina, at Duke. Also, I believe John Hopkins and there’s a handful of other places in the country.

Dr. Mike Patrick: Yeah. But, it’s probably more that allergist at those places are telling the parents, “Hey, you want to be involved in this study or not?” Parents saying, “Hey, I want my kid to be in this research.”

Dr. Peter Mustillo: And, you know, there’s actually very small numbers in this study that’s extremely hard to get into and a lot of them have closed at least for the moment.

1:00:06

Dr. Mike Patrick: So, please, folks, don’t start emailing Duke and saying, “Dr. Mike sent us here,” because I’ll get a nasty email from Duke and from Nationwide Children’s.

[Laughter]

Dr. Rebecca Scherzer: I think it’s important really to keep in mind, again, it is in a small number of places and it’s not… I always tell people it’s not ready for primetime. It is not something that’s standard right now, would not be considered standard of care.

Dr. Mike Patrick: Are there other current hot topics in the food allergy research to talk about?

Dr. Peter Mustillo: Well, I sort of alluded to earlier the incidents of food allergies and why it’s going up. So there’s a lot research being conducted in regards to that. And then, there’s also some research where they’re trying to actually alter the epitopes which are the allergic portion of the proteins. It’s pretty well known which specific portion of food — let’s take peanut, for example — it’s called Ara H1 and H2. That’s the allergenic part. And what they’ve done in some studies is they actually removed that portion of that protein and then, the person who was previously allergic to peanut is now able to ingest it.

So this is genetically modifying the food and there’s a lot of controversy as far as if that’s good or bad. But that’s another topic in research.

Dr. Mike Patrick: And we don’t know if that particular protein affects the taste. And could that be an issue? I guess it would have to be on a food-by-food basis to know.

Dr. Peter Mustillo: Sure.

Dr. Mike Patrick: What about blocking IgE? So if the antibody IgE mediates this whole response, is there any research going on to look at blocking IgE?

Dr. Peter Mustillo: Well, yes, there is. There is a medication that’s given by injection, generally once a month. And it has been studied now for more than 10 years. And given that the cases of anaphylaxis are IgE mediated, this medication actually binds to the IgE antibody itself and in some sense, it takes it out of action. So that if the person then ingest the protein such as peanut for example, they are much less likely to have an allergic reaction. And so, in some of the studies, this particular medication has been shown to allow the children to ingest up to eight peanuts, for example.

1:02:32

Dr. Mike Patrick: And this is really going to be more for those kids who are so allergic that their life is at risk if they come in to even a small amount of contact with it. Because I suspect that this is probably a pretty expensive medication. And if it’s just routine food allergies, it’s probably not something that you’ll be exploring.

Dr. Peter Mustillo: That’s right. And it’s still not a guarantee that it’s going to protect the children. And the cost are probably are in the realm of over $20,000 to $25,000 per year for the medication alone.

Dr. Mike Patrick: And probably, it would be difficult to get insurance to cover it and that whole business as well.

Dr. Peter Mustillo: Yes.

Dr. Mike Patrick: So, tell us a little bit about the allergy clinic here at Nationwide Children’s. So if a parent out there, you know, their child has a food allergy and they really do want an allergist to manage their care, do you guys take referrals to see new patients from all sorts of places?

Dr. Rebecca Scherzer: Yes, we actually get referrals from all over the states and multiple states, around Ohio and their borders. We have a very strong core faculty at Nationwide Children’s Hospital Allergy and Immunology. We’re also very lucky, there are several practicing allergist from Ohio State who spend time at Nationwide Children’s Hospital. And we have some terrific private allergists who also spends some time at Nationwide Children’s Hospital. So we are able to take care of really every disease that you find in the realm of allergy and immunology.

From a food allergy standpoint, we’re able to do the testing that’s necessary and the interpretation of the testing. And as Dr. Mustillo mentioned, we do a lot of food challenges in our clinic. So we are able to provide allergy and immunology care for whatever that child would need.

1:04:09.5

Dr. Mike Patrick: And really do it in a safe environment, because if something’s going to go wrong during that food challenge, you want it to be someone who isn’t going to panic and knows how to take care of the child who’s having that severe reaction.

Dr. Rebecca Scherzer: And we have really a wonderful whole team. We have wonderful nurses. And so, really, the whole team is geared at taking care of the kids and  geared at taking care of people with these diseases.

We also some multi-specialty clinics that we’re involved in. So we do a mix clinic with dermatology and nutrition. We have that which is an eczema clinic. We have a rhinology clinic which is Allergy along with ENT, and an eosinophilic esophagitis clinic which we do with the GI folks and dietitians. There’s also a high risk asthma clinic. And Dr. Mustillo is involved in the 22Q or DiGeorge Clinic.

So, really, we work with many other groups in Nationwide Children’s Hospital to provide the best care for patients.

Dr. Mike Patrick: Yeah. And we make it really easy. If you’re a mom or dad out there right now, and you’re interested in having your child seen in one of these clinics, it’s really easy to get connected. And if you go to the Show Notes, so pediacast.org, and find the Show Notes for this episode which is 259, you’ll find the link that say “Connect Now With A Pediatric Allergist At Nationwide Children’s”. And this is a special link just for you. It will take you to a page and you put in your contact information and someone from our allergy program will get back to you in whatever your preferred method of being contacted is. And then, they can help you set up the referral or the appointment.

Now, it may be depending on your insurance that your primary care doctor actually has to do a referral but the allergy folks here can help make that happen and connect with your regular doctor to help facilitate everything. So we just want to make it as easy as possible for folks to find you guys.

All right, we do have lots of links, in addition to the “Connect Now With a Pediatric Allergist” link. As I mentioned, at the beginning of the show, The Diabetes Calculator For Kids — we’ll have a link to that — The 700 Children’s blog, Allergy, Asthma, Immunology here at Nationwide Children’s. Also, there’s an article called “Food Allergies In Children” from the Nationwide Children’s Health Library and it also include some tips for dining out with food allergies. We have all that.

And Dr. Scherzer, you’d mentioned the EpiPen videos and the Helping Hand and the Food Allergy Network and we’ll put the links to all of those links in the Show Notes as well.

1:06:33

Well, it’s really been great to have you both stop by the studio, just really appreciate you sharing your knowledge with everyone.

Dr. Rebecca Scherzer: Thank you.

Dr. Peter Mustillo: Thank you so much.

Dr. Mike Patrick: All right, let’s go ahead and take another break. I’ll be back as I usually am with a final word, right after this.

[Music]

Dr. Mike Patrick: All right, for my final word this week, I want to give you a final reminder about the Autism Speaks 2013 National Conference for Families and Professionals. It’s right around the corner now, Friday, July 26th and Saturday, July 27th at the Hilton at Easton here in Columbus, Ohio.

It’s right around the corner but it’s not too late to register. The conference is sponsored by Autism Speaks, Nationwide Children’s Hospital, the Ohio State University Wexner Medical Center and the American Academy of Pediatrics. As the name of the conference suggests, it’s aimed at families and professionals with great information and educational programs for both groups. This year’s focus is treating the whole person with autism, care across the lifespan. And it will feature sessions and workshops focused on the most current guidelines for addressing medical issues, developing approaches to care that integrate behavioral and medical treatment across the lifespan and helping kids and teens with autism spectrum disorder to lead happy, healthy and successful lives.

Keynote speakers include Dr. Paul Carbone, associate professor of Pediatrics at the University of Utah — he’ll be speaking on understanding medical issues from childhood to young adulthood — and Dr. Steven Shore, an educator and author and assistant professor of education at Adelphi University in Garden City, New York and he’ll be speaking on creating a fulfilling life.

1:08:30

So, if you’re dealing with autism at home, elsewhere in the family or in the classroom, or if you’re a clinician or scientist interested in caring for kids with autism, be sure to check it out. Autism Speaks held this annual event in Columbus last year. And there’s a reason they’re returning to Columbus next week.

Again, it’s not too late to register. And I’ll put a handy link in the Show Notes for this episode at 259, over at pediacast.org. The link will take you to the conference homepage and you’ll find lots more information there, as well as a convenient sign-up sheet.

So, the Autism Speaks 2013 National Conference for Families and Professionals, Friday July 26th, Saturday July 27th right here in Columbus, Ohio. And that’s my final word.

All right, I want to thank all of you for taking time out of your day and making PediaCast a part of it. I also want to thank Dr. Rebecca Scherzer and Dr. Peter Mustillo, a pair of pediatric allergist from Nationwide Children’s Hospital for helping us understand food allergies a little better.

I also want to remind you, iTunes Reviews are helpful; as are links, mentions, shares, retweets, repins, all those good on your social media sites. PediaCast is on Facebook, Twitter, Google+ and Pinterest. And be sure to tell your family, friends, neighbors, co-workers about the program. And last but not the least, be sure to tell your child’s doctor, next time you’re in for a sick office visit or a well check-up, just let them know about PediaCast. We do have posters available under the resources tab at pediacast.org.

If you have a question, a comment, a show idea, head over to pediacast.org and click on the Contact link. And, of course, we do have that “Connect Now With the Pediatric Allergist from Nationwide Children’s” link over in the Show Notes.

All right, that wraps things up for today. Until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.

So long everybody!

[Music]

Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening! We’ll see you next time on PediaCast.

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