Answering Food Allergy Questions from Social Media Posts

Dr. Hoyt addresses three smart questions from Facebook posts that hit real pain points in pediatric food allergy: 

• Confusing “tree nut” lists
• OIT that turns into a nightly fight
• How real foods can be used to desensitize kids with food allergies. 

Mentioned link: FDA's List of Tree Nuts

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📖 Navigating Food Allergies: A Parent’s Guide to Care, Coverage, and Confidence by Dr. Alice Hoyt - order from Amazon and more 

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Transcript

Welcome And Listener Questions

SPEAKER_01 0:05

Hello and welcome to Food Allergy and Your Kiddo. I'm your host, Dr. Alice Hoyt. Talking today, a little something, a little something different than my typical show. Today, what I'm doing is I'm reviewing some questions posted on Facebook within different groups. As you might know, I tend to kind of like linger, don't post a whole lot. I could literally spend my entire life just responding to food allergy questions and um spreading good information and evidence-based information. Um and what I'm gonna talk about today are three posts that I think are just really good learning posts about questions people posted that I talk with my patients about very, very, very often. So the first post reads My two-year-old has a tree nut allergy. His allergist said there are nine tree nuts, which pictures I'm finding to list them confirm nine: hazelnuts, almonds, walnuts, pecans, cashews, brazil nuts, pistachios, macadamia, and pine nuts. Yesterday there was a dip with chestnuts, and I had to Google if they're a tree nut, and they are in fact a tree nut. Why doesn't anything I'm finding show them as one? That is such a good question. Let's talk about first the concept of a person being allergic to every tree nut. At face value, that would make sense, right? Because it's a tree nut, and all tree nuts must be the same, or else they wouldn't be tree nuts, right? Um, not necessarily the case. In fact, most or many tree nuts are not tree nuts, they're droops. Um, really the concept of everything of certain tree nuts and seeds being labeled as a tree nut is more so for FDA labeling purposes, to kind of like categorize them all, so that if any one of those is in a food in the United States, that it is being included as an allergen on that nutrition facts ingredients list. So I'm gonna put a link to the show notes to um fda.gov and on page 15 of this document entitled Questions and Answers Regarding Food Allergens, including the food allergen labeling requirements of the FDA, edition five, items for industry. This was published in January of 2025. So on page 15 of that is table one, and it lists the title of the table is tree nuts FDA considers as major food allergens with their common or usual name and their scientific name. So you can read this for their scientific name. I don't need to say that, but what I will say the common usual name. So these are the foods that are considered tree nuts by the FDA: almond, black walnut, zillnut, California walnut, ashew, filbert, hazelnut, heartnut slash Japanese walnut, macadamia nut slash bushnut, pecan, pine nut slash pignon nut, pistachio, and English and Persian walnut. So those are considered tree nuts. Now, not all of those are actually tree nuts. Some of those are actually droops. Um, so what is a droop? If we look at Britannica.com, a droop in botany. Simple fleshy fruit that usually contains a single seed, such as a cherry, peach, or an olive. As a simple fruit, the droop is derived from a single ovary of an individual flower. And the outer layer of the ovary wall is a thin skin or peel. The middle layer is thick and usually fleshy, though sometimes tough as in the almond or fibrous as in the coconut. And the inner layer, known as the pit or putumin, is hard and stony. The pit, which is often confused with the seed itself, usually has one seed or rarely two or three, in which case only one develops fully. Other representative droops are mango, walnut, and dogwood. And so, like, and they show a picture of a walnut, and you know, you crack the walnut, and you see the shell, and then the seed inside, and that's the part we eat. So different from technically a tree nut, all of this to say, does it really matter? Um yes in a way, and no in another way. It matters yes, because number one, if you are allergic to any foods that the FDA lists as an allergen, then those foods need to be very clearly marked on food labels by law. That's uh FDA regulations in the United States. And so it's very important to know what the FDA considers to be a tree nut for labeling purposes. Now, does it matter that some of these are droops? Like, no, it doesn't matter. What does matter is that you know what your child is allergic to. And if we're having this whole conversation about how some of these are droops, some of them are tree nuts, then is it possible that somebody is allergic to all of them? Anything is possible in the world of food allergy. But in most cases, most people aren't allergic to everything considered a tree nut. In fact, most people can tolerate many tree nuts, even if they have a severe allergy to say cashew. Now, cashew does cross-react with pistachio because cashew protein and pistachio protein look very similar. And as I've talked about before, food allergy is a very structural condition. The structure of things very much matters. So getting back to this post, asking about, well, I'm told I'm allergic to everything that's a tree nut, or my I'm told my child is allergic to everything that's a tree nut. Well, chestnuts kind of are, but they kind of aren't. So what really matters here is that I mean, the whole post matters. Don't get me wrong. I'm not trying to say any of it doesn't matter. It all very much matters. But what is important to focus on is that it is very possible in this day and age to key in on what foods are allergens and what foods are safe foods, right? What foods are not safe because they're allergens, and what foods are safe because your child is not allergic to them. And even though some kids can have positive skin tests to everything that's considered a tree nut, can have positive blood tests. Having IgE to a food, which is what it means when you have a positive skin test or a blood test, it means that either the the blood testing, the immunocap, is detecting IgE in your child's serum, in your child's blood, or the skin prick testing is that little bit of like um almond extract is binding to your child's almond-specific IgE on his or her mast cells and causing a little localized mast cell, act mast cell activation. But does that mean having a positive test? Does that mean you're allergic? No, it doesn't mean that. So a child can be allergic to some things called tree nuts, like cashews and pistachios, but then be fully tolerant of all of the other tree nuts. And in this day and age, we can absolutely sort that out. And having a positive skin test or a positive blood test does not necessarily mean that the child is allergic. It absolutely means that they're sensitized, they have IgE, allergic antibody to it, but that doesn't tell us anything about the child's level of tolerance at that time, which is not so much regulated by IgE or by mast cells, even, but is much more has a lot more to do with regulatory T cells, a different compartment of the immune system. So to answer this mom's question, why doesn't anything I'm finding show them as one? It's because when it comes talking about chestnuts, it's because when it comes to what really is a tree nut, it it is quite an interesting conversation. But ultimately what matters is that you know what your child is allergic to, what is safe and what is not safe, and you know how to determine whether or not a food includes that allergen. And so if you're listening to this and you've been told that your child's allergic to every tree nut, then it's time to make an appointment with your allergist to really discuss: okay, does this mean absolutely allergic to almond, absolutely allergic to cashew and pistachio, absolutely allergic to walnut macond, absolutely allergic to hazelnut? How is that allergist defining tree nut? Let's go on to number two, this next one. Um, aw, ug. It starts with ug. It's never good if it starts with ug. OID is turning into a horrible struggle with my five-year-old. She has abdominal pain, which is relatively controlled with Pepsid and Zertec. So she's, I'm sure, not thrilled about it for that reason. The latest issue is that she runs away or cries or begs for extra time before her dose. We already dose late in the day, pushing now to around 6 or 6:30 or later because of this. It's horrendous nightly struggle, and she always ends up crying, and I get mad and frustrated. The peanut is a particular issue. We're doing palphorsia, which was fine taste-wise, but then the volume on top of the volume of the walnut flour mix was a problem. And she started refusing part way through. I'll explain some of this in a minute. Now we are on the Hershey's Reese's topping, which she detests. I agree. It's gross. She will take the cashew and walnut and chocolate sauce. We have special bowls and spoons. I've offered all mixers under the sun, offering treats, TV, etc. after finishing. I'm almost ready to quit the whole thing, which I won't do, but I'm exhausted, and this is just one more thing. Should I ask for another peanut option? Take a break, do more cajoling. My son is the one for egg, and so far it's smooth, and the baby seems to be allergy-free, but I just hate this dynamic with my daughter. Oh my gosh, my heart breaks for you. OIT should not be like that. OIT, as I've discussed on the show, is oral immunotherapy, and it is a way that we take small amounts of your child's food allergen. You dose them every day, come into the office for updoses until they're eating a reasonable amount. Um, if it's peanut, I get kids eating half a teaspoon of peanut butter. Um, and then they stay on that maintenance dose for a year, two years, three years, depending on how old the kiddo is, what their numbers are, reaction history, all the things. The goal being over time teaching the immune system to tolerate the food. The goal with OIT, as I've talked about, is often to have the kiddo be bite-safe, meaning if they accidentally ate some of the food, they wouldn't have a severe allergic reaction. But a lot of OIT allergists, myself included, we're always really striving for freely eating. And in many kiddos, you can get them to freely eating. But this is definitely an art. There is significant science behind oral immunotherapy, but there's a lot of art to it as well. So in this patient, this patient is having belly pain, which it sounds like it's cons controlled with Pepsid and Zertech, but that that's a real red flag to me if somebody who's on OIT is having significant belly pain, needing two antihistamines to suppress it. Um that's a red flag to me that the kiddo is actually having um could be having eosinophilic esophagitis that's associated with OIT. We think that at about 5% of kids undergoing oral immunotherapy, that they develop eosinophilic esophagitis, which is somewhat like eczema of the esophagus, is how I describe it. Um and it could just also be that she's she's really like hitting that reaction threshold. She's having low-level reactivity in her gut um to her dose. It could also be that she doesn't like it. What was the word? Um she detests. I agree, it's gross. So if you know you have to eat something disgusting every day, that is that is not gonna go well. Um I am in the camp, and I I do not have I do not have data by which to confirm this. But I am in the camp based on my experience that, and based on looking at how powerful sublingual immunotherapy is, which is small amount of of allergen in the mouth when nothing else is in the mouth. So it's really just, and especially under the tongue. But we know Edwin Kim's data, it's very lovely data from Chapel Hill a few years ago, where he enrolled kiddos ages one year to 11 years. You know, a one-year-old is not holding anything under their tongue, but it's in those younger kids where slit was super powerful. So something about just having a little bit of allergen in the mouth without anything else in the mouth, every day, pretty low levels, like a maintenance dose of slit is right around the starting dose of OIT. We're talking like four milligrams. Whereas a lot of times with OIT, we'll start in the neighborhood of one to four, sometimes 10 milligrams of allergen, depending on the age of the patient. So in this case, it's very concerning that the child is having significant, significant resistance. And I'm wondering if part of it has to do with absolutely she's getting belly aches from it. Does she have EOE? And is that discomfort? I mean, if you if you get a belly ache every time you eat something or you know it just doesn't make you feel good, you don't want to eat it. And when you're five, you don't have the cog the cognitive development to really be able to describe that. All you know is that it doesn't feel good. Now, getting back to me being in a certain camp, I am in the camp that using butters like peanut butter, walnut butter, something that's going to hang out in the mouth longer than just a flour that you're mixing in with applesauce and like woofing it down. I am in the camp that having it hang out in the mouth for a longer period of time than just woofing it down really helps to grow tolerance. Um, and I'm also in the camp that the taste, when someone doesn't like the taste of their allergen, that that too is a marker of where their level of tolerance is. Um, it's it's really nice when I see our little kiddos in our practice go through OIT. And at first, I mean, they they can't even tolerate like a the the tiniest drop of peanut butter, the tiniest smear of peanut butter. But then they go through OIT and now they're eating multiple tablespoons of peanut butter and they love it, and they love it. And I do think that it's because we try to use foods that are hanging out in the mouth, like peanut butter. That wasn't my initial reasoning for using peanut butter. My initial reasoning was that it's accessible, it's relatively inexpensive, and it tastes good, especially if you get like the regular old stuff, not the naturally stuff. Even though I did taste one of the natural ones the other day and was pretty good. Um, but in this case, the next step is to schedule an appointment with the allergist to discuss this because this is setting up a really bad, bad situation, bad relationship with food. Um, bad, you know, just like what parent wants to see their child struggle like this? But then at the same time, you're trying to make sure that your child is hopefully not going to have to live their entire life with a potentially life-threatening food allergy. So, next step here, talk with the allergist. What would I do? I would step back on dosing, I would change how we're dosing, and I would send to GI, one of my GI colleagues who is well-versed in eosinophilic esophagitis. And I will say that it's not always the allergen when it comes to OIT and EOE associated OIT that I think is actually triggering the EOE. Sometimes it can be the vessel. So, in a lot of cases of EOE, milk is a food trigger, meaning the milk is really revving up that EOE. When it comes to OIT, sometimes people dose in ice cream or heavy dairy. And so they're eating a lot more dairy than they maybe were before. And that exposure can sort of give the allergen a bad name. So it's or a wrong association. EOE is can be a very challenging condition because there are limited ways to treat it. One of the ways is with avoidance diet, which can just be so hard in in kiddos and not necessarily effective. Um, it's we'll do an episode on EOE soon. So let's go to my next question. This is my last question. And this was actually what an allergist posted in one of our allergist groups. Hope this is not a stupid question. It is not a stupid question. There are no stupid questions when it comes to food allergy. But with palphorosia production ceasing, a lot of us are looking into non-FDA approved OIT for peanuts. When asking about protocols, most say to go to FAST, the Food Aller Support Team conference. Um, great conference. Um, but why are these protocols not published somewhere with some data on outcomes? Asking because I don't want to have to wait until the summer to go to a meeting or pay a registration fee. Well, at least they're being honest. Um, though they don't put their actual name. Now, now on Facebook you can put like pretend names. It's very interesting. Um, you know, and I did say going back to my the previous question, um, I said I would explain some of what they were talking about and palphorsia and taste-wise and the flour, the volume on top of the volume of the walnut flour. So when you're doing OIT, and this is relevant to the next question, the palphorsia, when you're doing OIT, if you're using flowers, then a lot of times you're you're weighing it out with a gram scale, which can be kind of annoying. Um, sometimes you'll just measure it with a spoon, uh, like a tiny teaspoon, but then you have to mix it with something, as I discussed, and miss it, mixing it with like applesauce, and then you just kind of like woof it down. So, and and now palphorsia, as I discussed in a prior episode, is not going to be produced anymore. It it's not because it doesn't work, it can work. I don't think it works as well as peanut butter. I don't think it works as well as peanut butter because peanut butter hangs out in the mouth and palphorsia does not. Um, so what this allergist is asking is well, what about non FDA approved OIT for peanut, which is very interesting. And you've heard me talk about this in that same Palforsia is going away episode about non FDA approved oral immunotherapy. Um, what they're asking. Is are there protocols available for using peanut butter instead of using palphorsia? Palphorsia went through all the regulatory, the whole regulatory pathway to become a food that is approved to treat peanut allergy. Peanut butter has not gone through that. Pasteurized liquid egg white that you get at Walmart has not gone through that. Um, the nut milks that you get at Whole Foods, they have not gone through that. But are they still effective at treating food allergies? Absolutely, because they're the food. They're the food that causes the reaction, and we can use low amounts of the allergen, which allergen is the food that causes the reaction. We can use low amounts of that food to teach the body to tolerate that. So not all foods that can be used to treat a food allergy need to go through FDA approval. We as allergists just need to know how to pick the foods and how to do the therapy. And when I teach other allergists how to do peanut butter OIT or supermarket OIT, one of the first things I teach them is how to read the nutrition label, which most know how to do that, I will say. So the only protein source is peanut. Then you look at in the nutrition label in the nutrition facts table where it says protein, and you look at how many grams of protein are per serving. So if there's seven grams of protein per two tablespoons of that peanut butter, and you know, looking at that ingredients list, the only source of protein is peanut, then you know that all seven grams are from peanut. So then you can calculate down and use a palphorsia protocol or use any of the other published protocols. My protocol is published, other protocols are published using PB2 powder. All you're doing is converting into whatever your food is and making sure you're you're giving that small amount, especially early on, that very small amount, to get down to approximately three milligrams. So you don't need an FDA-approved product to desensitize somebody to a food to which they're allergic. And if we waited, if we as allergists waited until there was an FDA-approved product for every food to which somebody can be allergic, to actually desensitize or embark on oral immunotherapy to help grow tolerance so that kids can be safer and live freer lives, then we would be waiting a very long time. So, all this to say, there are very, very good questions on social media. I hope that this episode has um walked through some of those questions and answered some of those funny questions about tree nuts, um, about what to do when a treatment plan is not going the way it really should be going. Um, and for my allergist listeners, you know, what to do about palphoria going away, and how can you really use supermarket foods to grow tolerance to your patient's food allergens? Um, yeah, so that's the episode. God bless you. God bless your family.

SPEAKER_00 27:07

Thanks so much for tuning in. Remember, I'm an allergist, but I'm not your allergist. So talk with your allergist about what you learned today. Like, subscribe, share this with your friends, and go to food allergy in your kiddo.com where you can join our newsletter. God bless you and God bless your family.