Ep 236: Navigating Food Allergies and Early Introduction with allergist Dr Akansha Ganju

Food allergies can feel incredibly overwhelming for parents — especially during infancy when introducing new foods for the first time. What does a true allergic reaction actually look like? And what should families know about new treatment options for food allergies?

In this episode, Dr. Jessica Hochman sits down with allergist Dr. Akansha Ganju of Latitude Food Allergy Care to discuss the latest science around food allergies, eczema, early allergen introduction, and oral immunotherapy (OIT).

They discuss:

• Why early allergen introduction matters
• The connection between eczema and food allergies
• What mild vs severe allergic reactions look like
• Why many first food reactions in babies are usually mild
• Common misconceptions about food allergy testing
• How OIT works and which children may benefit
• The role of Xolair in food allergy treatment
• Why food allergy treatment is changing rapidly

This episode is packed with practical advice, reassurance, and evidence-based guidance for families navigating food allergies.

To learn more about Dr. Ganju and Latitude Food Allergy Care, visit:
Latitude Food Allergy Care

Instagram:
Latitude Food Allergy Care Instagram

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Transcript

Unknown: 0:00

Welcome back to Your Child as Normal. I'm your host and pediatrician, Dr. Jessica Hochman. Today's episode is all about food allergies, a topic that brings up a lot of questions for parents. Parents want to understand, is there a best time to introduce common allergens like peanut or egg? What counts as a real allergic reaction? Should you avoid foods if your child has eczema? And if your child does have a food allergy. Are avoidance and EpiPens the only option? I'm so happy to be joined today by Dr. Akanksha Ganju, an allergist and immunologist who specializes in food allergy at Latitude Food Allergy Care. Dr. Ganju helped launch Latitude's first Los Angeles clinic, and she's doing really exciting work helping families better understand, diagnose, and treat food allergies, including through oral immunotherapy, also referred to as OIT. In this conversation, we're going to talk about all of those common questions that parents ask, and we also talk about the newer treatment options like OIT that are changing the way we think about food allergies. My hope is that this episode helps parents feel more informed, less fearful, and more empowered. And, as always, if you are enjoying this podcast, your child is normal. I would be so grateful if you would leave a five star review and share it with a friend. It really helps this podcast reach more families. Now, on to my conversation with Dr. Ganju. Dr. Ganju, thank you for being here. I'm really looking forward to this conversation. Thank you for having me. Excited to be here. So, tell everybody, what do you do for work, and where do you work? Yeah, so my name is Dr. Akoncha Gunju. I'm an allergist and immunologist who specializes in food allergy. I work at Latitude Food Allergy Care. So, this is a network of clinics that's focused on providing the most up-to-date diagnosis, but also treatment of food allergies. We have clinics now across New York and California, but I helped launch their first Los Angeles clinic last summer in West LA, and we already have three more clinics in Los Angeles, in Sherman Oaks, Irvine, and Pasadena as well. I'm so happy to know about you, because allergies are a big topic that come up in pediatrics, and parents are looking for guidance, and to be honest, I think the guidance that's out there is a bit confusing for pediatricians and for families alike. So, I'm so thrilled for you to educate me and to educate my audience. Definitely, I definitely feel for families. I always tell them, I know it's really hard to navigate, they can see like three different allergists or pediatricians, they're hearing like three different recommendations, so it can be really hard for families. So, before we get into what you do at Latitude, just to set things up for people listening, can you describe what is actually a food allergy, and how do we distinguish a food allergy from a normal reaction? Yeah, so a food allergy is an abnormal immune response against a food, so that can lead to serious reactions like anaphylaxis. So normally our immune system protects us from things like bacteria or viruses, but with a food allergy it is actually misidentifying the food as a threat, and then our body prepares to fight it, and it creates antibodies against that food, so that when you eat that food, your body releases chemicals like histamine, and then that's what causes symptoms like hives, swelling, vomiting, and those things can be life-threatening. What happens a lot in my practices, I'll talk to parents where they will try a food, let's say an egg, and the child will have a little bit of a rash in response to the egg. Is that an allergy? And how can they tell? How should a family proceed in that situation? Yeah, this is a great question, because we got this a lot, and I think it's hard when these infants are really young, because they can have eczema, and sometimes you're like, is it because it touched their skin and they were feeding themselves, or was it a real ingestion reaction? So, it can be confusing. So, there's kind of two things I really hone in on when I take a history for a food allergy, and that's timing, and the symptoms, so timing. I say, did the symptoms occur within one to two hours of eating the food, and is it reproducible? So, does it happen every time you eat the food, if you have enough of it? So, sometimes, if it's just a small rash, and they talk to their pediatrician, and it didn't seem like anything dangerous, maybe they'll try a small amount again, and that kind of acts as like that reproducibility of it, and then symptoms are pretty clear. So, skin symptoms - we're thinking about hives, so those red, itchy mosquito-like bumps, if there's swelling on their lips, face, or eyes. GI symptoms are common in babies, so vomiting within one or two hours of eating, and then any respiratory symptoms, so coughing, wheezing, shortness of breath. From your perspective, I would love to hear, how do you think a pediatrician should advise a family? Let's say they do come in and they are concerned that their child may have had a reaction, and it's not a bad reaction, meaning there's definitely a reaction, there might be coughing, there might be a rash. Do you advise a pediatrician at that point for the child to see an allergist, or should they try it again and see if it's reproducible? What's your advice? So, I always recommend that they should see a food allergy specialist at the start of any kind of food reaction. I think anytime you have food reaction, it's good to see this food allergy specialist and really get to the bottom of what's happening, see if you need testing. But I know that for a lot of people, they don't always have access, direct access to that food allergy specialist, and some people don't want. To wait, if there is a long waiting period, these allergens, you want to get them in in a timely manner. So I actually keep this up to the pediatrician's comfort level. If they feel comfortable, like it was a malreaction, if it was just a very minor skin symptom around their mouth, and the pediatrician feels comfortable that doing again, then I would take their guidance on them. But if there's any uncomfortability from the pediatrician, then I do think it's worth referring to the food allergist. I would never say,'Oh, this is a bad consult or anything like that. If anyone had a reaction, the point is for me to give them clarity in what happened, whether that is you actually have an allergy or you don't. I think you hit it on the head for me. I would always prefer to send to an allergist so that parents can get the clearest recommendations, but what's tricky is there can be a long wait to get into seeing allergist, and we know that delaying introduction of potential allergens can exacerbate true allergy in the future. Yeah, absolutely, it can be a fine balance with that. And do you mind expanding on what I just said? For people that may not know, tell us, what is the deal with early introduction and allergens, and how much of a difference does it actually make? Yeah, so we recommend allergens be introduced around four to six months of age, so early introduction. This is actually very different than what we used to say 1015 years ago. So, before, we used to think, hey, if we delay giving allergenic foods like peanut or egg, then maybe we'll actually reduce the allergy risk, but unfortunately, we saw the opposite occur, and we saw a dramatic increase in the rate of food allergies, or peanut allergies, specifically in the US. So then, interestingly, after that, they looked at some population studies, and they were like, in Israel, there's a really low rate of peanut allergy, like, what's going on over there? And they hypothesized that it was because so many parents in Israel are giving their babies this really popular peanut puff snack called a bomba, and they're giving it to their infants really early on. So, from there, in 2015 we had the LEAP study, which demonstrated that early introduction of peanuts between four to six months of age, and then keeping those allergenic foods in the diet significantly reduced the risk of developing a peanut allergy, and this was specifically studied in high-risk kids, so some people are like, 'Oh, my kid has eczema, I should wait till they're one year old. That's actually completely wrong. Those are the kids we actually want to give it early, so that their body sees the food and then doesn't recognize it as an allergen. So now the guidelines have changed. So basically, at four to six months of age, when your kid is developmentally ready to start solids, it's a great time to start introducing peanut egg, the other top nine allergens. My spiel to families is it doesn't need to be the first food you give them, but it should be one of the first foods. And from the research that you've followed, why do you hypothesize this is the case? Why is it that kids with eczema are more likely to develop peanut allergies or allergies in general. Yeah, so we actually think that there's a lot of ways you can be exposed to foods, and with babies with eczema, they have a skin barrier defect. So we actually hypothesize that they're actually seeing food in their body for the first time through their skin and not actually ingesting it, and their skin is seeing the food allergen, and their body's like, what is this? This must be dangerous for me. And then they can actually develop antibodies before they even eat the food, and that's because they have that skin barrier defect. So that's actually why we think they are at higher risk than those who don't have eczema. So there's something different about ingesting that protein through the gut and having the gut recognize that food directly, correct skin. Yes, exactly. And along the same lines, do you recommend really taking care of eczema in those early months, so that the skin barrier is as intact as possible? Absolutely, moisturize as much as you can. And have they ever shown that that helps with allergy prevention? They've been looking at it. I don't say they've seen an exact correlation, but they have seen some benefit, definitely with improving the skin barrier. So, I find this all really interesting, because for so long we've seen the allergy rates really increase in the United States, and I really just want to make sure that we are giving the best information and guidance to families, so that we can prevent this rise in allergies. Yeah, exactly, and there's a lot of different reasons for why the food allergy rate was increasing. We do think, obviously, delayed introduction played a big role in that. There is the hygiene hypothesis that in our more industrialized and developed countries, we're cleaner, so our immune system isn't seeing like all of the bad bacteria, and that can actually make us more allergic than other countries. So, we don't have an exact cause of food allergies, but we do think all of that plays a role, but the only thing we know to really prevent food allergies is that early introduction, and they even see that with environmental allergies, you know, kids, they say, who are around dogs or cats, or they studied kids on farms, they're less likely to develop those allergies too, because they're just constantly surrounded by it, it's an interesting conundrum, because nobody likes to get sick, and we know that keeping your hands clean and using sanitizer kills germs to avoid getting colds and whatnot, but at the same time, some exposure to what's out there is really healthy for your immune system. Keep being a kid, yeah, exactly. Be a kid, be healthy, take the appropriate precautions, but I don't think you have to be overly calm. Gosh, it is exactly, and how common are food allergies right now? Yeah, so we say about two kids in every classroom have a food allergy, probably a better way to be able to think about it. So it is still fairly common, and sometimes I feel like if your kid or your family doesn't have food allergies, you kind of forget what it's like to have your child have a food allergy or be someone with a food allergy, because I really had to think about things differently, and then I know there's just been good published data that we've seen a decrease in food allergies or peanut allergies in the United States. Why do you think that is? And do you think that research was validated and good? Yeah, so I think that research was really great in proving that our early introduction guidelines were making a difference, so you know one thing is to say, hey, and this controlled setting in the LEAP study, where we did randomized controlled methods, and we took these kids, and all that stuff, it worked right, early introduction worked, but what happens in the real world, like it's different when you're in a controlled study versus what is happening in the real world, so this study was really good, because it was like, okay, the Leap study showed that this works. Now it took some time to get the guidelines to change, and not just the guidelines to change, to have pediatricians and allergists even start recommending these new.. there's some pediatricians who are still telling people to wait till they're one year old, so it takes time to get that information out there. And so, since 2015 we're thinking, because the guidelines change, that that's why we're seeing the shift in peanut allergy. I have to tell you, I was so happy to read that study, because so often what we read, things are getting worse. But I was so pleased to see that actually peanut allergies are on the decline. Kudos to whoever's been helping with the education, getting the word out that early introduction is the way to go. Yeah, absolutely. And there's always like with data you always have to think about when they say that food allergies in general are on the rise, but peanut allergy is down trending, you know. I think we're also diagnosing more now than we did before, so that number can be skewed as well. I think that's a very good point. So, thanks for bringing that one up. So, in terms of introduction, because I find this is very anxiety provoking for a lot of parents, especially when it comes to the foods that are more likely to cause allergies in kids. How do you recommend that parents introduce foods like peanut and egg? I know you said there's a window between four and six months, but is there a way that they should be introducing it? Yeah, so I like just using the food itself, so like peanut, for example, I would use peanut butter. You should thin it out with like breast milk or formula, so it's not a choking hazard. For egg, you can just use scrambled egg, and then every time you introduce a new food, start with a really small amount, so either it's a lick of it or like an eighth of a teaspoon. Wait five to 10 minutes, make sure there was no reaction, give a little bit more, and then, if everything goes well, keep doing that until they're able to tolerate a full serving. But outside of just having them tolerate it the first time, a huge part of this is keeping it in their diet. I can't tell you how many times I have a family who was like, "Oh, they had peanut butter when they were four months old, everything was great, and then six months later they gave peanut again, and they actually had a reaction because they didn't give it in between that four months to a year, so after they tolerate the food, you want to keep it in the diet two to three times a week, so they maintain that tolerance. I think this is such an important point to stress, because you're absolutely right, parents will have their child try food once or twice, and then they assume that they're in the clear, but you really have to keep the food in the diet at least. I read three times a week. Yeah, I say it's just as if not more important than their first introduction. And then, out of curiosity, I know foods may be better tolerated when they're baked, or if that food is cooked and the protein is denatured, it may be an easier way to tolerate the food. So, do you recommend that at all in terms of introducing food? Should we be thinking about baking them or cooking them when they're first introduced? This is a great point. So, egg and milk specifically are very interesting allergens, and that if you extensively heat it, so in a baked form, like a muffin or a cake, it actually changes how that protein looks. So many kids who are egg or milk allergic can actually tolerate it in a baked form, and those that's very specific to egg and milk specifically, but what I say is actually the first time you give it, I don't need them to be giving it in a baked form, I'm totally fine with a cooked form, so scrambled egg, I wouldn't do raw, but I would do a fully cooked scrambled egg or an omelet, and then with milk you can even just start with yogurt, you don't need to start with the baked form and do like what we call the egg or milk ladders. We really recommend those if you've had a reaction to egg or dairy, and then they kind of come in and we talk about how to do those ladders. I think this is where I find a lot of parents get mixed advice from various allergists, as you mentioned the egg and the milk ladders, because they're looking for guidance, they're looking for information on how much exactly to give their child for future, you know, like let's say their child had a potential reaction to milk, and then they're looking for clear guidance on how to give it to them, and in what baked form, and they heard there's a muffin somewhere that they should give to their child, so I'm curious as an. Allergist, why is that? Is it that we haven't been doing this long enough, and there's just.. we're figuring out the guidance, or is it out there, and should we know about it? Yeah, I really love this point, as I hear this all the time, and they say it exactly the way you said it too. So, I will say it also comes down to everyone's comfort level, so even allergists, which is why I said I feel for parents who might go to a few different allergies and hear three different things. Food allergy is a lot of what you're used to, what you've seen, comfort level, not just what you study in the books. And so everyone has a different comfort level with these food challenges. So, say, for example, someone came in and they had a reaction to scrambled eggs. I almost give everyone a shot to tolerate egg in a baked form, because one, I think it opens up your diet extremely, if you can have eggs and baked goods. It also tells me that your prognosis of outgrowing that allergy is a lot higher than someone who can't tolerate in a baked worm. So I'm like, hey, come back for that baked egg challenge, like, come back for the muffin challenge in my office. But I will say, I have a food allergy practice, so I have staff that can monitor these food challenges. We can treat reactions. I feel comfortable treating those reactions. There's some allergists that might not have that comfort level, and I think that's where maybe the mixed messages can come, where there may be like, hey, instead of doing the big challenge, let's just wait six months and retest you. Yeah, I think what's hard is that parents want very clear specifics and direction on how to advance, they want to know what's the muffin recipe, how much to give, what to give tomorrow, what to give in two days, and I find not only is the advice different from allergist to allergist, but sometimes the parents have to actually bring it up to the allergen that they want to challenge the allergy that their child has. Yeah, and that's another good point, because even as an allergist we deal with families with different comfort levels, like maybe the allergy different colors, but families have different comfort levels too, and some people are just so afraid of doing food challenges, like that causes is very anxiety provoking for them, so even if I feel confident in doing the food challenge, sometimes I will have families who don't themselves feel confident, so it really is a shared decision making, as you said, that's a really fair point, because you don't have to introduce allergens, it's a choice, and I think what's tricky is this is where the education piece comes in, is that the more that parents learn about it and the potential upsides, the more comfortable they will be. Exactly, I think there's so much fear mongering in the food allergy world that I really want to get away from. I really want parents to feel confident introducing these foods at home. I do not think they should feel like they have to give peanut for the first time in the parking lot of the ER. That should not be the rhetoric around it. And I tell families, with what we know so much about the first food introductions, if your baby is going to react, the vast majority of that time that first reaction is usually going to be mild and something that they can recognize and manage at home, or they'll have time to seek emergency care. So, starting solids is such an exciting milestone for their infant, and it should feel fun and positive. It shouldn't be something that's driven by fear. So, I would love to delve into this point a little bit more, because parents are so anxious to try those allergenic foods, especially in the beginning. I would love to elaborate on this more. When you see kids that are little, it's atypical to see true anaphylaxis in young ones. Is that rare? Yeah, I wouldn't say it's impossible. Nothing is impossible, but the most common reactions they're going to have upon that first food allergen introduction, if they are going to react is going to be mild, so say it's just a few hives on their skin that either go away on their own, or if you have Zyrtec around, you could treat it, or maybe they'll have one episode of vomiting, and then feel better afterwards. The vast majority of time, their first reaction will be mild. And why do we think that is? That's a good question. I think you know one is probably that they're not eating as much volume of it. I think parents are good when they're introducing an allergen to start slowly, and the reason that we say to start slowly is that if they were to have a reaction, they didn't take so much of the protein in before they start reacting, so that's probably part of it. But that's my own hypothesis. Yeah, I always wonder, too, the immune system I feel like is a lot more flexible when you're young and things get more rigid as you get older, and I wonder if that has something to do with it as well. That the immune system in general tolerates a lot more, it's less reactive. Yeah, and we see that with treatment too, like oral immunotherapy, so when we're desensitizing kids, like we find that their immune system, we can actually change over time. It's a lot easier for us to see those numbers change versus treating an adult. So, I think this is such helpful information to get out there for families learning how to potentially prevent allergies. Can't stress enough how important it is to introduce the foods early, but now I'd love to talk more about the work that you do, because I think once it's established that a child has an allergy, I would love for parents to know that there are things that they can do. Yes, you can live with a child who has allergies, and we can talk about how to navigate that life, but there are now treatment options available through what you're doing. Yes, so it's a very exciting time in the food allergy world, we have all. These different treatment options that we really did not exist 1015 years ago or weren't widely available, at least. So, very exciting time. So, I would say that, like, the two biggest treatment options we have right now, it's first going to be oral immunotherapy, or OIT. So, this is where we gradually introduce tiny amounts of the allergen, so the food itself, we give it to the babies to eat under medical supervision to build tolerance over time. And then last year we had a biologic medication called Xolair approved for the treatment of food allergies. This is an every two to four week injectable that can raise the threshold of reacting to a food, and it can be used either alone or even alongside OIT. We used to only start o it in kids over one year old and now we're like actually earlier the better these infants are doing amazing and so we've learned so much and I know before and people probably still think that o it only means they're gonna get to cross contamination protection but we actually see especially with these young ones they're able to tolerate sometimes full servings over time, so everyone's goals can be different as well. We're just learning so much now, so I'm curious. Like, let's say, for example, a child is allergic to peanut, if they just simply avoid that peanut allergy compared to going through OIT, what are the odds in each group that they will develop tolerance to peanuts? Yeah, so peanut allergy, or even tree nut allergy on their own, there's only about a 15% chance that you're going to self outgrow it, so those are actually kids like peanut, tree nuts, sesame, these are allergens that I actually am very encouraging about, oh, it, because I'm like a 50% chance on your own you might outgrow it, but it's not the best job, it's not like things like egg and milk, where if an infant comes to me with an egg and milk allergy, over 80% of those kids are going to outgrow it on their own. So, it might be for egg and milk if they can pass that fake challenge. I'm like, okay, let's give it some time, it's still young, more than 80% of people are going to outgrow it. Maybe we don't need to jump to OIT, but things like peanut and tree nuts, and some of the other allergens, I'm a little bit more encouraging, so at Latitude, for example, we have a 92% success rate, but under the age of four that increases to 97% So really starting early is really important, and we can definitely get these foods back in their diet. This is an incredible statistic. So you're saying that if a baby is found to be allergic to peanuts, if they avoid peanuts entirely. There's basically a one in seven chance that they will eventually tolerate peanuts, so the odds are way more likely that they're going to stay allergic to peanuts. But if they start a program like OIT, where they learn how to introduce peanut in the diet, did you say it's over 90% likely that they'll be able to tolerate in the future? That's amazing. Yeah, exactly. So, under the age of four, for example, you have a 97% success rate of getting to their maintenance, so and their maintenance dose, I like I said, is the first goal, so that's about say one and a half peanuts, that's our cross contamination protection or bite proof protection, so if they accidentally ate it, they wouldn't have a severe reaction or a reaction at all, and that takes about six to nine months at latitude, and then after that, if you stay on their dose, that's where we really see the higher volume tolerance over time. So, the longer they're on that maintenance dose, we'll do these higher volume challenges and show that they can eat more of the food over time. So, for example, I have an eight year old, I just had an eight year old, and she completed OIT for milk, peanut, and tree nuts. She used to have anaphylaxis to milk, her IGE numbers to milk are over 100 very large, and now she eats all baked milk products. She's been starting to eat pizza, and this is all on top of her daily milk dough. So, truly life-changing, because milk's in everything, so it's a very life-changing food to be able to tolerate. And then, even for peanut, she is able to tolerate well beyond her daily maintenance dose for OIT. So, this is where I kind of emphasize that, oh, it doesn't just need to be about protecting against cross contamination, that's usually our first goal, but if your goal is to expand your diet, you know our goal is to get you there. I want to emphasize also how important I think just tolerating cross contamination is, because so many families that I meet whose children have allergies, they're so nervous to let their child go to sleep boy camp, or to sleep over at a friend's house, or to go out to a restaurant, because they're worried that they're going to be exposed to a little bit of peanut, and so just to know that a child can tolerate a little bit and not go into anaphylaxis, I think is tremendously beneficial for the anxiety of families. Absolutely, it's really every family says that their anxiety level has completely gone down. They feel so much more confident in the real world, going to restaurants, letting their kid go to a birthday party, letting them go to school. They just really gain a lot of confidence, because they're, I mean, they're literally seeing their kid eat it every day, and so I think just being able to see it, touch it, all of that, it gives them confidence. So, can you explain what the OIT process would look like a little bit more? What is the involvement for parents, and how are you introducing foods to kids? Is that you do you give them a little bit and increase it all the time? Paint a picture for us what an OIT treatment would look like. Yeah, so OIT again is a way to train the immune system. Tolerate the food, and so we're going to give tiny, gradual increasing amounts of the food itself, so say peanut or milk, over time under medical supervision, with the goal of reducing the risk of allergic reactions. So with us, we would start with a really tiny amount of the food. At latitude, we can treat multiple foods at once, so up to five at a time, which is very helpful and efficient for these families, we at our practice start with flowers, so either it's a peanut flour or a cashew flower, for example, we'll start with a really, really tiny amount, make sure they can tolerate it in the clinic, and then our parents will go home and give it to their child, or if it's an adult, give it to themselves once a day for about two weeks, and then they come back to the clinic for what's called an up dose visit, where we increase the amount of allergen they're having in the clinic, make sure they can tolerate their new increased volume, no reaction, and then they go home on that new dose for about two weeks, so that every two week up dose happens, like I said, for about six to nine months on average to get to that cross contamination dose, and when the parent gives the child that maintenance dose at home, if there's an issue, are you easily accessible? Because I've met families where literally I'll see them in our parking lot, and it turns out they're giving the child the maintenance dose in front of our office, because they're worried, should they have a reaction, they'll be close to their doctor. So, can you reassure families, what do they need to know about that process at home? Absolutely, I mean, there is always a risk of anaphylaxis because you're giving someone something they're allergic to, but it's very, very low risk. If anything, it might be a mild reaction, so maybe their mouth gets a little bit itchy, maybe they'll have a few hives around their mouth. Most commonly, they actually tolerate it without any reaction, and then after that, it might be a mild reaction. So, very rare to have anything serious happen, and it's because we do these up doses in a way that we don't expect reactions to happen. We're not expecting, we're expecting this to go very well. And when they come in for their first OIT appointment, we go through all of this teaching, so we tell them how to dose, when to dose, we go through how to again how to recognize and treat allergic reactions, not just for their OIT dose, but in the real world as well. It's really important for them to have that education. If it's a mild reaction, like, how is do you have Zyrtec at home? Here are the indications for when you would use Epi, so that they feel confident in that. And then, yes, we have a 24 hour hotline, because we are, we absolutely understand that there are going to be times where there is some confusion, they don't know what's happening. We want our families to feel very supported, so we always have a provider on call for our families. I'm thinking about a time where I was on call where a child was doing OIT at home and they had been exercising outside, the parent gave them their OIT dose, and then they actually had a bad reaction. And so, are there guidelines around how you give them OIT? Yeah, so there are specific guidelines, that's exactly what we go through when they start the OIT program. So, after you give your OIT dose, there is a quote unquote rest period. So, we don't want them to do any intense exercise after their dose. We don't want them to be giving their dose if they're sick, because in general, when you're allergic to a food, even outside of OIT, if you had that allergenic food at a time when you were sick, or at a time after your heart was racing, and you were running around outside, your reaction could be worse than if you were at baseline. So, these are all similar guidelines that we adopt for OIT as well. Now, you mentioned that it's okay to give a child Zyrtec or an antihistamine if they have a reaction at home. Sometimes I get mixed messages on this, because I've been told that should you give Zyrtec, you may be masking a greater reaction that's going on internally. Can you explain that to me? When is Zyrtec okay, and when should it not be recommended? Yeah, so Zyrtec, we absolutely recommend for any mild reaction. So say we talk about it as one body system, so say they have only some skin symptoms, so like hives, or maybe they have one episode of vomiting, or they just have a little bit of itchiness. Surttech is great for that. It's safe, even for our young infants. It is helping treat the reaction. It's not meant to mask a serious reaction. It's meant to help those mild symptoms, and then any what we call like a more serious or anaphylactic reaction, are I describe it as two or more body systems. So, say they have hives, which is a skin symptom, and they vomit, and that's a stomach symptom. So, I think of two organ systems. That's actually a time that we recommend using EpiPen. So, I think a lot of people think, oh, I have to wait till they have respiratory symptoms to use EpiPen, or I have to wait till it's a really, really bad reaction, and it's actually, you probably want to use Epi before you actually think our guidelines are actually telling you to use it a lot earlier. One, I want to emphasize that Epi is very, very safe. I tell this to my families, it will not hurt them, it will only help them. Do not be afraid of the medication, so that's one reason we'll use it early. And the goal of Epi is really to prevent those symptoms from getting worse, and that's why we tend to use it earlier on. And from your perspective, since you've been working in OIT, how does it make you feel about the future of allergies? I feel a lot more hope. Full, I see these families, and they come in with a lot of anxiety, and it's really interesting to see the comparison of families who didn't have these options before. They have older kids, and seeing like the anxiety in these older kids in the families who have had to avoid foods or or deal with food reactions, versus my families that come in and they start OIT at, say, six months old, you know, those kids are going to grow up and not even remember they have a food allergy, so to know that we can prevent that anxiety and completely change their quality of life is very exciting. And you had mentioned Xolair, do you find that Zolair has been a big benefit in terms of children tolerating OIT? Absolutely, OIT is very well tolerated, but there are going to be some people who struggle on it, especially if they're maybe a little bit older or they're doing harder allergens. We do find that milk and eggs, some people struggle with a little bit more than some of the other allergens, and Zolar has been an amazing option for us to use with OIT. So, sometimes if someone is having a hard time up dosing or getting to the next dose of OIT, we'll start using Xolair, and it will actually reduce a lot of the side effects that they may have had with OIT. So, using it in conjunction can be amazing with Xolair, is when you're off the medication, you're still allergic, right? The difference between OIT and Xolair, with OIT, I'm trying to change your immune response overall, but with Xolair, I'm just blocking that allergic response, but if you stop the medication, you're going to still be allergic at the end of the day. So, is this an indefinite treatment right now? It is, but when I use it with OIT, I can eventually, or hopefully, pull off the Xolair, and then maybe you're just staying on the food itself. So, for a parent who's listening to this, and they, in general, feel anxious about food allergies. What is something that you would want them to remember from this conversation? I want them to know that treatment options exist, and I think that they should seek out a food allergy specialist who is experienced in either Xolair or OIT or any of these treatment options. If you are still told in this day and age, when you have a food allergy, that you just need to avoid the food, then I would recommend getting a second opinion, because that's not the case anymore. We have amazing options available that will significantly change your quality of life, and we really shouldn't be in an age where someone is living where they have to have a fear of living or eating out or going to birthday parties or flying on an airplane. We have options now. Amazing. And are there any exceptions to that comment, meaning a really bad allergy or really bad eczema? Is there anybody that should be excluded from that statement? Yeah, I think a lot of parents, they tend to grab onto their numbers, they're like, "Oh, my, my skin test was too high, or my IGE antibodies to this food was over 100 like, how could I do OIT? And that's not true. We treat patients of all ages and all numbers. You are never too allergic to do OIT, and so I always think it's worth having a consult, so before we close, I'd love to just ask you some lightning round questions, just to have some fun at the end, if that's okay with you. Sure. All right. Okay. A mild reaction means future reactions will also be mild, myth or fact? Myth, but also I want to say it also doesn't mean that your future reactions are going to be worse? A lot of people get food allergy testing now. So, my question to you is, if food allergy testing is positive, you need to avoid that food myth or fact? Myth. So, food allergy testing has a very high false positive rate, so it's useful, but it's useful in the right context. So, I'm gonna go on a big tangent about this, but so if I did skin prick testing, if I gave skin for testing to someone who's never had a food before and it was a positive test, it's kind of like a coin flip, it's like a 5050 chance they're actually allergic. Now, a negative skin prick test is very good, it's a 95% chance they're not allergic, but the positive test, you really need to understand their history. Have you had a reaction? And at the end of the day, the gold standard is what happens when you eat it. So that's where we have these supervised oral food challenges, because I really want to know what happens when you eat the food. I don't just want to diagnose you from a test, because if we were only diagnosing kids off of tests, they would be labeled with a lot of allergies they don't actually have. So it sounds like the proof is in the pudding. See what happens in real life, so to speak. Exactly. Okay, just to hit this point again. Delaying allergenic food prevents allergies, myth or fact? Myth. Great. Okay. Most common food allergy in kids. It used to be peanut, but I think with the new studies they're saying egg. Most commonly outgrown food allergy, milk and egg. One food that you wish parents wouldn't unnecessarily avoid. It was a good one. I would say milk, and then sometimes wheat for eczema. Yeah, I'd see a lot of parents avoiding foods, especially milk, and I do see, like, some controversy around wheat or even egg with eczema exacerbations, but we actually don't recommend avoiding foods to treat eczema, and going back to, if we start avoiding foods, we could actually increase the risk of developing a true food allergy if they're not seeing it in their diet, so there's a lot of risk with avoiding foods that you don't have to avoid. Yeah, I would agree. I think the foods that I most commonly see parents avoid unnecessarily are milk, and the other is gluten. A lot of parents will see an allergist, or they'll get tested, and they'll find that their kid is gluten intolerant, and they'll take that out of the diet. Yeah, I agree. I say the same thing. In your opinion, one thing that pediatricians sometimes get wrong about food allergies, I think I don't hear it as often, but like the delayed introduction I still hear sometimes. And then I would say testing. I do sometimes see pediatricians get testing themselves, so they'll order like blood testing for food allergies, and this can really complicate the process, because when they come to see me, they do have a lot of positives on their blood tests, and you know they're like, what do I do with this, and they have to come in for a lot of food challenges. So I would rather them wait to get testing with the allergist. Oh, I'm so happy I asked you that question, because I am someone who does do allergy testing for a lot of parents. I think if you're focusing on the food that they reacted to, it can be okay, but sometimes you'll get Questor LabCorp, will offer food allergy panels, which is just a bunch of the top nine allergens and their foods that they haven't even had yet, and it can really muddy the picture and make it more complicated later on. In your opinion, the ideal age to introduce peanut, four to six months of age, epinephrine safe or scary, very safe rash around the mouth with strawberries, is that an allergy or more likely to be the irritation, irritation contact irritant vomiting once after peanut. What to do next? This is a great question. Talk to your pediatrician. One sentence to convince a parent to carry an EpiPen. It is a life-saving medication, so there is really no downside to carrying it. And, as you mentioned, it's safe, and it's very safe. One sentence to calm an anxious parent about food allergies: feel confident in being able to recognize and treat reactions, so my families, if they have a kid who has food allergies, like so much of what I do is education, and I feel like the more they're educated, the more confident they can feel in these situations, so instead of living their life where they think the worst thing could happen at all times, just feel confident that you know if your kid were to accidentally get into something they were allergic to, feel confident that you know how to recognize the signs and symptoms, and feel confident that you have the medications and the expertise to treat it when you need to, and they should live in that confidence and not fear. I love that so much. That's like my motivation for this podcast is exactly that I truly believe that the more people are armed with quality information, hopefully the less they worry. Yes. Biggest food allergy myth on social media right now,

say two things: 38:13

one is the mass food allergy sensitivity testing, like the IgG testing, it's not validated to test for food sensitivities or food allergies, and then I think there's a big myth with, like, airborne food allergies. I think that causes a lot of the fear in the food allergy world as well. So, I will say most foods are not airborne anaphylactic allergies. Everyone's threshold is different, so it's important that if you have an allergy, you speak to your allergist about your specific allergy and don't compare it to others. That's helpful to know, because I meet a lot of parents that are fearful of planes specifically. Should somebody have a peanut in the air? Will it affect their child? Will it put them into anaphylaxis? But you're saying that's not likely to be the case, exactly. And the IGG testing I find really interesting, because there's such a divide I find where some people are real believers in IGG testing and sensitivity testing, and a lot of allergists say not so credible. So, yeah, we just don't have any evidence to say that it's going to make a difference, and I get why people do it when you have a food sensitivity, which is different than an allergy - it's like you're bloating or your stomach hurts, and that kind of stuff with foods, it's hard because you are looking for answers, but unfortunately, there isn't a test that exists for many of those foods that can be like, hey, these are the exact three foods you have to avoid and you can move on. It just unfortunately doesn't exist, and so people are trying to grab for answers, and if this lab testing is available in the world, they're like, okay, if this could give me my answers, why not? But just because that lab exists doesn't mean it's actually diagnosing what you think it is, all right. Last one, if you could change one thing about how we talk about food allergies, what would it be? Getting away from this concept of avoidance, now that I do so much OIT, I truly see the difference it can make. I think at the first onset of diet. Noticing a food allergy, you should be put on OIT. I even describe it differently now, especially in the younger kids. It's like we tell people to introduce foods early, and if you have a reaction, even if you do introduce it early, OIT is just a different way to give you early introduction. The food is just a more monitored and slower way of doing it, but we're still doing early introduction, so sometimes I think about it that way instead of as a treatment. Okay, now tell us more about Latitude. How can parents find you? The big question I always get asked is, do you take insurance, and what can parents expect in terms of their time and financials? Yeah, so for Latitude, you can either find us Latitude Food Allergy care.com you can see all of our clinic locations, you can call and self-book, even without a referral, and we will get you to your closest clinic. We have allergists in every clinic that are specialized in food allergies. The biggest part of your first appointment is really understanding what your allergies are and getting to the correct diagnosis, because I will say the biggest thing I see is that people come in with probably diagnosed with more food allergies than they actually have, and so my first goal is to figure out what are you actually allergic to, and then after that, if we do decide you have allergies, then we can start talking about treatment. We are partnered with CHLA, and we are in network with similar PPO insurances that they take. Fantastic. Well, thank you so much. I so appreciate your time. Thank you for spreading awareness about OIT. Thank you for sharing your knowledge, and I've really enjoyed talking to you and learning from you. Thank you for listening, and I hope you enjoyed this week's episode of Your Child is Normal. Also, if you could take a moment and leave a five-star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow.