Keep calm and carry epinephrine: Easing food allergy anxiety

 “Introduce those allergens early, diversify that microbiome, and don't let fear rule you.”  -- Dr. Priya Bansal

On this episode of The Allergist, Dr. Mariam Hanna teams up with Dr. Priya Bansal, a triple board-certified allergist, to tackle the challenges of managing food allergies and the anxiety that often comes with them. Together, they walk through real-world cases that allergists frequently encounter, offering practical strategies to support patients and families.

On this episode:

• Introducing Allergens at Home: Handling parents’ hesitancy to introduce allergens like tree nuts in infants who already have a known allergy. Dr. Bansal offers approaches for building trust and using shared decision-making.
• What’s Not a Food Allergy: Dr. Hanna and Dr. Bansal discuss the common misconceptions around what qualifies as a food allergy and how to communicate with patients who might confuse intolerances or other reactions with true food allergies.
• Self-Carrying Epinephrine in Schools: Practical tips for helping children and teens manage epinephrine autoinjectors at school, including discussing comfort levels, age appropriateness, and new technologies like nasal epinephrine.
• School-Wide Allergy Bans: The pros and cons of school-wide bans on allergens like peanuts, and why such bans may cause more harm than good. Dr. Bansal shares alternative strategies for managing food allergies in schools without increasing social isolation.
• Health-Related Anxiety After a Reaction: Managing patients, especially children, who develop restrictive eating behaviors or heightened anxiety following a food allergy reaction. Discover when to involve mental health professionals and how to address fear in the clinic.

Join us as we explore food allergy management and anxiety, with actionable insights designed to support both healthcare providers and patients navigating the challenges of food allergies.

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

Transcript

Dr. Mariam Hanna:
Hello, I'm Dr. Mariam Hanna, and this is The Allergist, a show that separates myth from medicine, deciphering allergies and understanding the immune system. I saw a patient in follow-up for peanut allergy. His family had been early adopters of food immunotherapy, motivated but nervous. He'd undergone OIT (oral immunotherapy) nearly a decade ago, cleared an oral challenge even three years ago to peanuts, and now was eating his peanut-containing chocolate bars a few times a week to maintain his tolerance. Maybe the flavor wasn't his favorite, but actually nothing else. I congratulated them on their journey and encouraged them to keep going. They are at the limits of what we know of food allergy treatments and, dare we say, perhaps cured or in remission. The mom had two questions for me: What was the size of his skin test, and can he have peanut oil now? Today's guest is going to help me make sense of my encounter.
Immunotherapy did incredible things for this patient's peanut allergy. The family's anxiety around food allergy, on the other hand, seemed unchanged. It begs the question, are we doing enough to address that part of the story? Do we have our script sorted as to how to address food allergy-related anxiety in clinic? It's my distinct pleasure to introduce to you today's guest, Dr. Priya Bansal.

Dr. Priya Bansal is a triple board-certified allergist in internal medicine, pediatrics, and allergy and immunology. She currently works at the Asthma and Allergy Wellness Center in Illinois. She's a faculty member at Northwestern Feinberg School of Medicine and is a former president of the Illinois Society of Allergy, Asthma, and Immunology. She's a current member of the Quad AI Board of Directors and vice-chair of the Quad AI Advocacy Committee. Amongst other leadership roles with the American Academy and the American College, Dr. Bansal is also deeply committed to advancing care in food allergy and ensuring that all patients receive the best possible quality care, which is why I thought she would be a fantastic allergist to help us tackle today's topic. Dr. Bansal, welcome to the podcast.

Dr. Priya Bansal:
Thank you so much, Mariam. I'm so excited to be here. I completely appreciate the topic and have seen so much difficulty around food allergy and insecurity anxiety, so I think this is a perfect topic to tackle today.

Dr. Mariam Hanna:
And let's do just that. So today we're going to go through a few cases to help us work out a good approach or script around common scenarios that we will encounter in the allergy clinic. Let's start with the first one, food introduction. Typically, this is about a parent who's extremely hesitant to introduce foods at home, like tree nuts, in an already allergic infant.

Dr. Priya Bansal:
For me, it's interesting because it always depends on what the family is walking in with, what the burden is. So if they have another child that is peanut allergic and may have possibly had an allergic reaction to tree nuts, they're going to have a lot more hesitancy as opposed to someone else who might not have that situation going on. This might be their first child. So I try to get where they're coming from because, again, in this day and age, I'm a huge proponent of shared decision-making and trying to get to where the bottom line is. Where are your opinions? Where are you coming from? So I think it depends on what they're walking in with, which is the crux of this topic, right? The anxiety surrounding food allergy, and I wish I could say it was all one approach for every single patient, but it clearly is not. It varies by what they're walking in with and what they've experienced as a family together.

Dr. Mariam Hanna:
That's a great point to say, what is the baggage that they are bringing with them, because that'll dictate their goals, their motivation, and their reassurance or comfort with taking the next steps. Do you have a particular dialogue with them around how to introduce an allergen of concern at home?

Dr. Priya Bansal:
So it all depends on their nerves with the approach that we're going to take, and especially if we have diagnostic testing supporting that, "Hey, we can go ahead and do this." That makes it all the more that I'm going to say, "Hey, let's go ahead and try, go ahead and see if you can try this at home."

Dr. Mariam Hanna:
So I'm glad that you said diagnostic testing because the next thing I was going to ask you is how do you tackle their requests to screen for other allergens when they've only reacted to one particular food? So I guess I'm hearing that you sometimes will screen for other allergens, is that correct?

Dr. Priya Bansal:
It's hard because I know that this family is not going to try this food, and no matter how much I try to talk to them. So in general, if they have the one allergen, I say, "Look, this is a singular allergen. Statistically, you are not going to react to this other food. I feel pretty comfortable. I would never let you do something that you're not comfortable with, and I really feel comfortable that you can try this at home." But if they're still pushing back and saying, "No, I don't see myself doing this, this is never going to happen," then I have to say sometimes I cave. Because if I can give you, I would rather you eat the food and not develop allergies for the rest of your life as opposed to me being stuck on whatever my viewpoint is. So I believe that there's nuance. I'm always going to try to use science and try to explain it to you, but if I know that this is not going to happen unless either I skin test you or a blood test, whatever you need me to do at that moment, that needs to happen. I would rather do that and get early introduction to that food.

Dr. Mariam Hanna:
I completely hear you, Dr. Bansal, and I guess I've also seen it where they've been screened negative but never introduced and have also just held onto this false belief that just the negative test was sufficient to say that child is not allergic. How much do we need to emphasize that early introduction piece or follow through even on it?

Dr. Priya Bansal:
I mean, I think that is huge. For me, that is paramount because we discuss it. I discuss it with my women of childbearing age that come in with allergies. I say, "Look, we want that diverse microbiome. I really want you to be able to eat whatever, and your child to be able to eat whatever." And I know because some of the problem is, especially with women, especially women with food allergies of childbearing age, they, interestingly, some of them because they'll take their own bias and say, "I'm allergic to X, Y, and Z, so I'm not going to give it to my child," and that's not what we want. That's the antithesis of what we want. So I think that early introduction piece is very important. Diversifying is very important, and like you said, the opposite can happen. Let's say you test them and they come back positive, and even if it's slight positive, now they don't want to do it. So again, it's going to be part of convincing them to come into the office and try to get some of these things done that are so important. And I think that's where it's important to establish the rapport first and then once the rapport is established, go from there.

Dr. Mariam Hanna:
Do we have good predictors as to who's likely to succeed in introducing diversity in their diet and who's going to keep it in their diet? I feel like I spend so much energy trying to motivate these families in my office, and I don't know, is it a lost cause, hopeless, or are some people going to take me up on this?

Dr. Priya Bansal:
No, I mean, it's so interesting you say that because I've seen some of the patients come back and we've done the challenge and they're like, "Nope, they're not eating it." And I'm like, your heart just breaks because you're like, "Oh, I'm doing this for a purpose to help you and to make sure that it stays as a safe food for you." But interestingly, there is obviously a huge psychosocial component to this. I think if we look at poorer quality of life, interestingly, I know that Wete had done a study with, I think it was over 1100 caregivers, and she had looked at where is this poorer quality of life? Generally, we think it's more like caregivers that, let's say, had taken their child for a food allergy-related reaction or that child had a food reaction in the past year, or let's say they have multiple allergies. Unfortunately, certain ones like dairy, wheat, and egg are correlated a little bit worse.
And then I think the most interesting point I read about was that it's especially for caregivers who are more knowledgeable about food allergy. I found that fascinating because you would think, "Oh, if I know more about food allergy, I'm going to be more likely to do this." But I think sometimes you're reading about the negativity affiliated with food allergy, and it's almost like having too much information in your mind. And then again, that's a predictor of a poorer outcome. So I think recognizing that some of these are predictors of worse outcomes and recognizing your own personal bias, educating families about that, and saying, "Hey, I know your child has tree nut and egg allergy, but it's okay. We want them to go ahead and still try this. I know that this is creating a significant burden on you, but we are genuinely trying to make it easier for you."
A lot of times I'll use college or high school, or whatever their next big educational milestone is, and I'll say, "Oh, but they're going to be going to junior high, and they're going to be more independent. Let's try to knock some of this stuff out right now." Again, because I feel like the younger I can catch them, almost the easier it is. The likelihood of them staying with that allergen is a little bit less, I find, as they're aging a little bit.

Dr. Mariam Hanna:
Absolutely. Okay, so then let's wind back the clock and go to early school years. We're going to go to a different scenario that was brought up—parents who cite food allergy, their child or infant's food allergy, as a barrier to enrolling them in a daycare or school. This tends to be like priority allergens like milk, egg, or wheat that are quite ubiquitous within the school. What conversations become important to have with the family, or particularly with the school or daycare, with these children?

Dr. Priya Bansal:
I think that is stemming from more of a fear because, originally, a lot of things with science evolve. So at the beginning, we were looking at more bans, more difficulty in going to school, more social isolation. But I found, especially in the literature, that we’re seeing that this is causing more difficulty with children and adding to that anxiety issue. So I don't feel personally that it is to the point where I would counsel them and say, "No, I agree with you. You shouldn't go to school because of your food allergy." Quite the opposite. When I talk to patients about asthma or food allergy, I say, "There are Olympic athletes that have what you have, and they are rocking it. They're out there in the world doing amazing things, and you could be one of these people, or maybe you already are one of these amazing people who are going to do wonderful things in the future. Let's come up with a plan together where you feel safe and secure that they're doing what you need them to do."

Dr. Mariam Hanna:
Can we discuss self-carrying in school? So carrying the epinephrine autoinjector or the nasal epinephrine. Nowadays in the U.S., you guys are ahead of us. When is that appropriate? At what age do you recommend it, or does it need to happen?

Dr. Priya Bansal:
Again, that's going to come down to the comfort level of the child and the parent. I think the nasal epinephrine is going to make a huge difference, just because, obviously, we have... I remember my own son with his allergies when he was using a nasal spray, he was doing it himself at age three. So that tells you how nasal epinephrine is going to change the space. But usually what we do is, when I approach it every year or every time they have a follow-up, when we train them, I have them show it to me. I do it, they show it to me. So it's more about when they and I are feeling confident that, "Hey, if there's an emergency scenario, we could do this." And I do advise families to practice regularly, whether that be once a quarter, once every six months. Practice, because when you're nervous, sometimes all logic goes out.
I remember I had been going, I had a high-risk pregnancy. I had been calling the OB every single week, and when I went into labor, I couldn't remember the phone number for the life of me. So when you're in an emergency situation, all bets are off because you're nervous. And the way to get over some of that nervousness is practice. The more you practice, it becomes just... you're not even going to think about it. It's just snap of your fingers, it's so easy to do. We just want to make sure that they're confident to be able to grab it. And now, let's say that you can't use it—as long as you're by someone who can administer it, I still feel comfortable that it's on your body with you. And I think sometimes that's where the parents also feel a little bit more comfortable, as opposed to diving and searching and trying to find the epinephrine from somewhere.

Dr. Mariam Hanna:
Yeah, self-carrying is also challenging in the teen population because of their super cool outfits that may not be conducive to the self-carrying suggestions. How do you discuss that with them?

Dr. Priya Bansal:
It's interesting. I always tell them, I say, "Look, there's so many new things that are coming out, and for me, I'm the most excited for my teens for the sublingual." I kid you not, the sublingual epi is my... I'm like, "Oh, I hope one day we are going to be there so that they can put this on them and I don't have to worry about it." What's interesting is I had somebody show me something where you have a rubber band and you put an AirTag in there so it'll AirTag it, so it's close to them. Maybe they don't have to keep it directly like, "Oh, it's in my backpack or my bag over here," but I've got the AirTag to find it when I need it.
I've tried... sometimes we've had pouches. Sometimes, if I know that they definitely will not carry the longer epinephrine pen, then I try to get them the smaller one where they can fit it into their pockets. So I think, again, that's part of shared decision-making. I'd rather you be honest and tell me what you're going to do so that I can try to access what you need. Because I would say 90-some percent of them do not carry their epinephrine pens. They might have it in their backpack during the school day, but again, that's why they say there's other technology that we can use to help monitor where that is.

Dr. Mariam Hanna:
Speaking of technology, I always point to their bulky phone and say, "You manage to carry that everywhere you go." They do, but they do manage to. So they need something that can stick right to the phone—my next thing, including sublingual and needle-free options for epinephrine. So I hear you. Okay. Another scenario that someone suggested was families that request schoolwide bans due to the child's allergy or potential family anxiety. I heard you talk about schoolwide bans already, but can we summarize that a little bit? How do you address that topic with families? Are bans effective?

Dr. Priya Bansal:
No. Short answer: no. Okay. That's easy. Yeah, that one's an easy one. Again, in the literature, it's shown to create more social isolation and more social anxiety. And I approach it as, I want your child, yes, they have this, but this shouldn't be consuming them at all days and all times where it's always front of mind for them. And part of that is to have them try to do all of the activities that all of their classmates are doing and not create a situation where we're increasing social anxiety for them. And unfortunately, a lot of childhood is about wanting to try to fit in. They want to try to fit in, they want to have friends, they want to have a variety of friends. And I don't think that the schoolwide ban is the way to do it. I think there's creative ways around it so that you can still be a part of everything and not increase their social anxiety.

Dr. Mariam Hanna:
Increased anxiety after a reaction is, I think, where I want to take you next. So I've seen this a few times where a child will develop restrictive eating after an accidental exposure. So they'll refuse to eat in public, or they won't go out, or they'll really modify their diet after a reaction, specifically to their food allergen, or even a case of spontaneous hives or maybe idiopathic anaphylaxis, NYD—who knows? Have you seen this? How do we screen for those kids?

Dr. Priya Bansal:
I think that a lot of times the parents will come in saying that they're very picky and they're only eating a few things. So then it's sitting down and talking to them and finding, "Hey, is there something that you're worried about? Is there something I can do to help?" I think if you know the allergen, that is usually easier to talk a child off the ledge, to say, "Hey, we know this has only happened with this. I know that it only happened with this. Why don't we go ahead and try this? Would you feel more comfortable if we ate this over here?" Again, bringing them back to the clinic if that's what we need to do. I think when it's idiopathic, that is a lot harder because then they don't know what's going on. And it's very frustrating to me because every hive patient that comes in thinks they're allergic to something, and we know 80% of the time you are not allergic to anything.This is just viral. It's okay. But trying to convince them that they don't need skin testing, that they don't need this mega workup, and that we don't need to be avoiding a whole bunch of foods—those are a lot harder to convince. It’s about trying to talk them off the ledge or figuring out if there’s something else. I had someone come in about two weeks ago, and I had them describe everything that happened in the day: what happened here, what happened there. Because we know anaphylaxis can sometimes be multifactorial. Sometimes I have them write down thoughts at night, but I also have them journal about the attacks. We're not really controlling the situation, but it is helping us figure this out and do this detective work. And I feel like that way they're more amenable to try it because they say, "Okay, I'm going to be writing this down, and I'm going to see if I can track this.
And then lastly, if I’m still not making headway and there's significant fear involved, obviously, I'm going to involve a therapist—either a food allergy counselor, a therapist, or somebody else they can talk to where they can work through some of these food anxieties and insecurities.

Dr. Mariam Hanna:
Okay, I'll give you my last and my favorite one: health-related anxiety in an adult screened through either skin testing or, let’s say, that IgG panel test for nonspecific symptoms. It’s always chronic hives. It’s always hives.

Dr. Priya Bansal:
I know, and it just makes me want to cry. I mean, just start the crying right now. I haven’t even asked the question yet.

Dr. Mariam Hanna:
Just said IgG testing. I've used my most reassuring voice, Dr. Bansal, with them, but they’re not comfortable reintroducing foods at home. How does Dr. Bansal say, "This is not a food allergy?"

Dr. Priya Bansal:
I think nobody really wants to come in and be told that they're completely wrong right now. Some physicians do have that approach. They'll come in and say, "This is junk science; you shouldn't be doing this." But I find that taking that approach, at least for me and my clinic, doesn’t work. First of all, I just am not like that. I just don’t see myself saying those words and being more aggressive about it. I just say, "Hey, I understand, and I understand you might be very frustrated, but we don’t want you to develop nutritional deficiencies from avoiding certain foods that are not necessary for you to be avoiding. I completely understand where we could have a food intolerance, but let’s try to prove this. Let’s try to work ourselves through it."
So, for some of these patients who come in with these concerns, I say, "Okay, if you want to take it out, let’s bring it back. Eat it three times a day, three or four days in a row, and journal and tell me what happens. And if nothing happens, you know that this food is fine and you can move on." So I try not to completely discount what they’ve done, because they’ve spent money on this—even though in my head, I’m crying, right? I already told you I’m crying, so I’m crying with the test. A lot of the patients that come in and do this, they’re more into natural medicine, holistic, supplemental medicine. So I try to meet them where they’re at. That’s why I talk about the nutritional deficiencies more. I don’t want to make you deficient by avoiding something that, like wheat, for instance—we can get deficient in zinc. All of these can cause nutritional deficiencies by avoiding things unnecessarily. So, why don’t we go back to the basics, bring them back one at a time, and let’s journal and see what happens? Then we can go from there. So that’s usually my approach. I’m more delicate with it, I would say.

Dr. Mariam Hanna:
It’s all about learning different approaches and finding which one works for you in practice, with your patients, and with the different patients we see. All right. We walked through a lot of challenging cases. We laughed some, we cried some. Time to wrap up and ask today’s allergist, Dr. Priya Bansal, for her top three key messages to impart to patients and physicians on today’s topic: food-related anxiety. Dr. Bansal, over to you.

Dr. Priya Bansal:
So, I would say my top three takeaways are: one, try to work with the patient through their food allergy using shared decision-making. I don’t believe it is a one-size-fits-all, and I truly believe we have to meet the patient where they’re at. Discounting their anxiety about the anaphylaxis definitely isn’t the way to go. I genuinely believe we have to meet them where they’re at and work with each individual patient to see where we need to go.
My second takeaway is: early introduction—great introduction. Introduce those allergens early, diversify that microbiome, and don’t let fear rule you. The literature is clearly pointing in that direction. And the more we can do to embrace that, even though now it’s been quite a few years, it still feels like a paradigm shift for people. So, embracing that and trying to counsel women of childbearing age to plant that seed early on, I think, is very important.
Lastly, don’t be afraid to get help. It’s okay if you need help—if you need to see a food allergy counselor or if I need to connect with a therapist to help you, don’t be afraid to tell me. And as a physician, I shouldn’t think of it as a loss of, "Oh my gosh, I have to get someone else involved." We only have slivers of time with these patients. There’s so much encompassing food allergy. Let’s say this person also had asthma, allergies, and eczema—I still have to address all of that with you. So, this is one sliver of time. My hope is that all of us either recommend help or reach out for help when we need it, because we shouldn’t be doing this in isolation. We’re not our own little island. We need to embrace those around us to help bring ourselves up.

Dr. Mariam Hanna:
Perfect. What more can I say? Thank you. Thank you, Dr. Bansal, for joining us on today's episode of The Allergist.

Dr. Priya Bansal:
Thank you so much for having me, and I hope we helped to allay some food allergy anxiety today.

Dr. Mariam Hanna:
This podcast is produced by the Canadian Society of Allergy and Clinical Immunology. The Allergist is produced for CSACI by PodCraft Productions. The views expressed by our guests are theirs alone and do not necessarily reflect the views of the Canadian Society. This podcast is not intended to provide any individual medical advice to our listeners. Please visit www.csaci.ca for show notes and any pertinent links from today's conversation. The Find an Allergist app on the website is a useful tool to locate an allergist in your area.

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