Food Allergy and Your Kiddo
If your kiddo has a food allergy, then this is the podcast for you. Join food allergy experts - board-certified allergist Dr. Alice Hoyt, MD, FAAAAI, and food allergy mama Pam Lestage, MBA - as they dive into all things food allergy. Hear interviews with world-renown allergists as well as food allergy advocates and food allergy families, just like yours. This podcast will answer many of your food allergy questions and provide you with strategies to make your life and your family's life ones of LESS STRESS and MORE JOY.
Food Allergy and Your Kiddo
A New Option for Food Allergy Families: Xolair Prevents Severe Allergic Reactions to Foods
In this eye-opening episode, Dr. Alice Hoyt, the caring doctor voice behind the Food Allergy and Your Kiddo Show, and the eminent Dr. Dave Stukus, a trailblazer from Nationwide Children's Hospital, unpack the exciting news about Xolair (omalizumab).
After two decades of lending a helping hand to asthma sufferers, Xolair is now FDA-approved to combat severe allergic reactions from food allergies. The deep-dive discussion zeros in on how this well-seasoned medication works its magic by cozying up to allergic antibodies, decreasing the fright from accidental food allergen encounters. 🛡️ If you've been dealing with food allergies, lend us your ears as top allergists discuss who might benefit from Xolair. 🎧💕
Episode Highlights:
- Take a brief stroll down memory lane to hear Xolair's past.
- Consider how Xolair may add a layer of protection for your little one.
- Review the safety profile that makes Xolair a relatively safe option.
Guest Expertise:
Dr. Alice Hoyt, your go-to allergist and familiar voice on the podcast, chats with Dr. Dave Stukus, known for his heartfelt commitment to helping food allergy families at the renowned Nationwide Children's Hospital.
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Hello and welcome to the Food Allergy in your kiddo podcast. I am your host, dr Alice Hoyt, very excited to be joined today by one of my colleagues and friends, dr Dave Stukas. Dr Stukas, welcome back to the podcast, sir.
Speaker 2:Well, hi, dr Hoyt, it's a pleasure to be here. I'm excited.
Speaker 1:Well, good, I'm glad you're excited because there has been understatement a lot of exciting things going on in the world of food allergy. As you well know, and for those of you who are new to the kiddo show, Dr Stukas has been on our podcast before and he actually hosts the podcast for the American Academy of Allergy, Asthma and Immunology, an amazing organization of which I am a fellow, as is Dr Stukas, and Dr Stukas is here today to talk about the 2023 anaphylaxis practice parameters, which is awesome. So, Dave, before we really dive into what's in these practice parameters, can you please tell our listeners and our viewers for those watching us on the video what is a practice parameter?
Speaker 2:Yeah, how long do we have Right Right, a practice parameter? They're technically not guidelines, but essentially they're clinical guidelines and what they do is they go through for specific conditions and do an exhaustive search of the literature, so all of the peer-reviewed literature surrounding a topic, and then they look at the evidence, both foreign, against certain questions or certain disease states, and they formulate sort of recommendations about best ways to approach the diagnosis and or management of various conditions. Typically there's a work group of experts international experts that go through all of the literature and kind of write everything up and it goes back to the Joint Task Force on Practice Parameters, which I used to be a member of for five years, and we actually kind of edit everything together and make it so that it flows nicely for clinicians to kind of follow. So it is evidence-based, exhaustive, comprehensive and current.
Speaker 1:I love it. I love it. Evidence-based I love it. Yeah, when you look through these things, there's hundreds of references I think 600.
Speaker 2:You said joint. You said 600.
Speaker 1:That's pretty, pretty up-date. Yeah, joint Task Force. Tell our listeners a little bit more about that.
Speaker 2:Well, there's two professional organizations for allergist immunologists in the United States of America. We have the American Academy and American College of Allergy, Asthma and Immunology. So each organization appoints six members to the Joint Task Force and then they are eligible to serve two separate five-year terms. So I served a five-year term. Due to a lot of exciting things in my own personal professional life, I opted to defer my second term towards later in my career perhaps, but it was a wonderful experience and there's great individuals that really dedicate and volunteer their time to put these guidelines together, these parameters, I should say.
Speaker 1:Well, thank you as a fellow allergist and as a food allergy wife and mom, Thank you for spending your time doing that, because I know these things take a lot of time to really do them right and I know that you guys definitely do them right. So we talked a little bit about what practice parameters are. Why was there, why did this practice parameter come about? The anaphylaxis for 2023?.
Speaker 2:Yeah, it had been several years since there was a comprehensive document for anaphylaxis. There was an updated one in 2020 that really focused on biphasic anaphylaxis, which would be an anaphylactic reaction that resolves with or without treatment and then soon to come back again, sometimes hours later, and that specific document really walked through who's at risk to experience that and what kind of medications would prevent that, and so on and so forth. So it was time just to provide a much longer, more comprehensive document that really went through some of the newer evidence.
Speaker 1:And these parameters are super valuable to allergists, of course, and to other clinicians as well, but for our audience. Why do you think these are so important? For our audience food allergy moms, dads, family members to really know about these parameters?
Speaker 2:Well, again, it goes back to their evidence-based. There's so much outdated, incorrect information surrounding food allergy and anaphylaxis. A lot of it's actually addressed in these parameters and I think you know, a lot of times we kind of say the same things over and over again just because it's what we've been taught or what we once thought to be true. But a lot of it's changed for the better. I find these to be very reassuring actually, but it's interesting because there's a bit of a paradigm shift when it comes to anaphylaxis, as we'll talk about. So things don't have to seem maybe as dire as we were once taught a few years ago in regards to this. Now, of course, we want to respect it, as we'll talk about and discuss, but it doesn't have to be as scary as maybe everybody's led to believe not that long ago.
Speaker 1:No, that's really great, and so sort of. What I wanted to ask you and what I'm hoping is going to sort of guide our conversation today is really what are your sort of biggest three takeaways for food allergy families regarding these new updated parameters?
Speaker 2:Yeah, three is tough. Yeah, I'll try my best.
Speaker 1:You don't have to limit it to three, because I'm sure it's going to be. No, I think I can't.
Speaker 2:I think I can't. So for those watching, listening, the parameters cover a lot of ground in regards to the updates the diagnosis of anaphylaxis, anaphylaxis in infants and young children, management of anaphylaxis. It also dives into diagnostic testing as well as mast cell disorders and perioperative anaphylaxis, so I think we can probably skip a lot of that. The top three for me one is revolves around anaphylaxis in infants, and the parameters really address that. Severe life-threatening reactions in infants, especially upon first exposure to a food allergen, are extremely rare.
Speaker 1:Can you stop? Can you say it again?
Speaker 2:Yeah. So severe, life-threatening anaphylactic reactions are very rare in infants, especially the first time they eat a food allergen. So for all those parents that drive to the parking lot of the emergency department before they feed their baby peanut butter for the first time, the evidence would suggest that it's extremely unlikely extremely unlikely that your baby's going to have a severe reaction the first time they eat. That Anaphylaxis can occur, but typically it's going to be more. They get some hives and maybe they vomit once and then they feel better. That's anaphylaxis. So any combination of more than one part of the body involved in allergic reaction. But for most people it's self-resolved and relatively mild. We don't get patients as allergists because they end up in the ICU the first time they eat a food. We get patients because they get a rash, we get some hives, they get upset stomach. So that's what the evidence shows and that's one of the big take-homes for me from the new parameters.
Speaker 1:I love that and you know, sometimes data comes out and we're like huh really. But that, no, that clinically, is really what we see, I would say. So I don't think that was particularly shocking. What say you?
Speaker 2:No, I agree that echoes everything I've seen and I've talked about this for over a decade. When I educate pediatricians about how this is the typical presentation for food allergy in infants, as they get some hives and maybe they vomit, it's misconceptions that their airways are so small that they're prone to swelling shut. We simply don't see that, thankfully, which is very good. There are misconceptions that babies can't tell us how they feel, so there's some smoldering issues inside their body. That's not the case at all. If you're having an acute allergic reaction, you should look at a baby and be able to see that they're uncomfortable, they're not feeling well and you see the symptoms of that allergic reaction occurring before your eyes. So there's no sort of thing like a hidden food allergy that occurs or anything like that.
Speaker 1:I think that's just so valuable. That's so valuable. I think it's very valuable that this was not surprising to us, that this is consistent with, clinically, what we see. I think it's valuable to have all of this written out and really just the references there, the support there, the evidence there that this is what we see, that this is how it goes to bring that reassurance to families. I think that is just so, so important. So I love that. That was your first thing. That's awesome.
Speaker 2:Yeah, and of course, there are families that do witness. They watched their baby have more severe reactions, so it certainly can occur. I think the message is that it is much less likely than people have been led to believe, especially, and the reality of the situation is, if we take 95% of all babies, it doesn't matter how you feed them or when they feed them. They're never going to develop a food allergy, no matter what you do so?
Speaker 2:if we're telling 100% of parents that you have to drive to the emergency room before you feed your baby peanut butter, that's an overly cautious approach. That's a huge disservice to these families.
Speaker 1:What would be your second, Dave?
Speaker 2:Ooh, it's a combination and I love this so much because I know I'm cheating. But what it does is it kind of wraps in our understanding of individualized approach towards food allergy management and risk. And we now know that there are milder forms of food allergy. We also know that it's very unusual for somebody to have any reaction to trace amounts or especially severe reactions to trace amounts. Can it happen? Yes, but for the vast majority of people they have a higher threshold than that. So in the anaphylaxis practice parameters it really addresses a couple of key things. So one not everybody needs to have two epinephrine auto injectors prescribed. For a lot of folks it's quite reasonable just to have one of those devices because they're very costly. Most people go a whole year without ever using them and they just throw them away, and for a lot of folks out there they're just not at risk of an anaphylactic reaction. Another aspect along those realms is not everybody actually needs to have epinephrine prescribed. Now this gets very nuanced very quickly, but you and I both know there are children out there that have a very mild egg allergy. So they've eaten scrambled eggs six times. Every time they have mild self-result hives, we do the testing. Yes, they're allergic. They're eating baked egg all day and they're absolutely fine. They're very likely going to outgrow this in the next couple of years.
Speaker 2:And then the last part of this trifecta within my number two deals with some of those food allergy and anaphylaxis plans that state if somebody ate an allergen but they don't have symptoms, that you should give them an epinephrine immediately. And that is just completely false. I don't know where this came from. It was a highly conservative approach. Yeah, I get it, it's better safe than sorry.
Speaker 2:But here's the deal. So, one, how do you know if somebody actually ate with their allergic? To number two, how do you know that they ate enough to trigger a reaction? Number three if you give them epinephrine which treats anaphylaxis, it doesn't prevent it. If you give epinephrine before the allergic reaction actually occurs, it might be out of their system before they actually need to use the medication. And and then, lastly, the median time of onset for anaphylaxis from food is almost like 30 minutes. So if somebody ate something and you're not quite sure if they're gonna have a reaction, you have time to take a deep breath and monitor and, you know, be in a state zone to see what's gonna happen before you even Think about treating them with epinephrine.
Speaker 1:Wow, that was a lot for your number two.
Speaker 2:I love it. I love it and it's all.
Speaker 1:It's all. It's all tied in together. I completely agree with you. It's all. Those are all very big but very important points that, again, would not be in this parameter if they didn't have the data to back them up and didn't have the board certified allergists reviewing the data that backs this up, and I think this you know, you said it about it, you know it gets nuanced, and that just highlights the importance of having a board certified allergist who does stay up to date on the latest allergy information so that you and your child can have an evidence-based plan that Not just keeps him or her safe but also Improves your quality of life. If, if you've been told for a decade now that even smelling peanut could potentially kill your child, that is not evidence-based, that is not good for your mental health, and so here, it's just so lovely not just to have the parameters but to have you sort of like flushing things out like this, and I think that that all makes just so much sense.
Speaker 2:For a lot of folks this is completely foreign. I mean, these are foreign concepts and they it's. It's off-putting at first. I can make people highly emotional actually, and say you know how dare you suggest that my child's not at risk of having a severe life threatening reaction if they are near their Allergen or take a small bite of it? But that's the reality of it and I think that we do families a disservice if we don't have that conversation with them and help them Understand that because, as you mentioned this, that's what impacts their daily life.
Speaker 1:No, that's absolutely right. That's absolutely like right the. I will say that I have noticed that one at least the fair form, see whole light, give epi if it wasn't, if it may have been eaten, but no symptoms. That's gone now, so that's nice and they've sort of retooled that. So another reason not to just see your allergist once a year, but whenever new things come out it's totally reasonable to schedule a follow-up with your allergist specifically to ask very specific questions about your kiddos food allergy.
Speaker 1:You know, I think so much gets, so much pressure gets put on that like classic back-to-school allergy appointment, that sometimes you're focused on getting forms and these things filled out, that you don't get to just like have a few minutes where you're talking with your allergist about some of the newest data or newest treatments or whatever the case may be. So families should never feel, should ever feel like, oh well, I don't have a good enough reason to go in to the doctor, especially now with telehealth. You know you can have these telehealth appointments and get some very good evidence-based answers to your questions. Cool, dave, okay, you're pulling out some really good stuff from these practice parameters. What would you say? How many points is your third? It's your third point going to have, or your third most important thing for food allergy families from the parameters.
Speaker 2:It's just one, but it's the big one. So the new parameters contain provisions that if somebody experiences anaphylaxis at home, they don't have to automatically go to the emergency room or call 911 after they use epinephrine. And this is where you kind of shocker, so what?
Speaker 1:this and then you say it again. So say it again.
Speaker 2:So you no longer have to automatically call 911 or seek emergency medical care if you use epinephrine to treat anaphylaxis at home. And the reason why is because, well, there's a couple of reasons. So one the evidence again, the body of evidence shows that the vast majority of people who promptly receive epinephrine to treat anaphylaxis have complete resolution of symptoms, typically within 10, 15 minutes. Most people feel better pretty fast. So if you're at home in a very safe environment and you have access to more than one epinephrine, you have a cell phone and you can get care if you need it, use your epinephrine and hang out and monitor If symptoms are getting better or going away. You should be fine. You can call your allergist for you know, talk to their office about next steps and things like that.
Speaker 2:But a lot of people either were not using their epinephrine because they didn't want to go to the emergency room, or they were misinformed that epinephrine was dangerous and that just because you use it, that means you have to go to the emergency room because of side effects and the needle and things like that. All of that's incorrect. And what happens when most people go to the emergency room after they use their epinephrine? Well, typically they just sit there for six hours and they receive a bunch of treatment that they actually don't need, such as steroids and histamines and PEP-CID and things like that.
Speaker 3:So we Like Benadryl Dave.
Speaker 1:How do you feel?
Speaker 2:about that. Yeah, like Benadryl. You know how I feel about that. I read these ER notes of a patient arrived, had anaphylactic reaction at home to cashew, received epinephrine. By the time they were evaluated they were asymptomatic. We gave them Benadryl, predenosone for seven days and PEP-CID and had them monitor for four hours. What are we doing? That's insane. It's so outdated. So that's where this comes from and I think we can start to have those conversations with families. I know I have for the last couple of years, and this started during the pandemic. Right, we were afraid to send people to the emergency room. We don't want to give them COVID, especially before vaccines are available. So we started to actually learn how to monitor at home and treat them at home and have that conversation, and that's what the evidence supports as well.
Speaker 1:Yeah, no, I mean, I think that is such an important point. I will say, to caveat, if you're going to monitor at home, I do like them to have somebody there with them, yes, but otherwise absolutely. If they use their epinephrine promptly and they're improving and they have a second device with them, it all makes a lot of sense. Now, if they still want to go to the emergency room, you absolutely can. You absolutely can. But hopefully this will take away some of those barriers to actually promptly using the epinephrine, because the last thing we want is not using it or not using it promptly, and then a kiddo is getting worse and then you're putting the kiddo on the back of the car to drive and then they're throwing up on the way to the ER.
Speaker 1:It's just terrible. It's just terrible. We know that prompt use of epinephrine is what stops an allergic, a severe allergic reaction, anaphylaxis, and you're right, I totally love that. The whole like oh, they maybe ate it, no symptoms, then give them epi. I love that that is gone, because that has never made sense. I don't think to any of the allergists.
Speaker 2:Yeah, the dark secret with anaphylaxis, as you know, is if you look at all of the studies over the years, this has been shown repeatedly 50% of people having anaphylaxis never receive epinephrine. And what happens is 50% of people they do fine it. You know fatalities from anaphylaxis. They are tragic and they do occur. Thankfully they are not nearly as common as most people believe them to be. So we want to promote using epinephrine early because it makes people feel better a lot faster. Yeah, you're miserable. You are so miserable You're having an allergic reaction. Use it because you feel better.
Speaker 3:So we need to look at what.
Speaker 1:Right, and that's another reason benadryl, the okay. So like kind of before my time they used to say, oh well, give benadryl and it doesn't get better than give epi. Like that is absolutely wrong. That is not evidence-based, because then not only are you delaying use of epinephrine, but you're giving benadryl, which is just an antihistamine. And, as all my patients know, anaphylaxis is run by a lot more than just histamine and it's not the histamine that's going to cause the fatal issues. So you really want to get the epinephrine in promptly. It's going to make the kiddo feel better because you're really calming down those allergy cells so they stop spewing out all of the stuff that's causing all the reactions and they help prevent all those different symptoms, or causing all the symptoms. It's going to help stop the symptoms as well. As opposed to, an antihistamine is not going to be that multifaceted at all. It's just going to be antihistamine.
Speaker 1:No, I think you have pulled out amazing pearls for our patients or our families listening on the 2023 practice parameters and for y'all listening to this podcast. If you haven't listened to the Quadai Eyes podcast on the anaphylaxis practice parameters, where Dr Succas interviews Dr Golden, you definitely should, because it is a fantastic listen. It's a fantastic listen and they do get in the weeds on a few things, and I love that because it's too allergist just talking about it, kind of like we're doing it today, dave. So thank you so much for coming on the show and breaking that down for us. And where can people find the practice parameters?
Speaker 2:You can actually just search them online. So if you just look for allergy practice parameters, they pop right up. They're free for everybody. I believe there's teaching, which is awesome. Yeah, oh yeah. I think there's teaching slide decks for some of the latest ones as well for medical professionals out there, if you want to actually learn more or even educate those in your group or in your community. So, yeah, check it out.
Speaker 1:Awesome, dave, thanks so much for coming on the show.
Speaker 2:It's my pleasure. Thanks for having me.
Speaker 3: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 allergianyourkiddocom where you can join our newsletter. God bless you and God bless your family.