Food Allergy and Your Kiddo
If you are a parent of a food allergy kid, 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
OIT in 2025: How Advances in Oral Immunotherapy are Treating Food Allergies in Kids - Dr. Alice Hoyt and Dr. Tom Chacko
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Dr. Alice Hoyt welcomes Dr. Tom Chacko, a board-certified allergist from Atlanta, to dive into the complexities of food allergies, focusing on oral immunotherapy (OIT) and sublingual immunotherapy (SLIT). They discuss Dr. Chacko's journey into the field, the importance of whole foods in treatment, and collaborative efforts within the FAST network. The conversation also addresses the need for patient-centric care in allergy treatment.
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Hello and welcome to Food Allergy and your Kiddo. I am your host, dr Alice Hoyt, over the moon, excited to be joined today by Dr Tom Chaco, an amazing board-certified allergist out of Atlanta, georgia. And Dr Chaco and I have crossed paths, most recently at the big national OIT conference in Dallas, which really, as we'll talk about some, has become just the place to go if you are an allergist who is either wanting to get started doing oral immunotherapy or you're well in the weeds of it. I mean, it's just, it's an amazing experience and an amazing conference, and so I also follow Dr Chaco on social and I love Tom. Okay, I'm gonna start talking to you now. I love your, I love, I love your post. I love how you keep it so real. You're really trying to share good, evidence-based information, care, just what's going on in your office so that so many families can see what a good food allergy journey can look like. So I'm so excited. Thank you for joining us today.
Speaker 2:I am excited to be here, alice. You're great and I think we're on the same page. No, we're on the same page. We're just trying to educate people. You said just keep this talk real, like me. And you are just chatting, just virtually chatting, so I'm happy to be here.
Speaker 1:Well, awesome. So I think what I want to start with is really just asking you how did you find yourself in this part of your career with such a great focus on food allergy?
Speaker 2:So I probably started, probably 2014, 2015. And honestly, not on purpose, it was Hugh Wyndham. Dr Wyndham, who's one of the OGs, the godfathers in food allergies, and he's very ethical, very by the books. He was my mentor, one of my attendings in fellowship. Oh my gosh, I didn't know that. Yeah, yeah, yeah, it's a weird banter, but he's my attending. I love that. He's been on the podcast. Yeah, oh, he's great and you can tell he's great.
Speaker 2:And he sent me someone that was traveling from Atlanta to Tampa to get treatment for peanut allergy 2014,. No, maybe 2013. I don't know. And I'm like Hugh, what are you doing? This is kooky. And then he's like Tom, it really works, it's good. And I trusted him. And then he was the one and it game changed. It was a game changer for that family. And then I started learning about it. I started reading the articles I presented at Emory Journal Club. I was like learning and I was like, if he does it, yeah. And then eventually I was like all right, let me start dabbling it. And then I was like this seems like it works and this was before Palforzia and so Palforzia, but all the data was out there using peanut flour. The company was actually out of Georgia Bird Flour, peanut Flour and I was like we could just follow this and I probably started with peanut, probably 2015-ish.
Speaker 1:I love that. And wait, let me pause you for a second. If you're joining us, you're a parent and you're somewhat new to the food allergy space, especially when it comes to peanut allergy. There's currently one FDA-approved product to treat specifically peanut allergy. There's two FDA-approved products to treat food allergies. One is omalizumab or Zoller. It's an injectable medication that decreases the likelihood that someone will have anaphylaxis if they accidentally ingest their allergen. And then there's Palforzia, which is defatted peanut flour, which is what Tom is referring to, regarding there only being one, or what Palforzia is, and it was before Palforzia, because Palforzia came out I believe it was February of 2020 is when it got its FDA approval right. It was like right before COVID.
Speaker 2:Honestly, I don't know, because it was just peanut flour, can I guess?
Speaker 1:why you don't know. Yeah, because I'm like Because you've already been using other real peanut food that a parent can go to the grocery store to get, yeah, years prior.
Speaker 2:So I don't know, I haven't used it and I don't think now I think it's been falling out of flavor. To be quite honest, I think it's now like everyone kind of knows, like what is? The emperor is wearing no clothes. Whatever they say, they're just peanut flour. Come on man, Come on man, Stop talking about this.
Speaker 1:Yes, so I actually have some thoughts on Palforzia, though, and I did a blog post where I think I wrote the nine reasons Palforzia has not done well, and one of the reasons is this is anecdotal. So if you listen to this podcast regularly, you know I really like to live in evidence. I like to gain as much information as I can from evidence, but at the end of the day, some of this is coming from what are we seeing? And a lot of evidence-based medicine comes from somebody making an observation and then doing some science to figure out what's going on. And so, with it being defatted peanut flour and some of my colleagues who have, kind of like, dipped their toes into OIT by just doing Palforzia, they're getting a lot of belly aches in their kids.
Speaker 1:Now, historically, I have done peanut butter for OIT since I started in either 2018 or 2019. I had one kiddo earlier than that, but I've done peanut butter and I think peanut butter is great because it hangs out in the mouth. It's sticky. We'll talk some about slit and how we think all this immune stuff actually works, but I think the most whole foods we can use for immunotherapy the better. So I don't really like defatting it. I actually think it might mess with the digestion and cause more of the upset tummy. What say you, tom?
Speaker 2:So I would say it's your podcast, but I'm allowed to disagree.
Speaker 1:I love it. Yes, bring it on. Yeah cool, so I would say Iron, sharpens, iron, yeah, yeah, yeah.
Speaker 2:Well, I think the rookies that are doing the OIT and saying they're having issues with Palforzer because probably the people who are doing Palforzers aren't doing it too much but I think what they're doing is they're probably trying to get, they're probably trying to do it on the really allergic kids which I believe. So their IgE is greater than 100, greater than 50. And they're probably aiming at the high doses and the data that you do. Yeah, you're going to get problems, that's true.
Speaker 1:So that's so interesting because I feel like I hear from families that I've heard multiple times and I see on social I totally lurk in some of the groups that, oh, I've been told that my child is too allergic for OIT.
Speaker 2:Please, so okay.
Speaker 1:All you go, find some All right.
Speaker 2:This is what I'm going to say is what are you calling OIT? Because that's what the message comes out as, and you're going to see a post on this, because I say I just did a post on how spicy do you like your chicken curry? Because all chicken curry is not the same and all OIT is not the same, and I think that's important to say that Everyone wants to trend this. Oit is not the same and I think that's important to say that everyone wants to trend this OIT world Like it's one big thing, like OIT is one thing. That's not how it is. Just like. All right, this is for patients. But I'm going to talk to other allergists.
Speaker 2:We know there's a difference in reaction rate between the red vial and the green vial. Right, there's a difference in reaction rate of food introduction. Call it oit, call it. So. When you're aiming at 300 milligrams of protein, which palforzia did, which they did to try to get approved zolair, you're going to get more errors or more issues. I should say what if you're aiming at 50? What if you're aiming at five? So that's a long answer to there is no number that you can't do. Food introduction we just might have different goals.
Speaker 1:And I'm going to connect the dots here for our listeners.
Speaker 1:So when he's talking about vials he's talking about when we do allergy shots we start with like for pollen allergy, for cat allergy, things like that.
Speaker 1:We do allergy shots and we have for decades small amounts injected over a long period of time teaches the body to tolerate those allergens. But what you're getting at here about not necessarily pushing the dose so high is maybe two things One is being on a low dose for a long time can be very helpful, and two in growing tolerance, meaning getting kids to freely eating, possibly not always, but possibly Highly, possibly, highly, possibly. But two, getting kids to what really should be everybody's at least everybody's goal regarding any immunotherapy of decreasing the likelihood of a severe allergic reaction I talk about. There can be two goals with OIT really. One is let's get kids bite safe, meaning if they accidentally eat a bite of their allergen, they won't have a severe allergic reaction, hopefully no reaction. But then that other goal that's always in the back of my head, regardless of the age, regardless of what the IGE number is, is let's see if we can drive this bad boy home and get to freely eating and over time get this thing in the rearview mirror.
Speaker 2:Yep, so I agree, and it all depends on the patient, it depends on the case, it depends on the numbers. We're starting with their sensitivity IgE numbers talking about blood work IgE numbers.
Speaker 2:Ige numbers talking about blood work, ige numbers, and so I don't, I don't. I on my post, and with both patients and allergists and doctors and providers, I want them to know when you label OIT as one big thing, you don't. That's not the details, the devil's in the details. And so what, alice, when you asked me, hey, my numbers are too high for OIT, I'm like are you too high for 5 milligrams, 10 milligrams? And we know you mentioned the FAST meeting. Right, we've been doing that for what?
Speaker 2:Seven, eight years and we used to aim at super high doses. Now we know you go low and slow. You get there. You know, maybe what is it? Tortoise in the hair? Maybe don't go that, don't be that fast. Buddy. Us in the hair, maybe don't go that, don't be that fast buddy, slow and steady, and it's not a race. Yeah, so I, I and I think when we talk about this we're going to hear a lot of agendas of people like giving a negative point on OIT because they were going so high and these reaction rates and so. So that's when you said, hey, that going back to the Balfour's year thing, I think just depends on the case and it was somewhat immediately available. Then COVID happened.
Speaker 1:So I don't think anybody was doing a whole lot of starting Palforzia then, but it was 2020. People have been doing OIT for years before that. So people who were already very engaged allergists, who were already very engaged in the space, had already been using products that they were very comfortable with, that they could purchase, that their families could, their you know, their patient families could purchase at the grocery store. Whatever the case may be, and I mean I'll I agree that as a doctor, like if I get comfortable with something, it it's going to take a lot of evidence to move me over into a different camp.
Speaker 1:And I know there's some argument that oh well, if you're not using the Palforzia capsule, then do you really know how much dose they're getting? And do you really trust families to how dramatically I'm saying this do you really trust families to measure their allergen correctly, measure their allergen correctly? And my response is teaspoons, tiny teaspoons, milliliter syringes. They're all appropriately measured. The whole point of OIT is to be low and slow below the reaction threshold. And If I don't trust a family to give a child the correct dose of Tylenol, then maybe I would not trust them to give their correct dose of peanut butter, but most families can do that, and so we have to trust our families to work with them. And so I think it's really kind of insulting to families when we're like, oh well, we can't trust you to measure this, this has to go through big pharma, you can't measure this. Wow, this is getting really spicy today, tom.
Speaker 2:Well, also right. Part of it is because there's a lot of you are our meeting and it is what it is. Right, Like there's a lot of financial incentive to tell people that this is something different. Right, Like I've gotten, now that I've done social media, I probably get a call or a DM a week, maybe more, from allergists trying to learn about this, but we're not getting told because, like, they won't let this will not go on our academy or any big meeting. You know that right, Because there's big sponsorship to make us think that certain meeting. You know that right, Because there's big sponsorship to make us think that certain things are different than others. Right, and so I don't. It's not all, it's just who's funding that narrative. And I've said that numerous times.
Speaker 1:Well, ultimately the way studies get funded is there's a drug that could potentially help treat somebody and that drug is made by a company and in order for that company to make the drug, I mean they do have to raise money. Those studies cost so much money. But I mean you're hitting the nail on the head. I remember when I was in fellowship it was so hard to even contemplate writing an IRB an institutional review board application to do a study with something like peanut butter or pasteurized liquid egg white, because it's a food, it's not a drug. And the whole concept of using a food to treat a condition is very like, very strange to regulators minds, very strange to regulators' minds. And when you do follow the money trail then it is hard to say, oh well, okay, well, we're just going to do all this big study but then not have some way to get reimbursed or make money from it. Like I get that. You know what I mean.
Speaker 1:But at the end of the day, this is where healthcare is not traditional business. And look, I'm all about capitalism. This is not a political podcast. I think capitalism done well does serve our communities. Greedy capitalism is something completely different. It's not what I'm talking about here. At the end of the day, healthcare is different, different and health care has to be treated differently. We could go on and on about health insurance and all of those things right now, but it's a challenging situation, I would say, because we do want all of this data. And what I think is so beautiful, tom, and how we even got connected, really is because of FAST, the Food Allergies Support Team meeting in Dallas, because of this amazing network of OIT allergists. I think what Dr Wasserman said this looks like 700 people on the email list or something like that, which, compared to how many kids and adults have food allergies, is kind of small.
Speaker 1:We're still the minority is kind of small. We're still the minority, yes, we're still the minority, but it's nice that, how much information we all share. I mean, I check my email and I usually have at least two to three emails from members of FAST OIT. We're all like talking about different cases. What we're seeing you know what we're seeing with NEFI that's big on the chain right now Like, do we think it's working as well as the auto injectors? What different foods are we using for different OIT? Or now with SLIT. So it's nice to share information.
Speaker 1:Healthcare is just, it's such a unique, a unique beast and that's why I think, at the end of the day, it's so important for families to be very mindful, be informed, get your information from from good resources and that's again why I love your Instagram, cause it's it's not sensational, it's not sensationalized, it's just, it's just real. And have good discussions with your allergist. And if you're a parent, you're listening to this or watching this on our YouTube and you're like wait, my allergist hasn't talked about OIT at all. Then ask your allergist hey, what do you think about OIT for my kiddo with an anaphylactic food allergy? And ask if they don't do it, then ask okay, well, who do you know that does do it? It then ask okay, well, who do you know that does do it? And I would like to get an opinion from them, because it is high time, to your point earlier, that more patients know about this option.
Speaker 2:I would argue this, and I don't. First of all, my colleagues, my buddies, my guy that I trained with they don't offer it. So I want to be very clear because your allergist doesn't offer it doesn't mean they're bad doctors. It just might not be their thing and so that's okay. Just make sure you find someone who is their thing. So that's why I'm like ask them and they might just say, hey, our academies don't recommend it. Well, there's reasons why our academies don't recommend it. Our academies, we didn't get trained. I don't think they don't.
Speaker 1:Not, I don't think they don't not recommend it though.
Speaker 2:But I don't think if they recommended it, we wouldn't be having a separate FAST meeting. We'd be having a session on how to do OIT and we wouldn't be having. I like the patch test sessions. I like the rhinoscopy sessions. There should be a food introduction. I've actually went out to them. I emailed them and said can I do my talk? And they're like we have. And it was actually one of the folks does OIT, but she's like we're kind of regulated on how we do some of these talks.
Speaker 1:So I will say some of that is probably to obtain continuing medical education credits and so to get that CME hours, which a lot of us go to meetings to obtain the CME hours and the FAST. We don't even mess with that because, you're exactly right, there are regulations there that have to be followed so that people can feel good about the education that they're receiving. I will say the FAST meeting is some of the best, most practical information. They're the best meetings hands down I've ever attended.
Speaker 2:But then, what do you think?
Speaker 1:about and I get no CME from it.
Speaker 2:No, we get no FAST meeting is the best. You know. I spend a lot of. I spend hours, you know, doing lectures. You spend hours, hours preparing for it. Right, I pay for it too. I don't give a, I pay. It's not sponsored. I pay my hotel, which I love. I would never not, because I think it's very sincere, it's the most cleanest. We're just trying to good work.
Speaker 1:Yeah, so I agree with you. It's genuine. You know, the information being presented is just like unfiltered.
Speaker 2:Unfiltered, and people with a passion that want to teach, like we lose clinic, like we just we just think it should be out there. We think I know, I think we just sorry, I just want a big thunder. Yeah, um bolt, I don't even know that, so, um, no, but I think, I think it's I, you know, and now it's us, the guys who have more experience, just giving back. You know, the younger guys, you know.
Speaker 1:So I love it. It's on my calendar. I know it's a great meeting, okay, so I want to move into Slit, though, and then talk a little bit about that. I also love your little peanut puff approach. I love Mission Mighty Meat Puffs. I do some spokesperson work with them on occasion.
Speaker 2:There's my disclosure. I just did a podcast with them yesterday, but I'm not a speaker, I do it for fun. They live in Atlanta.
Speaker 1:How I got connected to them was my in-laws live in Atlanta and a few years ago my mother-in-law saw in the local newspaper this article about them. She cut it out, brought it to our family beach trip and I was like, oh my gosh, this is amazing. So I emailed her, catherine. I was like, hey, do you want to be on my podcast? And it was a lovely episode. So I love their mission mission reminding me. I love how they're working so hard to make their products really good products. But I really liked how you're doing some OIT with their products and I mean it's just so real world right. And also how you're thinking about SLIT and OIT. Let's dive into that, sir.
Speaker 2:So let's talk about SLIT. So SLIT a lot of people are talking about, and SLIT is sublingual, where you basically put the food allergen under your tongue and absorb it. And SLIT is sublingual where you basically put the food allergen under your tongue with an absorber and the thought is that it lets your body tolerate it. Right, it's all. Most of the SLIT data is based on Edward Kim's data. Who's out?
Speaker 1:of California. He's brilliant right. Yep had him on the podcast. It was great data.
Speaker 2:It was done very well. So I don't disagree with his data and I don't, but he mentions it himself and he actually says it. He did a Canadian podcast where there are one to two-year-olds. Most of the kids were like two-ish and they put it under their tongue. But I've said it numerous times, they can't hold their potty. There's no way they're kidding on this, they are swallowing it. They're swallowing and he doesn't. And he's credible. He doesn't say that's not the case, right.
Speaker 1:He's the real deal.
Speaker 2:Yeah, he's the real deal, he's keeping it honest. So, in my opinion, they're basically taking five milligrams of the protein of peanut, because that's the only one that's come out. They'll get an FDA-approved product. They're working on that and they're working on tree nut too, but it's just five milligrams of the protein swallowed and it works low and slow. It worked on the kids. It worked really well. So I just think it's another way of low dose OIT, I think the caveat is the kids.
Speaker 1:They I have to look back at the paper, but what I advise my families who are doing SLIT is no food 15 minutes before, 30 minutes after, if at all possible, Definitely five minutes before and 15 minutes after, so that it's literally just a fairy spit of allergen in their mouth and that's it. So just full access there, as opposed to with OIT. For parents who are listening and aren't super familiar with OIT, we like OIT to be dosed on a happy tummy that's how I describe it not on an empty tummy. So a lot of times kiddos will start to eat dinner and take their dose, or dose with a snack, and that's so that the tummy isn't just receiving this relatively large load of allergen relatively large compared to slit. To put it into perspective, one peanut has about 300 milligrams of peanut protein. So when we're talking about five milligrams, four milligrams like that is such a small amount. That is an amount that a lot of OIT allergists will start OIT or maybe a few doses before then will start OIT, and that's the maintenance dose with slit.
Speaker 1:When I talk about should we slit or should we OIT with my families, it's a lot of. What season of life is the family in? Would they even be able to do the OIT one hour before, two hour after, dosing, rest period of not you know running track, doing baseball, all the things right? And if they're not, then we're leaning a lot more into slit because the safety window is a lot less and that's very heterogeneous amongst allergists. I say 15 minutes before, 30 minutes after, but I think some people are just like whatever, it's such a low dose, it's not going to cause a problem.
Speaker 2:What are your thoughts on that? I would say I agree. So it's interesting because you were talking about slit on your baseball players, because yes, I think slits are good, or low dose OIT, which I would say is similar are good on your teenagers or the kids who are busy and kind of. The ship sailed. The IG is already up. Alice. You already published the data on the little ones On the little ones.
Speaker 2:Oh, thank you, yeah, you published that right, I've quoted you like numerous times, like every FAS meeting, I think. The publication came out in 2023 from Cleveland Clinic and I just reset it Like 22 kids. They gave them Bomba. They got them them to 500. No, we did peanut butter with these little tiny. Oh, I got the one. I did one. Oh, maybe peanut butter. I knew it was protein, though 500 milligrams of protein was the end point, and that's because of that, that's my goal. So sorry, I switched them to Bomba. So with the goal, that's fine, yeah, but with the goal of 500 milligrams of protein.
Speaker 1:So that's how I use that number. You know why I picked 500 milligrams? No idea. Because when I started doing this tiny teaspoon protocol it was after I came home from a quad AI meeting and I was like I can't keep telling families there's nothing I can do, like there's clearly something I can do to help their child with food allergy. And my mom had sent me these very cute teaspoons, like years before, because she thought they were cute. She thought I would think they were cute.
Speaker 1:So I was reading Brian Vickery's paper on his preschool OIT and I was like, well, how can I convert this into something that's like feasible, like peanut butter, that's normal, right and very practical? I'm a simple country doctor. How can I just make this easy and how can I make it effective? And when you look at that Vickery paper, he compared kids who did 300 milligrams of peanut protein to 3,000 milligrams of peanut protein. The kids got to the same amount of tolerance. They did equally as well, except the higher dose kiddos. They had more reactions. I'm like, well, I don't want reactions, I just want effectiveness, right. But I was like 300 milligrams. Well, I mean, I just want effectiveness, right, but I was like 300 milligrams. Well, I mean, I just want to make sure that they're getting a real dose, and what if there's some variation in the dosing? So why don't we go up to half a teaspoon? That's about 500, 600 milligrams. That sounds good to me.
Speaker 2:And that's why we did it. Practical application of science. So I aimed we're saying almost the same, different ways of saying the same thing with my babies. I try to get them three Bomba, then six Bomba. I leave them with that About 500 milligrams of protein.
Speaker 1:Are you using more Mission Mighty Me than Bomba now?
Speaker 2:I like my Mission Mighty Me on my tree nut ones. I do a lot of those for the tree nut ones. So we were talking about Slit right, and we're trying to get them to five to 10 mil. So slit dose is about five milligrams of protein, five to 10 milligrams plus or minus. So teenager comes to me 14 year old, I have literally three today that comes to me Peanut at 15, cashew not too bad too, it gets you, gets you. But so, and I've gotten burned on this one. But usually I'll build them up and then I'll put them on one Mission Mighty Me puff, it dissolves and I'll either send them on one or two. So that's my low dose RIT, that's my slit and it's easy, that is easy Not having to refrigerate, not having to use glycerin.
Speaker 2:And it dissolves. And you got that five to 10 milligrams. And the problem is if that gets. I think I'm doing the same thing that Edwin Kim's going to do with his FDA approved slant. I think it's the same thing, literally so and he's coming out and they're publishing it. They're going to try to do it for Trinod too. I think we're talking the same thing, I know I know.
Speaker 1:But you know, what's so nice about the studies and the pharmaceutical products is that, especially like when Palforzia came out, it put the period on the validation of this works. You know, it's no longer just in a journal, which I mean to us being in a journal, it's like I'm published in a peer reviewed high impact factor, not pay to play journal. Yes, you know, but getting through the FDA is. We won't go down the rabbit hole of FDA right now.
Speaker 2:And I don't deny that. That's why you need the studies to prove it, studies to prove it. I'm just saying when someone's like saying oh, I'm doing SLID or this because this FDA-approved product will likely there's multi-millions of dollars getting this to come out, I'm just not sure it's different than one or two Mighty Me Puffs Right.
Speaker 1:I'm with you. I'm with you. I love this conversation. Okay, I know we're going up on time. I could talk to you forever. Let's get to those social questions, because your amazing team asked for some questions. So what do we have?
Speaker 2:The big question one I get a lot is why aren't more allergists or academic institutions doing this?
Speaker 1:I have this conversation regularly. I will say why are not more institutions doing it? I would say because very rarely are doctors leading truly leading institutions. And if doctors were truly leading institutions, then there would be significantly less bureaucracy to get these types of protocols approved, where all you need is to bring in peanut butter to start to treat a child's medical condition. There's that. There's well. Now we have an FDA-approved product, the Palforzia, the Zoller. So these are FDA-approved. So maybe we, as a big institution, maybe we're supposed to use the FDA-approved ones before we try peanut butter that's not FDA-approved Like I've heard that before, when Palforzia first came out, I heard that the institution was not permitting it because the way Palforzia was working I don't know how it is still working, but they would actually mail it to the patient, which I know they do do that some and the patient would bring in their dose.
Speaker 1:Well, the hospital was not permitted to give a dose of something that did not come through the pharmacy. So there is that. And then there's the training bit, and how allergists are trained is you can be an internal medicine physician, do an internal medicine residency or a pediatrics residency or do med-ps, which is what I did, which is do both, decide to do both, but you are applying for all the same allergy spots. There are not nearly enough allergists in this country to take care of all the adult and pediatric allergy patients. And when you're applying so those internal medicine and pediatrics residents, they're applying for the same. It's not like just a pediatrics allergy fellowship or just an adult. It's not. And our board is a separate board. The American Board of Allergy and Immunology is separate from American Board of Pediatrics, american Board of Internal Medicine, and we are vying for different spots. So we don't have enough allergists.
Speaker 1:And then in the institutions, because of the multiple factors I listed I probably forgot some they're not doing a lot of the OIT, so then they're not getting these fellows which is a trainee in allergy and immunology, it's called a fellow. They're not getting taught how to do it, so then they're not coming out of training doing it. And then you're exactly right, they hear and especially allergists who have been in practice for a while they've heard a lot of the bad things about OIT and not as much of the good stuff, which again is one of the reasons I love what you're doing with your Instagram and I was so happy to have you on the podcast. So that's my answer. What do you say?
Speaker 2:My like five minute answer. Well, actually you understand the academic aspect more than I do. Like I didn't know about the distributing it and stuff like that. I agree with everything you said, but I would caveat that also pharma's big right Like all the guys that are publishing that speak, the leaders at our meeting are pharma. They're great, but they have pharmaceutical sponsored studies right, and so there's something to do like there's some agenda in that, and so I think that also influences a lot of the training and a lot of like they're not training, they don't know and they don't. I don't like. Scripps did it, you guys did it, but not many of our leading institutions in the US, in Canada, they do You're talking about the US Clinic.
Speaker 2:Yeah, cleveland Clinic right.
Speaker 1:That's what I saw. I'm in my own practice now, since 2021.
Speaker 2:No, no, but at least you're authored on the one that I posted. Yeah, I was at Cleveland Clinic. I love my Cleveland Clinic. Yeah, yeah, yeah.
Speaker 1:So we had amazing leadership with Dr David Lang supporting the development of the Food Allergy Center of Excellence at Cleveland Clinic when I was there, yeah, but I still saw the hurdles, the bureaucracy, everything we had to go through to get to that point and that's why I'm so like intricately aware of the challenges. But because we had that champion and Sandy Hong and these other just like really great people at Cleveland Clinic and at least when I was there they were pushing like physician leadership and at least when I was there they were pushing like physician leadership, we got it to where it needed to be. You know, and if you don't have that it makes it really hard and you're right with the pharma it gets really. It's tough and you know it's tough to sit in there and we can all have disclosures, right. So I mentioned I'm a spokesperson for Mission Mighty Me Like that's great right. What else? Oh, mission mighty me Like that's great right.
Speaker 1:What else? Oh, I do some consulting with Kaleo. I've stocked Kaleo forever because I think it's a very safe. But when I was polling the group, you know, talking with our fast OIT email, you know, I put that in there like hey, like I have a disclosure here. But one of the reasons, like I work with Kaleo is because I believe in their product. I've seen it work for years, long before I've been a consultant for them, you know. But it is to your point. It's hard to hear like talk after talk about how great this drug is or that is, when there is so much behind it that helps, you know, put food on someone's table.
Speaker 2:Yeah, it's hard, like, so I agree with everything you say, but I do think you have there's some financial biases that you have to think and that's part of the reason why our bodies are not different than the bodies in Canada, you know, but like, but the dynamics are right, like that makes sense. So I love the Canadian side. I absolutely love, I love, I love those guys there. Like I don't even know them personally, but I love what they do, they publish awesome stuff.
Speaker 1:Okay, next question.
Speaker 2:I have one this is you kind of asked me this but extremely elevated total IGE to whatever, whatever food. What can we do?
Speaker 1:So those are the kids that I'd say need support the most. Now, having a high number doesn't necessarily mean they're going to have a more severe reaction. Right, number and severity don't necessarily correlate, but likelihood of being allergic does correlate, and especially in these kids where the numbers aren't going down like that's a total bummer right, where like there's a baby diagnosed and it's like, oh well, let's wait and see. And then they come back a few years later and eczema can just have the body rev up making a whole bunch of immunoglobulin E, which is the allergic antibody. But yeah, I mean, I think the high numbers, those are the kids that need support.
Speaker 2:So I would agree with you and you've seen my case. I'm always very specific on telling people the numbers, like on my case, right. I'm always very specific on telling people the numbers, like on my case. I want people to see the numbers that are treated. It's very. I try to be detailed, maybe too detailed, but yeah, and it just depends on the case, right. So, for example, if the peanut's greater than 100, I'm not going to aim for 300 milligrams of protein, I might aim at a lower dose, I might go at the slit, I might go at 10. I might go at 20, but now let's switch that up. And now let's say it's the milk and the milk is 70. And I'm like man, but the kid can't eat milk. That hurts him every day. So I'm still going to say I would still consider treatment, but now we just go slower. It might take me six months to slowly roll that in, but I'm still aiming to get that kid to free eat, because milk it's hard to avoid milk.
Speaker 2:It is hard, especially our, our milk egg kids, yeah, and so my, and like my egg ones, I might now aim to just get them to eat in the baked form. So so, so, cause now I don't want Joey not being able to get a birthday cake at someone's house you know.
Speaker 1:So a million percent. So much of this is quality of life and improving the child's quality of life and, honestly, the family's quality of life. You know there's so much anxiety that goes along with having a child with food allergy. If there's something we can do to intervene to make it less likely that a child's going to have a severe allergic reaction, we need to do it.
Speaker 2:Yeah, so so my take on all of that is that options are there. Talk to someone who knows and kind of gives you can, can can walk you through your, your, your choices.
Speaker 1:I love it. And if you're in Georgia, parent listening, then you should go see Dr Chaco. So how many? You have a lot of offices.
Speaker 2:Yeah, so we're. We're all around Metro Atlanta, so you have a lot of offices. Yeah, so we're all around Metro Atlanta, north Atlanta, and we're happy to help. We'd be happy to see us, and not many people, I do think, not just in Atlanta, but across the country most parents are still hearing that avoidance is the only option. Or they might be saying that doctor only offers avoidance or Zolaire, and I think that's my message to everyone listening that those are not your only options.
Speaker 1:Right, it's great to have those. Avoidance is always an option. It's great to have Zolaire as a tool in our toolkit. I appreciate Palforzia, but there's more.
Speaker 2:Yes, and Allison, I know, not just us, but there's doctors like us across the country, and so I just want you all to know that there's options out there.
Speaker 1:There are options. I love it, dr Chaco, thank you so much for coming on the podcast. You're awesome. You're welcome back anytime this was so much fun. 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 foodallergyandyourkiddocom, where you can join our newsletter. God bless you and God bless your family.