Nutrition Essentials | Could a Child’s Diet Prevent Food Allergies? with Jaclyn Bjelac, MD

Podcast Transcript

John Horton:

Hello, and welcome to another episode of Nutrition Essentials, a side project of our popular Health Essentials Podcast. I'm John Horton, your host, here again with registered dietitian, Julia Zumpano.

Julia Zumpano:

Hi, John. I'm so excited to discuss food allergies today, a common thing that affects young children and families.

John Horton:

Oh, Julia, it is a topic that really hits close to home for me. I have a son with food allergies, and I can tell you, as he was growing up, it was difficult. We had to navigate our way and figure things out on our own. But thankfully, there is a lot more information out there today, and even some ways that people can, hopefully, avoid having food allergies develop in children.

Julia Zumpano:

That's why we brought in allergist Dr. Jaclyn Bjelac. She's the Associate Director of the Cleveland Clinic Food Allergy Center of Excellence.

John Horton:

Well, we've had Dr. Bjelac on before, and I can tell you, she has so much useful information, and really just presents it in a way that makes you feel a little more calm and comfortable as you're dealing with some of these. She even has some tips that could hopefully help your child maybe avoid food allergies. So, give it a listen. Welcome to the podcast, Dr. Bjelac. It is so nice to see you here.

Dr. Jaclyn Bjelac:

Thank you so much for having me. I'm looking forward to being back.

John Horton:

Well, we've been looking forward to it because I know we had you on for a few Health Essentials podcasts, and it's nice to get you on for a Nutrition Essentials one, just to really dig into this whole topic of food allergies and everything that's going on with it.

Dr. Jaclyn Bjelac:

Oh, it's so important, so thrilled to be here.

Julia Zumpano:

Very excited to have you here. Thanks for joining us today.

Dr. Jaclyn Bjelac:

Thank you.

John Horton:

Before we start, one thing that you say, which I always love, is that you hope that you're eventually out of a job.

Dr. Jaclyn Bjelac:

Yes. I think they usually say “funemployed,” but yes, I think, in medicine, we're always working to try and prevent disease as much as we can. I've dedicated my career to food allergy, and it would be a great joy for me to not have to focus on that anymore, for it not to be something that patients and families manage.

John Horton:

Well, it's definitely something I think that would be best for everyone, but unfortunately, we are not there yet, which is why we need your wisdom here today. So, to get started, let's just talk a little bit about food allergies because they're so prevalent. I was looking up numbers and I think it said 1 in 10 adults has a food allergy and 1 in 13 kids. Those numbers have just been going up, it seems like, every year.

Dr. Jaclyn Bjelac:

And depending on whose papers you read, they're increasing at a pretty exponential fashion, too. I'm glad that you mentioned adults because food allergy we used to think was a pediatrics-only disease. But unfortunately, many of our adult patients develop new allergies in adulthood or carry their allergy from childhood into their adult years. It's so prevalent. It's so impactful, not just for our individual patients and their family units, from the choices that they make every day at the grocery store, what they have for dinner, eating out at restaurants, but food is so social. So anyone who's making particular diet choices, whether it be for safety, like food allergy, cultural or personal preferences or intolerances, which can cause terrible symptoms if you have a slip-up, that impacts all facets of our lives because food is everywhere.

John Horton:

A lot of times, I think people don't truly understand what a food allergy is. It's like, you hear it, you know you shouldn't eat it. But walk us through a little bit, what happens to your body if you do have a food allergy?

Dr. Jaclyn Bjelac:

Yeah, that's a really great question, and I think it comes down to making sure we're using the words “food allergy” in an appropriate context. This is different from a food intolerance, and there's many medical reasons or social or personal or religious reasons to make food choices. But when we're talking about food allergy, we're talking about an immune response to a food. For reasons that we're still trying to understand, people's immune systems have identified this food as something that's potentially dangerous.

So, an exposure to the food, which almost always has to be you eat it or you touch it and have a mucosal exposure — mouth, nose or eyes — your immune system says, "Oh, my gosh, we've had this exposure," and the allergy antibody has already attached to allergy cells. Then, it forces them to break open when it's exposed to that particular food. Those allergy cells release chemicals like histamine. You hear about … we take antihistamines for allergies, but in just this amount, that can cause potentially serious whole-body allergic reactions to something that's not supposed to be dangerous. It's really just the immune system making a mistake.

John Horton:

We had a doctor on a podcast the other day, we were talking, and she described it as you have guards in your body guarding the castle. They look at something that shouldn't be a threat and they perceive it that way and they go a little crazy. The result is that your body can really have some damage, some bad things happen.

Dr. Jaclyn Bjelac:

I think that's a great analogy. They're guards or soldiers, however you want to call them. They're supposed to be there and they have really important jobs, recognizing germs and other things that don't belong in our body, but it's just inappropriate identification of food proteins, which are supposed to be very safe, as not safe.

Julia Zumpano:

I think it's also common that people do misunderstand the difference between an allergy and intolerance. We screen for allergies. For every patient I see, I check their allergies just to be sure that they don't have any food-related ones. Oftentimes, when I dig deeper, I realize the majority of the allergies listed are true intolerances. So, I think that the big differentiating factor here is that, one, the allergy affects the immune system, and the intolerance affects the GI system. So, you may get more of a GI effect, some nausea, maybe diarrhea, constipation. It may even affect your skin. But most likely, it's not going to be anything very compounding that's going to continue to get worse or create a life-threatening outcome.

Dr. Jaclyn Bjelac:

Julia, I think that's a really great way to put it. Intolerances are bothersome. I have people close to me in my life who, if they have an accident and they have wheat, they're miserable for hours. Not life-threatening, but certainly impactful. Differentiating between the two, I think, is important in understanding risk. The risk if you have an accident with an allergy is potentially anaphylaxis. The risk if you have an accident with most intolerances is certainly very unpleasant symptoms, but not something that requires a prescription for an epinephrine auto-injector or another epinephrine delivery device.

I think that it's important to reassure families and patients that while their condition is serious, and we absolutely would recommend not eating foods that make you feel sick, doesn't need epinephrine for potentially life-threatening allergic reactions.

John Horton:

Dr. Bjelac, I know we just threw out the term “anaphylaxis.” Tell us a little bit. One, describe what exactly anaphylaxis is, and two, how common it is, because that's the bogeyman of allergies. That gets tossed out there a lot and everyone's afraid of it. Sometimes, I think it's not as prevalent as what we think, but I know it's always a threat.

Dr. Jaclyn Bjelac:

So I think this is a really important question, John, and actually one that doesn't have a definitive answer. There are a couple of different definitions of “anaphylaxis” out there. So when I talk to my families and patients about food allergy, we talk about food reactions as a spectrum, and you can have very mild reactions. We don't have mild food allergy, but we can have mild food reactions. That can be even just a few hives where a food didn't touch, maybe an itchy drippy nose, some itchy, watery eyes. These are all things that we can see.

And then there's the spectrum. Any organ system in your body can be involved in anaphylaxis, which I think is really important.

So, thinking about … we've been talking about the gut — you can have anything from mild nausea to vomiting, multiple episodes over and over. When you're thinking about skin, you can have a few hives or you can have head to toe covered in hives and even swelling, which is, on the basic level, just hives underneath the skin. Then, we can have things that impact the respiratory system or our breathing. Of course, John, as you mentioned, that's something that brings a lot of fear around reactions to families. But you can have coughing or actually wheezing, especially in our patients with asthma. And then, you can also have impacts on your cardiovascular system.

So anaphylaxis, when severe, can cause a drop in your blood pressure that can keep the blood from flowing as well as it's supposed to, to important parts of your body, like your brain. So people will actually say that they feel dizzy or lightheaded, and kids may become actually very agitated when they're having severe reactions. So, while reactions can be severe, reactions that cause death and fatal anaphylaxis are, thankfully, very rare.

John Horton:

Thankfully.

Dr. Jaclyn Bjelac:

But they do happen. I think anytime there's a situation where you or someone that you love is at risk for that, it does create an understandable amount of fear. But we want to reassure families that these are usually preventable, and that's why we carry our epinephrine autoinjectors. So no matter where you are in that spectrum of anaphylaxis, so those whole-body allergic reactions, giving epinephrine early, “epi first, epi fast,” has been shown to reduce the risk of progressing to more severe symptoms, and is the fastest, safest way for kids to feel better. So absolutely, we want to equip families to recognize symptoms of allergic reactions and then to carry their epinephrine autoinjectors.

John Horton:

“Epi first, epi fast” is a great phrase. I had not heard that before, and I can't believe I haven't.

Dr. Jaclyn Bjelac:

Oh, well, good. Well, tell everyone, tell your friends.

John Horton:

I definitely will.

You had mentioned, with all those symptoms and that spectrum … I know with food allergies, the one thing that's there, too, is you don't know what your reaction is necessarily going to be. So you're allergic to a certain food, let's say peanuts, because that's one everyone's familiar with, and have a rash or that reaction time and time again. Then one day, it goes really haywire.

Dr. Jaclyn Bjelac:

So most reactions will mimic prior and severity, but we always want to be prepared for reactions that could potentially be worse and, hopefully, they might even be less severe. A lot of different things can play a part in the severity of a reaction. How much of the allergen are you exposed to? Did you have a bite or did you eat a whole bag of cookies? So that's going to be different. What are you doing around the time of the ingestion? Are you exercising? Anything that increases your heart rate is something that we call an “augmentation factor.” Or are you just sitting on the couch watching a movie? So many things can play a role, some of which are in our control and many are not. You can't control when you're going to have an accident and what's going on, which is why we're prepared for more significant symptoms to happen even if they've never happened before.

John Horton:

So, as we've been talking about allergies, I know there are nine foods that are the big nine of food allergies. Just, if you can walk us through those foods that are most likely to be triggers.

Dr. Jaclyn Bjelac:

Yeah, that's a great one. So in kids, the most common are cow's milk and hen's eggs, and then peanut, of course, always gets a lot of publicity, rightfully so. And then, the tree nuts, which get batched together. But we think about in particular, cashew, pistachio, walnut, pecan and, less commonly, almond and hazelnut, and other nuts like macadamia and Brazil nut. Then, we have sesame, which is really an emerging allergen. It was added to the required allergen labels in the U.S. a few years ago. So, something definitely to be aware of for families. Then, we have wheat, soy and fin fish and shellfish. I don't think I forgot any.

John Horton:

No, I had it written down. Whenever you're going through a list, you always forget that one. So, I've been checking them off as we've been going.

Dr. Jaclyn Bjelac:

You can certainly be allergic to any food, but far and away, that group of nine are the most common triggers. So when someone comes to me and they say, "My little one was enjoying peanut butter and bananas, and X, Y, Z happened," I'm feeling far and away, the most likely culprit here is going to be peanut as opposed to the banana.

John Horton:

The most common, the big ones there, I know, shellfish is the most common, which I was a little surprised. I don't feel like you hear as much about that one, but that's the top of the list.

Dr. Jaclyn Bjelac:

So for our adult patients in particular — and that's one that tends to persist — so if you develop a shellfish allergy, that will tend to persist into adulthood when you're a child. Whereas milk and egg are the most common in kids, but those tend to be outgrown.

John Horton:

So Dr. Bjelac, when people first find out that they have food allergies, what happens? Because you don't just go and take a random test at the store or something like that. How do you find out that you are allergic to a food?

Dr. Jaclyn Bjelac:

So when we're talking about true food allergy, reactions are not subtle. A patient will ingest a food and then have symptoms such that when they bring their child to me, or a patient comes to see one of our allergy colleagues on the adult side, they're going to say, "I had this after I ate that." Really, we're just there to confirm what they suspected all along. We do have some testing that can help confirm that your immune system is paying attention to a food in an allergic way, but there is no allergy test that can say, "Yes, you're allergic," or "No, you're not." The only perfect allergy test is what happens when you eat a food. History trumps everything.

So what'll happen is, someone comes in and they've had an exposure and symptoms. We do confirmatory testing and then walk families through managing that on a day-to-day basis. What does that look like with reading labels and advocating? What does trick-or-treat look like if there's someone who is celebrating that upcoming holiday and how do we recognize symptoms of allergic reactions and how do we intervene with medicines to keep their kids safe? And then, thinking about opportunities for treatments and things, that's usually a later conversation. The first visit is what should you expect and how can we support you. Because it is really a life-altering diagnosis.

John Horton:

Now, when do most people find out that they have a food allergy? Is this something that's during childhood or are there people who, they're in their 40s and all of a sudden, they can't eat crab?

Dr. Jaclyn Bjelac:

Most people with food allergy develop their food allergy in childhood, and it is very true that you can develop new food allergies in adulthood, but the vast majority of individuals will find out before grade school or in the early grade school years, especially with increased exposures in childhood, now that we've realized that eating allergenic foods earlier, there might've been a lot of kids out there who weren't eating peanuts until they were quite a bit older than now. So we're finding these allergies earlier and earlier.

Julia Zumpano:

I have a question on that. What if someone does develop an allergy later in adulthood? I've heard of a lot of my patients who say, "Well, I developed in college or right after high school," or maybe even transitions of their lives, “After I got married.” So do you think any of that plays a role, or do you have any insight on that?

Dr. Jaclyn Bjelac:

Yeah, I think that is a really great question. If I knew, I'd probably have a Nobel, but I think a lot of us in the community do feel like loss of immune tolerance to a food that you used to be able to eat, albeit infrequently, usually, it's foods like shellfish or “I used to be able to eat shrimp all the time and now I can't” is maybe perhaps post-infectious, like a post-viral immune switch happens and then you lose that tolerance. We are still learning about the impact of stress and how that impacts our immune system, possible loss of tolerance. I would be remiss in telling you I knew why, but it's an area of interest. Because if we could figure it out, if we could learn more about why we have food allergy, we would be working toward better prevention and cures.

Julia Zumpano:

That's very interesting.

John Horton:

Now, Dr. Bjelac, you brought up food introductions and that's where I know we want to spend a lot of our time talking today, because there's been so much new research and knowledge gained as to how maybe we can prevent food allergies going forward. So talk to us a little bit about, I guess, the importance of giving kids some of those big nine foods, exposing them to those foods early and how that might help prevent food allergies from developing.

Dr. Jaclyn Bjelac:

Yeah, I think this is such an important topic. When I was growing up, I don't want to date myself too much, but it was very much the recommendation from the major medical organizations that kids not be exposed to peanut, for example, until they were about 3. I think some families followed that guidance, some didn't, but that was what we were telling people. Then, the story of how things have flipped and what's actually a very short amount of time starts with some really brilliant researchers who noticed that in Israel, very few children there have peanut allergy. They said, "Why in the US do so many kids have food allergy and in the U.K. as well?" They're actually U.K. researchers. I don't want to make it sound like the U.S. is responsible for this.

John Horton:

There's a shared knowledge.

Dr. Jaclyn Bjelac:

Why in other Western countries are there such high rates of peanut allergy, but in Israel, there aren't? The answer comes from a puff snack that is the Cheerios®, if you will, of Israel. It's one of the first finger foods that families will offer to kids in their very young infant-toddler years, and it's covered in a peanut dust. So these children were eating peanut much sooner than kids in other Western countries and had lower rates of peanut allergy. So the researcher said, "Is this as simple as it might seem?" They did a beautiful study that showed that in kids who are at high risk of developing peanut allergy — so they had severe eczema or already had another food allergy like egg — if you give them peanut early in infancy, you can reduce their risk of developing peanut allergy by over 70%.

John Horton:

Wow.

Julia Zumpano:

Wow.

John Horton:

I mean, that's a number that gets your attention.

Dr. Jaclyn Bjelac:

Yeah, right? Everyone's excited. I'll take those odds. So that study is called Learning Early About Peanut or the LEAP study, and it has completely changed how we practice allergy across the world. There have been follow-up studies with other foods for some select ones, but LEAP was clearly the first and the most powerful effect. What we know about early introduction is that it can reduce the risk of food allergy. It can't prevent it for everyone, and it doesn't seem to have any adverse impacts, which is really important.

When we're feeding little babies, we want to make sure we're not doing something that could potentially cause harm. So it does not seem to impact rates of breastfeeding, which is so important for many of our mothers. They want to keep up with breastfeeding, and it does not ever seem to cause severe enough reactions that we need to be worried about fatality. There has never been an infant death from early peanut introduction that has been documented yet.

John Horton:

That is such an important point. I know when we were talking ahead of this and you said that, and I'm like, "Never?" You said, "Never."

Dr. Jaclyn Bjelac:

Never.

John Horton:

That's a big statement. It seems like one of those things, if you're a parent, to realize that there's some safety in doing that and maybe having a little bit of that peanut exposure early and not be worried about something bad happening.

Dr. Jaclyn Bjelac:

We take all food reactions seriously, and there are certainly kids who do react to those first doses of peanut. So we want to encourage patients and their families to talk to your pediatrician about your child's risk, and if there's anything you should be doing specially before you introduce these foods. But one of my partners says the line that we shouldn't be afraid to introduce the food, we should be afraid not to.

Julia Zumpano:

That's a great point.

Dr. Jaclyn Bjelac:

I love that.

Julia Zumpano:

I used to work in pediatrics. I started off in pediatrics, and I do remember the days where we avoided so many things and created a lot of fear around that. Then, as time went on, I had my own children, and I think the shift happened when I was having children. So, I remember my son, we restricted and, I think, I introduced peanut at a year.

Dr. Jaclyn Bjelac:

You were ahead of the game.

Julia Zumpano:

That study came out, and then my daughter was born, and I pretty much gave her everything right off the rip. She was so tiny, she needed so much extra food. I was like, "Peanut butter is the way to go. Let's get you fattened up." It's nice to not create that fear. It's very fearful. It really is if you do have, struggle with an allergy or have this fear that your child may develop one, but just knowing that you can have some ease around it, there's good data to support that, giving it early is now safe, it's the way to go.

Dr. Jaclyn Bjelac:

Julia, I love that because let's normalize that parenting can be an anxiety-provoking experience.

John Horton:

A little bit.

Dr. Jaclyn Bjelac:

The age of parenting-

Julia Zumpano:

…just mild.

Dr. Jaclyn Bjelac:

...of digital and social media, we have access to all this information, and I think it's great for certain things, but then also, all the bad things that can happen. To your point, I do think that we overmedicalized how we feed kids, and it's ingrained this fear in us about feeding our kids. I will share with you, too — and then anyone who listens to this, just in this safe space — that I was afraid to feed my kids their food allergens, too, and I'm a pediatric food allergist. Let's acknowledge that this happens.

Julia Zumpano:

It's real.

Dr. Jaclyn Bjelac:

So I would go in the other room, and I would have my husband do it because I felt like I was going to overinterpret anything. Did you just sneeze? What just happened? And whatever families need to feel empowered to feed their kids, they should feel like they can bring that out to their pediatrician. Do they need to meet with an allergist? We don't want to delay food introductions, but some of my favorite conversations are meeting with families of young kids and saying, "Here's a plan and here's what we're going to do." So hopefully, we can touch on some of that today, so all the listeners can skip the visit with me and still have those tools.

John Horton:

And that is what I was going to ask you next, because we say do these introductions, but how does one go about doing that? Because when do you give your toddler a lobster or eggs or any of these other things that we're talking about, and what's a safe amount to give them?

Dr. Jaclyn Bjelac:

Yeah, and it is. It's overwhelming. Let's acknowledge the overwhelm. I think there are a lot of wonderful pediatricians who are up-to-date, who might have print resources for families. There's some great social media accounts that I would love to name-drop. I think Solid Starts is a good one. They have an allergist on the team who emphasizes what to look for when you're introducing those allergenic foods. Of course, I think, as I mentioned, sitting down with your pediatrician before starting solids is important. Talking about any health concerns your child has, any increased risk for food allergy that they might have. Have you been managing really severe eczema?

It's really important to note that there's some pretty good guidelines, but at the end of the day, most kids don't have food allergy. So we want to introduce these foods in a way that feels right for your family. No matter what the outcome is, you did everything right. You did the best you could with the information you had at the time.

So when families come to see me, we talk about the major allergens. So cow's milk is one. Julia, I would love if you want to chime in, too, but one of the things that we recommend is actually whole-milk yogurt. I also am a fan of cottage cheese.

Those are great baby foods because whether you're going to do more of the baby-led weaning or just purees into more solids, whatever your journey looks like, I want to be supportive of that. Whole milk yogurt and cottage cheese — people will say don't drink milk before a year of age, and that is correct, but we can absolutely have cow's milk before a year of age, things made with cow's milk. So shredded cheese is another fabulous baby food. They can pick it up off their tray. One important tip when you're feeding especially allergenic foods for the first few times, if baby-led weaning is your journey, hear me say I am supportive of that, but I would really encourage trying to directly introduce the food into the mouth the first few times. The reason for that is that many kids with sensitive skin, especially kids with eczema, will get actually a rash around their mouth when it comes into contact with certain foods. Those can look anything from just some mild redness to actual hives. I think we could all appreciate why that might be anxiety-provoking to families. But most of the time, contact hives are not cause for alarm, and we want to keep feeding the food. So I don't want your first food allergen introduction, baby picks up a spoonful of peanut butter and licks it and then smears it all over their face and maybe on their super cute onesie or on their hands, and then they break out in hives everywhere it touched. I don't want that for you or for your family. So we want to directly feed into the mouth the first few times until you know your baby tolerates that food, where a few contact hives won't be alarming to you, if that makes sense.

Julia Zumpano:

Yeah, that's great advice. I love starting with dairy. I'm sorry, I love starting with yogurt. I think that's a perfect segue into some dairy, the whole-milk yogurt. Then, as you continue to introduce it, pairing it with some fruit, I think it's a great way to begin.

Dr. Jaclyn Bjelac:

So once you've introduced an allergen, we say early and often. So, we've gotten milk in. We want to keep it in the diet two to three times a week is what we recommend based on generally accepted knowledge. Your baby could have yogurt every day if you wish, but at a minimum, let's keep reminding the immune system that it's safe by continuing to keep it in the diet.

So the next on our list is eggs, so hen's eggs. Some kids don't love the texture of eggs. How do you like your eggs? Scrambled, sunny side up, hard-boiled. So one of my favorite ways to get eggs into the Bjelac kids is French toast.

When you have that lightly heated egg wash on a piece of wheat bread that you can get egg exposure with that and then also wheat as well. The first time baby eats an allergen, I'd probably have it be your only one. But once you've tolerated each one at least once, feel free to combine. That's how I think we will all survive this food introduction journey together is by combining foods because it's hard to keep track.

Julia Zumpano:

Would that count as the dairy as well, the dairy piece, since you're putting the milk and the egg wash together?

Dr. Jaclyn Bjelac:

It sure could. Amount-wise, it's probably not quite enough protein because most of us just do a splash, but some is better than none. So I'm here for it, right?

Julia Zumpano:

Sure.

Dr. Jaclyn Bjelac:

So I think that's great. Wheat, I think anybody who's managing non-celiac gluten intolerance, celiac or wheat allergy knows wheat is hard to avoid. Wheat is everywhere. So once you get wheat into the diet, whether it be soft breads, noodles, wheat-based multi-grain cereals, all of these are great baby food options. We just want to feed normal serving sizes for a baby, which is usually anywhere from a quarter to up to half of an adult serving at the most. Then, keep that in the diet a few times a week. For those of us who love our carbs, that's easy to keep in there, right?

John Horton:

Now, Dr. Bjelac, you had mentioned introducing them one at a time. How big of a gap should you have in between them? Do one week and see how they tolerate it and then bring another one in just to make sure you're looking at each one individually?

Dr. Jaclyn Bjelac:

John, I love that you asked me this question. No more than a day, right?

Julia Zumpano:

OK, one a day.

Dr. Jaclyn Bjelac:

If we are waiting a week in between our food introductions, whether they be common food allergens or other foods, we're never going to achieve the diet diversity that we know is actually really important for a lot of health implications for kids.

John Horton:

Let's be attentive. That's what you said because you get scared. So you're like, "OK, a week should be good." So one day.

Dr. Jaclyn Bjelac:

One and done. Move on, team. We got this. If something happens and you've introduced multiple foods together, once the dust has settled, hear me say, I am hugging you virtually, and then find a board-certified pediatric allergist and we will help you sort through which food it was.

So I tend to introduce lots of allergens together. The more appropriate answer to your question is at least a day apart. I think we can all agree, based on emerging evidence about the importance of diet diversity, we don't want to delay food introductions not based on any good evidence, waiting days at a time or I've heard weeks at a time, to see if they'll have a reaction. Food reactions aren't subtle. You're going to know within two hours if you've got a problem.

Julia Zumpano:

What happens when you filter that out as a physician? How do you filter out which one it could be if they introduced several?

Dr. Jaclyn Bjelac:

We can use testing to help us risk-stratify. Then, when in doubt, we do challenges to each of the potential culprits in the office if the testing doesn't help us identify a clear trigger.

John Horton:

Now, I know you said early and often, and let's get into what that means for these kids just nutritionally, because I imagine that there's a big benefit in getting these allergens in, and you're getting so much out of all this food that there are just health benefits that extend beyond what we're talking about.

Dr. Jaclyn Bjelac:

Yeah, so by early, we mean right around the six-month mark, when baby's ready for food. You should always talk to your pediatrician first. Then, once you've introduced it, ideally sometime between the four to six and the nine-month marks, you want to keep it in the diet if possible, two to three times a week. Because if you eat it that one time when you're 6 months, that's awesome. Regrettably, sometimes we hear about, "Well, we did that introduction and then a year later we had peanut again. That was the next time we had it,” and then you have a reaction. So we need to keep reminding the immune system that a food is safe.

The perfect answer of how often that needs to be is actually not well understood.

So we base a lot of these recommendations on that initial LEAP trial that we spoke about earlier, and they gave their kids the allergens three times a week in that study. So now we've got milk in, we've got eggs in, we've got wheat, too, and then getting into the food that changed all of us, peanut.

So we don't want kids eating choke hazards, especially when they're little. So we don't want kids eating whole nuts, at least until the age of 3. I have some pediatrics colleagues tell me, "You have to be able to spell it if you want to eat it." So we want to use either thinned peanut butter — there's a lot of sugar-free varieties out there for families who want to minimize added sugars. They make peanut powders as well. I want to try and minimize brands as much as I can.

Then, once baby's old enough for finger foods, they make really fabulous, as first seen in Israel, but now easily available at grocery stores near you, these peanut butter puffs, which a lot of kids love for finger foods. So lots of different opportunities to introduce peanut, and you can spread it on crackers or spoon-feed it or make sandwiches from it. Many kids like the taste of peanut butter, especially if they weren't initially allergic.

Julia Zumpano:

I always like to mix the peanut butter with a mashed banana or even with a little apple sauce, something with low allergen risk food, but you can liquefy it a little bit.

Dr. Jaclyn Bjelac:

So it's not super tacky.

Julia Zumpano:

Yes.

Dr. Jaclyn Bjelac:

Because then, you've got the kids like gagging, which is great. Gagging is protecting your airway, but also anxiety-provoking. The kids are gagging all over the place. We don't want that.

Then, there's tree nuts. The biggest bang for your proverbial luck is focusing on almond, cashew because it looks very similar to pistachios. You have those two together in one. Hazelnut and then walnut because that covers pecan. Certainly, kids could be allergic to other nuts. I don't want to minimize that for any family listening who's managing a different tree nut. But in the U.S., those are the biggest culprits for allergens, but also for exposures. A better allergist would tell the listeners to do those one at a time before combining them.

I tend to personally lean on commercially available mixed tree nut butters that have all of them, or if they don't have all of those big four, I will add the one that's missing. There are entire lines of products made with cashew. There's cashew cheese, cashew milk yogurts, cashew milk and cashew butters that you could add. A less variable story for walnut, but you certainly can buy walnut butter. Then, almond is one of my favorite foods to get into kids' diet because just like cashew, there's so many products made with almonds, many of which are really nutrient-dense — almond milk yogurts, almond butters. Many of those tend to be peanut-free and manufactured in peanut-free facilities. So simpler to introduce for families.

So you can either do them one at a time and then combine them. I, right out of the gate, do combine them at our house, and then my kids will enjoy a heaping tablespoon or two of that mixed tree nut butter a couple times a week, whether it be in a smoothie or on top of a waffle. That's how I know that when they want to enjoy pistachios out of the bag or cashews from some mixed nuts at a party that they've had those exposures, they're not going to have an allergic reaction. For me personally, I think it's more practical to keep in the diet in that fashion as opposed to all of them individually, but more power to people who do them individually.

John Horton:

And this is where it seems good to emphasize again what you brought up earlier is that it is very, very safe to do this because young kids just do not traditionally have those severe reactions to these allergens.

Dr. Jaclyn Bjelac:

Yeah, it's one of my big selling points, I think, for families, is the earlier we get it in, the less likely they are to have a severe reaction if they have reaction. It's not impossible. I've certainly seen it and heard of it, but thankfully, the risk is much, much lower the younger you are. You don't have that robust immune reaction that you do when you're a teenager.

John Horton:

As you're doing these trials and you're doing these challenges, what would be something that would happen where you'd really want to reach out to your pediatrician or an allergist to get a second opinion as to what's going on there or really look a little closer?

Dr. Jaclyn Bjelac:

Yeah, I think that's a really great question. Not to sound trite, but I think anything that worries you deserves a message or a call to your pediatrician.

John Horton:

Trust those instincts, right?

Dr. Jaclyn Bjelac:

Yeah. You know your child better than anyone else in the world. If your mom or dad Spidey sense is tingling, please trust yourself that something's not right with your child. That goes for all things, but especially food allergy. Then, those symptoms that we were talking about on that spectrum of allergic reaction — rash where a food did touch, repeated sneezing, itchy, watery eyes, runny nose, any vomiting, of course, would be an obvious sign that something's not quite right, I think respiratory coughing, wheezing — seek emergency medical attention and let your pediatrician know what happened. I think it's worth mentioning, I've had families ask, "Should I sit in the ER and feed my baby?" While I don't think that that's necessary, if that's what helps you feel empowered to feed your baby these foods, then please do it, right? Whatever we need to do to get the food in the child.

John Horton:

If you have a kid and maybe their sibling had a food allergy, does that raise your level of worry a little bit or is it completely unrelated?

Dr. Jaclyn Bjelac:

Well, so having a sibling with food allergy does not significantly raise your risk compared to the general population. I think it adds a layer of complexity. If you have a 4-year-old in your house that's allergic to peanut, how comfortable are you bringing peanut into your home with this early introduction? That's a family choice. I think every family has to weigh risk-benefit for them. Four might be a little old because I do think most 4-year-olds are equipped for us to say, "We know that this food isn't safe for us, don't eat it." So maybe a 2-year-old would be a better example. They don't quite have that impulse control yet. Maybe something fell on the floor. You don't want your 2-year-old to pick it up. How comfortable are you with that being in your home? I think there are many parents who've seen their children have food reactions and they just want to avoid that for their younger child. So talking with your pediatrician and your allergist about what that journey looks like for your family, it's really important.

Julia Zumpano:

What about if a parent has an allergy? Does that create more of a likelihood for the child?

Dr. Jaclyn Bjelac:

Yeah, so having any kind of allergy in a parent does increase your risk to have allergies in general, but not significantly higher for food and certainly not to a particular food. So if I had a dollar for grandma and me are all allergic to shrimp, I know little Johnny is going to be allergic. Well, he might be, but not because everybody in the family was. Only because it's a common allergen, and it's slightly increased risk for food allergy. So the actual particular food allergen is not heritable.

John Horton:

What I really love about this idea of doing these challenges early and really getting these different foods into the diet is just that it teaches kids just to eat a well-rounded diet and to get a lot in. I know both of you guys have kids. My wife and I have three kids. Kids eat weird and they're so odd. They'll go through stretches where they won't eat this or they won't eat that. It just seems like if you build this concept that you eat and try everything, maybe you set them up for better eating habits as they grow up.

Julia Zumpano:

I think it's important that we take away kid food and adult food. There's many families that may make a meal that is ideally served for the adults, and then they make your kids something separate that might be more kid-friendly, like chicken nuggets and French fries. But I really do try to encourage parents to make one meal, which is way simpler and way more effective use of your time and just feed everybody the same meal and continue to encourage a variety of foods, new foods, and then as they grow and as they develop into adolescents and even adults, they'll be more prone to have a more varied diet and try new things too.

So it's really important from even a long-term perspective of your perception of eating and eating habits and your diversity. We know the benefits of a diverse diet, and it plays such a great role in the gut microbiome, which houses 80% of our immune system. Seventy to 80% of our immune system is housed in our gut. So when we talk about food allergies and immune response, it's really important to really build up that gut microbiome and have that diversity as much as possible.

John Horton:

Yeah, making the one meal thing was always a rule with us. We always told the kids we're the worst restaurant ever. There's one option and not there. If you don't like it, we'll see you at the next meal. Maybe that one will hit you a little differently, but we're not getting into this game of making all this different stuff.

Julia Zumpano:

My daughter will still play that game. She'd be like, "Well, I'm not eating." I'm like, "OK, that's fine. You still have to sit with us."

John Horton:

My kids have horror stories. Yeah, I figured it's good for you. It builds up strength.

You talk about doing these challenges and specifically when you're young… So let's say you came of age at the point where this wasn't happening and you have this food allergy and now you're in your 20s. Is this something you can jump on that train now and try to introduce some of these foods, or once you cross a certain point, you just don't go there?

Dr. Jaclyn Bjelac:

I'm sure that I understand your question. If you've already developed a food allergy, we don't want to be eating the food on purpose, but I certainly think that no matter what you or your family chose when you were young, the vast majority of people don't have food allergies. We eat foods intermittently as they come. Most of your immune system is set in its ways before kindergarten. That doesn't mean it can't learn new things and it's not adapting and growing. But most of the benefit for allergen introduction likely happens in even very young kids as opposed to even earlier than grade school or certainly adulthood.

So if you don't have a food allergy, continue just as you were enjoying foods as they're part of your diet and as aligns with your goals and preferences. Then, if you have a young child in your life who hasn't had any of these food allergens yet, it's never too late to try new foods. We always want to encourage that.

Julia Zumpano:

What about an adult that may have an allergy, maybe even a young adult, and they're thinking they may want to challenge that allergy in a safe environment. Is that a possibility?

Dr. Jaclyn Bjelac:

So I would absolutely recommend that they connect with a board-certified allergist. One of my favorite things to do is de-label “food allergy,” either allergies that someone has outgrown over time or where they were labeled with a food allergy just based off testing that wasn't interpreted correctly or something like that, and then we're able to introduce the food. But once we know that you're at risk for possible anaphylaxis, that really should be done in a physician-supervised setting.

John Horton:

How often does that result then in somebody either finding out maybe they don't have the allergy that they thought they had, or is it even possible to switch that immune system response later in life?

Dr. Jaclyn Bjelac:

Every single encounter is really individualized. So it's the role of your allergist to tell you, "I think, based on your numbers, we have a 50/50 chance," or "I think there's a better than 75% chance." And then, you, as the patient, would decide, is that risk worth it to me to learn if I'm tolerant or still allergic? And then, in that setting, regardless of the outcome of the challenge, the supervised challenge, what an important question to answer. Even if we are treating symptoms during the food challenge, then when it's time for our patients to go home or adult patients, they'll say, "Well, I'm really glad I know that I need to still avoid this food." That's very powerful. It's really important.

Then again, one of my favorite things about my job is being able to de-label. Say, I have a kid who was avoiding hazelnuts their whole life, and now all of a sudden, they can eat the famous hazelnut spread or get more excited about what they can pick for their candy and trick or treat. It's a really, really cool experience.

John Horton:

So we've covered just an immense amount of ground here today and really looked at food allergies from a lot of different angles. So we're winding down our time here. So Dr. Bjelac, if somebody's listening here, what are the key points you want folks to take away from this talk when it comes to food allergies and, I guess, specifically if you have kids?

Julia Zumpano:

Yeah. What's the executive summary?

Dr. Jaclyn Bjelac:

We know that introducing common food allergens early can prevent food allergy for most people. We want to give foods early and often, and we should be more afraid of not feeding our kids than we should be to feed them.

Anything that you need on your journey to feel equipped with food introductions, making sure your kids are meeting your nutritional goals, fear of possible allergic reactions, or if symptoms occur with any food introduction that are of concern to you, please connect with your pediatrician.

The internet has a wealth of information.

While other people's anecdotes are true for them, that's not what's necessarily true for your child and your situation.

So I think connecting with a pediatrician that you have a good relationship with is really important.

Then, if you or your pediatrician feel like it's important based on what happened, please connect with a board-certified pediatric allergist, and we're happy to help you through that journey.

Julia Zumpano:

Great advice.

John Horton:

Definitely great advice. So I think we helped a lot of people here today.

Dr. Jaclyn Bjelac:

I hope so.

John Horton:

Yeah, no, we did. You always have such great information, and food allergies, as you brought up, it's one of those things, especially as a parent, you get so worried about it when you have kids, and you start hearing about it because you think the worst. I think you did a lot to help alleviate that, maybe help parents take a deep breath and just feel comfortable and confident as they introduce these allergen foods to their kids.

Dr. Jaclyn Bjelac:

Well, it's been a pleasure. Thanks to you both so much.

Julia Zumpano:

Thanks so much.

John Horton:

Julia, that conversation was so fabulous with Dr. Bjelac. I'm just really struck by how parents can help their kids overcome food allergies early by just introducing the foods at a young age.

Julia Zumpano:

Yeah, I think it's great how the recommendations have really advanced to include more early introduction. I think Dr. Bjelac did such a great job in breaking that down, putting a day-to-day perspective for a parent and how they're trying to maybe navigate that process. From a dietitian perspective, I love to hear that we're adding more foods to a child's repertoire versus avoiding and taking away.

John Horton:

Well, I know you always encourage us to eat a well-rounded diet. The thing that I really loved about what Dr. Bjelac said is that if you're a parent, you should really feel comfortable doing this. You shouldn't be overly worried, and that it's really safe to do these challenges at a young age.

Julia Zumpano:

Yeah, and that there are so many great resources, including allergists. So it's really very comforting to know that as a parent.

John Horton:

Oh, it definitely is.

So if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.