Overcoming Peanut Allergies with Jaclyn Bjelac, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials podcast. I'm John Horton, your host. Today we're going to look at ongoing research that could be lifesaving for young children with peanut allergies. A Cleveland Clinic treatment program designed for peanut allergic preschoolers and babies has proven effective at helping children overcome their food allergy. We're going to talk about the process, program results, and what this means moving forward for children with a peanut allergy. Joining us is allergist Jaclyn Bjelac, associate director of the Cleveland Clinic Food Allergy Center of Excellence. Dr. Bjelac is one of the many experts at Cleveland Clinic who visits our weekly podcast to share health information that you can trust. So, with that, let's find out how the lives of children with peanut allergies may be forever changed. Thanks to the work of researchers.

Dr. Bjelac, thank you so much for joining us again on the podcast. I always love having you on.

Dr. Bjelac:

It's a pleasure. Thanks for having me.

John Horton:

So today we're talking about peanut allergies, and I know this is something that people have become very familiar with because the numbers have just been going up and up and up, and I saw somewhere like in the last decade they've tripled or quadrupled. Are there just that many more kids with peanut allergies now?

Dr. Bjelac:

Yeah, that's a really great question. And the struggle is that many studies are patient or family reported and aren't really regulated, so there are many who argue that the numbers themselves are over reported, but certainly it can't be enough to account for the huge increase. So, we definitely believe that the prevalence is increasing, but also the awareness, the latter of which is really beneficial for the safety of our families who are managing peanut allergy.

John Horton:

And I think peanut allergies get so much attention too because we see the occasional headline, they can be pretty dangerous and deadly.

Dr. Bjelac:

All food allergy reactions we take very seriously, but unfortunately the percentage of fatal food allergy reactions is disproportionately attributable to peanut in the United States.

John Horton:

And that's what makes today's topic so important where, as I understand it, the work that we've been doing here at Cleveland Clinic, we're kind of getting to the point where can we even talk about almost like a cure for peanut allergies?

Dr. Bjelac:

Yeah, this is a really exciting time to be an allergist because even 10 years ago if you met a family and you diagnosed their child with food allergy, particularly peanut, you'd have to say, okay, this is probably lifelong, carry this epinephrine autoinjector and I'll see you in a year. Now we have treatment options and there are a couple of different modalities and some emerging ones, but the one that we really excel at, at the Cleveland Clinic, and is the best studied both nationally and internationally, is a desensitization treatment called oral immunotherapy or OIT. And what OIT does is it reteaches your immune system to just stop overreacting to peanut in that way. And we use it by actually giving the child infinitesimally small amounts of peanuts every single day, slowly building up over the course of time until they're eating the protein equivalent of one or two peanuts every day.

At the end of it, everybody's protected against at least one or two peanuts a day, which is really empowering for things like accidents. You know, you bite into a peanut butter cookie and you're like, this has peanut in it, and you spit it out, nothing should happen. Or if you're reading labels with precautionary labeling such as may contain or processed in a facility with, who cares if it may contain a little peanut protein, you're eating a peanut today. So, it can be hugely liberating for patients and families just at that goal dose. That's what we expect to achieve with every patient who starts the OIT journey. Some patients stop due to side effects or they're just kind of tired of the process, and that's understandable, but that's kind of where you're at. If you continue to be exposed to the peanut that's where your protection is.

Particularly for young children though, it's been a very exciting finding over the last couple of years, including at the Cleveland Clinic, where when we do this treatment for them not only are they protected against that small amount, but over a relatively short period of time their immune systems start to say like, oh, I'm sorry, I overreacted, and we start to see their levels of allergy antibody drop precipitously to the point that many of them are able to tolerate full serving sizes of the food without needing to take their dose every day. So, we hate to use the word cure, but over the long term it appears that most of these patients are able to continue to eat full serving sizes with no allergic reactions, and they live their lives as if they never had peanut allergy, which is a really, really cool thing.

John Horton:

That's amazing. No, that is truly, truly amazing. So, when you look at this, you said you start with this infinitesimal amount. I think it was like eight milligrams?

Dr. Bjelac:

Yeah, so protocols vary, but typically anywhere from four to eight milligrams, six milligrams. Three to six milligrams are the starting dose for the FDA approved product. And a typical peanut is about 250 milligrams of protein on average, so our goals are about 300 to 500 milligrams on the protocol. So you're starting orders of magnitude smaller than that.

John Horton:

Yeah, I was going to say eight milligrams, I mean, just to try to give people a visualization is to how large that is, are we talking like a pinhead?

Dr. Bjelac:

If even that. We usually can't do whole peanuts to get to that amount. We use peanut powders or peanut butters measured out and diluted to even get to that small of an amount. But there are some patients out there who can't even tolerate that small amount, which is incredible, and I think really eye-opening for us when we started doing this treatment.

John Horton:

So, the idea is these patients come in and you start them with just that small of an amount and their body just kind of adjusts to it and learns that maybe this is not a threat?

Dr. Bjelac:

Yeah, so this is based on the idea of desensitization and allergists love to desensitize. Probably the most common example is when your friends or family or perhaps you have ever gotten allergy shots where we retrain your body to stop overreacting to cats and dogs and trees and grasses and weeds and ragweed. We do that through shots. Allergists can desensitize to venom, so people with bee sting allergies can desensitize to that. Allergists can desensitize to drugs. So, there's patients who are allergic to medicines that they might need for different reasons. We can teach your body to just tolerate a given amount in a process called desensitization. And basically, what it is, is you sneak small amounts in, you try and get past the part of the immune system that flags danger, danger, and causes an allergic reaction while still poking the part of the immune system that says, oh, this is safe. I'm going to flag this with what we call a tolerance signal.

So, you either have allergies or you have tolerance. So, we want to hit that part of the immune system without causing allergic reactions. But that's of course one of the risks of a desensitization treatment, whether it be to allergy shots or to venom or to foods in OIT is you can have allergic reactions, you're still allergic to it until hopefully at the very end we say, oh, you're not needing doses every day, your immune system shut this part off. We're good.

John Horton:

And that's an important point here, because I think we want to emphasize this is not something that people should try at home. This is done in a doctor's office and in a very monitored situation. Right?

Dr. Bjelac:

Can we get a flashing banner across the bottom or something, like do not try this at home.

John Horton:

Very much so.

Dr. Bjelac:

It's a safety issue. And for better or for worse, there's actually very few allergists who even offer this treatment because of the risk and the logistics and the time involved. And the Cleveland Clinic is one of the very few academic medical centers in the country that offers it for very young children for these reasons too. And we're happy to offer it, we're proud to offer it, but it is not easy. And the process, the concepts, are actually very simple, but it is not a process without risk. And at the end of the day, we just want patients and families to be safe. That's why you're doing the treatment to begin with, to improve safety for your child or for you if you're doing the treatment. So, we would never want patients or families to try this at home without the guidance of a board-certified allergist just because of the significant risk involved.

John Horton:

And when you mention risk, I can't even imagine as you're doing this and somebody comes in and you start this process, what their reaction must be like the first time when you give them this small, small, small amount of something that they know their body is allergic to.

Dr. Bjelac:

So, the very young kids are actually the best to do it for because we haven't conditioned them yet to say like, don't eat peanut, don't eat peanut, don't eat peanut, don't eat peanut. Here's some peanuts, that's weird. So, our school age patients and our teenage patients very appropriately are like, you want me to do what? So, we're so lucky to have a child psychologist on our team who meets with every patient who's four years of age and older whose family's even thinking about doing OIT, because we want to address those very appropriate anxieties head on and say, what are your feelings about this? What can we do to empower you to navigate through those feelings to allow you to still be successful in treatment? I think it's really important to acknowledge that it's an anxiety provoking process for many.

John Horton:

Definitely. What ages are the most common for this sort of sort of approach? I mean, it sounds like the very young is kind of a sweet spot, but how old can you be to start it?

Dr. Bjelac:

The short answer is you could do this for any age. I would argue that many adult patients are really in their routine, and they don't think that the risk and the process and the side effects is worth it for the benefits for them. So many of our patients are very young, we call them preschool OIT, and there's actually a lot of literature now within the last couple of years, including our own data from the clinic, that doing it for the very young kids, less than three years of age, has improved outcomes and is less risky, fewer allergic reactions, very rare need to use your epinephrine autoinjector at home. Really all kinds of fabulous positive outcomes.

Whereas school age, teenagers, tends to vary. Anyone considering OIT really needs to sit down and have a conversation with an OIT allergist and kind of weigh those risks, the logistical considerations, time away from school or work versus what is my real anticipated potential outcome here and is that benefit worth it for you and your family? And if the answer is no, no matter what the age, that allergist should absolutely support you in an avoidance pathway with just good overall allergy care, counseling you on avoidance, preparing you for allergic reactions, making sure you have your epinephrine autoinjectors. The avoidance pathway is a great choice for so many patients and families.

John Horton:

Well, and the reason why you're doing this is obviously that it's working. So, tell me a little bit about the results that you've seen and kind of the successes.

Dr. Bjelac:

I'll focus a little bit on our preschool age because that's the most exciting data quite frankly, and there's national studies that support our numbers at the clinic that between 70 to 80 percent of our patients are able to eat full serving sizes of the food after they complete the treatment without needing daily dosing.

John Horton:

That's amazing.

Dr. Bjelac:

It is.

John Horton:

It really is.

Dr. Bjelac:

We take a number where only one in five kids would outgrow it, so some of these kids have naturally outgrown it, absolutely, but only one in five would naturally outgrow it. We take that to four out of five, which is really great. And even at the end, if you're not someone who naturally outgrows it, so many families feel just a sense of peace with having that shield, that layer of protection against one or two peanuts worth of protein, especially as their kids reach independence milestones. So, there's definitely utility to do OIT, even if we never reach that obvious amazing potential outcome of freely eating your old allergen, there's still utility in OIT for many patients and families.

John Horton:

Being able to go out in the world and know that you're bite tolerant to something, it's got to be very freeing.

Dr. Bjelac:

I think so, and I mentioned the precautionary labeling before and just being able to go out to ice cream parlors and things where cross contact was previously a huge concern. You still have to be cautious, you're still allergic. It's not like I told you to leave your epinephrine at home. But just being able to liberalize the diet somewhat and hopefully remove some of that anxiety that unfortunately pervades the day-to-day of so many of our patients and families.

John Horton:

Now is this program that's kind of happening at the clinic, is this kind of an offshoot of, I saw National Institute of Health recommendations to introduce infants to peanuts at an early age to prevent a peanut allergy from developing?

Dr. Bjelac:

You're speaking to the idea of an ounce of prevention. So, we're trying to treat it once we know it's present, but my ultimate goal in life would be to have nobody who needs me as a food allergist. So, if we could prevent all food allergies or cure them even, that'd be awesome, but we're not there yet. So, what we've seen as many patients as possible and families introduce peanuts early, the vast majority of infants do beautifully. They enjoy peanuts, they keep it in the diet, and then they never develop peanut allergy even if they're at high risk to develop peanut allergy, and they never need to meet me. Occasionally, what happens with trying peanuts the first or second time, a child will have an allergic reaction with that introduction, usually around six months of age. Thankfully, infant allergic reactions are very rarely severe. So, it's absolutely, if I may, the time you would want it to happen if it were ever to happen. We never want anybody to have allergic reactions, that's good.

John Horton:

It's the best time for a bad situation.

Dr. Bjelac:

There's no good time for a bad situation, but if there was, it's then. So, then these very young patients come to meet us and we're saying, hey, you have this super young immune system, it's like a puppy. It wants to learn new things. Let's start this food allergy treatment now when you're eight months, nine months, a year, two years old. And that's where we're seeing these fabulous results. So, the short answer to your question is they're two very different topics, but the early introduction strategies are allowing us to identify these kids with food allergies much younger and hopefully intervene in a more meaningful way.

John Horton:

How early can parents start an introduction?

Dr. Bjelac:

It really depends on your family's values and preferences. We typically recommend allergenic foods such as egg and peanut before six months of age, six months or before. And there's good data to support those two foods in particular. As just sort of an offshoot of that, if you may, my kids like fifth or sixth food is always a mixed tree nut butter and then I make sure to get some wheat crackers into them. So, I think most people familiar with the literature know that it doesn't hurt anything to introduce these allergenic foods early, which is very different from the guidance that used to be from the AAP when we thought we knew better, and we said don't give kids peanut till they're three.

That actually probably contributed quite a bit to the development of peanut allergy in this country. So, feeding kids allergenic foods early and often when your child is developmentally ready for solid food introduction, and that's a conversation with your pediatrician and for you all to decide as a family. We know that there's some risk factors to the development of food allergy, including severe eczema. That might make me suggest that you introduce a little sooner, maybe as young as four months of age if your child's developmentally ready.

John Horton:

And as you're doing this, what kind of signs that you might see that go I need to connect with an allergist?

Dr. Bjelac:

So, whenever you're feeding your child new foods, I think it's important to expect that things can change. Their poop might change color, they might get gassy or have changes in their bowel habits. But any concerning symptoms after feeding new foods, particularly common food allergens, such as immediate rash or hives, repeated vomiting, any coughing, stuffy nose, the babies like scratching at their eyes like they're uncomfortable. Food allergy reactions aren't subtle. I think we talked about that in our last session. So, it's an abrupt change in your child, typically with pretty obvious symptoms of an allergic reaction. Step number one there is to seek urgent medical attention. If symptoms are mild, many families will just contact their pediatrician's office and get some guidance that way. Never wrong to seek emergency care in those situations, particularly if your mom or dad's spidey-sense is tingling. Right?

John Horton:

Definitely, yeah.

Dr. Bjelac:

And then after that, after making sure the child's safe, kind of saying to your pediatrician this is what happened, what do you recommend? Hopefully they can get you in touch with a good pediatric allergist.

John Horton:

And I think it's important to really advocate for your child, because I know a lot of times, like you said, people don't take it seriously enough. And if you feel like there's something going on, push to see an allergist and get tests done.

Dr. Bjelac:

Yeah, and seeing an allergist is important if nothing else sometimes for reassurance, talking about the symptoms, especially weeks out, sometimes we can rule out life-threatening allergic reactions pretty quickly. And the testing, unfortunately, isn't perfect and can be useful in some situations to confirm allergy, but that's why it's really important to meet with a good pediatric allergist who isn't just going to panel test your child, diagnose them with a bunch of allergies that they may or may not even have, and then say see you next year. We really don't want to limit healthy foods for kids at any time if we can avoid it. We really only want to eliminate real food allergens because it's so impactful to live with a food allergy and we're setting you up with a potentially lifelong diagnosis.

John Horton:

And most of our discussion today has been focused on peanuts, but I know we were talking earlier, and you said this sort of process where you can introduce it little by little, you can use with a bunch of different allergens.

Dr. Bjelac:

Yeah, so the desensitization treatment, theoretically you could do it with anything. That which we have the most experience with at the Cleveland Clinic includes peanuts, tree nuts, sesame, wheat, because many other foods you're most likely to outgrow so sometimes it might be worth it to give the immune system a shot and see what it does on its own, though we can and do treat milk and egg as well. And then there's some foods that the practicality of OIT becomes a little bit more limited because you do have to eat the food every day, at least during that buildup process, and likely very long term. Getting a three-year-old to buy into consuming multiple fin fish a day and/or shellfish is sometimes not that practical.

John Horton:

It's tough to get them to eat anything much less that.

Dr. Bjelac:

I hear you. So, depending on the allergen, it may or may not be potential for risk versus benefit, and you also have to weigh the nutritional relevance of the food too, and also how impactful this particular food allergy is to you and your family's quality of life. Lots of these things need to be weighed in deciding whether or not to pursue a food allergy treatment.

John Horton:

All big decisions for families to make together. So now I'm going to ask you to get out your crystal ball, and when we're looking at allergies, where do you think we're going to be in a few years as far as solving these or helping people overcome them?

Dr. Bjelac:

Well, I'm really excited about the recent emphasis on prevention. After there was a study published right when I was starting fellowship that showed that feeding peanut early decreased peanut allergy, there's been this whole shift in movement to how do we keep kids from ever developing a food allergy or ever even needing to meet an allergist. So hopefully that trend continues. There'll be more uptake in the community both from doctors but also just directly to patients and families as they're feeding their kids, reach for those common food allergens when they're still little and keep feeding them.

And then there's emerging treatment options. OIT is really exciting but certainly has limitations and unfortunately is not for everyone. So, thinking about other treatment options such as sublingual immunotherapy, there are a couple of trials out there now for patches that deliver peanut protein through the skin and other food allergens through the skin. And there's also other studies in the food allergy space that hopefully will allow us more options. And I think at the end of the day that's what patients and families who are managing food allergies are looking for, until we get to a real cure, which I don't think is imminent but hopefully one day soon-ish. What are some options to improve safety, quality of life, and just really relieve some of the burden that unfortunately is shouldered by these patients and families?

John Horton:

Because it is terrifying to go out there and think that you might take one bite and it could be deadly. So, it's a relief to know that you might be able to somehow block that.

Dr. Bjelac:

Yeah, and thankfully, fatal food allergy reactions are extremely rare. The most important tenant of any food allergy management is reading every label every time and always having your epinephrine autoinjector available in case of emergency. And that's why we have it. But yeah, to your point, just reducing risk is what all medicine is all about.

John Horton:

You had mentioned the patches, and I don't want to let you go before I ask one more question, and that is, I thought there was a shot too, that was available?

Dr. Bjelac:

So, there's no shot available currently for food allergy, but there was published just a few months ago, a study design for both children and adults that they've enrolled patients in, for an allergy antibody blocking product that we use a lot in allergy for things like asthma and hives, that they're investigating in the food allergy space. So, I know we're all waiting with great anticipation to see some of these early data to see if it might be effective.

John Horton:

Well, hopefully that will come out soon and we can have you back to talk about it. I appreciate you coming today, and it's been fascinating.

Dr. Bjelac:

Thank you so much, John. Hope you have a great rest of the day.

John Horton:

If your child has a peanut allergy today, it might not be a forever condition. Optimism is growing regarding treatment advances that could help them outgrow their allergy and maybe even one day enjoy a PB&J. Till next time, be well.

Speaker 3:

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