Food Allergies in Kids

Podcast Transcript

Speaker 3: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now here's today's host.

Jackie Bjelac, MD: Welcome back to Little Health. I'm your host, Dr. Jackie Bjelac, and I'm a pediatric allergist immunologist at Cleveland Clinic Children's.

Today we're gonna talk about food allergies. Food allergies in kids are increasingly common and managing them can feel really scary. So today as we begin our season on pediatric allergy and immunology, we wanted to start by discussing what parents need to know from recognizing food allergy symptoms and understanding a diagnosis to really what are some exciting advances in treatment.

So my guest today is Dr. Kara McNamara. She's a colleague, friend, and pediatric allergist immunologist at Cleveland Clinic Children's. So welcome to Little Health, Dr. McNamara.

Kara McNamara, MD: Thanks so much. I'm glad to be here. Look forward to speaking about food allergies.

Jackie Bjelac, MD: So Dr. McNamara and I are not super young, and Kara, I feel like when we were in school you didn't hear a lot about food allergies and now you know, I hear like we're hearing so much more about it. So are food allergies becoming more common?

Kara McNamara, MD: They are in the United States, although we are also very good and increasingly good at recognizing them. There's probably a lot of different reasons that food allergies are being more common, and no one has one exact answer as to why that's the case. Uh, but we know that for a while, pediatricians in the US and other countries actually recommended postponing the introduction of certain allergens such as peanut or egg, until kids were a little bit older and that actually made everything worse.

So because of this, um, the recommendations on feeding kids allergens in early life have changed and shifted a lot over the past 10 years or so, and where we once used to tell people to wait, we're now actually encouraging people to introduce food allergens earlier in kids' diets, and we hope that will reverse some of the problem, but we don't have one answer as to why food allergies are more common.

Jackie Bjelac, MD: Well, I'm excited you brought that up, um, this early in our conversation, honestly, because that's something that we can control. And I know as a parent, sometimes I feel really overwhelmed by all of the information out there, and it feels like I can't control some of these things that my kids are exposed to in their environment, things that we're learning may have contributed to food allergies, but sounds like early introduction is something that we can do to help prevent food allergy, which is really exciting.

Kara McNamara, MD: That's absolutely right. And we know there are certain foods such as peanut for example, where it probably makes a big difference and for some foods it's a little bit less certain.

Um, but at the end of the day, it's almost never a problem to introduce early. Overall, I think it's great for our kids to also start a diverse diet early in life. So early food introduction and allergen introduction is great for everyone.

Jackie Bjelac, MD: That's awesome. So we've talked already about peanut, and I know that that's an allergen that gets a lot of special attention. Can you comment on some of the more common food allergens in kids? Like as a parent, what do we need to be aware of when we're feeding our kids these foods?

Kara McNamara, MD: So definitely peanut is one of them. Milk and egg are some of the other ones we see most commonly, and especially the infants and young children.

There are overall now nine allergens that are the most common in account for the vast majority of food allergies, although many different foods have been reported. So in addition to milk, egg, and peanut, the other most common allergens are wheat, soy, tree nuts, fish, shellfish and sesame.

And there are certain ones such as milk, egg, that are very common on our young infants and babies, but tend to be outgrown. So you see them a little bit less in older kids or adults. And some foods in contrast, like peanut, tree nuts or some of the seafood tends to be more likely to stick around if kids develop those allergies. So this does change over different ages as well.

Jackie Bjelac, MD: Well, I think that's good to know. So I want to picture the first time that I fed my oldest peanut, and I think it would be really empowering for families who are listening who want to introduce food allergens.

So after the okay from their pediatrician to introduce solid foods what are some good tips for introducing foods early to hopefully prevent peanut allergy? Let's focus on peanut.

Kara McNamara, MD: One of the things to consider is that, um, when we say the word peanut as allergists, a lot of times we mean the allergen, not necessarily a whole peanut.

So despite the using the term peanut, there are a lot of different baby friendly ways to introduce foods, including peanut. For example, there are a variety of peanut powders, um, that are commercially available even in your local grocery stores or online if you like, to Amazon shop, as a lot of us do.

There are options to give young infants peanut butter. If they're not quite developmentally ready for the texture of peanut butter you can sometimes water it down and thin it out a little bit. And there are a variety of products now available, um, marketed for introducing allergens to young babies.

There's no one right way to go about it, so I think talking with a pediatrician can be very helpful. But the biggest key is once you find a way that your infant enjoys is to keep it in the diet. It's not a checklist to go through and introduce a food one time. Once you get that allergen such as peanut into the diet, you really need to keep it in the diet and keep that consistent exposure to maintain that tolerance, meaning that the baby can eat the food with no signs of a reaction.

Jackie Bjelac, MD: So once we get the food introduced, we can celebrate our victory. But it's important to keep it in the diet to prevent allergy 'cause we have to keep reminding the immune system. That's what I'm hearing?

Kara McNamara, MD: Correct. And we don't know exactly how often we need to keep it in. A lot of the studies on prevention have looked at two or three times a week, but we don't know for sure that's the key magic amount. It is a goal we typically use because we know it does work. Uh, so if you can get something in the diet a few times a week, that's great.

And we know that's a long list of food allergens that we've talked about. I mentioned peanuts, the one with the best data on introducing early, but we like to get those other top the nine in there as well.

Again, there are different ways to go about it, and some products make it easier where you mix multiple allergens in one source. I think the most important thing is getting each of those allergens in individually off the bat. And then once you get it in, keeping it in, and whether you need a calendar to say, Monday's peanut day, Tuesday's egg day, Wednesday's milk day, or you do it a little more relaxed. It just depends on what's right for your family.

Jackie Bjelac, MD: Do you think after you've introduced a food once, it's okay to combine them? Like maybe using French toast for wheat and for egg?

Kara McNamara, MD: That definitely is an option. Uh, once you know that your child is tolerating the foods, combining them can make it a lot easier to keep that long list of foods in the diet, and typically allergic reactions happen pretty quick.

Frequently, food allergies will happen on the first exposure or within the first several exposures. So if your child has eaten egg, for instance, several times, then it should be safe to go ahead and introduce it as French toast.

Jackie Bjelac, MD: That sounds great. So you mentioned, I think, what's top of mind for a lot of parents and caregivers when they're feeding their kids these allergens. I think there's fear surrounding that, and I know what I do for a living and what you do for a living, and I wanna normalize and acknowledge that the first time I feed my kids their allergens, I still feel really nervous. So I think it would be helpful for us to walk families through what are some symptoms of food allergy reactions. Like what do we need to look for when we're feeding our kids these foods?

Kara McNamara, MD: Absolutely. It can be scary. Most food allergy reactions happen fast. So the good news is if you feed your child a food in the middle of the day at lunch, uh, you can sleep soundly, knowing they won't have a reaction in the middle of the night.

Food allergic reactions typically happen within minutes and usually a maximum of about two hours after exposure to a food. So presumably if you have a young child and you eat dinner, maybe five, 6:00 PM and you put them to bed a few hours later, there's no concerns for allergic reaction happening beyond that.

And some of the symptoms that we would think about, um, I like to group in terms of the body system that is involved. So you can have allergic reactions that involve the skin, such as hives, which look like raised red mosquito bites, and are often very itchy. You can have swelling such as lip swelling, tongue swelling, even facial swelling. You can have symptoms that involve the belly or the GI tract. That would be things like nausea, vomiting, or even sometimes diarrhea.

You can have symptoms that involve breathing or the respiratory system that would be symptoms such as coughing, wheezing. And in a very worst case scenario, you can have symptoms that in affect the blood or the blood flow through the body, and kids can have low blood pressure or even lose consciousness. Thankfully, those types of symptoms are very rare.

And while we're talking about feeding young babies and infants foods and introducing all these things very early, the good news is that young infants are less likely to have the very severe reactions. While it can happen and babies can have a whole body reaction, which we call anaphylaxis

it's less common and there has never been a fatality from introducing a food allergen to a young infant. So hopefully that can give parents a little bit of peace of mind that while we do want you to introduce these foods very young, this is the best time to do it and to teach the body that these things are benign.

Jackie Bjelac, MD: Well, I'm sure that'll be reassuring to families. I mean, we take all food reactions seriously, but it's a relief to know that infants and very young children rarely have severe anaphylaxis. And hopefully with that knowledge, families can feel empowered knowing that early introduction, there's more risk to not giving the food, right? You could be setting up this child for a lifetime of food allergies by not introducing these things early. So I think that's a really important point. I'm so glad you brought that up.

And the other thing I wanna mention, I like to tell our families when they come in, kids having food allergy reactions aren't happy. Right? They are clearly uncomfortable. There's a very clear behavior change and a lot of families are worried that because their little one can't talk to them, that they shouldn't introduce their allergens. Can you comment on that a little bit?

Kara McNamara, MD: Absolutely. I agree. The the body will tell us. So even though they may not be using words, even our young infant patients can show us when they're having symptoms. They can cry, they can fuss. They might be vomiting or having hives, but it would be unusual for food allergies not to show some sort of obvious sign. So if you're questioning whether your baby is having a reaction their body will tell you.

Jackie Bjelac, MD: Which can be anxiety provoking, but I think really important to know food allergy is not subtle. I think this is really, really helpful. So let's say, um, you're doing these food introductions and you do notice that your child has symptoms of concern. What should families do in that moment?

Kara McNamara, MD: That's a great question. I think it depends a little bit on the relationship they have with their pediatrician. If ever in doubt and parents feel like there are dangerous symptoms happening, it never hurts to call 9 1 1 and get someone to evaluate your child in the moment.

That being said, if if parents are introducing these foods and there's some kind of mild symptom, such as perhaps hives on the face and the baby is otherwise happy, acting normally still playing, there are options to use some over the counter medications such as cetirizine to treat mild symptoms.

Or perhaps the option to call the pediatrician's office and get a little bit more of an opinion. The most important thing is to address what's going on in the moment and then it can't hurt to find your friendly local allergist after that.

Jackie Bjelac, MD: Yeah, so following up with the board certified pediatric allergist I think is really important and would love to hear your opinion. You know, I see a lot of ads for at home allergy tests. Staying or things you can do at home. Why would people take time out of their busy schedules to come into a clinic when we can just order allergy tests at home?

Kara McNamara, MD: That's a great question. Allergy tests are unfortunately very tricky and nuanced, which is why we spent several years in a fellowship learning more about it.

There are some blood tests that are sold straight to consumers and can be found online or other places. Typically, those tests are not validated and many of them do not truly have the ability to diagnose a true food allergy. So I would definitely caution families from turning to those type of products.

The other difficulty is that even when we do use testing that is validated, such as a skin prick test, which we can talk more about in a moment, or a blood test that looks for something called IgE, which is an allergy antibody. Those tests are not perfect tools. They are really good at not missing a food allergy, but they have a lot of false positive results, meaning what initially looks like a positive test may not turn out to indicate an allergy. So we have to interpret all those findings very carefully.

I like to talk about how an allergy diagnosis, not only food, but for some of the other things we take care of is primarily based on the history, meaning the story that the parents tell us is the most important thing for figuring out whether a child has a food allergy more so than any single test. So we have some tools, but the biggest thing is, is talking about what has happened. And so. Anytime parents are worried about the possibility, like we said, they should really be getting into a board certified allergist to help them figure everything out.

Jackie Bjelac, MD: I think that's helpful to hear. So when a family makes an appointment, what are some tests that they could expect us to do depending on the history and how do we use those tests then if these tests aren't super accurate? I'm hearing they don't even diagnose the allergy. Why would we even use these tests? How do they help us?

Kara McNamara, MD: These tests are more about confirmation and sometimes monitoring over time when a child has a food allergy rather than a screening test. And what I mean by screening test is if you have a child that you bring in and you ask a physician, can you do some allergy tests to find out what is my child allergic to?

Our tests aren't really built for that. That's where they can have a lot of false positive results and results that aren't really that meaningful. I've at times said, this is like going in and asking someone for a map. If I go and ask you for a map and you give me a map of Columbus, Ohio, and I'm standing in Cleveland, Ohio, it's not going to be very helpful information. Similarly, when we are looking at food allergy tests, we really want information that will help support the diagnosis or support the story that you've already told us. They can't be used on their own.

But some of the tools that you may encounter are something called a skin prick test. This is where different allergens can be tested usually either on the back or the forearm, and there are different devices out there, but ultimately small drops of an allergen such as peanut, for example, are applied to the skin and there's some sort of small scratch on the skin. We are able to look for a result where there's a red itchy bump, which indicates a positive test.

That can as I mentioned before, help support a diagnosis, but it doesn't a hundred percent mean someone has an allergy, so it's one piece of the puzzle.

Another test we might use is something called an IgE level, which is a version of a blood test that looks for the allergy antibody, which is IgE aimed at a specific food again, for example, peanuts. That gives us a number on a scale, but again, there's not one specific number that tells us, yes, no a child, or yes or no, a child is allergic. It really gives us information about how likely an allergy is. So typically allergists will use some information, including the story, and maybe one or more of those testing tools to put it all together and determine how likely it is a child's allergic to a food.

The other important part about those tests is they really only tell us how likely an allergy is, but not how severe it is. Unfortunately, there's no test out there that can tell you how severe an allergy is once a food allergy is diagnosed in your child if it's IgE needed food allergy, which we can come back to, but this means regular allergy, if you will then there's always a potential for severe reactions, even if your child has only had mild reactions in the past. So unfortunately, all this is very nuanced and difficult, which is why you really need the allergist to put it all together.

Jackie Bjelac, MD: I think that's helpful for families to hear and hopefully understand that this diagnosis is hard. What are some things that we do for families when they come into the office, um, when we've made the diagnosis to help support them and empower them in being prepared for reactions at home?

Kara McNamara, MD: That's a great question. I will add one thing about testing as well in, in that if those initial tools and history do not give us a definite diagnosis, sometimes we'll actually invite families into the office for what we call an oral food challenge, where we give the food in question and we monitor carefully in a controlled setting for signs of a reaction. That's our gold standard, meaning the best test there is for diagnosing food allergy. And there may be times that is or is not appropriate that your allergist could talk about.

But once we've performed all the necessary testing tools to arrive at a definite diagnosis, then really every child should be provided with a food allergy action plan and an epinephrine device that they would have available at all times to be able to treat allergic reactions should they happen.

Jackie Bjelac, MD: I think that's great to to know and understand and unfortunately, a lot of families come to us in clinic and they were never provided with an epinephrine autoinjector. And that's something that I tell our family is, I hope you never need this, but we never wanna wish that we had it and we don't.

So thinking about, you know, we've introduced the food, we've unfortunately had symptoms, we've made this diagnosis. One of the things that I wanna talk about in our time left is what's important do you think, to support the social emotional component of food allergy? You know, food is so social. It's everywhere. Every one of my kids' school parties, there's like a food option. Holidays, especially in the states, seem to revolve around food.

I feel like there's this increasing awareness around the social emotional impacts and would love to hear what you think families should expect from their allergy office to help manage this really important part about food allergy.

Kara McNamara, MD: Absolutely it, it can be very difficult and very socially isolating for kids to live with food allergies, not only for the child themselves, but for their families.

So I think information and is, is always key. We need to help families understand how to live safely with these food allergies. I like to tell families that there should be a healthy amount of fear in a food allergy diagnosis. We don't want families that are not worried and end up having accidents and exposures to the food allergies where their child is at risk for severe reactions.

We also don't want a family to be paralyzed with fear and unable to go enjoy those birthday parties or holidays that you were talking about. We want kids to be able to live their life and enjoy time with their friends. So I think some of the things that families have to consider is how to safely live with the food allergy, how to still have those social activities, like eating out, going to the parties and knowing what carries risk, like what activities will carry risk?

So families really do need to know how to read food labels, for example, to know whether certain foods can be safe for their child with food allergies. And I think having that really well outlined information can help families, um, be confident.

And we also know that bullying is a big part of life with food allergies unfortunately sometimes. Uh, there are many kids in the pediatric age groups that have experienced bullying because of their food allergies, whether it's kids making fun of them, or kids actually threatening to expose them to food allergies. So that's a big part of life with food allergies and needs to be considered by the allergist and the pediatrician and addressed if it comes up.

Jackie Bjelac, MD: Dr. McNamara, I appreciate that you, you know, went through how we use these tests to help us diagnose and sounds like there's a lot of opportunity to empower families to feel equipped to avoid their food allergen, recognize symptoms of reactions if they happen.

What do we offer for our families who want to do more? You know, I think there's kind of that standard of care of excellent food allergy management. Are there any treatments available for food allergy?

Kara McNamara, MD: It is a great time in food allergy practice actually, because we have really had an explosion of the, of the possible food allergy treatments in the past decade or so.

So we can't get into too much detail today. Um, but there are a growing number of treatment options out there. They're not appropriate for everyone, and some families will simply choose to continue avoiding foods, but there are several options available for. Immunotherapy or desensitization is another term, but the idea being that we expose kids to their food allergen, starting in tiny amounts and gradually increasing to build some sort of protection over time.

And the newest kid on the block for food allergy treatments is a medication called Xolair, which actually fights against the allergy antibody and can help protect kids with food allergies as well. None of these food allergy treatments are a cure for food allergies. Maybe we'll get there someday, but not yet. And all of them have various pros and cons.

So as I mentioned, they're not right for everyone. But definitely anyone that has a child with food allergy could ask their allergist to learn more about these options that are out there. And it's only growing over time. So it's an exciting time for food allergy because of this.

Jackie Bjelac, MD: Do all allergists offer food allergy treatments?

Kara McNamara, MD: Not all allergists participate in food allergy therapies. There is a center at the Cleveland Clinic called the Food Allergy Center of Excellence or FACE, which includes several allergists at the Cleveland Clinic who are particularly interested in this area and do offer some of these treatments.

Jackie Bjelac, MD: That's great. And I've had some families come to me and say, you know, we were told by a different allergist that my kid's too young for food treatment. Do we have any age limits, whether too young or too old for food allergy treatments?

Kara McNamara, MD: There is definitely no young age limit. In fact, at the Cleveland Clinic, we find many of the young infants and children's respond very well to treatments when their immune systems are still very flexible.

There also is not any hard and fast rule about therapies in an older age. I will just say that there are some treatments that are a little bit more difficult, um, especially with lifestyle considerations and are more logistically hard, um, for some of our older patients. So they might lean towards one category or another, but there's no hard and fast rules about age that treatment could be considered.

Jackie Bjelac, MD: So it sounds like there's a couple of different options, which is really exciting and different than a decade ago for sure, and really an opportunity for shared decision making. So you need an allergist who can lay out these different options for you and your family and help you find a good fit.

Kara McNamara, MD: Absolutely.

Jackie Bjelac, MD: Do you think there's utility for support staff like a dietician and child psychologist when you're managing a food allergy?

Kara McNamara, MD: Absolutely. And we know we have these individuals here at the Cleveland Clinic that are able to help some of our families, and we've seen the difference it can make.

Dieticians may be able to take time to go over some of the food allergy labeling practices in depth. And a psychologist may be able to help deal with some of the fear that comes from avoiding foods or perhaps the fear with utilizing a self-injectable epinephrine device if necessary. So absolutely having this whole support system in place can be great as well as having, uh, good resources and places to look.

The internet can be a dark place, um, for some things, and food allergy is not alone in that it has some information that's great out there and some that is not so great or can be very misleading. So I think we as allergists can also help direct our families to the best places.

For example, if I don't have time to talk for 30 minutes about food allergy labeling, like I would love to, then I might direct them to, um, the FARE or Food Allergy Research and Education site where I know there's trusted information and handouts on that topic.

Jackie Bjelac, MD: That's so great. Well, I really appreciate you taking the time to kinda walk our families through this.

Hopefully everybody has a really successful food allergen introduction experience, and one day we will not be needed, um, as food allergists, but can't thank you enough for taking the time.

Kara McNamara, MD: Great. Thanks so much. Glad to be here.

Jackie Bjelac, MD: So we do understand the heavy weight that comes with raising a child with food allergies and frankly, how overwhelming it can feel to have that worry. I hope we've provided you with some support and practical guidance today. Next time on Little Health, we'll be discussing environmental allergies, things in the world around us like dust mites, pollens, and your friendly household pet.

If you'd like to schedule an appointment with one of our pediatric allergist immunologists, please call 216.444.KIDS. That's 216.444.5437. Thank you.

Speaker 3: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit Cleveland Clinic Children's.org/littlehealth.