Curing Food Allergies in Children with Early Oral Immunotherapy

Podcast Transcript

Raed Dweik:

Hello and welcome to the Respiratory Inspirations Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short digestible episodes is intended for patients and families and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Sandra Hong, MD:

Hello everyone and welcome to the Respiratory Inspirations Podcast. I'm your guest host Sandy Hong. I am the department chair of the Allergy and Immunology Department, and my guest today is Dr. Jackie Bjelac and we'll be talking about baby oral immunotherapy and food allergies. So, Dr. Bjelac, how can you tell if a patient has a food allergy?

Jaclyn Bjelac, MD:

Yeah, this is a really common question that comes up probably more than you would think. A lot of families bring us their children and say, "Does my child have a food allergy?" And when we talk about allergies in our allergy clinic, we're not really talking about food intolerances, things that cause tummy troubles or skin issues. We're talking about an immune response to a food that causes an immediate allergic reaction. So, this immune response causes symptoms typically within two hours of eating the food, occasionally a little bit longer. And you can see anything from a rash called hives. So, an itchy rash on your kid's skin. Many kids having food allergy reactions might vomit. Some kids will cough or complain that they're having trouble breathing and some kids, you know, and thankfully very rare circumstances might even pass out or lose consciousness. But thankfully, like I said, that's very rare.

Sandra Hong, MD:

So, what do you usually do when they come in with symptoms of allergies?

Jaclyn Bjelac, MD:

Yeah. So, when families come in and they, you know, tell us, "My child ate this food, and they have these symptoms." You know, certainly if there's more than one food in question, we'll test for any of those foods. But just right off the bat there's a short list of foods that cause most of the food allergy reactions in kids in this country. So pretty much just based on history, you tell me what your child's allergic to. The testing that we have in the office is used to just confirm our suspicions. Occasionally we'll use it to rule out other possible culprits. Sometimes if you're allergic to one food it might be more likely that you would be reactive to another. So, the testing that we have can really help guide how we safely move forward.

Sandra Hong, MD:

So, what are the most common foods to cause these reactions?

Jaclyn Bjelac, MD:

Yeah. So, in children in the United States, milk and egg are the most common food allergens. We see a lot of peanut allergies and then allergy to tree nuts. So peanut is actually a legume. But tree nuts are things like cashews, pistachios, walnuts, pecans. And we're seeing a lot of reactions to those. Kids can also have anaphylactic potential to wheat, soy and sesame and fin fish and shellfish tend to be more adult allergens, but we do see those in children as well. So, while you can certainly be allergic to any food, that very short list of nine different things comprises more than 90 percent of food allergies in kids.

Sandra Hong, MD:

So, one of the questions that comes up all the time is, is my child allergic to tree nuts or peanuts, are they allergic to coconuts?

Jaclyn Bjelac, MD:

So, when you get together in an allergy meeting, you can watch us argue back and forth, is coconut a nut or some fruit? And botanically, coconuts are actually some fruits. It's an exceedingly rare allergen. So thankfully families can be reassured even if they're avoiding selecting tree nuts, that their child could eat coconut safely.

Sandra Hong, MD:

Perfect. So, my child has a food allergy. When I come in, what would I expect would happen in the office?

Jaclyn Bjelac, MD:

Yeah. So, the most important thing is that your allergist listens to you. This can be a really scary time. You've watched your child have an allergic reaction that can be extremely anxiety provoking. And I think you, no matter who you see or where you go, should always feel empowered at the end of the visit. You know what else you can safely feed your child or have a plan to introduce other common allergens. You should have a safety plan in place in case accidents do happen. Somebody forgets that, you know, "Oh, there's butter in this cookie and we know you can't have milk," but your child takes some bites of it. If they have an allergic reaction, how do we intervene to keep them safe? So, every child with anaphylactic potential to food, even if their reactions have been mild in the past, should be prescribed an epinephrine autoinjector. And you should feel really confident when and how to use it.

And then you also should feel like you have a plan moving forward. You know, some families will choose what we call an avoidance pathway where you just read every label every time and your child live a full healthy, happy life with their food allergy. And that should be something that we empower you to do. We can help you with the tools for when your kid starts preschool or grade school, that their food allergy is something that they manage but doesn't define them. Right. But then there's also treatment options for food allergies. So oftentimes, to be honest, after the first visit, we don't talk a ton about it, but at least we should mention it to see if you have an interest in learning more.

Sandra Hong, MD:

How old can you be to be diagnosed with a food allergy?

Jaclyn Bjelac, MD:

Yeah, so unfortunately if you're old enough to eat, you're old enough to have an allergic reaction to a food. And sometimes it is with babies, quote unquote first bite of a food. You know, we've moved towards this really exciting discovery that if you feed kids allergens early around four to six months of age, that can help prevent food allergies. But sometimes if you give your kid peanuts at five months old, they could react. And so, we're seeing kids as young as four, five months old in clinic, but then, you know, food allergy can certainly develop in adulthood as well.

Sandra Hong, MD:

So, I saw an allergist and they told me my five-month-old had a peanut allergy, but they asked me to avoid the peanut from there on out. What are your thoughts on that?

Jaclyn Bjelac, MD:

Yeah. So, you know, first of all the most important thing is does your child have a convincing history of reaction or is this based just on a test? And one of our favorite things to do with the clinic is what we call de-label kids with food allergies. Because unless your child's actually eaten food, we really don't know based on a test alone if they're allergic or not. We could certainly predict likelihood based on a couple of factors, but it's not a slam dunk diagnosis until you eat it. So, it's important that we make sure that that's actually something that's true for your child. But there are treatment options even for very young children. And one of the things that we do at the Cleveland Clinic that we're really excited about is early oral immunotherapy or OIT for short.

Sandra Hong, MD:

So, you're telling me that babies can actually start therapy for food allergies?

Jaclyn Bjelac, MD:

Yeah, so what we do in this treatment is we teach the immune system very slowly over time that the thing to which your child is allergic is actually safe. That's a process called desensitization. It's actually the same idea as if you've ever gotten allergy shots. Basically, we're just telling the immune system, "Hey, you need to calm down." So, with food, let's take peanuts for example because it's the thing for which we have the most experience. And we see the most reactions to, quite frankly in clinic these days, we start by giving your child an infinitesimally small amount of peanut by mouth. We don't do it in a shot, and they eat that amount every single day. And then slowly over the course of months we build up until your child's eating the protein equivalent of two peanuts a day.

At the very least, at that point you have this incredible level of protection against accidents. Foods with precautionary labeling don't matter anymore. "I don't care if it may contain peanut little Johnny is eating two peanuts a day." But what's really, really cool about doing this treatment, this OIT in young kids is that their immune systems seem to really want to forget that they were ever allergic in the first place. So, for many of our patients, between 70 and 80 percent, if we catch you before four years of age, are able to eat full serving sizes of the food without having any allergic reactions or needing to dose every day. We basically force your immune system to outgrow it by doing this treatment if your kid is young.

Sandra Hong, MD:

Should I be doing it at home without coming in to see an allergist?

Jaclyn Bjelac, MD:

Absolutely not. Because you know, nothing is without risk. And certainly, that is very true of OIT, you know, your kid's eating something every day that they're allergic to. So, one of the most important parts about doing this treatment is that you understand the risk, you understand the things that we have that can help reduce that risk, which is huge. And that you have someone to turn to when questions come up. "My kid had these mild symptoms, what do I do with my dose?" There are probably very few examples in healthcare at this time where the treatment is so individualized to the patient. We tailor every decision based on how your child is responding. That's just not something that could ever be done safely at home without an allergist.

Sandra Hong, MD:

And I think that's the key is safety is the goal here. Right? So, if I didn't do the therapy, what would be the chances of outgrowing some of these food allergies?

Jaclyn Bjelac, MD:

Yeah, that's a really good question. And that's something that we talk about before we decide to start treatment too, right? So, if a child's allergic to some foods like milk and egg, your chances of naturally outgrowing it are pretty good. About 80 percent. There are some kids who are allergic to milk and eggs who can eat some forms of those foods and that helps me feel more confident that you'll probably outgrow it. Whereas foods like peanuts, tree nuts, sesame, based on what we know, you have less than a 20 percent chance of outgrowing those. So given how much less likely it is, we tend to try and be really aggressive with treating those food allergens early. You know, not only because the treatment's so effective when a child is young, but it's also extremely safe. So, you know, not to harp on this point of safety, but very few reactions to the dose itself, they tend to be mild. Whereas if you're a teenager, I'm having a really different conversation with you about the safety profile of doing something like OIT.

Sandra Hong, MD:

Yeah. So, I think that that's a really important point, you know, by leaving someone with a peanut or tree nut allergy that their chances of growing out of it are more 10 to 20 percent. So, they will always have to read packaging.

They will always have to be worried about the bite of the cookie. They'll always have to kind of ask at restaurants, does it contain whatever food they're allergic to. However, if you're able to do early OIT, especially below four years of age it's closer to 80 percent even higher if you get them even younger than that.

And so, it's really important to recognize that there is a time limit. And it's not that you can't do therapy as they get older, however the younger the patient, the rate of success goes up so much more.

Jaclyn Bjelac, MD:

Absolutely. It's a very different conversation when your kid's eight months or when they're eight years old or when they're 18, your discussion about what your journey will look like, and the outcomes are just very different at those intervals. It doesn't mean that at any point the treatment must be done for anyone. And it doesn't mean that at any point it can't be done for anyone. But I think the sort of risk benefit discussion really varies by age.

Sandra Hong, MD:

For those listeners out there that don't have food allergies what is it like to live with a food allergy?

Jaclyn Bjelac, MD:

So, we got to do a really interesting experiment when I was a fellow that I think was really empowering as an allergist because I myself don't have any food allergies. So up to that point in my life I hadn't had to avoid it. So, I would challenge every listener to pick food. I would suggest milk or egg because those are very pervasive. And just for two or three days, try and avoid that food. Read every label of anything that crosses your lips, foods, drinks. You want to use toothpaste or a ChapStick, you got to look at that label. If you go out to eat, you have to tell a person in a restaurant, "I have an allergy, I can't eat this food." If you go to a barbecue, you have to tell the hostess, "I can't eat, you know, insert food here." These families have to make decisions at every point where food is involved and think about how necessary and socially pervasive food is.

Every single decision point that they make about food has to be done in the context of, "If I make a mistake, my kid could have an allergic reaction." It's something that's incredibly impactful. And many of our families really struggle with social isolation. They feel like their kids can't participate in birthday parties or do things away from them. Their grocery bills are higher. Certainly, milk alternative yogurt costs a lot more than cow's milk yogurt. So, it's several hundred dollars a year difference based on what we know for families that have to buy food alternatives. So, the short answer to your question is extremely impactful, but I think it's a really cool social fit, experiment to do to try yourself to avoid. I think it gives us a lot of empathy when we have to send the food to class that can't have, you know, peanuts and tree nuts in it because one of your kids' classmates couldn't participate if they can't eat that food.

Sandra Hong, MD:

Yeah. I think the other thing that is a really big deal is the bullying portion of it. You know, so you know the studies that look at bullying and show that if your patient, if a person has more than one food that they're allergic to, they've got a 50 percent chance of being bullied at some point in their life, sometimes from teachers, sometimes from other school personnel because you know, "We can't have the party because you know, Jimmy has a milk allergy - bring in pencils for Halloween this year or we'll pass out stickers." Right? And that can become really, really isolating for these families and really challenging for them. So, what does the Food Allergy Center of Excellence have to look at these difficulties with nutrition and social wellbeing and psychological wellbeing?

Jaclyn Bjelac, MD:

Yeah, so managing food allergy isn't just about the allergist and the family. We have a dietician as part of our team who can help make sure that kids are meeting nutritional goals. And we also have a child psychologist to address these issues. Not just bullying, feelings of social isolation, but a lot of kids feel anxious about eating understandably. You know, they're worried that if they make a mistake, they could have an allergic reaction. So, it's really a multidisciplinary approach and we're so lucky to be able to offer that to our families.

Sandra Hong, MD:

Yeah. What types of food allergies do you treat with OIT?

Jaclyn Bjelac, MD:

Yeah, so OIT could treat foods to which you have allergic potential, any food really. Some foods, you know, we talk to families about would you really want your kid to eat a piece of cod every single day to treat a fish allergy? Probably not. But we can treat milk and egg though sometimes we'll wait a few months to see if you might outgrow that on your own. The foods that we treat most often are peanuts, tree nuts, like cashew and walnut and sesame is one that we treat quite a bit. We can also treat wheat, soy, but those are the ones with which we have the most experience.

Sandra Hong, MD:

Great. So, if I have a child that is over four years of age are there any therapies for them or is it just, you know, we're all done, there's no chance at this point?

Jaclyn Bjelac, MD:

Yeah. So, I think we hinted a little bit earlier in the conversation that OIT is still a really wonderful tool for older children and even adults if they wish to pursue it. At the very least, when you get to the gold dose of the treatment, you're protected against a whole protein's worth of a single peanut, two peanuts and usually quite a bit more. So that can be really liberating from a food avoidance standpoint. All of a sudden you can go to a bakery where there's clearly a peanut next to the, you know, doughnut that you want. Who cares? You eat two peanuts worth of protein every day. So, the avoidance of foods that may contain or process in a facility with our cross contact, cross-contamination just becomes much less top of mind, which is really, really powerful. And if you do have an accident and eat something that has peanut in it, if you do react, the reaction's gonna be much less severe than if you didn't do the treatment.

So, it's still an incredible tool, even if we're not telling you that, it's very likely that you'll be able to eat full serving sizes. So that being said, you know, the logistics of oral immunotherapy can be really challenging and there's certainly some risk to it that I think we've already talked about. So, there's other treatment options, particularly something called sublingual immunotherapy that we offer at the Cleveland Clinic. It's much smaller doses, so the logistics and the risks are much less. It just takes a lot longer to build up the level of protection. So that's a trade-off there, but one that a lot of our families of older kids have been really excited about.

Sandra Hong, MD:

That's great. Is it common to be able to find these therapies for families?

Jaclyn Bjelac, MD:

Yeah, so oral immunotherapy is not something that is new, but offering it in very young children is pretty novel. So, the Cleveland Clinic is one of very few academic medical centers in the entire country that does it. And the fact that we offer it to a number of foods is really unique. So, we're really proud of that. I'm really excited to be able to offer that. SLIT as well is pretty novel, the sublingual immunotherapy. So, the fact that we have all of these options, whether or not you or your family choose to take advantage of treatments, it's just really cool to be able to know that they're available.

Sandra Hong, MD:

Yeah. The early OIT, is it as successful with all of the foods or really do I need to focus on, you know, just certain ones?

Jaclyn Bjelac, MD:

Yeah. So, we can offer it to any food and the effectiveness doesn't seem to vary based on our experience. You can treat anything. And it's been really exciting as we've gotten better and better at it to be able to make multiple foods at one time to try and save families trips and visits. Not just our families who come locally, but many of our families are traveling from a distance.

Sandra Hong, MD:

Yeah. And I think that one of the most rewarding things about allergy is being able to see these families where you know that when they walk through the door the first time, you know that that family is going to have a child even though they're only five months old that they're gonna have a food allergy for the rest of their life if they don't do the therapy.

Jaclyn Bjelac, MD:

Yeah.

Sandra Hong, MD:

And then to see them go through the therapy and you know, in a year that they're absolutely basically done with that food allergy they're cured from that food allergy as long as they continue to eat it in their diet.

I think that is incredibly rewarding, especially for us and the families. To not have to carry an EpiPen any longer is just so freeing for them. To know that they can drop them off at daycare or they can go off to school with a milk allergy and not have to worry about having an anaphylactic reaction.

Jaclyn Bjelac, MD:

Yeah. It's been really amazing and an incredible tool to be able to offer to families. It's a really, really exciting time.

Sandra Hong, MD:

Yeah. Is there anything else that you'd like to share with our audience?

Jaclyn Bjelac, MD:

Well, I just want to thank everyone for their time and listening to us. It's really exciting, you know, for Dr. Hong and I to be able to offer this treatment at the clinic because we do really feel so passionately about the outcomes, especially when you bring us your kids when they're young, to be able to tell you that we can change the natural history of your child's food allergy is something that really no one could have said five, 10 years ago. So, this is really cutting edge and exciting and it's just an honor to be a part of it. And no matter where you end up getting care, you should always feel empowered by your allergist. And until you do, please get other opinions, even if they're not from us. But we're always happy to see you at the Cleveland Clinic.

Sandra Hong, MD:

Thank you for everything.

Jaclyn Bjelac, MD:

Thank you.

Sandra Hong, MD:

Thank you Dr. Bjelac. And thank you everyone for listening to our podcast today. I'm your guest host Sandy Hong, the allergy and immunology chair at the Cleveland Clinic. And my guest today was Dr. Jackie Bjelac, our associate director of the Food Allergy Center of Excellence, and we talked about oral immunotherapy, baby OIT. Thank you.

Raed Dweik:

Thank you for listening to this episode of the Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.