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"Let the Babies Eat: Revolutionizing Infant Feeding and Allergy Prevention" · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmint, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Today, I'm bringing you Grand Rounds, a fascinating talk, Let the Babies Eat,
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a practical guide for food introduction and allergy prevention.
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He's a professor of clinical pediatrics and the director of the Food Allergy
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Treatment Center at Nationwide Children's Hospital and the Ohio State University College of Medicine.
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Let's listen in. It's a pleasure to be with you today. What I'm going to talk
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about is something near and dear to my heart.
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And as you see, as we go through things, I hopefully will present information
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and a new perspective for you all that may hopefully adjust the way that you
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communicate with families.
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And here are the objectives. We're going to talk about the confusion surrounding infant feeding.
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I'm going to give you the best practical advice I possibly can,
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and then really talk about ways we can anticipate parental concerns during those
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visits that you have with them throughout your day. including.
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Here's my goal. So I want to give you new perspective.
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Everything I talk about will be evidence-based information. This isn't just Dave's opinion here.
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This is me serving as a conduit to give you all the published,
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you know, guidelines and research and things like that, and then hopefully help
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you appreciate, you know, your very important role in helping families feed
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their babies and ideally prevent food allergies.
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So when we talk about this, we have a lot of outdated information,
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which I'm going to address sort of right off the bat.
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We have wonderful new evidence and guidelines, which I'll share with you.
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And this is how we develop progress. And I think it's a good thing for all of
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our families and their babies.
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So before we begin, I think it's always important to acknowledge the enormous
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elephant in the room when it comes to this topic, because,
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I think we've done a very good job as a medical establishment at confusing parents
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and frankly, scaring them at feeding their babies.
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And a lot of it has to do with our own guidelines and flip flopping evidence and things like that.
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So I think if we go in this with some humility, and when we talk to parents
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about how this is what we once thought it was, and this is where we are today,
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and acknowledge how confusing it has all been, I think that's a very good starting place for all of us.
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So how did all this start? Well, in the year 2000, the AAP published guidelines
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in regards to food allergy and feeding infants, and it basically said no milk
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until one year of age, no eggs until two,
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no nuts, peanuts, or seafood until three. If you're pregnant or breastfeeding,
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avoid all of these things.
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Just eight years later, which is a remarkable turnaround when it comes to national
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guidelines, they said, well, hold on a second.
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Maybe we don't need to avoid these things, but if you feel like it, you can introduce them.
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It wasn't an active guideline to recommend get these foods in the diet.
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It was more of a passive suggestion.
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But just within eight years, it's very confusing, and a lot of people still
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held on to the 2000 guidelines.
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2015 was a pivotal landmark trial I'm sure you're all familiar with, the LEAP trial.
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This was the first prospective randomized controlled trial that demonstrated
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if we introduce peanut into an infant's diet before a year of age and keep it
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in their diet consistently up till five years of age, compared to those infants who avoided it,
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there was an 86% reduction in peanut allergy at five years of age. This was remarkable.
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This changed everything for us in regards to our understanding of tolerance
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and food allergy prevention.
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2017, I was part of the US guidelines that we wrote and we said we should test
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babies for peanut before introducing it when they're at risk to develop allergies,
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specifically those with moderate to severe eczema. That was based upon one study.
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I frankly think we jumped the gun a little bit, and we're going to talk about
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screening and things like that.
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And then in 2021, we also reversed and wrote the North American guidelines,
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which basically said no need to test.
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So flip-flop after flip-flop after flip-flop. All that to say is,
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did we fix it? We have no idea.
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This is a hard thing to study in regards to prevalence of food allergy.
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I'll share some data about how we're still not consistent with talking to families,
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but this is why it's been so confusing for all of us.
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There was a survey a few years ago talking to U.S. parents, 3,000 of them.
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Only 13% were aware of the peanut guidelines. Half of them didn't really understand
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that if you introduce foods early, we could prevent food allergies or decrease the risk.
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Half still felt that it wasn't safe to introduce peanut prior to 12 months of age.
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And then 40% said their pediatrician never really discussed this with them.
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So that was a few years ago.
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We don't have really good data
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since then, but this is something that we need to continue to monitor.
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So here's a common scenario. When it comes time to introducing foods to babies.
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A lot of parents are just scared out of their minds. I don't know about all
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of you, but I have families tell me that they've driven to the parking lot of
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the emergency room before they feed peanut to the baby the first time.
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And that's heartbreaking because this should be a really fun milestone when
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we start introducing solid foods to babies and we want to try to provide that reassurance.
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There's a lot of messaging that's been displayed over the years,
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but I'd like to correct some of that with the actual evidence.
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So for years, I think people have been told that babies are more at risk to
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have severe reactions because they're small, they're nonverbal,
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they have little airways.
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The reality is it's extremely unlikely for a severe reaction to be the presenting food allergy reaction.
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Almost always, 97% of the time, it's going to be some combination of hives.
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Maybe they vomit once or twice. That's how I get patients as a pediatric allergy.
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I don't get patients because they end up in the ICU the first time they eat peanuts.
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We really want to reassure families, even when food allergy reactions occur,
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they're almost always more mild and self-resolved.
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I don't know where this came from. It's a very conservative approach to introducing
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foods, but the message has been only one new food every five days,
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seven days, once a month, things like that.
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There is zero evidence to support this. This is an ultra conservative approach.
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And now I'll share evidence with you where we actually want to promote,
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let's give multiple foods even all at once, because odds are nothing's going to happen.
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And if something does happen, we can go back and sort it out and clarify what's going on.
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Some parents have been told to just rub a little bit on their skin first.
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We don't want to do that for two big reasons.
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One, you're going to get nonspecific rashes that's going to raise alarm and
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cause unnecessary angst.
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And number two, that's a great way to sensitize people to allergens,
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whereas we want them to eat it to promote tolerance and expose it to the amazing
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immune system involved in the gut.
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The message has always been, well, food allergies can occur the third time you
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feed your baby or the fourth or the seventh, and you're never really out of
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the woods. Your baby's a ticking time bomb.
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The reality is no matter what we do, 92 to 95% of babies will never develop a food allergy.
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So we want to flip this on its head and reassure people. And I'll talk about
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risk factors in a moment.
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And then the message has been that eczema must be because of something you're
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eating. And that is completely false. And I'll share all that with you as well.
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So I just want to lead off with the bat of some of the flip-flopping and inconsistent
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sort of recommendations that have been placed over the years and where we are
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with our current understanding.
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So let's talk about some of the hot topics right off the bat,
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and then we'll talk about some practical tips. So.
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Atopic dermatitis or eczema and allergies are intricately linked,
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but allergies don't cause eczema.
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Eczema is a chronic skin condition hallmarked by a defective skin barrier with
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a very complex immune pathology underneath the skin.
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And allergies can play a role, but that's not why people have eczema.
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When we look at systematic reviews, this is a great one published in the last couple of years.
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We look at, does food elimination improve eczema?
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I'll cut right to the chase. Dietary elimination may lead to a slight improvement
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in eczema severity for some patients, typically those with the most severe eczema
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that's refractory to treatment.
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However, the degree of benefit is potentially unimportant compared with the
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risk for harm because what happens is if we start removing food from the diet
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of babies with eczema and they're already making IgE but they're not reacting
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to that food and then they avoid it,
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that's when they can develop an actual food allergy that can transition to hives and anaphylaxis.
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So that can cause real harm. The most recent atopic dermatitis guidelines or
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practice parameters were published about a year ago.
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There is a recommendation we suggest against the use of elimination diets.
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Again, it can cause harm. It's not going to provide much benefit.
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And most importantly, right now for atopic dermatitis, we have dozens,
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dozens of effective therapies. And we're moving beyond just topical corticosteroids.
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We have calcineurin inhibitors. We have JAK inhibitors.
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We have biologics. So we can fix the skin without removing food from the diet.
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This is one of the most common diagnoses that I see at our Food Allergy Treatment
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Center. It's L24.6, irritant contact dermatitis due to food in contact with the skin.
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We have a beautiful blonde-haired, blue-eyed, fair-skinned baby who starts to
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eat things like tomatoes and strawberries and ranch dressing and citrus,
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and they get rashes around their mouth every time they eat. This is not a food allergy.
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These children are often well-appearing. The foods that are causing these rashes
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are uncommon causes of food allergies, such as fruits and purees and things
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like that. this can come and go over time and this can occur for dozens of foods.
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So we always want to make sure we clarify the diagnosis, but we don't want to
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raise alarm when we have a well-appearing infant who gets a rash when they eat
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cinnamon and things like that.
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Other things that are not due to food allergy. So we know that colic is not a food allergy.
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Reflux is not a food allergy. It's a physiologic condition. These are things
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that you can find online and in social media.
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Fatigue, chronic abdominal pain, migraines. It's interesting because these are
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some conditions that may be worsened by certain food.
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Like we know migraines may be triggered by foods that have tyramine,
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for instance, or caffeine.
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And you're not allergic to those foods. You have the condition that may be worsened
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by that same thing with reflux.
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I have reflux. If I eat a dozen buffalo wings, it acts up. I'm not allergic
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to buffalo wings, but that's an example of that.
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Diaper rashes are not caused by food allergy, changes to the bowel pattern,
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chronic hives are not caused by food allergy, same thing with bloating and things like that.
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So when we see these very common concerns from parents, we can reassure them
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that it's not due to an allergic reaction to any specific food.
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Then we talk about this nebulous diagnosis of quote-unquote cow's milk allergy.
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And there was a recent review of the guidelines published regarding cow's milk
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allergy over the past decade.
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And basically, they attributed this diagnosis to every symptom imaginable,
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from rashes to colic to poor sleep to reflux and things like that.
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They also talk about how maternal breast milk really doesn't contain a lot of allergenic protein.
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So 99% of the time, it's not going to pass through and cause any symptoms.
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And then there is a conspiracy because a lot of these guidelines are actually
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written by folks who have conflicts of interest because of their work with industry
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and former manufacturers.
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And there was an interesting review in JAMA Pediatrics a few years ago that
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looked at recent guidelines, and they found that a lot of them actually included
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symptoms that are just nebulous and not really due to allergies,
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such as just rashes or colic or reflux or things like that.
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And they also looked at maternal diet. It rarely, if ever, passes intact cow's
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milk protein through the breast milk when they're breastfeeding.
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And some of these guidelines, there are significant conflict of interest with
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people who had connections with industry and formula manufacturers.
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So there are good guidelines now. It's through the World Allergy organization.
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There's a 12-part series. I encourage you to read this on your own.
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But this really talks about using milk elimination as a diagnostic and therapeutic trial.
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And it acknowledges that this diagnosis of cow's milk allergy is overused.
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It can also be underused. We talk about the elimination diet in a second.
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And then reintroduction. We don't need to wait until 12 months of age for dairy
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because a lot of times these are benign conditions that resolve on their own
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or it's actually not due to milk allergy.
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This is the most common presentation. I apologize for those of you eating your breakfast right now.
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The cow's milk-induced allergic product to colitis. You have an otherwise well-appearing
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infant who's growing normally, acting fine.
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You change their diaper and you see gross red blood or you have hemocult positive.
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That's the more common presentation for this.
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So when we go back to the guidelines, it talks about if you consider this diagnosis
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in an infant of cow's milk allergy, we can do a trial elimination diet.
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So if they're on cow's milk-based formula, you can put them on a soy formula.
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If we think that it is passing through maternal breast milk,
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we can do a maternal dietary elimination, but do it for two to four weeks.
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We don't need to eliminate it for six months or nine months.
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Do symptoms completely resolve?
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Then put milk back in the diet. Do symptoms come back again?
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If not, it's not cow's milk allergy or whatever it was it's resolved.
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If they do come back again, then remove it for a period of months at a time.
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If you take it out of the diet and symptoms do not completely resolve,
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it's not cow's milk allergy.
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Put it back in the diet and consider another diagnosis. So we can really use
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these much shorter elimination diets now.
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And the reason why is because the vast majority of these infants that have this
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diagnosis, there's another cause or is a self-limited benign condition.
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So I think we can just be more thoughtful and more helpful for families when it comes to this.
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And this goes for breastfeeding mothers as well. So I think it's now well-recognized
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that blanket recommendations for mothers to eliminate certain foods from their
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diet due to conditions in their infant really are probably incorrect.
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This is a great review article, and it really talks about how a thoughtful approach
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is necessary, and we want to minimize unnecessary diets.
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I have so many mothers in my practice that are just in tears because they've
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taken out dairy and egg and wheat because of improper reasons such as eczema
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in their infant or reflux or colic or stuff like that.
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And their baby either doesn't get better or they've gotten better just because
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tincture of time is what fixes this.
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And these mothers stop eating these foods that they blame themselves because
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they slipped up and had some butter in their meal or something like that.
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Here's the algorithm. So if you are going to recommend that a mother remove
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food from her diet, it really starts with what's the diagnosis.
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So are we diagnosed, what are we diagnosing the infant with?
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If it's eczema, as we talked about before, it's unlikely to be due to the diet
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and especially food passing through. So we don't need to even recommend that.
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Is it GI symptoms? Again, what's the diagnosis?
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If it's reflux, that's not going to be specific food related.
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Is it cow's milk allergy? We can do a trial elimination and things along those
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lines. So just being more thoughtful to help the families that we care for,
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I think is going to be important.
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And then lastly, this is a great review article that really looked at how much
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intact allergenic protein passes through breast milk.
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And they found that there's less than one in a thousand actually had intact
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allergenic protein pass through the breast milk.
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So it's pretty rare. Even in infants who have IgE-mediated peanut allergy anaphylaxis,
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those mothers don't need to stop eating peanut.
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They're not causing allergic reactions after breastfeeding.
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So again, it's a complete reversal of what many of us have taught.
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The way we've practiced, but it all goes back to just being more thoughtful
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and how we're recommending these things for families.
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All right. So now we talk about the outdated, incorrect approaches and these
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rapidly evolving new evidence and paradigms.
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And it's enough to make your head spin. So let's talk about food introduction.
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We know that these babies that have eczema are raising their hands saying,
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I'm going to have an allergic life.
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So oftentimes their eczema resolves within the first one to two years.
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They may or may not develop food allergies. that may or may not develop environmental
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allergies as they get older than asthma.
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But this is the common progression that I see in my practice,
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at least on a regular basis.
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We can't prevent eczema, unfortunately. There have been many trials that have
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done that. They've even using emollients from day of life one.
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It can delay the onset or lessen the burden of it, but we can't actually prevent that.
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We can't prevent asthma. There's no interventions that can do that.
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There's no good way to prevent allergic rhinitis, but we do actually have ways
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that we can potentially prevent food allergy, which is what we're gonna talk about next.
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So why should we try to do this? Well, we know that food allergies are relatively
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common. They affect about 8 to 10% of children, depending upon what studies you read.
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They can be lifelong, especially when it comes to peanuts, tree nuts, seafood, sesame.
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So it can be a big burden for throughout their lives. It can put them at risk
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to have allergic reactions.
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It can also cause decreased quality of life. While we do have treatment options
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available, we don't have a known cure for food allergies.
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So if this isn't a call to arms to do everything we can to try to prevent this
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from happening in the first place.
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I'm not sure what is. So what are risk factors? I think we can now,
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you know, stratify infants into low, medium, and high risk to develop food allergy.
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Family history is actually not a very strong risk factor. So we know that parents
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don't pass specific food allergies down to their babies.
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So we have a lot of parents that have their own history of peanut allergy and
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they're afraid to feed peanut to the baby, but that actually isn't a very strong
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risk factor. So we don't need to worry about that so much.
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The age of introduction can be a risk factor. If we delay this and we wait until
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kids are over a year of age, that may actually put them at risk to develop food allergies.
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And then the severity of their eczema. So it's not like that little patch that
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gets better with some topical cortisone and it just keeps coming back over time.
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It's those infants that have a large body surface area that's affected or they
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require more potent topical corticosteroids to control their disease.
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Those are the ones that are at highest risk.
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So the one thing we can modify, we can't change the family history.
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We can treat eczema, but we can't prevent it from happening,
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but we can modify the age of introduction. So that's what we can target.
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Now, hopefully we can all agree. And if you're not familiar with the literature,
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I'll go through some of that.
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But we have study after study after study and meta-analyses all showing that
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the earlier we introduce allergenic foods into a baby's diet and,
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most importantly, keep it in their diet consistently, it's not try a little
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dab with peanut butter and then wait six months before you try again.
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It's keeping it in the diet consistently and diversify their diet.
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This is our best path towards preventing food allergy. Is it 100% effective? No.
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Nothing we do in medicine is 100% effective, but this is what we want to recommend
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as much as we possibly can.
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However, we have to balance this. So for those families that if they don't hit
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this window and they haven't tried it, we want to reassure them that it's going
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to be okay and we can still introduce this.
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We don't need to avoid it because they haven't had it by 12 months of age or things like that.
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Here's just a nice little, you can see all the different odds ratios and things like that.
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So the meta-analysis, we have over 14,000 children that look at this.
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The evidence is strongest for peanut and egg, but it's also accumulating for milk and other foods.
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But I mean, it's robust evidence that early introduction to ongoing inclusion
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is the best path towards preventing allergy.
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But these are just some of the things that parents have been told traditionally of.
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My pediatrician told me to see an allergist before I introduced these foods.
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I'm too scared to give peanut. Again, as we talked about earlier,
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we've done a really good job of scaring parents and people want to be tested
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for everything or they think that their child's eczema is caused by food and stuff like that.
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So we can address this and reassure families as much as we can.
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But how do we make this happen? Well, it's going to take all of us.
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So you're on the front lines.
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You're meeting these families at their well visits. So this is hopefully a conversation,
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hopefully a conversation that even obstetricians are having.
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And there's been some interesting quality improvement studies that look at,
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you know, can we have this conversation about solid food and allergenic food
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introduction during pregnancy before the baby's even born?
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But we're going to have to do this, you know, all together and systematically to make this work.
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So the timing does matter. So we know that for prevention efforts,
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we really want to get this before the disease sets in.
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Earlier the better. There's a risk that actually increases over weeks to months.
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So it's not like, you know, we want to go for between four to six months of
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age once they're already showing interest in eating other solid foods.
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So we want to start with the typical purees and things like that.
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And then we want to introduce the allergenic foods, but it's okay if they don't
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hit that window, but it does, the risk does increase after, you know,
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six months and in between six and 11 months. So that's what we want to promote.
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In addition, we want to, you know, use good science to talk to people about the latest evidence.
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So when it comes to anaphylaxis, there was a great update to our practice parameters
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that was published last year as well. And they address certain things with infants.
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So when it comes to infant anaphylaxis, I'll read some of the consensus-based statements.
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We suggest clinicians be aware that in infants and toddlers,
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age does not correlate with severity. As we talked about at the start of this,
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it's unlikely for infants to have truly severe life-threatening reactions the first time they react.
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We suggest clinicians be aware that anaphylaxis is unlikely to be a initial reaction.
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We suggest clinicians be aware that parents of infants and toddlers may report
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age-specific symptoms.
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So for babies that can't verbalize, maybe it's more subtle and it's just they
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have acute onset irritability and crying while they're developing hives after
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eating a food. That can be a presenting symptom.
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And most of these are going to be hives and vomiting and not anaphylaxis.
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So when we look at all of the guidelines that have been published,
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it's interesting because the United States is the only one that has their latest
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guideline or the last guideline that recommends screening with testing prior to introduction.
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For the rest of the world, that's all looking at the exact same evidence.
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They suggest not testing before introduction. And we'll talk about why.
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So there's some pitfalls if we screen.
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So from a caregiver standpoint, we can cause undue anxiety. They may think that
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they have to have a test done for food allergy before they introduce the food,
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or there's really distrust in these changing guidelines.
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For the clinician, it is well-established that IgE tests are grossly misinterpreted
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that leads to over-diagnosis and misdiagnosis.
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It can give an inaccurate diagnosis and unnecessary avoidance.
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Plus, it takes time to get them in to get referred and tested and things like
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that. So we can delay the introduction and miss this critical window.
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And it's also not very cost-effective. And, you know, with the disparities in
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access to specialists, we have to address that as well.
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So when we over-diagnose food allergy, this is where these screening tests come in.
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So there's no indication to ever order just like a panel of IgE tests for food allergies.
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And I know all of you have these folks coming into your practice saying,
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wouldn't it be great if you could just test your patient's blood,
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tell them everything they're allergic to? Well, that's not how these work.
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So the IgE tests only detect sensitization. They don't actually diagnose allergy.
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When we know 40% of children are sensitized to things like egg,
20:40
milk, peanut, and shrimp, but only 5% are allergic, we're over-diagnosing the
20:44
vast majority of them by using these tests.
20:46
So we don't want to use these as screening tests. And we go back to the first
20:50
days of medical school or undergraduate education, we talk about,
20:52
all right, what makes a really good screening test?
20:54
When we think about IgE tests for foods, it doesn't meet any of the criteria.
20:58
So these have never been screening tests and they shouldn't be used like that.
21:02
There's tons of false positives and they get grossly misinterpreted.
21:06
So when we talk about those families that we're seeing, there's different ways
21:09
we can have the conversation.
21:10
So for those parents that are having the first baby, no concerns.
21:13
My advice is just proactively discuss the benefits of early introduction.
21:16
We want to introduce these foods in your baby's diet around four to six months
21:19
of age and keep them in the diet on a regular basis.
21:21
If it's their first baby and they have a lot of anxiety, we want to anticipate that.
21:25
And then we can discuss the risks and benefits of different approaches.
21:28
Talk about why we don't want to wait for testing. We don't need testing.
21:31
We can provide reassurance as much as possible.
21:33
And then for those that already have children that have food allergies,
21:37
we want to proactively address this and say, listen, I know you went through
21:40
this with your older child.
21:41
Here are current recommendations. We can provide reassurance as best we can.
21:45
And again, discuss the risks and benefits of the different approaches.
21:48
But this is where the art of testing comes in. And believe me,
21:50
I see parents every day that just, I need to see the negative result before
21:54
I feed this to my baby. And I get it.
21:56
So the medicine says, don't do screening.
22:00
But that's not real life and we have some families. So we want to identify those
22:03
with true anxiety and really discuss the risks and benefits.
22:06
And before I do any testing, I ask them, is this going to change how you do it?
22:11
Like if we have a negative test, will you go home today and introduce these foods to your baby?
22:15
Or I'll say, if we have an elevated test result, I'm not going to diagnose your
22:19
baby with an allergy to something they've never eaten, but maybe we'll do it
22:22
here in the office. So here's my spiel.
22:24
Feel free to borrow this at will. Take a screenshot. You have my slides.
22:27
Here's what I say to families pretty much every day. There's no medical indication
22:31
to test before introducing any food to your baby.
22:33
I meet enough parents to know that some need to see a negative result to give them confidence.
22:37
I'm happy to test for select foods if a negative result will help you go home and introduce today.
22:41
If we see an elevated result, I'm not going to diagnose allergy,
22:44
but we can easily have you introduce that food in my office if that's okay.
22:47
So even after this, sometimes I say, now what foods would you like to be tested for?
22:51
And every once in a while, they just say, well, everything. And I just kind
22:55
of go, all right, well, let's go back to the top. I can't test for everything.
22:58
So why are parents so scared? So there's a lot, you know, our cognitive biases
23:03
are very powerful forces in our lives. So, you know, they don't want to make the wrong call.
23:07
They're riddled with what if scenarios and what if they introduce too early
23:11
and cause a reaction? There's a lot of guilt that comes like that.
23:14
They're more likely going to recall negative events than positive ones.
23:17
So they're not going to go back and say, well, we introduced 25 foods and nothing happened.
23:21
It's going to be that one food that may have caused rash or symptoms or stuff like that.
23:24
They want to do everything they can to avoid that painful outcome and go for the easy stuff.
23:29
The emotional state can really impact the decision they're making.
23:32
We often see this, especially in babies that have not had a hard first couple
23:38
months of life, whether it's colic or poor sleep or reflux.
23:41
And these parents are exhausted and they're not quite sure what to do.
23:44
And they really want to avoid any potential future regrets.
23:47
So we can address all this with the way that we discuss this with families.
23:50
But we also have to talk about why are we so scared.
23:52
So there's a lot of conservative, you know, approaches towards,
23:55
you know, pediatric care that have been adopted over the years.
23:59
Most of us, you know, we're just really bad at assessing risk.
24:02
And hopefully with all the evidence that I gave you today and the latest guidelines,
24:05
it gives you that reassurance of like, hey, we're not actually going to harm
24:07
these babies by doing this. And we're going to benefit a lot of them.
24:11
And then ultimately, who are we to tell parents when to feed their baby?
24:14
Like this is them feeding their baby. Like if they want to feed the food to
24:18
them, that we shouldn't be telling them no, we should be supporting them and talking about it.
24:21
So what's the risk if something does happen? Well, they could have a reaction
24:24
at home. We may lose their trust after having that conversation.
24:27
But what's the reward? Well, odds are they're going to do great.
24:30
They're not going to have food allergies, and we're going to have a happy family.
24:33
This is a really interesting phenomenon because we're never going to know which
24:37
children we prevented food allergy from occurring in, right?
24:40
So this is something we kind of have to go in, not with blind faith,
24:43
but we don't know the outcome.
24:45
If these kids don't develop food allergy, we don't know if that was going to
24:47
happen with or without early introduction, but we sort of have to trust the process.
24:51
So what are some practical approaches for all of us to take just for our own sort of understanding?
24:55
I think it's important to assume the best, not the worst, because that's what
24:59
the evidence shows is going to be the outcome the vast majority of the time.
25:02
We can anticipate these concerns and talk about it at well visits,
25:05
and we can provide them with education resources to help support them as best we can.
25:10
Now, we talk about like how much do we need to give and how often?
25:13
You know, a lot of this is sort of made up based upon prior studies.
25:16
So there's no exact amount. I don't want you to get hung up on details,
25:19
but there's a great resource here in this chart.
25:21
If you do want some families, especially those that are like engineers,
25:24
they need to see the numbers and the details.
25:26
And they say, do you tell me exactly when to do it and how much? And I'll hand them this.
25:30
So when it comes to peanut, we can just use thinned peanut butter.
25:33
There's peanut puffs that we can use, peanut powder we can mix into things.
25:36
And we want to do this at least three times a week, one to two teaspoons.
25:39
That's generally about two grams of protein.
25:42
So when it comes to an egg, we want to cook this, chop it up as much as we can
25:46
so they can tolerate it. This can be scrambled eggs or finger food.
25:48
About a third of an egg is a good starting point. And then when it comes to
25:52
dairy, we can do things like yogurt or just formula if they're taking that or
25:55
cheese and things like that in two to four ounces.
25:58
There's not great evidence for things like tree nuts, wheat,
26:01
soy, sesame, and seafood, but these are some guidance that we can offer them.
26:04
And really it's, you know, especially when it comes to seafood,
26:07
a lot of families don't enjoy seafood.
26:09
So they say, do I need to force my child to eat this we don't have in our house,
26:12
I say, listen, odds are they're not going to have an allergy to seafood,
26:15
regardless of when you give it.
26:17
If it's not part of your family's regular diet, I don't think you need to go
26:20
out of the way to make sure that you give this on a regular basis.
26:23
So there are ways that we can keep this simple. So if we focus on practical
26:27
tips, this is something from the Canadian Allergy Society that really has a
26:31
nice little infographic that walks through four main steps.
26:34
We want to give messages such as keeping the diet as consistently as possible.
26:38
Don't worry if you miss a day or two. But the point being, don't avoid it on purpose.
26:43
It could be worse if you just give it like once every three or four months.
26:46
That's how we may create allergies.
26:48
So we want to avoid doing that if we can. if for whatever reason they're
26:51
not going to do this then we say okay that's fine just you know avoid it
26:54
and we can deal this deal with this as they get older and then
26:57
we need to make ourselves available if and when concerns arise so when
27:01
we talk about you know the advice that we give it really depends on who's that
27:05
person in front of you are they highly anxious well then we can offer in-office
27:09
introduction and now some of you may not be able to do that or feel comfortable
27:11
doing that that's where you hopefully have a good relationship with your community
27:15
allergists but this is something i recommend all the time like listen if you're
27:18
too scared to do this come to the office.
27:20
My personal record was we introduced 11 different foods at the same time to
27:24
a nine month old. She got a little rash on her chin.
27:27
Her mother was highly anxious, wondering if I was going to send her down to
27:29
the emergency room. And I said, no, no, this is fine.
27:32
Like this is not an allergic reaction. So it was a wonderful visit to give reassurance.
27:36
Or if we want to start at home, like start with this stuff that doesn't cause
27:39
allergies, fruits and vegetables, cereal, grains, things like that.
27:44
If they're moderately anxious, you can say, listen, if you have concerns with
27:47
some of the allergenic foods. It's okay to do it at home.
27:50
Offer a few small bites and take a break.
27:53
Monitor them for the next five or 10 minutes. If they're not fussy,
27:56
if they're not developing hives on their skin, basically double the amount they're
27:59
getting every 10 minutes or so till they eat a serving size.
28:02
And then that can give reassurance as well.
28:04
If they're mildly anxious, then we can say we can do this at home.
28:07
We can try several foods in the same group all at the same time.
28:10
And then if something occurs, we can go back and clarify what the cause was.
28:14
And if they're not anxious at
28:15
all. Just talk about how they can offer several new foods in any amount.
28:18
I mentioned before how it's just incorrect to say one new food every three,
28:23
four, five days, because that's assuming that something is going to happen.
28:25
We can now offer, you can try a dozen new foods today if you want.
28:30
Now, we all know as pediatricians that it can take time for these babies to
28:33
really like the tastes and textures and learn how to like these foods,
28:36
but there's no reason not to take that approach if you feel comfortable.
28:39
Here are some things I recommend you don't say. Please don't advise people to
28:42
drive to the ER parking lot before introducing a food that just is going to
28:45
put their anxiety on level 12 out of a scale of one to 10. We don't want to
28:49
recommend rubbing on their skin first.
28:51
We don't want to send the message that reactions can occur basically at any
28:55
point because then all they're hearing is that their child's a ticking time bomb.
28:58
We don't want to tell them like keep them awake for a certain period of time
29:01
after eating because that again sends a very fear-based message.
29:04
We don't want to prescribe epinephrine autoinjectors prior to feeding because
29:07
again that's a very fear-based message and it's extremely unlikely that they're
29:11
ever going to need to use that.
29:12
And we also don't want to sort of chastise and say, if you don't get it in their
29:15
diet by 11 months of age, then you missed the window.
29:17
So we want to support them wherever
29:19
they are on their journey and reassure as much as we possibly can.
29:23
So what about reactions? Well, this is a question I'm sure all of you get,
29:26
and I get as well. They say, okay, what if I do this? What if they do react?
29:29
Well, let's talk about this. We say the most common reactions will be some hives.
29:33
If they do have some hives after that, if they're otherwise acting fine,
29:36
those are going to self-resolve.
29:37
If you want to treat it, we can use something like a second-generation antihistamine.
29:41
We do want to recommend not using things like diphenhydramine because it's very
29:45
outdated. They make kids drowsy. They have tons of side effects.
29:48
Second-generation antihistamines such as statirazine, loradadine,
29:52
they actually work faster than first-generation antihistamines.
29:55
They last four times as long, and they don't have those terrible side effects.
29:58
So that's what we can counsel families to give in the right dose,
30:01
you know, if they have hives or stuff like that.
30:03
We can put it in context. So if they're going to have a reaction to what they're
30:06
eating, it's going to happen within, you know, one to two hours of eating.
30:10
So if they get a rash or they get fussy or they vomit 12 hours after eating
30:13
something, that's not a food allergy reaction.
30:15
All of the symptoms that can occur due to food allergy can to occur for unrelated reasons.
30:20
So we want to put that in the context of if they're going to react,
30:22
it's going to happen pretty fast, typically while they're in their high chair at the table eating.
30:27
We can review the common signs and symptoms. And then we can also anticipate,
30:31
all right, as you expand your child's diet, here's a couple of things that are going to happen.
30:34
One, their stooling is going to change. They're going to poop a lot more.
30:37
It's going to be firmer. And that's a good thing. It may change colors, maybe foul smelling.
30:40
That's all because they're expanding the diet, eating all these different things,
30:43
more fiber, things like that.
30:45
We can also anticipate just because of the developmentally, their sleep will
30:48
probably change, hopefully for the better as well.
30:50
These are not signs of an allergic reaction. And then we can write these things
30:54
down, hand it to them, make ourselves available should they have concerns.
30:57
So when should we provide this advice? This is really where all of you are.
31:01
We need all of you to make this work because you have the point of contact with
31:05
them at their well visits at two, four, six, and nine months or in between.
31:09
So this is really where we want to have these conversations.
31:12
Shared decision-making, and meet them at those points.
31:14
I don't see them until after they've had a reaction. But if you can have this
31:17
conversation with them early, the earlier the better, and then reinforce this every time.
31:22
So even if they come in for other concerns, we can still reinforce this or have
31:26
handouts available or put it as part of their after-visit summary or something like that.
31:30
The other thing we have to always recognize would be the impact of disparities,
31:34
especially on food allergies.
31:36
And we know that those from lower socioeconomic backgrounds or in certain minority
31:40
groups, they have a higher risk of having food allergies.
31:42
So as I mentioned before, with the different risk factors, we want to help everybody,
31:46
but these are the folks that really warrant our attention. So we want to help
31:49
them as much as we can, especially the African-American population.
31:52
So if you have an African-American baby that has pretty persistent eczema,
31:56
they're the ones really saying, hey, pay attention to me. I may go on to develop
32:00
food allergies and have a very allergic life.
32:02
So let's support these families and give them all that education and reassurance
32:06
that we can and help them get these foods in their babies' diet and try to prevent food allergy.
32:11
I encourage you to work with allergists in your area. I don't know if you're
32:14
doing this now. I hope you are, but talk to them about what happens if I have these concerns.
32:19
Can we set up a good referral pipeline where they can see you within a week
32:22
or two and we don't have to wait six months for an evaluation because then it's too late?
32:25
As I mentioned before, incorporate this in the well-child visits.
32:28
If you want to come up with handouts.
32:30
From the 2017 NIAID guidelines in the U.S., there's like a little infographic in how to give peanuts.
32:37
So you can put it, you can mix it with water and thin out the peanut butter,
32:40
peanut puffs. It tells you how much to give and things like that.
32:43
But there's other resources available as well.
32:45
And then think about just making
32:46
this part of your EHR and put it in the after visit summary as well.
32:50
In Australia, they have a public health approach. So if you want reassurance about how safe this is.
32:56
For years, they've been recommending, they call it nip allergies in the bub.
32:59
There's literally like, you know, billboards on the side of the highway and commercials.
33:03
And this is just widely, you know, adopted of it's safe.
33:06
We want to feed these babies, you know, peanut and allergenic foods.
33:09
And they've been doing this for years and they've studied this and they have
33:12
not seen an increase in anaphylaxis in infants.
33:16
They have not seen an increase in food allergies.
33:18
To date, they haven't seen a decrease in food allergy, but that's a different
33:21
story for a different time, but it's working on a, just on a public health level.
33:25
So there's no reason why we can't adopt this approach here in the U.S.
33:28
Or having these conversations during our healthcare visits and things like that.
33:32
So what if we're wrong, right? We were wrong before. What if we're wrong now?
33:36
So we are starting to see some interesting case reports of food protein-induced
33:40
enterocolitis syndrome to causes that typically aren't known causes of F-PIs, like peanut.
33:45
But, you know, it's not like it's rampant or anything like that.
33:47
And as I mentioned, we have good studies from Australia, especially that are
33:51
leading the charge on this, that people are doing really well.
33:54
So this is something that we want to try to promote.
33:57
And even if we are wrong and some of these kids do develop allergy earlier,
34:01
we have ways of treating that.
34:03
So we're doing things like salvage oral immunotherapy.
34:05
So if we have infants that do react to peanut and they develop a peanut allergy,
34:10
a lot of them, if we put them on oral immunotherapy in the first couple of years
34:13
of life, we can help them promote tolerance and maybe cure this.
34:16
And so we have all these different approaches now that we didn't have just a few years ago.
34:20
So the changing landscape. So, you know, sometimes you can have food allergy
34:25
despite early introductions. So when that occurs, we really want to recommend
34:29
get all the other foods in their diet and then we can address this.
34:32
And as I mentioned, we have oral immunotherapy and now omelizumab is indicated
34:36
for treating food allergies for anybody down to the age of one year of age.
34:40
What omelizumab does is it's an anti-IgE monoclonal antibody.
34:44
So it binds the IgE, doesn't care what you're allergic to.
34:47
It's great for people with multiple food allergies, and you'd have to eat a
34:50
higher amount to trigger a reaction. So it increases your threshold and decreases
34:54
the risk for reactions from accidental ingestion. So we have...
34:58
Rapidly evolving treatment options available, and it's going to change even a year from now as well.
35:04
What about other prevention strategies? So when we look at maternal diet,
35:08
it really doesn't impact the baby, whether it's during pregnancy or breastfeeding.
35:11
And I think it goes back to what we talked about before, how just very little
35:13
intact protein gets passed through either the uterus or breast milk.
35:17
So we want to advise families, eat whatever you want.
35:20
By the way, what's the number one food when I ask mothers after our conversation,
35:24
what food do you miss the most.
35:26
Number one on the list, cheese, by far. Number two, lattes.
35:30
So we don't want to deprive these amazing mothers from their cheese or lattes
35:33
by telling them to take milk out of their diet for when it's not necessary.
35:37
What about maternal diet diversity when they're pregnant?
35:39
It's weak signals, probably not, you know, it's hard to tell association data more than anything.
35:44
Vitamin D is not moving the needle on this. We look at vitamin D for pretty
35:47
much every chronic health condition.
35:49
We can do a really good job of increasing vitamin D levels in the bloodstream
35:52
by supplementing with it, but the downstream effects generally aren't there.
35:56
Okay. What about cow's milk-based formula? So this goes with very early introduction.
36:00
So those infants that do start on cow's milk formula have less cow's milk allergy
36:05
just because they're exposed to it in early age and they have more tolerance.
36:08
The microbiome, there's a very, there's a good signal there,
36:11
but it's a little too early for us to recommend like stool analysis and specific
36:17
interventions, but there's probably something there, you know,
36:20
nothing that we can strongly recommend.
36:22
And then, as I mentioned before with eczema, if we put emollients on the skin
36:26
from day of life one, it may delay the onset of atopic dermatitis,
36:29
but it's actually not preventing it and it's not preventing allergies from developing.
36:32
So this is kind of where we are in the prevention landscape.
36:35
So lots of exciting stuff that's being looked at.
36:37
Nothing that has a really strong
36:39
signal other than early introduction and ongoing inclusion of the diet.
36:43
So we'll have some take-home talking points, and I'm more than happy to take any questions.
36:46
So we want to recommend introducing allergenic foods around four to six months
36:50
of age. That's very safe. It's our best path towards preventing allergy.
36:53
And as I mentioned, even though the U.S. guidelines and the AAP hasn't changed
36:57
their guidelines, and as a member of the executive committee for the section
37:01
of allergy and immunology, the AAP is not going to because we already have other guidelines.
37:04
We have the North American feeding guidelines and things like that.
37:06
So if you're waiting to say, well, the AAP has to recommend this before I do
37:10
it, it's not going to happen for various reasons.
37:12
So, but we have good evidence. We have, you know, good approaches elsewhere.
37:16
So this is what we want to recommend. And it's all about perspective.
37:20
So nothing we do in medicine is 100% effective. Nothing we do in medicine is 100% effective.
37:25
And if we look at this, more than 920,000 out of a million children will never
37:30
develop a food allergy, regardless of when they eat it or what they eat.
37:33
So I think that's important as well. So we want to recommend,
37:36
let's get the food in the diet.
37:37
Let's try to prevent this as much as we possibly can, but also just reassure
37:40
people everything's going to be okay.
37:41
So in conclusion, we know that infants with moderate to severe eczema are those at highest risk.
37:46
That's the biggest risk factor. We want to address this with them and catch
37:49
them as much as possible.
37:50
We want to counsel families on early introduction, make it a standard party
37:54
of your visits, get your spiel going, have handouts available.
37:58
And then with this new perspective and great accumulating evidence,
38:01
this is a reassuring thing. This is a good thing that we can offer families.
38:05
And I hope that I gave you some of that perspective today.
38:09
I already have questions. I'm going to start from the bottom here in the chat box.
38:13
Breastfeeding and celiac disease. One of my parent concerns is vertical transmission.
38:19
Any research on this topic?
38:21
Oh, breastfeeding and celiac disease. Yeah, not that I'm aware of.
38:25
No, I think celiac, it can run in families. It's an autoimmune condition,
38:29
as you all know. But I'm not, yeah, I have not seen anything where gluten passes
38:33
through the breast milk that can cause those symptoms.
38:36
So that's obviously a very specific case. And, you know, it involves shared decision making.
38:42
Is there any rationale to the packets or is there any rationale to the food
38:47
industry's label first foods, second foods, etc.? The first food,
38:52
second foods is an irrational. know?
38:55
Oh, I think, you know, it's just like most things we do in medicine,
38:59
you kind of give a guidance, right?
39:02
So when we think about the COVID pandemic, we said stand three feet apart.
39:06
Was there something magical about three feet? No, but it makes sense,
39:10
right? It's something we can all follow.
39:11
So when you have these guidance of like first food, second foods,
39:14
it's just giving families a blueprint.
39:16
Does every baby need to follow that? Absolutely not. You all know this.
39:19
Is it helpful for some families? Absolutely. So these are just guidance and we can vary from that.
39:24
Any thoughts on allergen packets, powders advertised for babies?
39:28
Yeah, there's a couple of thoughts on this, and I should probably start including
39:31
this in the base of my talk.
39:33
So there's multiple companies that have various products available,
39:36
whether it's powders or cookies or crackers, where they put very small amounts
39:40
of allergenic foods, combine them and say, this makes it a lot easier to introduce
39:44
these allergenic foods into your baby's diet.
39:47
So one, these are costly, so it can increase cost for families.
39:51
Number two, the dose is involved in a lot of these. You haven't been studied
39:55
as a way to actually prevent food allergies.
39:57
So if there's micro dosing, is that actually enough?
40:00
Number three, some of these products that when they study them off the shelves,
40:03
they don't actually contain what they say they contain.
40:05
So I don't want to introduce conspiracy here, but it's like every other supplement
40:08
out there. We don't quite know what's going on in there.
40:11
And then lastly, we still don't want to get away from feeding babies.
40:15
We want them to learn how to enjoy different tastes and textures and the nutrition
40:20
that comes from that. So is it necessary? Absolutely not.
40:23
Would some families like to do that as part of their early introduction plan?
40:26
That's fine. But I can't recommend one specific one over another.
40:31
There's a question about anaphylaxis. Do you consider generalized hives plus
40:35
the GI symptoms such as vomiting anaphylaxis?
40:38
Yeah. So when we talk about anaphylaxis, it's more than one body system.
40:42
So hives and vomiting, that's anaphylaxis. It's important to note that there's a range in severity.
40:47
So a lot of people have very mild anaphylaxis. They break out in hives,
40:51
they vomit once. That's anaphylaxis, but oftentimes it's actually self-resolved.
40:55
So you can have more moderate and severe as well, but it's pretty unusual for
40:58
infants, especially to have true severe anaphylaxis, especially with respiratory involvement.
41:03
When we think about respiratory involvement with anaphylaxis,
41:05
it's almost always going to be those with underlying asthma,
41:09
specifically poorly controlled asthma, and then they get the bronchoconstriction
41:13
and because they already have hyperreactive airways. So that's typically when we see it.
41:16
The whole concept of like your throat swelling shut, it's such a rare phenomenon.
41:20
So we want to reassure families with that as well.
41:23
There's a comment by Dr. Weimer, but I think there's a question.
41:26
How much allergy is prevented by no food until six months?
41:31
Many babies with cow's milk problem did well on goat's milk.
41:36
Well, yeah. So it goes back to what's the diagnosis? So what's the reason for avoiding these things?
41:42
So if you have a true, like an IgE-mediated milk allergy, you generally need
41:47
to avoid all mammalian forms of milk because there's cross-reactivity with those.
41:52
So a lot of this too can be tincture of time.
41:55
So whatever's going on with these babies as they are developing and it just
41:58
naturally resolves no matter what you feed them.
42:01
So I think this whole concept is just, we don't need to go their entire first
42:06
year of life and avoiding it. If we truly feel that cow's milk is causing issues,
42:09
all right, let's avoid it for two to four weeks and let's reassess and then
42:13
think about putting it back in the diet if they're doing well.
42:16
Please mention a little bit about, I think, food-induced enterocolitis,
42:20
any approach other than avoidance of the food.
42:23
Yeah, so F-Pi, food-protein-induced enterocolitis syndrome, the most common
42:28
presentation, it typically occurs in infants or young children.
42:31
They eat something, they're completely fine, and then, you know,
42:34
typically two to three hours later, they have profuse vomiting,
42:36
sometimes followed by diarrhea.
42:38
This is not IgE-mediated. There should not be hives associated with this.
42:41
There's no diagnostic test for it, which is really hard. but you almost always
42:45
have to have two episodes or more to establish a diagnosis because there's a
42:50
million reasons why babies can vomit.
42:52
And these foods are very different from IgE food allergies.
42:55
So now we're talking about cow's milk and soy are more common because of formula-based,
42:58
but now we're talking about rice and oats and vegetables and things like that.
43:02
The good news is this is often self-resolved and it gets better as kids get older.
43:06
It also doesn't cause anaphylaxis. We don't need to be prescribing EpiPens or things like that.
43:10
And it's typically only one food. Rarely is it going to be three or more foods?
43:15
So if you started thinking there's like six foods causing F-Pi's,
43:17
we need to reconsider the diagnosis.
43:19
And then as far as there's questions, we don't know.
43:22
So like we know with milk and egg allergy in babies, 75% of them can tolerate
43:27
it when you bake it in things, because when you heat it in the oven extensively,
43:29
it changes the protein structure and they can tolerate it.
43:32
It's likely the case with F-Pi's. We just don't have good evidence for that.
43:35
It's very unlikely that they're going to react to trace amounts cross contact.
43:38
And it's very, very unlikely that it's going to be transmitted through breast milk.
43:43
Any other questions, comments for
43:44
Dr. Stukas? You can ask him questions directly or put them in a chat box.
43:50
So I know this topic tends to be not controversial, but it's very different
43:56
from what many of us have taught and practiced.
43:58
And I encourage you to read through the guidelines that I shared with you.
44:03
Again, this isn't just my opinion here. I'm just merely relaying what the evidence shows.
44:07
But yeah, it's interesting stuff and it's relatively good for the most part.
44:12
David, do you have a question here? What about the premature,
44:15
well-appearing baby with bloody stools?
44:18
Yeah, it goes back to, I think we need to question, you know,
44:21
why do we think they have that?
44:23
What's going on? There's a differential diagnosis for all of these symptoms.
44:27
If we do think it's cow's milk allergy, again, go through a trial elimination.
44:30
When it comes to cow's milk-induced proctocolitis, we need to give it,
44:34
like, a good three to four days to heal.
44:36
So I think it would be harmful to tell parents, it should be cleared by the
44:39
next diaper if you take milk out. We want to give it three or four days.
44:42
It's a benign condition.
44:43
It's often self-resolved, even if you continue milk in the diet.
44:47
So we want to reassure. It's very unsettling when a parent changes the diaper
44:50
and they see that, right?
44:51
But that's something where we can say, okay, if they're otherwise acting okay,
44:54
let's give it some time. Let's see if we can make this resolved by changing
44:57
from a cow's milk-based formula and go from there.
45:00
Any other questions, comments?
45:03
Dr. Weimer, go ahead and ask you a question, please. You are muted.
45:07
We don't hear you. So you may have to unmute yourself.
45:12
I'm not sure how to do that. We can hear you now. Oh, okay. I just,
45:19
I thought it'd be interesting for students to understand the history, the reflux boondoggle.
45:27
And that started about the 80s when they did go or recommend no food until six months.
45:34
Because the problem was until that, for probably a century, all babies started food at three months.
45:43
So when they changed to no food
45:46
till six months the the babies were
45:49
flat hungry and the reason they
45:52
they spit up is because they took too much milk
45:55
and they keep taking milk and taking milk and finally they spit up some of those
46:00
babies did reflux but the reflux of course diagnosis and then they started the
46:08
string test for stomach acid, if you remember,
46:13
but that whole reflux boondoggle was due to going to food at six months.
46:22
Of course, my question is statistically just how much allergy is prevented by
46:29
not feeding until six months.
46:31
Was that ever shown to be significant at all?
46:37
That's a great question. I don't believe that that was looked at.
46:41
We didn't really have good evidence on this until that LEAP trial showed in
46:45
the prospective manner about how to prevent it.
46:48
But I mean, you're right. So that's a good question.
46:51
And I appreciate your perspective on, well, just infant feeding in general,
46:55
right? There's an ebb and a flow to all of this of whatever is the pervasive
46:58
trend in that particular time and then how that influences things.
47:02
So I think the best comment I can provide is it's always healthy for all of
47:07
us to look back at things and with a healthy dose of skepticism and say,
47:11
what does the evidence actually show?
47:13
And, you know, it's interesting how we got to this point. Where are we now?
47:16
Do we need to change anything?
47:18
We have a follow-up question on premature male-appearing baby with bloody stools.
47:22
How long would you keep them on non-cow's milk formula, and would you use soy formula?
47:29
Yeah, I think you can go to soy. We were all taught there's a ton of cross-reactivity
47:35
between them, but they're different. Soy is a plant-based protein.
47:37
It's very different than the mammalian protein. So you can go to soy first.
47:40
And then the recommendations now are, let's go for a two- to four-week elimination
47:44
and then reassess. If symptoms are completely resolved, you can put it back
47:48
in the diet and see if they come back again.
47:50
If symptoms aren't resolved, you can consider putting it back in the diet because
47:53
that probably wasn't the cause anyways.
47:55
And then one more question. Should patients with peanut allergy avoid foods
47:58
that are prepared in the place where they have peanuts, but the food does not have peanut?
48:04
I think it depends on how well the manufacturer avoids cross-contamination.
48:08
Some patients avoid it and others don't and are fine.
48:13
Well, very quickly, in the United States, if a food contains one of the top
48:17
nine food allergens, milk, egg, wheat, soy, peanut, tree nut,
48:20
fish, shellfish, or sesame, it must state contains.
48:23
All of the other wording may contain processed and facility shared equipment
48:27
is not regulated and is not meaningful.
48:29
Very few of those products contain any allergen, let alone enough allergen to
48:35
trigger an allergic reaction in an individual.
48:37
So the vast majority of these are safe. We have also understood a lot more about
48:42
individual thresholds.
48:44
Most people with peanut allergy need to eat a whole peanut before they have any reaction at all.
48:50
So there's a lot that goes into this, but for those precautionary labels,
48:53
those are generally very safe.
48:54
Now, some people choose to avoid them just to eliminate all risk,
48:56
and that's fine, but that's a conversation we have with folks and they can make up.
49:00
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