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Let Babies Eat: New Guidelines to Prevent Food Allergies · 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.
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Let the Babies Eat, 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.
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Here's my goal. So I want to give you new perspective. Everything I talk about
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will be evidence-based information.
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This isn't just Dave's opinion here. This is me serving as a conduit to give
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you all the published guidelines and research and things like that,
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and then hopefully help you appreciate your very important role in helping families
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feed 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,
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because I think we've done a very good job as a medical establishment at confusing
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parents 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 about
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how this is what we once thought it was, and this is where we are today and
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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.
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And it basically said no milk 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.
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I don't know about all of you, but I have families tell me that they've driven
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to the parking lot of the emergency room before they feed peanut to the baby
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the first time. And that's heartbreaking because this should be a really fun
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milestone when we start introducing solid foods to babies and we want to try
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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.
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That's how I get patients as a pediatric allergist. I don't get patients because
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they end up in the ICU the first time they ate peanuts.
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So 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
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to happen. And if something does happen, we can go back and sort it out and
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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, Tom. taking 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.
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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 high
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and anaphylaxis. So that can cause real harm.
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The most recent atopic dermatitis guidelines or 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 Center.
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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.
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This is not a food allergy. These children are often well-appearing.
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The foods that are causing these rashes are uncommon causes of food allergies,
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such as fruits and purees and things like that.
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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 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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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 from
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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.
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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.
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We talk about the elimination diet in a second. And then reintroduction.
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We don't need to wait until 12 months of age for dairy because a lot of times
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these are benign conditions that resolve on their own 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 breakfast right now.
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The cow's milk-induced allergic proctocolitis. 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 hemococl positive.
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That's the more common presentation for this. So when we go back to the guidelines,
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it talks about if you consider this diagnosis in an infant of cow's milk allergy,
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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 is necessary.
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And we want to minimize unnecessary diets. I have so many mothers in my practice
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that are just in tears because they've taken out dairy and egg and wheat because
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of improper reasons such as eczema 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, you know, 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, and they found that there's
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less than one in a thousand actually had intact allergenic protein passed through
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their breast milk. So it's pretty rare.
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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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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. They 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 been 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 going to 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,
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seafood, sesame. So it can be a big burden for throughout their lives.
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It can put them at risk to have allergic reactions. It can also cause decreased quality of life.
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While we do have treatment options 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?
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I think we can now 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
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allergies and then the severity of their eczema.
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So it's not like that little patch that gets better with some topical cortisone
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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,
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or they 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.
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It's not try a little dab with peanut butter and then wait six months before
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you try again. 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 and 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. You're meeting these families at their well visits.
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So this is hopefully a conversation, 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 we want to go for between four to six months of age once they're
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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 an 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 non-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 overdiagnosis 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 overdiagnose 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?
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Well, that's not how these work. So the IgE tests only detect sensitization.
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They don't actually diagnose allergy.
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When we know 40% of children are sensitized to things like egg,
20:39
milk, peanut, and shrimp, but only 5% are allergic, we're over-diagnosing the
20:43
vast majority of them by using these tests.
20:45
So we don't want to use these as screening tests. And we go back to the first
20:49
days of medical school or undergraduate education, we talk about,
20:51
all right, what makes a really good screening test?
20:53
When we think about IgE tests for foods, it doesn't meet any of the criteria.
20:57
So these have never been screening tests and they shouldn't be used like that.
21:01
There's tons of false positives and they get grossly misinterpreted.
21:05
So when we talk about those families that we're seeing, there's different ways
21:08
we can have the conversation.
21:09
So for those parents that are having the first baby, no concerns.
21:12
My advice is just proactively discuss the benefits of early introduction.
21:15
We want to introduce these foods in your baby's diet around four to six months
21:18
of age and keep them in the diet on a regular basis.
21:20
If it's their first baby and they have a lot of anxiety, we want to anticipate that.
21:24
And then we can discuss the risks and benefits of different approaches.
21:27
Talk about why we don't want to wait for testing. We don't need testing.
21:30
We can provide reassurance as much as possible.
21:32
And then for those that already have children that have food allergies,
21:36
we want to proactively address this and say, listen, I know you went through
21:39
this with your older child.
21:40
Here are current recommendations. We can provide reassurance as best we can.
21:44
And again, discuss the risks and benefits of the different approaches.
21:47
But this is where the art of testing comes in. And believe me,
21:49
I see parents every day that just, I need to see the negative result before
21:53
I feed this to my baby. And I get it.
21:55
So the medicine says don't do screening.
21:59
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?
22:10
Like if we have a negative test, will you go home today and introduce these foods to your baby?
22:14
Or I'll say, if we have an elevated test result, I'm not going to diagnose your
22:18
baby with an allergy to something that I've never eaten, but maybe we'll do
22:21
it here in the office. So here's my spiel.
22:23
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
22:30
to test before introducing any food to your baby.
22:32
I meet enough parents to know that some need to see a negative result to give them confidence.
22:36
I'm happy to test for select foods if a negative result will help you go home and introduce today.
22:40
If we see an elevated result, I'm not going to diagnose allergy,
22:43
but we can easily have you introduce that food in my office if that's okay.
22:46
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 kind of go,
22:54
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
23:02
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.
23:13
They're more likely going to recall negative events than positive ones.
23:16
So they're not going to go back and say, well, we introduced 25 foods and nothing happened.
23:20
It's going to be that one food that may have caused rash or symptoms or stuff like that.
23:23
They want to do everything they can to avoid that painful outcome and go for the easy stuff.
23:28
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
23:37
months of life, whether it's colic or poor sleep or reflux.
23:40
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.
23:46
So we can address all this with the way that we discuss this with families.
23:49
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,
23:54
you know, pediatric care that have been adopted over the years.
23:58
Most of us, you know, we're just really bad at assessing risk.
24:01
And hopefully with all the evidence that I gave you today and the latest guidelines,
24:04
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.
24:10
And then ultimately, who are we to tell parents when to feed their baby?
24:13
Like this is them feeding their baby.
24:15
Like if they want to feed a food to them, that we shouldn't be telling them
24:18
no. We should be supporting them and talking about it.
24:20
So what's the risk if something does happen? Well, they could have a reaction
24:23
at home. We may lose their trust after having that conversation.
24:26
But what's the reward? Well, odds are they're going to do great.
24:29
They're not going to have food allergies and that we're going to have a happy family.
24:33
This is a really interesting phenomenon because we're never going to know which
24:36
children we prevented food allergy from occurring in, right?
24:39
So this is something we kind of have to go in, not with blind faith,
24:43
but we don't know the outcome.
24:44
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.
24:50
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
24:58
the evidence shows is going to be the outcome the vast majority of the time.
25:01
We can anticipate these concerns and talk about it at well visits,
25:04
and we can provide them with education resources to help support them as best we can.
25:09
Now we talk about like how much do we need to give and how often,
25:12
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,
25:18
but there's a great resource here in this chart.
25:20
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? How much? And I'll hand them this.
25:29
So when it comes to peanut, we can just use thinned peanut butter.
25:32
There's peanut puffs that we can use peanut powder. We can mix into things.
25:35
And we want to do this at least three times a week, one to two teaspoons.
25:38
It's generally about two grams of protein.
25:41
So when it comes to an egg, we want to cook this, chop it up as much as we can
25:45
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.
25:50
And then when it comes to dairy, we can do things like yogurt or just formula
25:54
if they're taking that or cheese and things like that in two to four ounces.
25:57
There's not great evidence for things like tree nuts, wheat,
26:00
soy, sesame, and seafood, but these are some guidance that we can offer them.
26:03
And really, especially when it comes to seafood, a lot of families don't enjoy
26:07
seafood. So they say, do I need to force my child to eat this we don't have in our house?
26:11
I say, listen, odds are they're not going to have an allergy to seafood,
26:15
regardless of when you give it.
26:16
If it's not part of your family's regular diet, I don't think you need to go
26:19
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
26:26
tips, this is something from the Canadian Allergy Society that really has a
26:30
nice little infographic that walks through four main steps.
26:33
We wanna give messages such as, keep in 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. So we wanna avoid doing that if we can.
26:49
If for whatever reason they're not gonna do this, then we say,
26:51
okay, that's fine. just, you know, avoid it.
26:53
And we can deal with this as they get older. And then we need to make ourselves
26:57
available if and when concerns arise.
27:00
So when we talk about, you know, the advice that we give, it really depends
27:04
on who's that person in front of you. Are they highly anxious?
27:07
Well, then we can offer an office introduction. And now some of you may not
27:09
be able to do that or feel comfortable doing that.
27:11
That's where you hopefully have a good relationship with your community allergists.
27:15
But this is something I recommend all the time. Like, listen,
27:17
if you're too scared to do this, come to the office.
27:19
My personal record was we introduced 11 different foods at the same time to a nine-month-old.
27:24
She got a little rash on her chin. Her mother was highly anxious,
27:28
wondering if I was going to send her down to the emergency room.
27:29
And I said, no, no, this is fine.
27:31
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, start with the stuff that doesn't cause allergies,
27:39
fruits and vegetables, cereal, grains, things like that.
27:43
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.
27:52
Monitor them for the next five or 10 minutes. If they're not fussy,
27:55
if they're not developing hives on their skin, basically double the amount they're
27:58
getting every 10 minutes or so till they eat a serving size.
28:01
And then that can give reassurance as well.
28:03
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.
28:13
And if they're not anxious at
28:14
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,
28:22
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.
28:29
Now, we all know as pediatricians that it can take time for these babies to
28:32
really like the tastes and textures and learn how to like these foods,
28:35
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.
28:48
We don't want to recommend rubbing on their skin first.
28:50
We don't want to send the message that reactions can occur basically at any
28:54
point because then all they're hearing is that their child's a ticking time bomb.
28:57
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 auto-injectors prior to feeding because
29:07
again that's a very fear-based message and it's extremely unlikely they're ever
29:10
going to need to use that.
29:11
And we also don't want to sort of chastise and say, if you don't get it in their
29:14
diet by 11 months of age, then you missed the window. So we want to support
29:17
them wherever they are in their journey and reassure as much as we possibly can.
29:22
So what about reactions? Well, this is a question I'm sure all of you get and
29:26
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.
29:32
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,
29:51
they actually work faster than first-generation antihistamines.
29:54
They last four times as long, and they don't have those terrible side effects.
29:58
That's what we can counsel families to give in the right dose if they have hives or stuff like that.
30:02
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 one to two hours of eating.
30:09
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 occur for unrelated reasons.
30:19
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.
30:26
We can review the common signs and symptoms. And then we can also anticipate,
30:30
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.
30:44
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
30:53
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
31:04
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.
31:11
Shared decision-making, and meet them at those points. I don't see them until
31:15
after they've had a reaction.
31:16
But if you can have this conversation with them early, the earlier the better,
31:20
and then reinforce this every time.
31:21
So even if they come in for other concerns, we can still reinforce this or have
31:25
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.
31:35
And we know that those from lower socioeconomic backgrounds or in certain minority
31:39
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
And so if you have a 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 baby's diet and try to prevent food allergy.
32:10
I encourage you to work with allergists in your area. I don't know if you're
32:13
doing this now. I hope you are, but talk to them about what happens if I have these concerns.
32:18
Can we set up a good referral pipeline where they can see you within a week
32:21
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.
32:29
From the 2017 NIAID guidelines in the U.S., there was 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.
32:42
But there's other resources available as well.
32:44
And then think about just making
32:45
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.
32:55
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 it's commercials.
33:02
And this is just widely 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
33:11
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 just on a public health level.
33:24
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?
33:35
So we are starting to see some interesting case reports of food protein-induced
33:39
enterocolitis syndrome to causes that typically aren't known causes of FIs, like peanut.
33:44
But it's not like it's rampant or anything like that. As I mentioned,
33:48
we have good studies from Australia, especially that are leading the charge
33:51
on this, that people are doing really well.
33:53
So this is something that we want to try to promote.
33:56
And even if we are wrong and some of these kids do develop allergy earlier,
34:01
we have ways of treating that.
34:02
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,
34:09
a lot of them, if we put them on oral immunotherapy in the first couple of years
34:12
of life, we can help them promote tolerance and maybe cure this.
34:15
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
34:24
despite early introductions. So when that occurs, we really want to,
34:28
you know, recommend 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.
34:43
So it binds the IgE, doesn't care what you're allergic to.
34:46
It's great for people with multiple food allergies and you'd have to eat a higher
34:49
amount to trigger a reaction. So it increases your threshold and decreases the
34:54
risk for reactions from accidental ingestion. So we have,
34:57
rapidly evolving treatment options available, and it's going to change even a year from now as well.
35:03
What about other prevention strategies? So when we look at maternal diet,
35:07
it really doesn't impact the baby, whether it's during pregnancy or breastfeeding.
35:10
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.
35:25
Number one on the list, cheese, by far. Number two, lattes.
35:29
So we don't want to deprive these amazing mothers from their cheese or lattes
35:32
by telling them to take milk out of their diet for when it's not necessary.
35:36
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.
35:48
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
36:04
just because they're exposed to it in early age and they have more tolerance.
36:07
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
36:16
interventions, but there's probably something there, you know,
36:19
nothing that we can strongly recommend.
36:21
And then, as I mentioned before with eczema, if we put emollients on the skin
36:25
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.
36:34
So lots of exciting stuff that's being looked at.
36:37
Nothing that has a really strong
36:38
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
36:49
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
37:00
of allergy immunology, the AAP is not going to, because we already have other guidelines.
37:03
We have the North American feeding guidelines and things like that.
37:05
So if you're waiting to say, well, the AAP has to recommend this before I do
37:09
it, it's not going to happen for various reasons.
37:12
But we have good evidence. We have good approaches elsewhere.
37:15
So this is what we want to recommend. And it's all about perspective.
37:19
So nothing we do in medicine is 100% effective.
37:22
Nothing we do in medicine is 100% effective. And if we look at this,
37:26
more than 920,000 out of a million children will never develop a food allergy,
37:30
regardless of when they eat it or what they eat.
37:32
So I think that's important as well. So we want to recommend,
37:35
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
37:39
people everything's going to be okay.
37:41
So in conclusion, we know that infants with moderate to severe eczema are those
37:44
at highest risk. That's the biggest risk factor.
37:47
We want to address this with them and catch them as much as possible.
37:50
We want to counsel families on early introduction, make a standard party of
37:54
your visits, get your spiel going, have handouts available.
37:57
And then, you know, with this new perspective and great accumulating evidence,
38:01
this is a reassuring thing.
38:02
This is a good thing that we can offer families. And I hope that I gave you
38:06
some of that perspective today. And I will stop sharing my screen.
38:10
I sincerely apologize for that terrible interruption. Technology,
38:14
we're still trying to figure it out, right? But so thank you again.
38:18
Dr. Sukas, that was wonderful. Thank you. Thank you very much for that fascinating
38:22
presentation i already have questions i'm going to start from the bottom here in the chat box,
38:27
breastfeeding and celiac disease one of my parent parent concern is vertical
38:32
transmission any research on this topic,
38:36
breastfeeding and celiac disease. Yeah, not that I'm aware of.
38:40
No, I think, you know, celiac, it can run in families.
38:42
It's an autoimmune condition, as you all know, but I'm not, yeah,
38:46
I have not seen anything where gluten passes through the breast milk that can
38:49
cause, you know, those symptoms.
38:50
So that's obviously a very specific case and, you know, it involves shared decision-making.
38:57
Is there any rationale to the packets or is there any rationale to the food
39:01
industries label first food, second foods, et cetera.
39:06
The first food, second foods is an irrational.
39:09
Oh, I think, you know, it's just like most things we do in medicine,
39:14
you kind of give a guidance, right?
39:17
So when we think about the COVID pandemic, we said stand three feet apart.
39:21
Was there something magical about three feet? No, but it makes sense,
39:24
right? It's something we can all follow.
39:26
So when you have these guidance of like first food, second foods,
39:28
it's just giving families a blueprint.
39:30
Does every baby need to follow that? Absolutely not. You all know this.
39:33
Is it helpful for some families? Absolutely. So these are just guidance,
39:36
and we can vary from that.
39:38
Any thoughts on allergen packets, powders advertised for babies?
39:42
Yeah, there's a couple thoughts on this, and I should probably start including
39:45
this in the base of my talk.
39:47
So there's multiple companies that have various products available,
39:51
whether it's powders or cookies or crackers, where they put very small amounts
39:54
of allergenic foods, combine them and say, this makes it a lot easier to introduce
39:59
these allergenic foods into your baby's diet.
40:01
So one, these are costly, so it can increase cost for families.
40:05
Number two, the dose is involved in a lot of these. You haven't been studied
40:09
as a way to actually prevent food allergies.
40:11
So if there's microdosing, is that actually enough?
40:14
Number three, some of these products that when they study them off the shelves,
40:18
they don't actually contain what they say they contain.
40:19
So I don't want to introduce conspiracy here, but it's like every other supplement
40:23
out there. We don't quite know what's going on in there.
40:25
And then lastly, we still don't want to get away from feeding babies.
40:30
We want them to learn how to enjoy different tastes and textures and the nutrition
40:34
that comes from that. So is it necessary? Absolutely not.
40:37
Would some families like to do that as part of their early introduction plan,
40:40
that's fine. But I can't recommend, you know, one specific one over another.
40:45
There's a question about anaphylaxis. Do you consider generalized hives plus
40:49
the GI symptoms such as vomiting, anaphylaxis?
40:52
Yeah. So when we talk about anaphylaxis, it's more than one body system.
40:56
So hives and vomiting, that's anaphylaxis.
40:58
It's important to note that there's a range in severity. So a lot of people
41:02
have very mild anaphylaxis, they break out in hives, they vomit once.
41:06
That's anaphylaxis, but oftentimes it's actually self-resolved.
41:09
So you can have more moderate and severe as well, but it's pretty unusual for
41:12
infants especially to have true severe anaphylaxis, especially with respiratory involvement.
41:17
When we think about respiratory involvement with anaphylaxis,
41:19
it's almost always going to be those with underlying asthma,
41:23
specifically poorly controlled asthma, and then they get the bronchoconstriction
41:27
because they already have hyperreactive airways. So that's typically when we see it.
41:30
The whole concept of like your throat swelling shut, it's such a rare phenomenon.
41:34
So we want to reassure families with that as well.
41:37
There's a comment by Dr. Weimer, but I think there's a question,
41:40
how much allergies prevented by no food until six months?
41:44
Many babies with cow's milk problem did well on goat's milk.
41:50
Well, yeah. So it goes back to what's the diagnosis. So what's the reason for avoiding these things.
41:56
So if you have a true, like an IgE-mediated milk allergy, you generally need
42:01
to avoid all mammalian forms of milk because there's cross-reactivity with those.
42:05
So a lot of this too can be tincture of time.
42:08
So whatever's going on with these babies as they are developing,
42:12
and it just naturally resolves no matter what you feed them.
42:14
So I think this whole concept is just, we don't need to go their entire first
42:19
year of life and avoiding it.
42:21
If we truly feel that cow's milk is causing issues, all right,
42:23
let's avoid it for two to four weeks and let's reassess and then think about
42:27
putting it back in the diet if they're doing well.
42:29
Please mention a little bit about, I think, food-induced enterocolitis,
42:33
any approach other than avoidance of the food.
42:37
Yeah, so FPI is food protein-induced enterocolitis syndrome.
42:41
The most common presentation, it typically occurs in infants or young children.
42:45
They eat something, they're completely fine. And then, you know,
42:48
typically two to three hours later, they have profuse vomiting,
42:50
sometimes followed by diarrhea.
42:52
This is not IgE-mediated. There should not be hives associated with this.
42:55
There's no diagnostic test for it, which is really hard.
42:58
You almost always have to have two episodes or more to establish a diagnosis
43:02
because there's a million reasons why babies can vomit.
43:05
And these foods are very different from IgE food allergies.
43:08
So now we're talking about cow's milk and soy are more common because it's formula-based,
43:12
but now we're talking about rice and oats and vegetables and things like that.
43:16
The good news is this is often self-resolved and it gets better as kids get older.
43:20
It also doesn't cause anaphylaxis. We don't need to be prescribing EpiPens or things like that.
43:24
And it's typically only one food. Rarely is it going to be three or more foods.
43:28
So if you start thinking there's like six foods causing F-Pi's,
43:31
we need to reconsider the diagnosis.
43:33
And then as far as there's questions, we don't know.
43:36
So like we know with milk and egg allergy in babies, 75% of them can tolerate
43:40
it when you bake it in things because when you heat it in the oven extensively,
43:43
it changes the protein structure and they can tolerate it.
43:46
It's likely the case with F-Pi's. We just don't have good evidence for that.
43:49
It's very unlikely that they're going to react to trace amounts across contact.
43:52
And it's very, very unlikely that it's going to be transmitted through breast milk.
43:56
Any other questions, comments for Dr. Stukas?
44:00
You can ask him questions directly or put them in the chat box.
44:04
So I know this topic tends to be not controversial, but it's very different
44:09
from what many of us have taught and practiced.
44:11
And I encourage you to read through the guidelines that I shared with you.
44:16
Again, this isn't just my opinion here. I'm just merely relaying what the evidence shows.
44:21
But yeah, it's interesting stuff, and it's relatively good for the most part.
44:26
David, there's a question here. What about the premature, well-appearing baby with bloody stools?
44:32
Yeah, it goes back to, I think we need to question, you know,
44:35
why do we think they have that?
44:37
What's going on? There's a differential diagnosis for all of these symptoms.
44:40
If we do think it's cow's milk allergy, again, go through a trial elimination.
44:44
When it comes to cow's milk-induced proctocolitis, we need to give it like a
44:48
good three to four days to heal. So I think it would be harmful to tell parents.
44:52
It should be cleared by the next diaper if you take milk out.
44:54
We want to give it three or four days. It's a benign condition.
44:57
It's often, you know, self-resolved even if you continue milk in the diet. So we want to reassure.
45:02
It's very unsettling when a parent changes the diaper and they see that, right?
45:05
But that's something where we
45:06
can say, okay, if they're otherwise acting okay, let's give it some time.
45:09
Let's see if we can make this resolved by changing from a cow's milk-based formula and go from there.
45:14
Any other questions, comments?
45:17
Dr. Weimer, go ahead and ask you a question, please. You're muted.
45:21
We don't hear you. So you may have to unmute yourself.
45:25
I'm not sure how to do that. Yeah, we can hear you now. Oh okay I just,
45:32
I thought it'd be interesting for students to understand the history,
45:36
the reflux boondoggled.
45:40
And that started about the 80s when they did go or recommend no food until six months.
45:47
Because the problem was until that, for probably a century, all babies started food at three months.
45:56
So when they changed to no food till six months, the babies were flat hungry.
46:04
And the reason they spit up is because they took too much milk.
46:09
And they kept taking milk and taking milk. And finally, they spit up.
46:13
Some of those babies did reflux.
46:15
But the reflux, of course, diagnosis, and then they started the string test
46:22
for stomach acid, if you remember.
46:26
But that whole reflux boondoggle was due to going to food at six months.
46:35
And of course, my question is statistically just how much allergy is prevented
46:41
by not feeding until six months.
46:44
Was that ever shown to be significant at all?
46:50
That's a great question. I don't believe that that was looked at.
46:54
We didn't really have good evidence on this until that LEAP trial showed in
46:58
the prospective manner about how to prevent it.
47:01
But I mean, you're right. So that's a good question. And I appreciate your perspective
47:06
on, well, just infant feeding in general, right?
47:08
There's an ebb and a flow to all of this of whatever is the pervasive trend
47:12
in that particular time and then how that influences things.
47:15
So I think the best comment I can provide is it's always healthy for all of
47:20
us to look back at things and with a healthy dose of skepticism and say,
47:24
what does the evidence actually show?
47:26
And, you know, it's interesting how we got to this point. Where are we now?
47:29
Do we need to change anything?
47:31
We have a follow-up question on premature will-apparing baby with bloody stools.
47:36
How long would you keep them on non-cow's milk formula and would you use soy formula?
47:42
Yeah, I think you can go to soy. We were all taught there's a ton of cross-reactivity
47:48
between them, but they're different. Soy is a plant-based protein.
47:50
It's very different than the mammalian protein. So you can go to soy first.
47:53
And then the recommendations now are, let's go for a two to four-week elimination and then reassess.
47:59
If symptoms are completely resolved, you can put it back in the diet and see if they come back again.
48:03
If symptoms aren't resolved, you can consider putting it back in the diet because
48:06
that probably wasn't the cause anyways.
48:08
And then one more question. Should patients with peanut allergy avoid foods
48:12
that are prepared in the place where they have peanuts, but the food does not have peanut?
48:17
I think it depends on how well the manufacturer avoids cross-contamination.
48:21
Some patients avoid it and others don't and are fine.
48:26
Well, very quickly, in the United States, if a food contains one of the top
48:30
nine food allergens, milk, egg, wheat, soy, peanut, tree, nut,
48:33
fish, shellfish, or sesame, it must state contains.
48:36
All of the other wording may contain processed and facility shared equipment
48:40
is not regulated and is not meaningful.
48:43
Very few of those products contain any allergen, let alone enough allergen to
48:48
trigger an allergic reaction in an individual.
48:50
So the vast majority of these are safe. we
48:54
have also understood a lot more about individual thresholds most
48:58
people with peanut allergy need to eat a whole
49:01
peanut before they have any reaction at all so there's a lot that goes into
49:04
this but for those precautionary labels those are generally very safe now some
49:08
people choose to avoid them just to eliminate all risk and that's fine but that's
49:11
a conversation we have with folks and they can make up don't forget to click
49:17
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49:25
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He just moved here from England, and he's heading up our new pediatric plastic surgery program.
49:38
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49:43
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49:45
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