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How to Tell a True Food Allergy from an Intolerance · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Sarah Gubara (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sarah Gubara.
• 0:09
  And today, I'm joined by Dr.
• 0:11
  Aarti Pandya, Medical Director of the Food Allergy Center at
• 0:15
  Children's Mercy Kansas City.
• 0:17
  Today, we're exploring food allergy testing and diagnosis.
• 0:21
  Dr.
• 0:22
  Pandya, thank you for joining us today.
• 0:25
  Dr. Aarti Pandya:
• 0:25
  Thank you so much for having me on your podcast.
• 0:28
  Host: It's wonderful to have you.
• 0:30
  Now, when a family says, "I think it's a food allergy," what history or details
• 0:36
  can help you quickly distinguish from a true allergy versus an intolerance or a
• 0:41
  sensitivity or some unrelated symptoms?
• 0:44
  Dr. Aarti Pandya:
• 0:44
  Absolutely.
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  Food allergies are a challenging, often both diagnosis as well as
• 0:51
  problem that ails our community as well as our patients that we see.
• 0:55
  And they are typically seeking answers for, "Do I truly have something where
• 1:01
  this can be life-threatening and this can cause severe harm to me?"
• 1:04
  So, it's generally what a family is coming in with mindset-wise.
• 1:08
  And so, to kind of accompany that with the proper history that
• 1:12
  distinguishes between a true food allergy, as you mentioned, versus an
• 1:16
  intolerance or sensitivity, there's a good set of questions we can ask.
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  Just one quick thing here.
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  On true food allergies, this is typically mediated or driven by the immune system,
• 1:27
  whereas intolerances or sensitivities to foods will typically be driven
• 1:32
  independent of the immune system.
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  So, that's an important mindset thing for us as clinicians to
• 1:38
  remember as we are asking questions about this particular topic.
• 1:42
  Symptoms in particular can include hives, swelling, vomiting, diarrhea,
• 1:48
  trouble breathing, flushing, wheezing, presyncope, feeling
• 1:52
  lightheaded, loss of consciousness.
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  In addition to having these symptoms, the timeline is crucial to making a
• 2:00
  correct diagnosis for food allergy.
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  What I mean by that is a food allergy reaction, truly one that's mediated by
• 2:07
  the immune system, is going to come on within two hours of ingestion of the food.
• 2:13
  And honestly, in most cases, within one hour of ingestion of the food.
• 2:17
  There are some rare exceptions to that.
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  But when we talk about the majority of IgE-mediated food
• 2:23
  allergy or immune-mediated food allergy, that rule applies.
• 2:28
  Host: That's wonderful to know about the timeline.
• 2:30
  What are some of the biggest testing mistakes that you're seeing in primary
• 2:34
  care, and how can pediatricians avoid over-testing, especially if an infant
• 2:40
  has never tried that food before?
• 2:42
  Dr. Aarti Pandya:
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  The biggest pitfall I definitely see with regards to food allergy testing
• 2:47
  is the performance of food panels when there is not a strong clinical
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  history to suggest food allergy.
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  So, what I mean by that is there are many conditions that individuals can
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  present with where because they don't have a good treatment, let's say, or a
• 3:05
  good management plan, they are seeking, well, what internally is causing that?
• 3:09
  They come with that mentality to you.
• 3:12
  So, this can mean somebody who has atopic dermatitis or eczema
• 3:16
  that's not resolving, or somebody who's getting hives frequently.
• 3:20
  The assumption often on the family's end is, "Well, it has to be something
• 3:24
  I'm ingesting, otherwise why am I getting these types of skin rashes?"
• 3:27
  And so, food panels are performed.
• 3:29
  So, what is a food panel?
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  A food panel is a broad panel that tests for many different foods that
• 3:36
  don't accompany the clinical history.
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  What I mean by that is with regards to a food allergy diagnosis, you're
• 3:43
  going to have a reaction to that culprit food every time you eat it.
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  And let's say you're taking milk as an example.
• 3:50
  So, you'll ingest milk, you'll develop a reaction.
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  So in that particular individual, milk testing would be relevant.
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  But if they're eating and tolerating peanut, or if they haven't put peanut
• 4:01
  in the diet, or if they haven't put shellfish in the diet, it's harmful
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  to perform food allergy testing to foods that are not the culprit food.
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  These lead to five specific harms that I would encourage us to remember.
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  The first is physical harm, where we actually develop
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  loss of tolerance to a food.
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  We were previously ingesting a food, but we started avoiding it
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  because of a food panel testing, and that results in development
• 4:28
  of an IgE-mediated food allergy.
• 4:31
  Along with that part of physical harm, you can also develop a nutritional deficiency.
• 4:35
  The second part is psychological harm.
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  So individuals with true food allergies experience high levels
• 4:42
  of bullying, anxiety, and poor health-related quality of life.
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  The third is financial cost.
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  So, we have increased costs of allergen-free foods and then increased
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  healthcare costs too, which can result in more testing from the allergist's
• 4:57
  end to truly determine whether the individual has a food allergy or not.
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  The fourth harm is going to be opportunity cost, which means delayed
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  introduction of highly allergenic foods.
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  So now, we miss a window of preventing food allergy because
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  we don't put the food in the diet.
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  Or second, you can eliminate less allergenic versions of the
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  food for not a clinical reason.
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  And so, that gets eliminated from the diet.
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  And then, lastly is healthcare disparities.
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  So, there are high rates of false positive allergy testing among minorities.
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  And so, that can lead to lower access to specialist care, et cetera.
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  So, the food panel testing that I mentioned here, this can result
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  in what we call false positives, where a test is positive, but the
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  individual can tolerate a food.
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  It's a flaw of the testing.
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  And so, when we unnecessarily overly test for foods, we are resulting
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  potentially in these five major harms.
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  Host: Thank you for taking us across the five major harms.
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  That's really important information to know.
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  So as a pediatrician, if I'm considering testing, what is your Test Wisely
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  approach that you would recommend?
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  Dr. Aarti Pandya:
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  I think one thing to keep in mind is we welcome, of course,
• 6:13
  pediatricians to perform testing.
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  But if there's ever any uncertainty, the first thing in Test Wisely is to consider
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  referral to a specialist as that referral can result in specialized testing that
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  we perform and limit costs that come with over testing, and it narrows it
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  down to exactly what needs to be tested.
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  So, that's the first thing.
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  But if testing is performed on the pediatrician's end, then narrowing
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  it down to just the culprit foods would be the best approach.
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  In terms of interpretation of that testing, that can be very
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  tricky and very difficult.
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  I would strongly suggest, having a specialist that you can have a
• 6:51
  conversation with because there are so many different levels that occur in foods.
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  Like, you can have a milk IgE level of 2 that one would inherently think
• 7:00
  accompanies a food allergy, and it could with the right history.
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  But in the context of a different history, it may not.
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  And it may be something on the specialist's end that we don't
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  recommend avoidance for or we don't even deem as a food allergy.
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  So, the best approach would be have a specialist that you can
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  have those conversations with.
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  Host: When should a pediatrician refer to allergy and immunology?
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  And what information would make that referral the most effective
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  and efficient for your team?
• 7:31
  Dr. Aarti Pandya:
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  So, a pediatrician should always feel encouraged to refer to
• 7:36
  allergy and immunology if there is concern for food allergy.
• 7:40
  If there's even that concern for a food allergy, I think
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  that is a great time to refer.
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  If there's also conditions where there are symptoms like chronic hives
• 7:52
  or uncontrolled atopic dermatitis or eczema where someone is requesting
• 7:56
  food allergy testing, that's also an appropriate time for referral.
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  The thing that streamlines the referral and makes it very efficient is just
• 8:04
  knowing the reaction history for the food.
• 8:07
  And that's never expected necessarily on the specialist end because it takes
• 8:12
  so much time to dig into the exact reaction history for every single food
• 8:16
  that the individual is concerned about.
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  But it can be helpful to know that.
• 8:21
  Host: After diagnosis, what's the pediatrician's ongoing role?
• 8:25
  What do you want primary care to reinforce with families at follow-ups
• 8:29
  about safety, label reading and, most importantly, emergency readiness?
• 8:36
  Dr. Aarti Pandya:
• 8:36
  The primary role I would say is communication if there is something
• 8:41
  that happens in the interim that doesn't get relayed to the allergist.
• 8:45
  For instance, there is an accidental exposure that results in a reaction.
• 8:50
  That is something that we would love communicated with us.
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  And that is kind of what would aid our management for the patient
• 8:58
  in terms of the next steps.
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  In terms of reinforcement at follow-ups with regards to safety, label reading,
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  emergency readiness, generally when someone has a true food allergy,
• 9:09
  IgE-mediated food allergy in particular, the emergency readiness means having
• 9:14
  an anaphylaxis action plan as well as an accompanying epinephrine device.
• 9:18
  So, that can mean an auto-injector or a nasal spray epinephrine device.
• 9:23
  Label reading, we typically want to avoid labels that say "contain"
• 9:27
  in terms of the culprit food.
• 9:29
  And then, in terms of the last thing with regards to safety,
• 9:32
  just informing individuals about the food allergy diagnosis.
• 9:35
  For instance, if you're out at a restaurant and eating, make it very clear
• 9:39
  that, "Hey, I have this food allergy."
• 9:41
  And so, there is a risk of cross-contamination that the restaurant
• 9:46
  or other area would need to know about.
• 9:48
  Those I would say are the most important.
• 9:51
  Host: Wonderful.
• 9:52
  How do you explain the current options and how should families
• 9:56
  consider those current options?
• 9:59
  Dr. Aarti Pandya:
• 9:59
  Firstly, there has been a surgence in terms of the options that are
• 10:04
  available for food allergy treatment.
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  It's a very exciting time, to be honest with you, to be offering
• 10:10
  treatments for food allergy patients.
• 10:12
  In the past, we were limited for just avoidance.
• 10:15
  And now, there's so many things that are available, which makes it a
• 10:17
  very exciting time for food allergy.
• 10:20
  I will tell you the conversations we have on our end and maybe what's easiest
• 10:24
  on the pediatrician's end to discuss.
• 10:27
  On our end as the specialist, we do talk about avoidance as a treatment option.
• 10:31
  There are immunotherapy options that are available, whether that be oral
• 10:35
  immunotherapy or sublingual immunotherapy.
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  There are ongoing clinical trials across the country for other
• 10:41
  modalities of immunotherapy.
• 10:44
  And lastly, there is an injectable medication called omalizumab that
• 10:48
  targets IgE proteins that can also be used in treatment for food allergy.
• 10:54
  So, that is the whole gamut of what we offer on the specialist end.
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  There are nuances with regards to risks and benefits of each
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  of those treatment modalities.
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  So, we have a very, very detailed risk-benefit conversation when
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  we're in the clinic as a specialist discussing these with patients.
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  From the pediatrician's end, to simplify that, you can say that there are lots of
• 11:19
  new treatment options that have emerged for food allergy, and you would encourage
• 11:24
  discussing with a specialist to ensure that they know the full gamut of what
• 11:29
  is available out there In terms of how pediatricians should counsel families
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  about early introduction and continued exposure, that is a great question.
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  And I would say that is maybe the primary role that pediatricians can really play in
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  to help both prevent food allergy and keep tolerance of ongoing foods in the diet.
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  So firstly, with regards to early introduction, generally the timeline of
• 11:55
  food introduction, which we say between four and six months of age, is when
• 11:59
  we start introducing allergenic foods.
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  One thing as the specialist that we recommend is when introducing allergenic
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  foods, try not to introduce multiple allergenic foods in one setting.
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  The reason being is because if there is a reaction, it is a lot of work
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  on the family's end, and there's a lot of fear on the family's end of
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  backtracking to figure out what is the culprit food for the food allergy.
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  So, what we generally say is one new allergenic food in
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  the diet every couple of days.
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  Continue doing it for a few days.
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  Make sure there's no reactions prior to moving on to the next one.
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  And the other part about that is also counseling that in general practice
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  out there is that food panels are not needed prior to introduction of foods
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  for the vast majority of patients.
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  Even testing is not needed for the vast majority of patients.
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  And also, the majority of individuals do not carry things like epinephrine
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  devices when introducing foods.
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  So, those questions do come up even on our end too, and I know for sure
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  come up on the pediatrician's end.
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  There's one nuance to consider, which there's a discrepancy between how this
• 13:10
  is done internationally versus in the US.
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  So, it's one thing to keep in mind because the pediatrician should feel
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  encouraged to counsel on what they feel is best based on the literature.
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  So, one approach for introduction with regards to peanut allergy is
• 13:26
  following the trial that's called the LEAP trial and what that data showed
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  about early introduction of peanuts.
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  So, the trial ultimately showed that early introduction of peanut served as
• 13:38
  a primary prevention of peanut allergy.
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  However, there is two conditions that can result in potentially
• 13:44
  increased risk of peanut allergy.
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  Those two conditions would be moderate to severe atopic dermatitis or egg allergy.
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  So in those two demographics, there is potentially a role of peanut
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  testing prior to introduction.
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  And so if they meet that, that would be a time for a specialist referral.
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  Beyond that, you would introduce the remainder of allergenic foods
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  as we would recommend introduction of the remainder of foods.
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  However, internationally, there is a discrepancy, like I said, in
• 14:15
  how peanut introduction is done even in those two conditions.
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  When I say discrepancy, I mean internationally, in other places around
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  the world, there could be advocacy of just putting peanut in the diet without
• 14:28
  delaying that introduction even with testing because of that risk of false
• 14:33
  positives that come with testing.
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  But I would encourage you, if you're leaning on that end, to just review
• 14:38
  the data yourself and make sure you feel confident on either option.
• 14:42
  And even on the specialist option, there is a wide variety of what we discuss with
• 14:47
  regards to peanut introduction in those more severe conditions like moderate to
• 14:51
  severe atopic dermatitis or egg allergy.
• 14:55
  So to distill that down and make it simple, the best practice with early
• 14:59
  introduction of foods is to introduce at the time that you can introduce the
• 15:03
  majority of other foods in the diet when there's readiness for solid introduction.
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  You would introduce one allergenic food at a time over a course of a couple of days.
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  Don't put multiple allergenic foods in the diet at once.
• 15:15
  And with peanut introduction, there's two conditions to keep in mind.
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  The first is egg allergy,
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  and the second is moderate to severe atopic dermatitis.
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  In those two conditions, there could be consideration of specialist referral
• 15:31
  prior to introduction of peanuts.
• 15:34
  Host: Thank you.
• 15:34
  And my final question for you is the psychological aspect for new parents that
• 15:40
  are introducing foods to their infants.
• 15:44
  Anything else they should keep in practice or at top of mind about how
• 15:48
  to keep themselves regulated when they may not have these emergency
• 15:52
  readiness tools or medications on hand?
• 15:57
  Dr. Aarti Pandya:
• 15:57
  That is something that I deeply both sympathize with as an
• 16:01
  allergist-immunologist and as a specialist in food allergy, and
• 16:04
  I empathize with as a parent.
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  So, I certainly feel that from the parental end as well.
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  So, what I can say in general about that is there should be
• 16:16
  vigilance when you introduce foods.
• 16:18
  You know, we want to ensure that, especially with allergenic foods, we
• 16:22
  are watching our kiddos in terms of that timeline of when an IgE-mediated
• 16:27
  food allergy can occur, one to two hours after introduction of foods.
• 16:31
  Maybe don't consider introducing foods right before bedtime, as
• 16:36
  that's a vulnerable time for kids.
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  They're going to go to sleep right after potentially, so we don't want a
• 16:40
  reaction in the middle of the night.
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  So, potentially moving it up earlier in the day could be a great tool
• 16:45
  to bring peace of mind to parents.
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  And the third thing is food allergy in general is a rarer diagnosis.
• 16:52
  About 8% to 10% of the population has it.
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  So while it is, of course, very scary to experience a food allergy
• 16:59
  reaction, the vast majority of the population does not have food allergy.
• 17:03
  It's even more rare to have more severe reactions in terms of food allergies.
• 17:09
  The majority of food allergy systemic reactions, whole body
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  reactions, are on the milder end.
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  Many anaphylaxis self-resolves.
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  So, that doesn't mean that we take it lightly.
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  Of course, we want to keep vigilance.
• 17:22
  We want to be very mindful and conscientious when we're introducing
• 17:25
  allergenic foods in the child's diet.
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  However, if there's anything concerning that comes up when you're introducing
• 17:33
  allergenic foods, just know that having access to something like an urgent care
• 17:39
  or emergency department facility is kind of the best way to go, and knowing that
• 17:44
  there are many specialists out there that are more than happy, willing, and ready
• 17:48
  to help treat your child's condition if you do end up with a food allergy.
• 17:52
  Host: Thank you so much, Doctor, for anchoring us on food allergy testing and
• 17:57
  diagnosis, and your recommendations have been both clear and direct, which we love.
• 18:04
  Dr. Aarti Pandya:
• 18:04
  Excellent.
• 18:04
  I really appreciate being on here and talking to you about one of my
• 18:09
  favorite topics, which is food allergy.
• 18:11
  Host: Wonderful.
• 18:13
  And as a reminder to our audience, claim your CME credits after listening
• 18:17
  to this fascinating episode today.
• 18:20
  You can do so by visiting cmkc.link/cmepodcast
• 18:26
  and then click the Claim CME button.
• 18:29
  If you enjoyed this podcast, please share it on your social channels
• 18:33
  and check out the entire podcast library for topics of interest to you.
• 18:38
  I'm Dr.
• 18:38
  Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.