November 18, 2025 • 31 mins
In this first of a two-part conversation, I’m joined by Dr. Michael Pistiner, pediatric allergist and Director of Food Allergy Advocacy, Education, and Prevention at Mass General for Children, Harvard Medical School.
Dr. Pistiner discusses his work on developing the newly updated criteria for recognizing anaphylaxis in infants and toddlers, breaking down medical terminology into clear, everyday language parents can understand. He explains how reactions can progress from early to advanced anaphylaxis, the importance of giving epinephrine early, and how to recognize the signs even when they don’t look the way we might expect.
Dr. Pistiner has a gift for translating complex medical concepts into practical visuals that help parents see what’s happening, both in their child’s body and in their own decision-making process.
If you’ve ever worried about missing the signs or hesitated to give epinephrine, this conversation will give you the clarity and confidence to act when it matters most.
Food Allergy Management and Prevention
Support Tool for Infants and Toddlers:
https://famp-it.org/
Creating an Allergy and Anaphylaxis Plan:
https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Create-an-Allergy-and-Anaphylaxis-Emergency-Plan.aspx?sfns=mo
AAP Allergy and Anaphylaxis Emergency Plan:
https://publications.aap.org/pediatriccare/resources/17512/AAP-Allergy-and-Anaphylaxis-Emergency-Plan?autologincheck=redirected
Parental experience administering epinephrine for systemic reactions during infant and toddler oral food challenges: https://www.jaci-inpractice.org/article/S2213-2198(24)00687-1/fulltext
Development and Evaluation of Modified Criteria for Infant and Toddler Anaphylaxis:
https://pubmed.ncbi.nlm.nih.gov/38777125/
How to Use an Epinephrine Auto Injector:
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/How-to-Use-an-Epinephrine-Auto-Injector.aspx
Mass General Food Allergy Buddies Program:
https://www.massgeneral.org/children/food-allergies/food-allergy-community
Special thanks to Kyle Dine for permission to use his song The Doghouse for the podcast theme!
www.kyledine.com
Find Dr. Whitehouse:
-thefoodallergypsychologist.com
-Instagram: @thefoodallergypsychologist
-Facebook: Dr. Amanda Whitehouse, Food Allergy Anxiety Psychologist
-welcome@dramandawhitehouse.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Michael Pistiner, MD, MMSc, (00:00):
As more and more babies are showing
(00:02):
up to allergists and primarycare offices.
With allergic reactions comesthe increased need for
improvement in recognizing andtraining people about
anaphylaxis.
A severe, potentiallylife-threatening allergic
reaction that may not look quitethe same in a baby as compared
(00:23):
to a bigger kid or a grownup.
Speaker (00:25):
Welcome to the Don't Feed the Fear podcast, where we
dive into the complex world offood allergy anxiety.
I'm your host, Dr.
Amanda Whitehouse, food allergyanxiety psychologist and food
allergy mom.
Whether you're dealing withallergies yourself or supporting
someone who is, join us for anempathetic and informative
journey toward food allergy calmand confidence..
(00:47):
On today's episode.
I'm excited to introduce you tosomeone you may already know.
He's a huge voice in the allergyworld and doing such important
work to help protect ourchildren.
Dr.
Michael Pistiner is a pediatricallergist and the director of
Food Allergy Advocacy Educationand Prevention, At Mass General
for children.
Harvard Medical School.
Dr.
Pistiner is a leading voice inthe field specializing in food
(01:07):
allergy and anaphylaxismanagement in infants and
toddlers, which is what he'shere to talk to us about today.
Dr.
Pistiner is here to walk usthrough the newly updated
criteria for diagnosinganaphylaxis in infants and
toddlers.
Explain to us why those updatesmatter and share what we should
be looking for when a youngchild is potentially having a
reaction, he even demonstratesthe best approaches for
(01:28):
administering epinephrine safelyand effectively in very young
children.
And what epinephrine is the mostappropriate to have on hand for
most children in this age andweight range?
I have met few people who are soenthusiastic about helping young
children to be safer and to helptheir families navigate their
food allergies.
He combines his clinicalexpertise with his compassion
and clarity and motivation toget the word out, which makes
(01:50):
him an incredible advocate forour community.
Amanda Whitehouse, PhD (01:53):
Dr.
Pistiner, thank you so much forjoining me here today.
There's so many things I'vewanted to have you on the show
to talk about, thank you forbeing here
Michael Pistiner, MD, MMSc, (01:58):
all right.
Thanks for having me.
Amanda Whitehouse, PhD (02:01):
Give us a little background about you
and your career and how you gotconnected with the food allergy
world and research?
Michael Pistiner, MD, MMS (02:06):
Yeah.
Um, so I am a pediatricallergist and I.
Am the father of a 22-year-oldwith food allergy.
And when I was training to be apediatric allergist, uh, that's
when he had his first allergicreaction.
And so when I became the dad ofa kid with food allergy, um, I
(02:28):
started learning how tricky andchallenging things can be.
And so it took my family abouttwo months before we got
comfortable and I startedrealizing that their.
Were major gaps when it came toadvocacy and community education
and really started gettinginvolved and engaged.
(02:49):
And, uh, now I like saying thatI kind of don't know what my
hobby is and my job is anymore.
And so now I'm at Mass General,uh, for children and I am a, um,
director of food allergyadvocacy education and
prevention.
Um, my clinical focus now is.
(03:11):
Managing food allergy andanaphylaxis in infants and
toddlers.
Um, and then I also, uh, um,help run the Food Allergy
Buddies program, um, and otheradvocacy and educational, um,
uh, programs and projects.
Amanda Whitehouse, PhD (03:28):
I, I have to say, we like hearing
from you when we know that youget it from that side too,
especially.
Michael Pistiner, MD, MMS (03:33):
Yeah, I think that I did, uh, um, I
learned, learned the most as adad.
Um, doctoring is easy.
Amanda Whitehouse, PhD (03:42):
Let's start by talking about what
prompted this update?
To modify the criteria in theseyounger ages of children for
anaphylaxis?
Michael Pistiner, MD, MMSc, (03:50):
So our field has been recognizing
that early introduction in, um,babies food allergy.
And so where decades ago peoplewere recommending delaying the
introduction of highlyallergenic foods, um, after the
(04:11):
leap.
in 2015 was published.
That was good hard evidence.
That early introduction.
In that case, peanut uh, babiesfrom developing peanut allergy.
And so as our field has figuredthis out and is feeding babies
earlier, um, now we allergens.
(04:33):
Um, now we are starting toidentify more and more infants
that have food allergies.
And so where traditionally, 20years ago, allergists weren't
seeing that many kids underagetoo.
Now they're coming like a firehose.
Um, and the babies just keepgetting born and we really need
(04:56):
to accommodate to this newpatient population.
Um, and as.
More and more babies are showingup to allergists and primary
care offices.
With allergic reactions comesthe increased need for
improvement in recognizing andtraining people about
anaphylaxis.
(05:17):
A severe, potentiallylife-threatening allergic
reaction that may not look quitethe same in a baby as compared
to a bigger kid or a grownup.
Amanda Whitehouse, PhD (05:28):
So how do you go about studying a
concept that big?
Michael Pistiner, MD, MMSc, (05:32):
All right.
Well, there's some challengesthat are gonna come specific to
the infants and the toddlers.
One of them is babies don'ttalk.
So when the criteria foridentifying anaphylaxis was put
together, it wasn't validatedfor kits less than age two.
(05:54):
Some of the language in thereactually asks for subjective
signs and symptoms, things thatsomeone would describe.
So itchiness, dizziness, ache,of breath.
And now as I'm saying'em, youcould see how a baby can't tell
(06:16):
us these things.
We gotta know what to look for.
So one of the challenges is.
Babies can't talk, so they can'ttell us what they're feeling.
So we need to find surrogates.
We need to find replacements ofthings we can look for that
would otherwise tell us this.
Another thing is that infantsand toddlers have behaviors that
(06:38):
can overlap with.
Signs and symptoms of allergicreactions.
A teething kid who's droolingall over the place crying and
their hands are in their mouth.
That's a little hard sometimesto differentiate that behavior
from what might be the sensationof itching in a kid's mouth
who's very uncomfortable andhaving an allergic reaction.
(07:01):
And so this is where parents,babysitters.
Doctors, emergency departments,we all need to start paying
attention to these nuanced waysto recognize signs and symptoms
in infants and toddlers.
The criteria technically wasmeant for the healthcare setting
(07:25):
for clinicians, and it involvesusing vital signs, exam history,
and this was.
Published and utilized now foryears.
2006 was when, um, this proposedcriteria, the N-I-A-I-D
(07:51):
criteria, um, led by HughSampson and his colleagues and.
Has been used readily in theUnited States and then also
beyond.
We've been.
Seeing some of these anecdotallyand other groups have also had
(08:15):
publications where they wereshowing that maybe infants and
toddlers don't have the verysame signs and symptoms as the
bigger kids.
And so there were publicationsfrom other teams over the years,
from, Ruchi Guptas group, andothers where they were showing
(08:35):
that many babies tended to haveskin and GI findings.
They were reporting much lowercardiovascular findings and also
some lower respiratory findingsthan the older cohort and the
older kids.
Many of those publications wereretrospective emergency room
(09:00):
studies, so they would go backto was documented in the
emergency department, and theywere looking for the signs and
symptoms that were built intothe criteria that I was talking
about.
And so around that time.
(09:21):
My team worked with afa, asthmaAllergy Foundation of America,
and we published a survey thatAFA led and that was asking
primary caregivers who werepresent for their kids most
(09:41):
severe allergic reaction whenthey were under age three.
We were asking.
What were the signs and symptomsthat they observed in those most
severe reactions?
And we used some of the languagethat was proposed and used in
past studies, but alsoanecdotally what we were
(10:04):
experiencing in seeing in ourpatients.
we that there were reports ofsigns and symptoms that weren't
necessarily being.
Communicated in some of thoseretrospective emergency room
(10:25):
visits, because imagine if afamily goes into an emergency
department and the team doesn'tknow to ask for certain things,
and even if a family says thatmy kid was raking at their
tongue, they had their fingersin their ears, then that might
not be something that someonewould write in their note.
So there were.
(10:48):
that we wanted to know that youreally needed to get from the
person who was actually watchingthe kid have the reaction.
Um, and so part of the findingsfrom that were then used to help
us with the project where weproposed modifications to the
(11:10):
criteria.
Um, we also used.
Pals, um, pediatric advancedlife support recommendations for
how someone would identifycardiovascular compromise in a
child younger than age four.
(11:30):
so.
Cardiovascularly, infants andtoddlers behave a little
different than a bigger kid or agrownup when it comes to what
they might show and the waytheir heart responds.
'cause little kids' hearts areawesome at being able to
compensate.
And so where a grownup mighthave low blood pressure,
(11:51):
hypotension, a baby have lowblood pressure until they're
very, very sick.
So a baby's heart can compensatereally well and can get very,
very fast.
And so that's how a baby isgonna deal with cardiovascular
symptoms in the middle ofanaphylaxis if they have'em by
(12:14):
potentially getting tachycardicfast heart rate.
Um, babies may also have poorperfusion, meaning that then the
blood flow doesn't go great totheir extremities.
Babies might get cyanotic blue.
They might have, um, be verypale.
Uh, they might also havemodeling of their skin, and some
(12:38):
of that is because of poorperfusion.
Babies may also, because ofcardiovascular symptoms, have
something tachypnia.
might breathe very fast eventhough they may not have.
Wheezing issues or coughingissues or lung issues that just
the cardiac compensation canalso make them tick knick.
So these are signs thatpediatricians and pediatric
(13:03):
teams know to look for in whatused to be called compensated
shock.
We don't wanna wait for a babyto have decompensated shock,
which is low blood pressure.
So this was something else thatwe proposed in the modifications
to that criteria.
another thing in the criteriathat might be a bit different in
(13:24):
the infants and toddlers isthat.
Some mucocutaneous changes, sosome changes that you could see
in the mucus membranes and theskin.
A baby's is kind ofunacceptable, like a swollen
tongue or swollen uvula.
Those we were considering moreof an airway issue.
So taking all of that intoconsideration the that babies
(13:52):
can't communicate quite thesame, and so we.
Offered surrogates replacementsof subjective symptoms.
was one change.
Then the other change Imentioned was, um, modification
in cardiovascular symptoms,allowing for cardiovascular
compromise, compensated shock asopposed to waiting for
(14:15):
decompensated shock, um, andthen also having the shift in
some of the airway symptoms.
Amanda Whitehouse, PhD (14:23):
Can you talk to us about the
misconceptions then thatparents, caregivers,
grandparents are having aboutwhat they think it will look
like in their child and what itmight actually look like that
they would be likely to miss?
Tell us from our eyes, what wewould see, what we need to be
looking for.
Michael Pistiner, MD, MM (14:39):
Great.
So we.
Had that question when we puttogether the survey I was
mentioning before with, uh,asthma Allergy Foundation of
America and one of the banks ofquestions that we had was now in
retrospect now after the dusthas settled and now you're
(15:02):
filling this thing out, werethere signs and symptoms that
you actually saw but you didn'tknow?
It was an allergic reaction, andover 45% of people said that
they did identify at least onesign or symptom.
That now in retrospect, theyknow was part of the allergy,
(15:23):
but they didn't then.
So behavior change was one ofthe ones that people were
reporting.
Um, also skin findings alsocough.
And so there were some thingsthat are important for people to
know to recognize as potentialallergic reactions.
Um, I've seen children lickchairs.
(15:46):
I've seen people put theirfingers in their ears and
seemingly scratch at their ears.
Um, can pull up their knees totheir chest back arch hiccups.
Now, these are also, as I'msaying them, these are things
that our kids do all the time,even when they're well.
And so the thing to recognizeand the thing to think about is
(16:11):
that.
In the setting of multiplesystems, so signs and symptoms
that represent more than onesystem, especially in the
setting of a trigger, then thismakes it a little easier for a
family to be able to recognize,Hey, these behaviors, this is
not just normal, baby.
This is a potential allergicreaction.
Amanda Whitehouse, PhD (16:33):
We talk about that two systems, right?
Identifying anaphylaxis is twosystems involved.
Is there a shortcut or is therean easy way that you teach this
to parents as far as what fallsunder what systems?
Michael Pistiner, MD, MMS (16:43):
Yeah.
Alright, so first off, foodallergy and anaphylaxis
emergency care plans are a nicecheat.
So having a or something that afamily, or important, a
babysitter or.
Secondary caregiver who now wehave taught, so we, parents of
(17:07):
kids with food allergies are nowteaching all these other people
to watch our kids so we couldfinally get a break.
And so when we do that training,we definitely want to pass along
these emergency care plans,which is a cheat sheet that
somebody can look at that makesit easy to know when you would
treat with epinephrine.
And epinephrine is the treatmentof choice for anaphylaxis.
(17:31):
And it shuts the reaction downquickly and keeps it from
progressing.
And so we want people to havethose cheat sheets readily
available and understand them.
Um, currently the AmericanAcademy of Pediatrics has one
that has been created for allages.
And what's nice about attemptingto have a universal action plan
(17:53):
is that Primary care clinicians,pediatricians, family medicine,
clinicians, if school nurses, ifpreschools, if allergists all
accept this plan, then it canmake communicating and passing
the plan along very easy.
(18:14):
Now, one thing with this plan isthat it's not exactly.
Created specifically for thoseinfants and toddlers.
It's got a couple of thosesubjective symptoms that I've
been talking about where we needto know to look for surrogates.
And so one of the things I'vebeen doing is collaborating with
Allergy Asthma Network to helpcreate resources to help parents
(18:41):
be able to know how to interpretthat action plan when they have
an infant or a toddler.
And so.
very, very long-winded answer toyour question is getting an
action plan and gettingcomfortable with it is a great
way to, um, make it a littleeasier.
But that aside, and I'd sayeverybody go look up the
(19:05):
American Academy of PediatricsAllergy and Anaphylaxis
Emergency Care Plan and getcomfortable with it.
Amanda Whitehouse, PhD (19:13):
I'll link that in the notes so
Michael Pistiner, MD, MMSc, (19:15):
All right,
Amanda Whitehouse, PhD (19:15):
people can find it easily.
Michael Pistiner, MD, MMSc, (19:16):
And then talking about ultimately
you mentioned the more than onesystem, and so a system is a end
organ skin derm could beconsidered one system, so
swelling, hives, itching.
(19:37):
A kid might be scratching, a kidmight be rubbing their body up
against the carpet.
Um, you might see, um.
Redness that's all over.
You might also see welts hives.
Um, in light skinned kids, youmight see those hives look pink.
(19:57):
Um, in a dark skinned kid, itmight just be that you just see
that it has contour, that it'sraised, um, it might even look
darker.
And so getting used to your ownkid and knowing what their skin
looks like at their baseline isgonna be really helpful.
Those would all be consideredthe skin system derm, um, GI
(20:22):
vomiting, diarrhea.
I would say more mild symptomslike hiccup and belly pain that
a baby might show us becausethey're bringing their knees up.
um.
So respiratory system, wheezing,sneezing, would be more mild
(20:43):
symptoms in the respiratorysymptom.
Um, in a little baby who'shaving a hard time breathing,
where a big kid or a grownupmight say they're short of
breath, a little baby might havenasal flaring.
That means their nostrils aremoving back and forth.
Um, they may have tugging wherethe skin in between their ribs
(21:06):
goes in and out.
They might be belly breathingwhere their belly goes up and
down.
Uh, they may also have, um, theskin above their sternum.
Right in their neck might looklike it's going in and out.
So those are called retraction.
So that's something we could seein a kid who is having a hard
time breathing.
(21:27):
Um, we may also then see forcardiovascular where a grownup
might say that they're dizzy,um, or pass out.
A little kid might have mentalstatus change.
They might have behavioralchange, um, that's not
attributable to anything elseother than the allergic
(21:49):
reaction.
And so they might have quicklethargy, which is very quiet.
Um, one of the words that we useis obtunded.
Um, they might almost be passingout, falling asleep, have a hard
time keeping their head up, getfloppy, wobbly, a poor head
control.
Um.
(22:10):
You also might see the opposite,where a kid might become very
irritable, inconsolable, um,total change in behavior.
Um, no obvious trigger or causeother than the potential
allergic reaction.
And so those behavioral changesactually can be thought to be
cardiovascular.
(22:31):
You also then have the systemof.
Neuro, which overlaps a littlebit with what I was talking
about here.
and so getting comfortableunderstanding which signs and
symptoms fit in which system canbe a helpful tip and trick to
(22:52):
know, ah, you know what?
We're dealing with an allergicreaction that's more than just
mild and contained.
Amanda Whitehouse, PhD (22:59):
This is so helpful.
Thank you so much, becausedescribing it in those.
terms that, parents, wouldn'thave known, but to think that
specifically and connect it, Ithink is so important for people
in having a better idea of whatthis looks like.
Michael Pistiner, MD, MMSc, (23:11):
Do you
Amanda Whitehouse, PhD (23:11):
It's helpful.
Michael Pistiner, MD, MMS (23:12):
some?
Amanda Whitehouse, (23:13):
Absolutely.
Michael Pistiner, MD, MMSc, (23:14):
All right.
So.
One of the things to talk aboutwhile we're talking about
recognizing a potentially severeallergic reaction is gonna be
what do you do when yourecognize it?
So once you think that thisthing might be anaphylaxis, now
you're gonna wanna shut it downwith epinephrine.
(23:35):
is the drug of choice to treatanaphylaxis and epinephrine
helps you get control of thesituation.
And so you'll hear me say thatprobably four or five times in
the rest of what we're talkingabout is when in doubt if you
gotta get control.
If you're losing control,epinephrine gets you control.
(23:56):
Um, because it works everywherewhere we want it to.
In all those systems that I wastalking about, epinephrine is
gonna wind up taking care ofbusiness.
Um, and so most importantly,epinephrine works on the
receptors of the cell membranesof the allergy cells.
Uh, the two that we talk about,a lot of the mast cells in the
(24:17):
basophils.
And so when epi is around.
It's less likely that these guysare gonna be able to de
granulate and release what'sinside them.
And what's inside these allergycells is more than just
histamine.
We got platelet activatingfactor leukotrienes, all these
baddies that are gonna makeblood vessels, leaky and floppy,
(24:40):
that leakiness.
Then you can have hives andswelling.
When the fluid leaves the bloodvessels, it's leaving the
intravascular space, and when itleaves, it doesn't just go back
in.
And so the longer you're gonnago with that leakiness, the more
fluid you're gonna lose.
(25:01):
And then that's when IV fluidmight be needed when somebody
goes a while without shutting itdown.
And so.
Another thing that can happenwhen the reaction is going on is
that smooth muscle of the upperairway, or smooth muscle, excuse
(25:22):
me, of the lungs and the lowerairway, can constrict and make a
picture that looks very muchlike an asthma attack.
Coughing, wheezing, mucussecretion, all things that are
gonna make it harder to breathe.
And the longer then someone goeswithout epinephrine, the more
that process can keep happening.
(25:43):
And so in when we're thinkingabout respiratory, if early on
somebody would've had fivesneezes, then if they wait and
they don't treat, then it mightturn into a bunch of coughs.
Then those coughs turn intowheezes.
And now we have somebody who'sreally working hard to breathe
and has the nasal flaring andthe intercostal retractions I
(26:06):
was talking about.
Um, and then they need oxygenand then they need more
epinephrine.
Um, and so this is where earlyon treating, you wouldn't
necessarily know what it wasgonna turn into.
Where when we're thinking aboutgi um, winds up being able to
(26:27):
kind of turn off the peristalsisthat would be causing vomiting
and it can turn off the diarrheaand shut things down.
Um, so if someone waited to giveepinephrine, then the hiccups
and the.
Belly pain that you might belooking at from pulling up the
(26:49):
knees and a kid back archingmight turn into the vomiting,
which then turns into vomitingand diarrhea.
And now we have more fluidlosses, which I was talking
about before.
And then we might have this kidwho has behavioral changes in
the setting of other signs andsymptoms, and first they get
cranky and then they getirritable, and now they're
(27:12):
inconsolable.
But if someone waits to treat,then they might get obtunded,
lethargic, um, and difficult toarouse.
And so every person whoexperiences an allergic
reaction, every one of the youngkids might look different than
another young kid.
(27:33):
And then each time they have anallergic reaction, they might
look different from themselvesfrom the last time they had one.
Being able to kind of recognizesome of these patterns and
understand these systems andunderstand symptoms within the
system will really help you knowwhen it's time to get that epi
and shut things down.
Amanda Whitehouse, PhD (27:54):
Yeah, and I, I'm so glad that you
emphasized that because I dothink a lot of us as parents, we
get hooked on, well, this iswhat happens to him.
He always has a rash first, orhe always has this or that, and
it might not look the.
Same from reaction to reaction,
Michael Pistiner, MD, MM (28:06):
that's right.
And then just having that senseof pattern recognition is gonna
help.
And now to bring it back to whatyou said, which.
I like thinking about it thatway is more than one system is
two systems or more, then it'sgo time.
Um, and so if somebody has anexposure to likely allergen and
now they have sneezing.
(28:30):
They have hives around theirmouth in the area where the food
touched.
I feel good that that's a greattime to use epinephrine and shut
things down.
And so those are mild symptoms.
I'd say they're nothing burgers,but you take two of them in two
different systems.
And then I like saying thisalso.
(28:53):
I would never call it mildanaphylaxis because that's an
oxymoron.
I'd call it early anaphylaxis,the perfect time to use
epinephrine'cause we're notinterested in seeing what's
gonna happen.
And as I mentioned it before,you don't need to wait for your
five sneezes to turn intocoughing, wheezing, respiratory
distress.
(29:14):
You don't need to wait untilyour local hives turn into full
body hives with swelling,angioedema, and then a floppy
kid who's having cardiovascularsymptoms.
Let's just treat'em early on.
We will pause our conversationthere with Dr.
Pistiner and pick up again nextweek.
I hope this gives you a clearer,more confident understanding of
(29:35):
what anaphylaxis can look likein very young children and how
it's different from what we'veheard in the past and how it
presents in older people.
It's such an important stepforward in helping caregivers
and clinicians confidentlyidentify reactions early and Act
fast by administeringepinephrine, which is what we'll
be talking about next week.
So your first action step is tocome back for part two next
(29:56):
week.
That's where we'll dive into howto administer epinephrine safely
and effectively in infants andtoddlers.
How to get comfortable with theconcept of using the epinephrine
and talk about which device isthe best suited for this age
group.
Number two, learn more about theupdated criteria that Dr.
Pistiner told us about today andexplore the resources that he
has created@fpi.org.
(30:17):
And that's FAMP-it.org.
The link will be in the shownotes, and this is where Dr.
Pistiner and his team have, haveshared tools for food allergy
management and prevention.
Including information aboutearly food introduction skincare
and eczema management.
IgE mediated food allergy andnon IgE mediated food allergy.
(30:38):
to Follow Dr.
Pistiner's work.
The website is massgeneral.org/children/allergy.
You'll find so many resources,and so much information there,
as well as links to their socialmedia.
On Facebook, you can find thefood allergy center at mgh.
And an account for their foodallergy buddies program.
(30:58):
And third.
Share this episode with yourco-parent with family members,
childcare providers,babysitters, healthcare
professionals in your circle.
Anyone who might be caring foran infant or a toddler with food
allergies who might not yet knowabout these changes in the
recommendations for identifyingand treating anaphylactic
reaction, in people who aren'told enough to express it in the
(31:20):
words that are typically used.
Thank you for tuning in and forbeing part of this growing
community with me, and we willbe back next week with more on
administering epinephrine tothis population of young
children and babies.
the content of this podcast isfor informational and
educational purposes only, andis not a substitute for
professional medical or mentalhealth advice, diagnosis, or
(31:43):
treatment.
If you have any questions aboutyour own medical experience or
mental health needs, pleaseconsult a professional.
I'm Dr.
Amanda Whitehouse.
Thanks for joining me.
And until we chat again,remember don't feed the fear.
As more and more babies are showing
(00:02):
up to allergists and primarycare offices.
With allergic reactions comesthe increased need for
improvement in recognizing andtraining people about
anaphylaxis.
A severe, potentiallylife-threatening allergic
reaction that may not look quitethe same in a baby as compared
(00:23):
to a bigger kid or a grownup.
Speaker (00:25):
Welcome to the Don't Feed the Fear podcast, where we
dive into the complex world offood allergy anxiety.
I'm your host, Dr.
Amanda Whitehouse, food allergyanxiety psychologist and food
allergy mom.
Whether you're dealing withallergies yourself or supporting
someone who is, join us for anempathetic and informative
journey toward food allergy calmand confidence..
(00:47):
On today's episode.
I'm excited to introduce you tosomeone you may already know.
He's a huge voice in the allergyworld and doing such important
work to help protect ourchildren.
Dr.
Michael Pistiner is a pediatricallergist and the director of
Food Allergy Advocacy Educationand Prevention, At Mass General
for children.
Harvard Medical School.
Dr.
Pistiner is a leading voice inthe field specializing in food
(01:07):
allergy and anaphylaxismanagement in infants and
toddlers, which is what he'shere to talk to us about today.
Dr.
Pistiner is here to walk usthrough the newly updated
criteria for diagnosinganaphylaxis in infants and
toddlers.
Explain to us why those updatesmatter and share what we should
be looking for when a youngchild is potentially having a
reaction, he even demonstratesthe best approaches for
(01:28):
administering epinephrine safelyand effectively in very young
children.
And what epinephrine is the mostappropriate to have on hand for
most children in this age andweight range?
I have met few people who are soenthusiastic about helping young
children to be safer and to helptheir families navigate their
food allergies.
He combines his clinicalexpertise with his compassion
and clarity and motivation toget the word out, which makes
(01:50):
him an incredible advocate forour community.
Amanda Whitehouse, PhD (01:53):
Dr.
Pistiner, thank you so much forjoining me here today.
There's so many things I'vewanted to have you on the show
to talk about, thank you forbeing here
Michael Pistiner, MD, MMSc, (01:58):
all right.
Thanks for having me.
Amanda Whitehouse, PhD (02:01):
Give us a little background about you
and your career and how you gotconnected with the food allergy
world and research?
Michael Pistiner, MD, MMS (02:06):
Yeah.
Um, so I am a pediatricallergist and I.
Am the father of a 22-year-oldwith food allergy.
And when I was training to be apediatric allergist, uh, that's
when he had his first allergicreaction.
And so when I became the dad ofa kid with food allergy, um, I
(02:28):
started learning how tricky andchallenging things can be.
And so it took my family abouttwo months before we got
comfortable and I startedrealizing that their.
Were major gaps when it came toadvocacy and community education
and really started gettinginvolved and engaged.
(02:49):
And, uh, now I like saying thatI kind of don't know what my
hobby is and my job is anymore.
And so now I'm at Mass General,uh, for children and I am a, um,
director of food allergyadvocacy education and
prevention.
Um, my clinical focus now is.
(03:11):
Managing food allergy andanaphylaxis in infants and
toddlers.
Um, and then I also, uh, um,help run the Food Allergy
Buddies program, um, and otheradvocacy and educational, um,
uh, programs and projects.
Amanda Whitehouse, PhD (03:28):
I, I have to say, we like hearing
from you when we know that youget it from that side too,
especially.
Michael Pistiner, MD, MMS (03:33):
Yeah, I think that I did, uh, um, I
learned, learned the most as adad.
Um, doctoring is easy.
Amanda Whitehouse, PhD (03:42):
Let's start by talking about what
prompted this update?
To modify the criteria in theseyounger ages of children for
anaphylaxis?
Michael Pistiner, MD, MMSc, (03:50):
So our field has been recognizing
that early introduction in, um,babies food allergy.
And so where decades ago peoplewere recommending delaying the
introduction of highlyallergenic foods, um, after the
(04:11):
leap.
in 2015 was published.
That was good hard evidence.
That early introduction.
In that case, peanut uh, babiesfrom developing peanut allergy.
And so as our field has figuredthis out and is feeding babies
earlier, um, now we allergens.
(04:33):
Um, now we are starting toidentify more and more infants
that have food allergies.
And so where traditionally, 20years ago, allergists weren't
seeing that many kids underagetoo.
Now they're coming like a firehose.
Um, and the babies just keepgetting born and we really need
(04:56):
to accommodate to this newpatient population.
Um, and as.
More and more babies are showingup to allergists and primary
care offices.
With allergic reactions comesthe increased need for
improvement in recognizing andtraining people about
anaphylaxis.
(05:17):
A severe, potentiallylife-threatening allergic
reaction that may not look quitethe same in a baby as compared
to a bigger kid or a grownup.
Amanda Whitehouse, PhD (05:28):
So how do you go about studying a
concept that big?
Michael Pistiner, MD, MMSc, (05:32):
All right.
Well, there's some challengesthat are gonna come specific to
the infants and the toddlers.
One of them is babies don'ttalk.
So when the criteria foridentifying anaphylaxis was put
together, it wasn't validatedfor kits less than age two.
(05:54):
Some of the language in thereactually asks for subjective
signs and symptoms, things thatsomeone would describe.
So itchiness, dizziness, ache,of breath.
And now as I'm saying'em, youcould see how a baby can't tell
(06:16):
us these things.
We gotta know what to look for.
So one of the challenges is.
Babies can't talk, so they can'ttell us what they're feeling.
So we need to find surrogates.
We need to find replacements ofthings we can look for that
would otherwise tell us this.
Another thing is that infantsand toddlers have behaviors that
(06:38):
can overlap with.
Signs and symptoms of allergicreactions.
A teething kid who's droolingall over the place crying and
their hands are in their mouth.
That's a little hard sometimesto differentiate that behavior
from what might be the sensationof itching in a kid's mouth
who's very uncomfortable andhaving an allergic reaction.
(07:01):
And so this is where parents,babysitters.
Doctors, emergency departments,we all need to start paying
attention to these nuanced waysto recognize signs and symptoms
in infants and toddlers.
The criteria technically wasmeant for the healthcare setting
(07:25):
for clinicians, and it involvesusing vital signs, exam history,
and this was.
Published and utilized now foryears.
2006 was when, um, this proposedcriteria, the N-I-A-I-D
(07:51):
criteria, um, led by HughSampson and his colleagues and.
Has been used readily in theUnited States and then also
beyond.
We've been.
Seeing some of these anecdotallyand other groups have also had
(08:15):
publications where they wereshowing that maybe infants and
toddlers don't have the verysame signs and symptoms as the
bigger kids.
And so there were publicationsfrom other teams over the years,
from, Ruchi Guptas group, andothers where they were showing
(08:35):
that many babies tended to haveskin and GI findings.
They were reporting much lowercardiovascular findings and also
some lower respiratory findingsthan the older cohort and the
older kids.
Many of those publications wereretrospective emergency room
(09:00):
studies, so they would go backto was documented in the
emergency department, and theywere looking for the signs and
symptoms that were built intothe criteria that I was talking
about.
And so around that time.
(09:21):
My team worked with afa, asthmaAllergy Foundation of America,
and we published a survey thatAFA led and that was asking
primary caregivers who werepresent for their kids most
(09:41):
severe allergic reaction whenthey were under age three.
We were asking.
What were the signs and symptomsthat they observed in those most
severe reactions?
And we used some of the languagethat was proposed and used in
past studies, but alsoanecdotally what we were
(10:04):
experiencing in seeing in ourpatients.
we that there were reports ofsigns and symptoms that weren't
necessarily being.
Communicated in some of thoseretrospective emergency room
(10:25):
visits, because imagine if afamily goes into an emergency
department and the team doesn'tknow to ask for certain things,
and even if a family says thatmy kid was raking at their
tongue, they had their fingersin their ears, then that might
not be something that someonewould write in their note.
So there were.
(10:48):
that we wanted to know that youreally needed to get from the
person who was actually watchingthe kid have the reaction.
Um, and so part of the findingsfrom that were then used to help
us with the project where weproposed modifications to the
(11:10):
criteria.
Um, we also used.
Pals, um, pediatric advancedlife support recommendations for
how someone would identifycardiovascular compromise in a
child younger than age four.
(11:30):
so.
Cardiovascularly, infants andtoddlers behave a little
different than a bigger kid or agrownup when it comes to what
they might show and the waytheir heart responds.
'cause little kids' hearts areawesome at being able to
compensate.
And so where a grownup mighthave low blood pressure,
(11:51):
hypotension, a baby have lowblood pressure until they're
very, very sick.
So a baby's heart can compensatereally well and can get very,
very fast.
And so that's how a baby isgonna deal with cardiovascular
symptoms in the middle ofanaphylaxis if they have'em by
(12:14):
potentially getting tachycardicfast heart rate.
Um, babies may also have poorperfusion, meaning that then the
blood flow doesn't go great totheir extremities.
Babies might get cyanotic blue.
They might have, um, be verypale.
Uh, they might also havemodeling of their skin, and some
(12:38):
of that is because of poorperfusion.
Babies may also, because ofcardiovascular symptoms, have
something tachypnia.
might breathe very fast eventhough they may not have.
Wheezing issues or coughingissues or lung issues that just
the cardiac compensation canalso make them tick knick.
So these are signs thatpediatricians and pediatric
(13:03):
teams know to look for in whatused to be called compensated
shock.
We don't wanna wait for a babyto have decompensated shock,
which is low blood pressure.
So this was something else thatwe proposed in the modifications
to that criteria.
another thing in the criteriathat might be a bit different in
(13:24):
the infants and toddlers isthat.
Some mucocutaneous changes, sosome changes that you could see
in the mucus membranes and theskin.
A baby's is kind ofunacceptable, like a swollen
tongue or swollen uvula.
Those we were considering moreof an airway issue.
So taking all of that intoconsideration the that babies
(13:52):
can't communicate quite thesame, and so we.
Offered surrogates replacementsof subjective symptoms.
was one change.
Then the other change Imentioned was, um, modification
in cardiovascular symptoms,allowing for cardiovascular
compromise, compensated shock asopposed to waiting for
(14:15):
decompensated shock, um, andthen also having the shift in
some of the airway symptoms.
Amanda Whitehouse, PhD (14:23):
Can you talk to us about the
misconceptions then thatparents, caregivers,
grandparents are having aboutwhat they think it will look
like in their child and what itmight actually look like that
they would be likely to miss?
Tell us from our eyes, what wewould see, what we need to be
looking for.
Michael Pistiner, MD, MM (14:39):
Great.
So we.
Had that question when we puttogether the survey I was
mentioning before with, uh,asthma Allergy Foundation of
America and one of the banks ofquestions that we had was now in
retrospect now after the dusthas settled and now you're
(15:02):
filling this thing out, werethere signs and symptoms that
you actually saw but you didn'tknow?
It was an allergic reaction, andover 45% of people said that
they did identify at least onesign or symptom.
That now in retrospect, theyknow was part of the allergy,
(15:23):
but they didn't then.
So behavior change was one ofthe ones that people were
reporting.
Um, also skin findings alsocough.
And so there were some thingsthat are important for people to
know to recognize as potentialallergic reactions.
Um, I've seen children lickchairs.
(15:46):
I've seen people put theirfingers in their ears and
seemingly scratch at their ears.
Um, can pull up their knees totheir chest back arch hiccups.
Now, these are also, as I'msaying them, these are things
that our kids do all the time,even when they're well.
And so the thing to recognizeand the thing to think about is
(16:11):
that.
In the setting of multiplesystems, so signs and symptoms
that represent more than onesystem, especially in the
setting of a trigger, then thismakes it a little easier for a
family to be able to recognize,Hey, these behaviors, this is
not just normal, baby.
This is a potential allergicreaction.
Amanda Whitehouse, PhD (16:33):
We talk about that two systems, right?
Identifying anaphylaxis is twosystems involved.
Is there a shortcut or is therean easy way that you teach this
to parents as far as what fallsunder what systems?
Michael Pistiner, MD, MMS (16:43):
Yeah.
Alright, so first off, foodallergy and anaphylaxis
emergency care plans are a nicecheat.
So having a or something that afamily, or important, a
babysitter or.
Secondary caregiver who now wehave taught, so we, parents of
(17:07):
kids with food allergies are nowteaching all these other people
to watch our kids so we couldfinally get a break.
And so when we do that training,we definitely want to pass along
these emergency care plans,which is a cheat sheet that
somebody can look at that makesit easy to know when you would
treat with epinephrine.
And epinephrine is the treatmentof choice for anaphylaxis.
(17:31):
And it shuts the reaction downquickly and keeps it from
progressing.
And so we want people to havethose cheat sheets readily
available and understand them.
Um, currently the AmericanAcademy of Pediatrics has one
that has been created for allages.
And what's nice about attemptingto have a universal action plan
(17:53):
is that Primary care clinicians,pediatricians, family medicine,
clinicians, if school nurses, ifpreschools, if allergists all
accept this plan, then it canmake communicating and passing
the plan along very easy.
(18:14):
Now, one thing with this plan isthat it's not exactly.
Created specifically for thoseinfants and toddlers.
It's got a couple of thosesubjective symptoms that I've
been talking about where we needto know to look for surrogates.
And so one of the things I'vebeen doing is collaborating with
Allergy Asthma Network to helpcreate resources to help parents
(18:41):
be able to know how to interpretthat action plan when they have
an infant or a toddler.
And so.
very, very long-winded answer toyour question is getting an
action plan and gettingcomfortable with it is a great
way to, um, make it a littleeasier.
But that aside, and I'd sayeverybody go look up the
(19:05):
American Academy of PediatricsAllergy and Anaphylaxis
Emergency Care Plan and getcomfortable with it.
Amanda Whitehouse, PhD (19:13):
I'll link that in the notes so
Michael Pistiner, MD, MMSc, (19:15):
All right,
Amanda Whitehouse, PhD (19:15):
people can find it easily.
Michael Pistiner, MD, MMSc, (19:16):
And then talking about ultimately
you mentioned the more than onesystem, and so a system is a end
organ skin derm could beconsidered one system, so
swelling, hives, itching.
(19:37):
A kid might be scratching, a kidmight be rubbing their body up
against the carpet.
Um, you might see, um.
Redness that's all over.
You might also see welts hives.
Um, in light skinned kids, youmight see those hives look pink.
(19:57):
Um, in a dark skinned kid, itmight just be that you just see
that it has contour, that it'sraised, um, it might even look
darker.
And so getting used to your ownkid and knowing what their skin
looks like at their baseline isgonna be really helpful.
Those would all be consideredthe skin system derm, um, GI
(20:22):
vomiting, diarrhea.
I would say more mild symptomslike hiccup and belly pain that
a baby might show us becausethey're bringing their knees up.
um.
So respiratory system, wheezing,sneezing, would be more mild
(20:43):
symptoms in the respiratorysymptom.
Um, in a little baby who'shaving a hard time breathing,
where a big kid or a grownupmight say they're short of
breath, a little baby might havenasal flaring.
That means their nostrils aremoving back and forth.
Um, they may have tugging wherethe skin in between their ribs
(21:06):
goes in and out.
They might be belly breathingwhere their belly goes up and
down.
Uh, they may also have, um, theskin above their sternum.
Right in their neck might looklike it's going in and out.
So those are called retraction.
So that's something we could seein a kid who is having a hard
time breathing.
(21:27):
Um, we may also then see forcardiovascular where a grownup
might say that they're dizzy,um, or pass out.
A little kid might have mentalstatus change.
They might have behavioralchange, um, that's not
attributable to anything elseother than the allergic
(21:49):
reaction.
And so they might have quicklethargy, which is very quiet.
Um, one of the words that we useis obtunded.
Um, they might almost be passingout, falling asleep, have a hard
time keeping their head up, getfloppy, wobbly, a poor head
control.
Um.
(22:10):
You also might see the opposite,where a kid might become very
irritable, inconsolable, um,total change in behavior.
Um, no obvious trigger or causeother than the potential
allergic reaction.
And so those behavioral changesactually can be thought to be
cardiovascular.
(22:31):
You also then have the systemof.
Neuro, which overlaps a littlebit with what I was talking
about here.
and so getting comfortableunderstanding which signs and
symptoms fit in which system canbe a helpful tip and trick to
(22:52):
know, ah, you know what?
We're dealing with an allergicreaction that's more than just
mild and contained.
Amanda Whitehouse, PhD (22:59):
This is so helpful.
Thank you so much, becausedescribing it in those.
terms that, parents, wouldn'thave known, but to think that
specifically and connect it, Ithink is so important for people
in having a better idea of whatthis looks like.
Michael Pistiner, MD, MMSc, (23:11):
Do you
Amanda Whitehouse, PhD (23:11):
It's helpful.
Michael Pistiner, MD, MMS (23:12):
some?
Amanda Whitehouse, (23:13):
Absolutely.
Michael Pistiner, MD, MMSc, (23:14):
All right.
So.
One of the things to talk aboutwhile we're talking about
recognizing a potentially severeallergic reaction is gonna be
what do you do when yourecognize it?
So once you think that thisthing might be anaphylaxis, now
you're gonna wanna shut it downwith epinephrine.
(23:35):
is the drug of choice to treatanaphylaxis and epinephrine
helps you get control of thesituation.
And so you'll hear me say thatprobably four or five times in
the rest of what we're talkingabout is when in doubt if you
gotta get control.
If you're losing control,epinephrine gets you control.
(23:56):
Um, because it works everywherewhere we want it to.
In all those systems that I wastalking about, epinephrine is
gonna wind up taking care ofbusiness.
Um, and so most importantly,epinephrine works on the
receptors of the cell membranesof the allergy cells.
Uh, the two that we talk about,a lot of the mast cells in the
(24:17):
basophils.
And so when epi is around.
It's less likely that these guysare gonna be able to de
granulate and release what'sinside them.
And what's inside these allergycells is more than just
histamine.
We got platelet activatingfactor leukotrienes, all these
baddies that are gonna makeblood vessels, leaky and floppy,
(24:40):
that leakiness.
Then you can have hives andswelling.
When the fluid leaves the bloodvessels, it's leaving the
intravascular space, and when itleaves, it doesn't just go back
in.
And so the longer you're gonnago with that leakiness, the more
fluid you're gonna lose.
(25:01):
And then that's when IV fluidmight be needed when somebody
goes a while without shutting itdown.
And so.
Another thing that can happenwhen the reaction is going on is
that smooth muscle of the upperairway, or smooth muscle, excuse
(25:22):
me, of the lungs and the lowerairway, can constrict and make a
picture that looks very muchlike an asthma attack.
Coughing, wheezing, mucussecretion, all things that are
gonna make it harder to breathe.
And the longer then someone goeswithout epinephrine, the more
that process can keep happening.
(25:43):
And so in when we're thinkingabout respiratory, if early on
somebody would've had fivesneezes, then if they wait and
they don't treat, then it mightturn into a bunch of coughs.
Then those coughs turn intowheezes.
And now we have somebody who'sreally working hard to breathe
and has the nasal flaring andthe intercostal retractions I
(26:06):
was talking about.
Um, and then they need oxygenand then they need more
epinephrine.
Um, and so this is where earlyon treating, you wouldn't
necessarily know what it wasgonna turn into.
Where when we're thinking aboutgi um, winds up being able to
(26:27):
kind of turn off the peristalsisthat would be causing vomiting
and it can turn off the diarrheaand shut things down.
Um, so if someone waited to giveepinephrine, then the hiccups
and the.
Belly pain that you might belooking at from pulling up the
(26:49):
knees and a kid back archingmight turn into the vomiting,
which then turns into vomitingand diarrhea.
And now we have more fluidlosses, which I was talking
about before.
And then we might have this kidwho has behavioral changes in
the setting of other signs andsymptoms, and first they get
cranky and then they getirritable, and now they're
(27:12):
inconsolable.
But if someone waits to treat,then they might get obtunded,
lethargic, um, and difficult toarouse.
And so every person whoexperiences an allergic
reaction, every one of the youngkids might look different than
another young kid.
(27:33):
And then each time they have anallergic reaction, they might
look different from themselvesfrom the last time they had one.
Being able to kind of recognizesome of these patterns and
understand these systems andunderstand symptoms within the
system will really help you knowwhen it's time to get that epi
and shut things down.
Amanda Whitehouse, PhD (27:54):
Yeah, and I, I'm so glad that you
emphasized that because I dothink a lot of us as parents, we
get hooked on, well, this iswhat happens to him.
He always has a rash first, orhe always has this or that, and
it might not look the.
Same from reaction to reaction,
Michael Pistiner, MD, MM (28:06):
that's right.
And then just having that senseof pattern recognition is gonna
help.
And now to bring it back to whatyou said, which.
I like thinking about it thatway is more than one system is
two systems or more, then it'sgo time.
Um, and so if somebody has anexposure to likely allergen and
now they have sneezing.
(28:30):
They have hives around theirmouth in the area where the food
touched.
I feel good that that's a greattime to use epinephrine and shut
things down.
And so those are mild symptoms.
I'd say they're nothing burgers,but you take two of them in two
different systems.
And then I like saying thisalso.
(28:53):
I would never call it mildanaphylaxis because that's an
oxymoron.
I'd call it early anaphylaxis,the perfect time to use
epinephrine'cause we're notinterested in seeing what's
gonna happen.
And as I mentioned it before,you don't need to wait for your
five sneezes to turn intocoughing, wheezing, respiratory
distress.
(29:14):
You don't need to wait untilyour local hives turn into full
body hives with swelling,angioedema, and then a floppy
kid who's having cardiovascularsymptoms.
Let's just treat'em early on.
We will pause our conversationthere with Dr.
Pistiner and pick up again nextweek.
I hope this gives you a clearer,more confident understanding of
(29:35):
what anaphylaxis can look likein very young children and how
it's different from what we'veheard in the past and how it
presents in older people.
It's such an important stepforward in helping caregivers
and clinicians confidentlyidentify reactions early and Act
fast by administeringepinephrine, which is what we'll
be talking about next week.
So your first action step is tocome back for part two next
(29:56):
week.
That's where we'll dive into howto administer epinephrine safely
and effectively in infants andtoddlers.
How to get comfortable with theconcept of using the epinephrine
and talk about which device isthe best suited for this age
group.
Number two, learn more about theupdated criteria that Dr.
Pistiner told us about today andexplore the resources that he
has created@fpi.org.
(30:17):
And that's FAMP-it.org.
The link will be in the shownotes, and this is where Dr.
Pistiner and his team have, haveshared tools for food allergy
management and prevention.
Including information aboutearly food introduction skincare
and eczema management.
IgE mediated food allergy andnon IgE mediated food allergy.
(30:38):
to Follow Dr.
Pistiner's work.
The website is massgeneral.org/children/allergy.
You'll find so many resources,and so much information there,
as well as links to their socialmedia.
On Facebook, you can find thefood allergy center at mgh.
And an account for their foodallergy buddies program.
(30:58):
And third.
Share this episode with yourco-parent with family members,
childcare providers,babysitters, healthcare
professionals in your circle.
Anyone who might be caring foran infant or a toddler with food
allergies who might not yet knowabout these changes in the
recommendations for identifyingand treating anaphylactic
reaction, in people who aren'told enough to express it in the
(31:20):
words that are typically used.
Thank you for tuning in and forbeing part of this growing
community with me, and we willbe back next week with more on
administering epinephrine tothis population of young
children and babies.
the content of this podcast isfor informational and
educational purposes only, andis not a substitute for
professional medical or mentalhealth advice, diagnosis, or
(31:43):
treatment.
If you have any questions aboutyour own medical experience or
mental health needs, pleaseconsult a professional.
I'm Dr.
Amanda Whitehouse.
Thanks for joining me.
And until we chat again,remember don't feed the fear.
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