March 8, 2024 • 27 mins
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In this eye-opening episode, Dr. Alice Hoyt, the caring doctor voice behind the Food Allergy and Your Kiddo Show, and the eminent Dr. Dave Stukus, a trailblazer from Nationwide Children's Hospital, unpack the exciting news about Xolair (omalizumab).
After two decades of lending a helping hand to asthma sufferers, Xolair is now FDA-approved to combat severe allergic reactions from food allergies. The deep-dive discussion zeros in on how this well-seasoned medication works its magic by cozying up to allergic antibodies, decreasing the fright from accidental food allergen encounters. 🛡️ If you've been dealing with food allergies, lend us your ears as top allergists discuss who might benefit from Xolair. 🎧💕
Episode Highlights:
- Take a brief stroll down memory lane to hear Xolair's past.
- Consider how Xolair may add a layer of protection for your little one.
- Review the safety profile that makes Xolair a relatively safe option.
Guest Expertise:
Dr. Alice Hoyt, your go-to allergist and familiar voice on the podcast, chats with Dr. Dave Stukus, known for his heartfelt commitment to helping food allergy families at the renowned Nationwide Children's Hospital.
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This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:10):
Hello and welcome to the Food Allergy in your kiddo
podcast.
I am your host, dr Alice Hoyt,very excited to be joined today
by one of my colleagues andfriends, dr Dave Stukas.
Dr Stukas, welcome back to thepodcast, sir.
Speaker 2 (00:26):
Well, hi, dr Hoyt, it's a pleasure to be here.
I'm excited.
Speaker 1 (00:29):
Well, good, I'm glad you're excited because there has
been understatement a lot ofexciting things going on in the
world of food allergy.
As you well know, and for thoseof you who are new to the kiddo
show, Dr Stukas has been on ourpodcast before and he actually
(00:51):
hosts the podcast for theAmerican Academy of Allergy,
Asthma and Immunology, anamazing organization of which I
am a fellow, as is Dr Stukas,and Dr Stukas is here today to
talk about the 2023 anaphylaxispractice parameters, which is
awesome.
(01:11):
So, Dave, before we really diveinto what's in these practice
parameters, can you please tellour listeners and our viewers
for those watching us on thevideo what is a practice
parameter?
Speaker 2 (01:24):
Yeah, how long do we have Right Right, a practice
parameter?
They're technically notguidelines, but essentially
they're clinical guidelines andwhat they do is they go through
for specific conditions and doan exhaustive search of the
literature, so all of thepeer-reviewed literature
surrounding a topic, and thenthey look at the evidence, both
(01:45):
foreign, against certainquestions or certain disease
states, and they formulate sortof recommendations about best
ways to approach the diagnosisand or management of various
conditions.
Typically there's a work groupof experts international experts
that go through all of theliterature and kind of write
everything up and it goes backto the Joint Task Force on
Practice Parameters, which Iused to be a member of for five
(02:06):
years, and we actually kind ofedit everything together and
make it so that it flows nicelyfor clinicians to kind of follow
.
So it is evidence-based,exhaustive, comprehensive and
current.
Speaker 1 (02:17):
I love it.
I love it.
Evidence-based I love it.
Yeah, when you look throughthese things, there's hundreds
of references I think 600.
Speaker 2 (02:24):
You said joint.
You said 600.
Speaker 1 (02:26):
That's pretty, pretty up-date.
Yeah, joint Task Force.
Tell our listeners a little bitmore about that.
Speaker 2 (02:34):
Well, there's two professional organizations for
allergist immunologists in theUnited States of America.
We have the American Academyand American College of Allergy,
Asthma and Immunology.
So each organization appointssix members to the Joint Task
Force and then they are eligibleto serve two separate five-year
terms.
So I served a five-year term.
Due to a lot of exciting thingsin my own personal professional
(02:56):
life, I opted to defer mysecond term towards later in my
career perhaps, but it was awonderful experience and there's
great individuals that reallydedicate and volunteer their
time to put these guidelinestogether, these parameters, I
should say.
Speaker 1 (03:09):
Well, thank you as a fellow allergist and as a food
allergy wife and mom, Thank youfor spending your time doing
that, because I know thesethings take a lot of time to
really do them right and I knowthat you guys definitely do them
right.
So we talked a little bit aboutwhat practice parameters are.
(03:31):
Why was there, why did thispractice parameter come about?
The anaphylaxis for 2023?
.
Speaker 2 (03:38):
Yeah, it had been several years since there was a
comprehensive document foranaphylaxis.
There was an updated one in2020 that really focused on
biphasic anaphylaxis, whichwould be an anaphylactic
reaction that resolves with orwithout treatment and then soon
to come back again, sometimeshours later, and that specific
document really walked throughwho's at risk to experience that
(04:00):
and what kind of medicationswould prevent that, and so on
and so forth.
So it was time just to providea much longer, more
comprehensive document thatreally went through some of the
newer evidence.
Speaker 1 (04:11):
And these parameters are super valuable to allergists
, of course, and to otherclinicians as well, but for our
audience.
Why do you think these are soimportant?
For our audience food allergymoms, dads, family members to
really know about theseparameters?
Speaker 2 (04:27):
Well, again, it goes back to their evidence-based.
There's so much outdated,incorrect information
surrounding food allergy andanaphylaxis.
A lot of it's actuallyaddressed in these parameters
and I think you know, a lot oftimes we kind of say the same
things over and over again justbecause it's what we've been
taught or what we once thoughtto be true.
But a lot of it's changed forthe better.
I find these to be veryreassuring actually, but it's
(04:50):
interesting because there's abit of a paradigm shift when it
comes to anaphylaxis, as we'lltalk about.
So things don't have to seemmaybe as dire as we were once
taught a few years ago inregards to this.
Now, of course, we want torespect it, as we'll talk about
and discuss, but it doesn't haveto be as scary as maybe
everybody's led to believe notthat long ago.
Speaker 1 (05:09):
No, that's really great, and so sort of.
What I wanted to ask you andwhat I'm hoping is going to sort
of guide our conversation todayis really what are your sort of
biggest three takeaways forfood allergy families regarding
these new updated parameters?
Speaker 2 (05:30):
Yeah, three is tough.
Yeah, I'll try my best.
Speaker 1 (05:35):
You don't have to limit it to three, because I'm
sure it's going to be.
No, I think I can't.
Speaker 2 (05:38):
I think I can't.
So for those watching,listening, the parameters cover
a lot of ground in regards tothe updates the diagnosis of
anaphylaxis, anaphylaxis ininfants and young children,
management of anaphylaxis.
It also dives into diagnostictesting as well as mast cell
disorders and perioperativeanaphylaxis, so I think we can
probably skip a lot of that.
(05:58):
The top three for me one isrevolves around anaphylaxis in
infants, and the parametersreally address that.
Severe life-threateningreactions in infants, especially
upon first exposure to a foodallergen, are extremely rare.
Speaker 1 (06:16):
Can you stop?
Can you say it again?
Speaker 2 (06:19):
Yeah.
So severe, life-threateninganaphylactic reactions are very
rare in infants, especially thefirst time they eat a food
allergen.
So for all those parents thatdrive to the parking lot of the
emergency department before theyfeed their baby peanut butter
for the first time, the evidencewould suggest that it's
extremely unlikely extremelyunlikely that your baby's going
to have a severe reaction thefirst time they eat.
(06:40):
That Anaphylaxis can occur, buttypically it's going to be more
.
They get some hives and maybethey vomit once and then they
feel better.
That's anaphylaxis.
So any combination of more thanone part of the body involved
in allergic reaction.
But for most people it'sself-resolved and relatively
mild.
We don't get patients asallergists because they end up
in the ICU the first time theyeat a food.
We get patients because theyget a rash, we get some hives,
(07:03):
they get upset stomach.
So that's what the evidenceshows and that's one of the big
take-homes for me from the newparameters.
Speaker 1 (07:10):
I love that and you know, sometimes data comes out
and we're like huh really.
But that, no, that clinically,is really what we see, I would
say.
So I don't think that wasparticularly shocking.
What say you?
Speaker 2 (07:28):
No, I agree that echoes everything I've seen and
I've talked about this for overa decade.
When I educate pediatriciansabout how this is the typical
presentation for food allergy ininfants, as they get some hives
and maybe they vomit, it'smisconceptions that their
airways are so small thatthey're prone to swelling shut.
We simply don't see that,thankfully, which is very good.
(07:49):
There are misconceptions thatbabies can't tell us how they
feel, so there's some smolderingissues inside their body.
That's not the case at all.
If you're having an acuteallergic reaction, you should
look at a baby and be able tosee that they're uncomfortable,
they're not feeling well and yousee the symptoms of that
allergic reaction occurringbefore your eyes.
So there's no sort of thinglike a hidden food allergy that
occurs or anything like that.
Speaker 1 (08:10):
I think that's just so valuable.
That's so valuable.
I think it's very valuable thatthis was not surprising to us,
that this is consistent with,clinically, what we see.
I think it's valuable to haveall of this written out and
really just the references there, the support there, the
evidence there that this is whatwe see, that this is how it
(08:31):
goes to bring that reassuranceto families.
I think that is just so, soimportant.
So I love that.
That was your first thing.
That's awesome.
Speaker 2 (08:42):
Yeah, and of course, there are families that do
witness.
They watched their baby havemore severe reactions, so it
certainly can occur.
I think the message is that itis much less likely than people
have been led to believe,especially, and the reality of
the situation is, if we take 95%of all babies, it doesn't
matter how you feed them or whenthey feed them.
(09:02):
They're never going to developa food allergy, no matter what
you do so?
if we're telling 100% of parentsthat you have to drive to the
emergency room before you feedyour baby peanut butter, that's
an overly cautious approach.
That's a huge disservice tothese families.
Speaker 1 (09:15):
What would be your second, Dave?
Speaker 2 (09:18):
Ooh, it's a combination and I love this so
much because I know I'm cheating.
But what it does is it kind ofwraps in our understanding of
individualized approach towardsfood allergy management and risk
.
And we now know that there aremilder forms of food allergy.
We also know that it's veryunusual for somebody to have any
reaction to trace amounts orespecially severe reactions to
(09:41):
trace amounts.
Can it happen?
Yes, but for the vast majorityof people they have a higher
threshold than that.
So in the anaphylaxis practiceparameters it really addresses a
couple of key things.
So one not everybody needs tohave two epinephrine auto
injectors prescribed.
For a lot of folks it's quitereasonable just to have one of
those devices because they'revery costly.
Most people go a whole yearwithout ever using them and they
(10:01):
just throw them away, and for alot of folks out there they're
just not at risk of ananaphylactic reaction.
Another aspect along thoserealms is not everybody actually
needs to have epinephrineprescribed.
Now this gets very nuanced veryquickly, but you and I both
know there are children outthere that have a very mild egg
allergy.
So they've eaten scrambled eggssix times.
Every time they have mildself-result hives, we do the
(10:24):
testing.
Yes, they're allergic.
They're eating baked egg allday and they're absolutely fine.
They're very likely going tooutgrow this in the next couple
of years.
And then the last part of thistrifecta within my number two
deals with some of those foodallergy and anaphylaxis plans
that state if somebody ate anallergen but they don't have
symptoms, that you should givethem an epinephrine immediately.
And that is just completelyfalse.
(10:46):
I don't know where this camefrom.
It was a highly conservativeapproach.
Yeah, I get it, it's bettersafe than sorry.
But here's the deal.
So, one, how do you know ifsomebody actually ate with their
allergic?
To number two, how do you knowthat they ate enough to trigger
a reaction?
Number three if you give themepinephrine which treats
anaphylaxis, it doesn't preventit.
If you give epinephrine beforethe allergic reaction actually
occurs, it might be out of theirsystem before they actually
(11:08):
need to use the medication.
And and then, lastly, themedian time of onset for
anaphylaxis from food is almostlike 30 minutes.
So if somebody ate somethingand you're not quite sure if
they're gonna have a reaction,you have time to take a deep
breath and monitor and, you know, be in a state zone to see
what's gonna happen before youeven Think about treating them
with epinephrine.
Speaker 1 (11:28):
Wow, that was a lot for your number two.
Speaker 2 (11:32):
I love it.
I love it and it's all.
Speaker 1 (11:34):
It's all.
It's all tied in together.
I completely agree with you.
It's all.
Those are all very big but veryimportant points that, again,
would not be in this parameterif they didn't have the data to
back them up and didn't have theboard certified allergists
reviewing the data that backsthis up, and I think this you
(11:56):
know, you said it about it, youknow it gets nuanced, and that
just highlights the importanceof having a board certified
allergist who does stay up todate on the latest allergy
information so that you and yourchild can have an
evidence-based plan that Notjust keeps him or her safe but
also Improves your quality oflife.
(12:19):
If, if you've been told for adecade now that even smelling
peanut could potentially killyour child, that is not
evidence-based, that is not goodfor your mental health, and so
here, it's just so lovely notjust to have the parameters but
to have you sort of likeflushing things out like this,
and I think that that all makesjust so much sense.
Speaker 2 (12:41):
For a lot of folks this is completely foreign.
I mean, these are foreignconcepts and they it's.
It's off-putting at first.
I can make people highlyemotional actually, and say you
know how dare you suggest thatmy child's not at risk of having
a severe life threateningreaction if they are near their
Allergen or take a small bite ofit?
But that's the reality of itand I think that we do families
a disservice if we don't havethat conversation with them and
(13:04):
help them Understand thatbecause, as you mentioned this,
that's what impacts their dailylife.
Speaker 1 (13:08):
No, that's absolutely right.
That's absolutely like rightthe.
I will say that I have noticedthat one at least the fair form,
see whole light, give epi if itwasn't, if it may have been
eaten, but no symptoms.
That's gone now, so that's niceand they've sort of retooled
that.
So another reason not to justsee your allergist once a year,
(13:35):
but whenever new things come outit's totally reasonable to
schedule a follow-up with yourallergist specifically to ask
very specific questions aboutyour kiddos food allergy.
You know, I think so much gets,so much pressure gets put on
that like classic back-to-schoolallergy appointment, that
sometimes you're focused ongetting forms and these things
(13:56):
filled out, that you don't getto just like have a few minutes
where you're talking with yourallergist about some of the
newest data or newest treatmentsor whatever the case may be.
So families should never feel,should ever feel like, oh well,
I don't have a good enoughreason to go in to the doctor,
especially now with telehealth.
You know you can have thesetelehealth appointments and get
(14:17):
some very good evidence-basedanswers to your questions.
Cool, dave, okay, you'repulling out some really good
stuff from these practiceparameters.
What would you say?
How many points is your third?
It's your third point going tohave, or your third most
important thing for food allergyfamilies from the parameters.
Speaker 2 (14:38):
It's just one, but it's the big one.
So the new parameters containprovisions that if somebody
experiences anaphylaxis at home,they don't have to
automatically go to theemergency room or call 911 after
they use epinephrine.
And this is where you kind ofshocker, so what?
Speaker 1 (14:57):
this and then you say it again.
So say it again.
Speaker 2 (14:59):
So you no longer have to automatically call 911 or
seek emergency medical care ifyou use epinephrine to treat
anaphylaxis at home.
And the reason why is because,well, there's a couple of
reasons.
So one the evidence again, thebody of evidence shows that the
vast majority of people whopromptly receive epinephrine to
treat anaphylaxis have completeresolution of symptoms,
(15:22):
typically within 10, 15 minutes.
Most people feel better prettyfast.
So if you're at home in a verysafe environment and you have
access to more than oneepinephrine, you have a cell
phone and you can get care ifyou need it, use your
epinephrine and hang out andmonitor If symptoms are getting
better or going away.
You should be fine.
You can call your allergist foryou know, talk to their office
(15:42):
about next steps and things likethat.
But a lot of people either werenot using their epinephrine
because they didn't want to goto the emergency room, or they
were misinformed thatepinephrine was dangerous and
that just because you use it,that means you have to go to the
emergency room because of sideeffects and the needle and
things like that.
All of that's incorrect.
And what happens when mostpeople go to the emergency room
after they use their epinephrine?
Well, typically they just sitthere for six hours and they
(16:04):
receive a bunch of treatmentthat they actually don't need,
such as steroids and histaminesand PEP-CID and things like that
.
Speaker 3 (16:11):
So we Like Benadryl Dave.
Speaker 1 (16:13):
How do you feel?
Speaker 2 (16:13):
about that.
Yeah, like Benadryl.
You know how I feel about that.
I read these ER notes of apatient arrived, had
anaphylactic reaction at home tocashew, received epinephrine.
By the time they were evaluatedthey were asymptomatic.
We gave them Benadryl,predenosone for seven days and
(16:33):
PEP-CID and had them monitor forfour hours.
What are we doing?
That's insane.
It's so outdated.
So that's where this comes fromand I think we can start to
have those conversations withfamilies.
I know I have for the lastcouple of years, and this
started during the pandemic.
Right, we were afraid to sendpeople to the emergency room.
We don't want to give themCOVID, especially before
vaccines are available.
So we started to actually learnhow to monitor at home and
(16:55):
treat them at home and have thatconversation, and that's what
the evidence supports as well.
Speaker 1 (16:59):
Yeah, no, I mean, I think that is such an important
point.
I will say, to caveat, ifyou're going to monitor at home,
I do like them to have somebodythere with them, yes, but
otherwise absolutely.
If they use their epinephrinepromptly and they're improving
and they have a second devicewith them, it all makes a lot of
(17:24):
sense.
Now, if they still want to goto the emergency room, you
absolutely can.
You absolutely can.
But hopefully this will takeaway some of those barriers to
actually promptly using theepinephrine, because the last
thing we want is not using it ornot using it promptly, and then
a kiddo is getting worse andthen you're putting the kiddo on
(17:46):
the back of the car to driveand then they're throwing up on
the way to the ER.
It's just terrible.
It's just terrible.
We know that prompt use ofepinephrine is what stops an
allergic, a severe allergicreaction, anaphylaxis, and
you're right, I totally lovethat.
The whole like oh, they maybeate it, no symptoms, then give
(18:08):
them epi.
I love that that is gone,because that has never made
sense.
I don't think to any of theallergists.
Speaker 2 (18:15):
Yeah, the dark secret with anaphylaxis, as you know,
is if you look at all of thestudies over the years, this has
been shown repeatedly 50% ofpeople having anaphylaxis never
receive epinephrine.
And what happens is 50% ofpeople they do fine it.
You know fatalities fromanaphylaxis.
They are tragic and they dooccur.
Thankfully they are not nearlyas common as most people believe
(18:37):
them to be.
So we want to promote usingepinephrine early because it
makes people feel better a lotfaster.
Yeah, you're miserable.
You are so miserable You'rehaving an allergic reaction.
Use it because you feel better.
Speaker 3 (18:47):
So we need to look at what.
Speaker 1 (18:48):
Right, and that's another reason benadryl, the
okay.
So like kind of before my timethey used to say, oh well, give
benadryl and it doesn't getbetter than give epi.
Like that is absolutely wrong.
That is not evidence-based,because then not only are you
delaying use of epinephrine, butyou're giving benadryl, which
is just an antihistamine.
(19:09):
And, as all my patients know,anaphylaxis is run by a lot more
than just histamine and it'snot the histamine that's going
to cause the fatal issues.
So you really want to get theepinephrine in promptly.
It's going to make the kiddofeel better because you're
really calming down thoseallergy cells so they stop
spewing out all of the stuffthat's causing all the reactions
and they help prevent all thosedifferent symptoms, or causing
(19:31):
all the symptoms.
It's going to help stop thesymptoms as well.
As opposed to, an antihistamineis not going to be that
multifaceted at all.
It's just going to beantihistamine.
No, I think you have pulled outamazing pearls for our patients
or our families listening on the2023 practice parameters and
(19:56):
for y'all listening to thispodcast.
If you haven't listened to theQuadai Eyes podcast on the
anaphylaxis practice parameters,where Dr Succas interviews Dr
Golden, you definitely should,because it is a fantastic listen
.
It's a fantastic listen andthey do get in the weeds on a
few things, and I love thatbecause it's too allergist just
(20:18):
talking about it, kind of likewe're doing it today, dave.
So thank you so much for comingon the show and breaking that
down for us.
And where can people find thepractice parameters?
Speaker 2 (20:28):
You can actually just search them online.
So if you just look for allergypractice parameters, they pop
right up.
They're free for everybody.
I believe there's teaching,which is awesome.
Yeah, oh yeah.
I think there's teaching slidedecks for some of the latest
ones as well for medicalprofessionals out there, if you
want to actually learn more oreven educate those in your group
or in your community.
So, yeah, check it out.
Speaker 1 (20:49):
Awesome, dave, thanks so much for coming on the show.
Speaker 2 (20:52):
It's my pleasure.
Thanks for having me.
Speaker 3 (20:55):
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to food
allergianyourkiddocom where youcan join our newsletter.
God bless you and God blessyour family.
Hello and welcome to the Food Allergy in your kiddo
podcast.
I am your host, dr Alice Hoyt,very excited to be joined today
by one of my colleagues andfriends, dr Dave Stukas.
Dr Stukas, welcome back to thepodcast, sir.
Speaker 2 (00:26):
Well, hi, dr Hoyt, it's a pleasure to be here.
I'm excited.
Speaker 1 (00:29):
Well, good, I'm glad you're excited because there has
been understatement a lot ofexciting things going on in the
world of food allergy.
As you well know, and for thoseof you who are new to the kiddo
show, Dr Stukas has been on ourpodcast before and he actually
(00:51):
hosts the podcast for theAmerican Academy of Allergy,
Asthma and Immunology, anamazing organization of which I
am a fellow, as is Dr Stukas,and Dr Stukas is here today to
talk about the 2023 anaphylaxispractice parameters, which is
awesome.
(01:11):
So, Dave, before we really diveinto what's in these practice
parameters, can you please tellour listeners and our viewers
for those watching us on thevideo what is a practice
parameter?
Speaker 2 (01:24):
Yeah, how long do we have Right Right, a practice
parameter?
They're technically notguidelines, but essentially
they're clinical guidelines andwhat they do is they go through
for specific conditions and doan exhaustive search of the
literature, so all of thepeer-reviewed literature
surrounding a topic, and thenthey look at the evidence, both
(01:45):
foreign, against certainquestions or certain disease
states, and they formulate sortof recommendations about best
ways to approach the diagnosisand or management of various
conditions.
Typically there's a work groupof experts international experts
that go through all of theliterature and kind of write
everything up and it goes backto the Joint Task Force on
Practice Parameters, which Iused to be a member of for five
(02:06):
years, and we actually kind ofedit everything together and
make it so that it flows nicelyfor clinicians to kind of follow
.
So it is evidence-based,exhaustive, comprehensive and
current.
Speaker 1 (02:17):
I love it.
I love it.
Evidence-based I love it.
Yeah, when you look throughthese things, there's hundreds
of references I think 600.
Speaker 2 (02:24):
You said joint.
You said 600.
Speaker 1 (02:26):
That's pretty, pretty up-date.
Yeah, joint Task Force.
Tell our listeners a little bitmore about that.
Speaker 2 (02:34):
Well, there's two professional organizations for
allergist immunologists in theUnited States of America.
We have the American Academyand American College of Allergy,
Asthma and Immunology.
So each organization appointssix members to the Joint Task
Force and then they are eligibleto serve two separate five-year
terms.
So I served a five-year term.
Due to a lot of exciting thingsin my own personal professional
(02:56):
life, I opted to defer mysecond term towards later in my
career perhaps, but it was awonderful experience and there's
great individuals that reallydedicate and volunteer their
time to put these guidelinestogether, these parameters, I
should say.
Speaker 1 (03:09):
Well, thank you as a fellow allergist and as a food
allergy wife and mom, Thank youfor spending your time doing
that, because I know thesethings take a lot of time to
really do them right and I knowthat you guys definitely do them
right.
So we talked a little bit aboutwhat practice parameters are.
(03:31):
Why was there, why did thispractice parameter come about?
The anaphylaxis for 2023?
.
Speaker 2 (03:38):
Yeah, it had been several years since there was a
comprehensive document foranaphylaxis.
There was an updated one in2020 that really focused on
biphasic anaphylaxis, whichwould be an anaphylactic
reaction that resolves with orwithout treatment and then soon
to come back again, sometimeshours later, and that specific
document really walked throughwho's at risk to experience that
(04:00):
and what kind of medicationswould prevent that, and so on
and so forth.
So it was time just to providea much longer, more
comprehensive document thatreally went through some of the
newer evidence.
Speaker 1 (04:11):
And these parameters are super valuable to allergists
, of course, and to otherclinicians as well, but for our
audience.
Why do you think these are soimportant?
For our audience food allergymoms, dads, family members to
really know about theseparameters?
Speaker 2 (04:27):
Well, again, it goes back to their evidence-based.
There's so much outdated,incorrect information
surrounding food allergy andanaphylaxis.
A lot of it's actuallyaddressed in these parameters
and I think you know, a lot oftimes we kind of say the same
things over and over again justbecause it's what we've been
taught or what we once thoughtto be true.
But a lot of it's changed forthe better.
I find these to be veryreassuring actually, but it's
(04:50):
interesting because there's abit of a paradigm shift when it
comes to anaphylaxis, as we'lltalk about.
So things don't have to seemmaybe as dire as we were once
taught a few years ago inregards to this.
Now, of course, we want torespect it, as we'll talk about
and discuss, but it doesn't haveto be as scary as maybe
everybody's led to believe notthat long ago.
Speaker 1 (05:09):
No, that's really great, and so sort of.
What I wanted to ask you andwhat I'm hoping is going to sort
of guide our conversation todayis really what are your sort of
biggest three takeaways forfood allergy families regarding
these new updated parameters?
Speaker 2 (05:30):
Yeah, three is tough.
Yeah, I'll try my best.
Speaker 1 (05:35):
You don't have to limit it to three, because I'm
sure it's going to be.
No, I think I can't.
Speaker 2 (05:38):
I think I can't.
So for those watching,listening, the parameters cover
a lot of ground in regards tothe updates the diagnosis of
anaphylaxis, anaphylaxis ininfants and young children,
management of anaphylaxis.
It also dives into diagnostictesting as well as mast cell
disorders and perioperativeanaphylaxis, so I think we can
probably skip a lot of that.
(05:58):
The top three for me one isrevolves around anaphylaxis in
infants, and the parametersreally address that.
Severe life-threateningreactions in infants, especially
upon first exposure to a foodallergen, are extremely rare.
Speaker 1 (06:16):
Can you stop?
Can you say it again?
Speaker 2 (06:19):
Yeah.
So severe, life-threateninganaphylactic reactions are very
rare in infants, especially thefirst time they eat a food
allergen.
So for all those parents thatdrive to the parking lot of the
emergency department before theyfeed their baby peanut butter
for the first time, the evidencewould suggest that it's
extremely unlikely extremelyunlikely that your baby's going
to have a severe reaction thefirst time they eat.
(06:40):
That Anaphylaxis can occur, buttypically it's going to be more
.
They get some hives and maybethey vomit once and then they
feel better.
That's anaphylaxis.
So any combination of more thanone part of the body involved
in allergic reaction.
But for most people it'sself-resolved and relatively
mild.
We don't get patients asallergists because they end up
in the ICU the first time theyeat a food.
We get patients because theyget a rash, we get some hives,
(07:03):
they get upset stomach.
So that's what the evidenceshows and that's one of the big
take-homes for me from the newparameters.
Speaker 1 (07:10):
I love that and you know, sometimes data comes out
and we're like huh really.
But that, no, that clinically,is really what we see, I would
say.
So I don't think that wasparticularly shocking.
What say you?
Speaker 2 (07:28):
No, I agree that echoes everything I've seen and
I've talked about this for overa decade.
When I educate pediatriciansabout how this is the typical
presentation for food allergy ininfants, as they get some hives
and maybe they vomit, it'smisconceptions that their
airways are so small thatthey're prone to swelling shut.
We simply don't see that,thankfully, which is very good.
(07:49):
There are misconceptions thatbabies can't tell us how they
feel, so there's some smolderingissues inside their body.
That's not the case at all.
If you're having an acuteallergic reaction, you should
look at a baby and be able tosee that they're uncomfortable,
they're not feeling well and yousee the symptoms of that
allergic reaction occurringbefore your eyes.
So there's no sort of thinglike a hidden food allergy that
occurs or anything like that.
Speaker 1 (08:10):
I think that's just so valuable.
That's so valuable.
I think it's very valuable thatthis was not surprising to us,
that this is consistent with,clinically, what we see.
I think it's valuable to haveall of this written out and
really just the references there, the support there, the
evidence there that this is whatwe see, that this is how it
(08:31):
goes to bring that reassuranceto families.
I think that is just so, soimportant.
So I love that.
That was your first thing.
That's awesome.
Speaker 2 (08:42):
Yeah, and of course, there are families that do
witness.
They watched their baby havemore severe reactions, so it
certainly can occur.
I think the message is that itis much less likely than people
have been led to believe,especially, and the reality of
the situation is, if we take 95%of all babies, it doesn't
matter how you feed them or whenthey feed them.
(09:02):
They're never going to developa food allergy, no matter what
you do so?
if we're telling 100% of parentsthat you have to drive to the
emergency room before you feedyour baby peanut butter, that's
an overly cautious approach.
That's a huge disservice tothese families.
Speaker 1 (09:15):
What would be your second, Dave?
Speaker 2 (09:18):
Ooh, it's a combination and I love this so
much because I know I'm cheating.
But what it does is it kind ofwraps in our understanding of
individualized approach towardsfood allergy management and risk
.
And we now know that there aremilder forms of food allergy.
We also know that it's veryunusual for somebody to have any
reaction to trace amounts orespecially severe reactions to
(09:41):
trace amounts.
Can it happen?
Yes, but for the vast majorityof people they have a higher
threshold than that.
So in the anaphylaxis practiceparameters it really addresses a
couple of key things.
So one not everybody needs tohave two epinephrine auto
injectors prescribed.
For a lot of folks it's quitereasonable just to have one of
those devices because they'revery costly.
Most people go a whole yearwithout ever using them and they
(10:01):
just throw them away, and for alot of folks out there they're
just not at risk of ananaphylactic reaction.
Another aspect along thoserealms is not everybody actually
needs to have epinephrineprescribed.
Now this gets very nuanced veryquickly, but you and I both
know there are children outthere that have a very mild egg
allergy.
So they've eaten scrambled eggssix times.
Every time they have mildself-result hives, we do the
(10:24):
testing.
Yes, they're allergic.
They're eating baked egg allday and they're absolutely fine.
They're very likely going tooutgrow this in the next couple
of years.
And then the last part of thistrifecta within my number two
deals with some of those foodallergy and anaphylaxis plans
that state if somebody ate anallergen but they don't have
symptoms, that you should givethem an epinephrine immediately.
And that is just completelyfalse.
(10:46):
I don't know where this camefrom.
It was a highly conservativeapproach.
Yeah, I get it, it's bettersafe than sorry.
But here's the deal.
So, one, how do you know ifsomebody actually ate with their
allergic?
To number two, how do you knowthat they ate enough to trigger
a reaction?
Number three if you give themepinephrine which treats
anaphylaxis, it doesn't preventit.
If you give epinephrine beforethe allergic reaction actually
occurs, it might be out of theirsystem before they actually
(11:08):
need to use the medication.
And and then, lastly, themedian time of onset for
anaphylaxis from food is almostlike 30 minutes.
So if somebody ate somethingand you're not quite sure if
they're gonna have a reaction,you have time to take a deep
breath and monitor and, you know, be in a state zone to see
what's gonna happen before youeven Think about treating them
with epinephrine.
Speaker 1 (11:28):
Wow, that was a lot for your number two.
Speaker 2 (11:32):
I love it.
I love it and it's all.
Speaker 1 (11:34):
It's all.
It's all tied in together.
I completely agree with you.
It's all.
Those are all very big but veryimportant points that, again,
would not be in this parameterif they didn't have the data to
back them up and didn't have theboard certified allergists
reviewing the data that backsthis up, and I think this you
(11:56):
know, you said it about it, youknow it gets nuanced, and that
just highlights the importanceof having a board certified
allergist who does stay up todate on the latest allergy
information so that you and yourchild can have an
evidence-based plan that Notjust keeps him or her safe but
also Improves your quality oflife.
(12:19):
If, if you've been told for adecade now that even smelling
peanut could potentially killyour child, that is not
evidence-based, that is not goodfor your mental health, and so
here, it's just so lovely notjust to have the parameters but
to have you sort of likeflushing things out like this,
and I think that that all makesjust so much sense.
Speaker 2 (12:41):
For a lot of folks this is completely foreign.
I mean, these are foreignconcepts and they it's.
It's off-putting at first.
I can make people highlyemotional actually, and say you
know how dare you suggest thatmy child's not at risk of having
a severe life threateningreaction if they are near their
Allergen or take a small bite ofit?
But that's the reality of itand I think that we do families
a disservice if we don't havethat conversation with them and
(13:04):
help them Understand thatbecause, as you mentioned this,
that's what impacts their dailylife.
Speaker 1 (13:08):
No, that's absolutely right.
That's absolutely like rightthe.
I will say that I have noticedthat one at least the fair form,
see whole light, give epi if itwasn't, if it may have been
eaten, but no symptoms.
That's gone now, so that's niceand they've sort of retooled
that.
So another reason not to justsee your allergist once a year,
(13:35):
but whenever new things come outit's totally reasonable to
schedule a follow-up with yourallergist specifically to ask
very specific questions aboutyour kiddos food allergy.
You know, I think so much gets,so much pressure gets put on
that like classic back-to-schoolallergy appointment, that
sometimes you're focused ongetting forms and these things
(13:56):
filled out, that you don't getto just like have a few minutes
where you're talking with yourallergist about some of the
newest data or newest treatmentsor whatever the case may be.
So families should never feel,should ever feel like, oh well,
I don't have a good enoughreason to go in to the doctor,
especially now with telehealth.
You know you can have thesetelehealth appointments and get
(14:17):
some very good evidence-basedanswers to your questions.
Cool, dave, okay, you'repulling out some really good
stuff from these practiceparameters.
What would you say?
How many points is your third?
It's your third point going tohave, or your third most
important thing for food allergyfamilies from the parameters.
Speaker 2 (14:38):
It's just one, but it's the big one.
So the new parameters containprovisions that if somebody
experiences anaphylaxis at home,they don't have to
automatically go to theemergency room or call 911 after
they use epinephrine.
And this is where you kind ofshocker, so what?
Speaker 1 (14:57):
this and then you say it again.
So say it again.
Speaker 2 (14:59):
So you no longer have to automatically call 911 or
seek emergency medical care ifyou use epinephrine to treat
anaphylaxis at home.
And the reason why is because,well, there's a couple of
reasons.
So one the evidence again, thebody of evidence shows that the
vast majority of people whopromptly receive epinephrine to
treat anaphylaxis have completeresolution of symptoms,
(15:22):
typically within 10, 15 minutes.
Most people feel better prettyfast.
So if you're at home in a verysafe environment and you have
access to more than oneepinephrine, you have a cell
phone and you can get care ifyou need it, use your
epinephrine and hang out andmonitor If symptoms are getting
better or going away.
You should be fine.
You can call your allergist foryou know, talk to their office
(15:42):
about next steps and things likethat.
But a lot of people either werenot using their epinephrine
because they didn't want to goto the emergency room, or they
were misinformed thatepinephrine was dangerous and
that just because you use it,that means you have to go to the
emergency room because of sideeffects and the needle and
things like that.
All of that's incorrect.
And what happens when mostpeople go to the emergency room
after they use their epinephrine?
Well, typically they just sitthere for six hours and they
(16:04):
receive a bunch of treatmentthat they actually don't need,
such as steroids and histaminesand PEP-CID and things like that
.
Speaker 3 (16:11):
So we Like Benadryl Dave.
Speaker 1 (16:13):
How do you feel?
Speaker 2 (16:13):
about that.
Yeah, like Benadryl.
You know how I feel about that.
I read these ER notes of apatient arrived, had
anaphylactic reaction at home tocashew, received epinephrine.
By the time they were evaluatedthey were asymptomatic.
We gave them Benadryl,predenosone for seven days and
(16:33):
PEP-CID and had them monitor forfour hours.
What are we doing?
That's insane.
It's so outdated.
So that's where this comes fromand I think we can start to
have those conversations withfamilies.
I know I have for the lastcouple of years, and this
started during the pandemic.
Right, we were afraid to sendpeople to the emergency room.
We don't want to give themCOVID, especially before
vaccines are available.
So we started to actually learnhow to monitor at home and
(16:55):
treat them at home and have thatconversation, and that's what
the evidence supports as well.
Speaker 1 (16:59):
Yeah, no, I mean, I think that is such an important
point.
I will say, to caveat, ifyou're going to monitor at home,
I do like them to have somebodythere with them, yes, but
otherwise absolutely.
If they use their epinephrinepromptly and they're improving
and they have a second devicewith them, it all makes a lot of
(17:24):
sense.
Now, if they still want to goto the emergency room, you
absolutely can.
You absolutely can.
But hopefully this will takeaway some of those barriers to
actually promptly using theepinephrine, because the last
thing we want is not using it ornot using it promptly, and then
a kiddo is getting worse andthen you're putting the kiddo on
(17:46):
the back of the car to driveand then they're throwing up on
the way to the ER.
It's just terrible.
It's just terrible.
We know that prompt use ofepinephrine is what stops an
allergic, a severe allergicreaction, anaphylaxis, and
you're right, I totally lovethat.
The whole like oh, they maybeate it, no symptoms, then give
(18:08):
them epi.
I love that that is gone,because that has never made
sense.
I don't think to any of theallergists.
Speaker 2 (18:15):
Yeah, the dark secret with anaphylaxis, as you know,
is if you look at all of thestudies over the years, this has
been shown repeatedly 50% ofpeople having anaphylaxis never
receive epinephrine.
And what happens is 50% ofpeople they do fine it.
You know fatalities fromanaphylaxis.
They are tragic and they dooccur.
Thankfully they are not nearlyas common as most people believe
(18:37):
them to be.
So we want to promote usingepinephrine early because it
makes people feel better a lotfaster.
Yeah, you're miserable.
You are so miserable You'rehaving an allergic reaction.
Use it because you feel better.
Speaker 3 (18:47):
So we need to look at what.
Speaker 1 (18:48):
Right, and that's another reason benadryl, the
okay.
So like kind of before my timethey used to say, oh well, give
benadryl and it doesn't getbetter than give epi.
Like that is absolutely wrong.
That is not evidence-based,because then not only are you
delaying use of epinephrine, butyou're giving benadryl, which
is just an antihistamine.
(19:09):
And, as all my patients know,anaphylaxis is run by a lot more
than just histamine and it'snot the histamine that's going
to cause the fatal issues.
So you really want to get theepinephrine in promptly.
It's going to make the kiddofeel better because you're
really calming down thoseallergy cells so they stop
spewing out all of the stuffthat's causing all the reactions
and they help prevent all thosedifferent symptoms, or causing
(19:31):
all the symptoms.
It's going to help stop thesymptoms as well.
As opposed to, an antihistamineis not going to be that
multifaceted at all.
It's just going to beantihistamine.
No, I think you have pulled outamazing pearls for our patients
or our families listening on the2023 practice parameters and
(19:56):
for y'all listening to thispodcast.
If you haven't listened to theQuadai Eyes podcast on the
anaphylaxis practice parameters,where Dr Succas interviews Dr
Golden, you definitely should,because it is a fantastic listen
.
It's a fantastic listen andthey do get in the weeds on a
few things, and I love thatbecause it's too allergist just
(20:18):
talking about it, kind of likewe're doing it today, dave.
So thank you so much for comingon the show and breaking that
down for us.
And where can people find thepractice parameters?
Speaker 2 (20:28):
You can actually just search them online.
So if you just look for allergypractice parameters, they pop
right up.
They're free for everybody.
I believe there's teaching,which is awesome.
Yeah, oh yeah.
I think there's teaching slidedecks for some of the latest
ones as well for medicalprofessionals out there, if you
want to actually learn more oreven educate those in your group
or in your community.
So, yeah, check it out.
Speaker 1 (20:49):
Awesome, dave, thanks so much for coming on the show.
Speaker 2 (20:52):
It's my pleasure.
Thanks for having me.
Speaker 3 (20:55):
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to food
allergianyourkiddocom where youcan join our newsletter.
God bless you and God blessyour family.
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