Food Allergy Update – PediaCast CME 105
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Show Notes
Description
Dr Dave Stukus visits the studio for an updated discussion on food allergies. We explore their cause, symptoms, diagnosis, management, and prevention. We hope you can join us!
Instructions to obtain CME/CE Credit
- Read this information page.
- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
- Please Note: CME credit expires 3 years from this episode’s release date
- You can view your transcript and print a certificate of completion at Cloud CME.
- Need help creating a Cloud CME account? Click Here.
- Still have questions? Contact CMEOffice@nationwidechildrens.org
Topics
Food Allergy
Anaphylaxis
Oral Immunotherapy
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr David Stukus
Allergy and Immunology
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Define the differences between food allergies, intolerances, and sensitivities, including common symptoms and diagnostic criteria.
- Explain the mechanisms of anaphylaxis and the role of epinephrine in managing severe allergic reactions.
- Employ evidence-based guidelines to educate families on risk management, including interpreting precautionary labels and managing exposure to allergens.
- Evaluate the risks and benefits of oral immunotherapy and use this information to guide shared decision-making.
Links
Allergy and Immunology at Nationwide Children’s Hospital
Food Allergy Treatment Center at Nationwide Children’s
Food Allergy Yardstick: Where Does Omalizumab Fit?
EAACI Guidelines on the Diagnosis of IgE-Mediated Food Allergy
Anaphylaxis: A 2023 Practice Parameter Update
Disclosure Statement
No one in a position to control content has any relationships with commercial interests.
Commercial Support
Nationwide Children’s has not received any commercial support for this activity.
CME/CE Information
In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.
Contact Us
CMEOffice@nationwidechildrens.org
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by the Food Allergy Treatment Center at Nationwide Children's Hospital.
Hello, everyone, and welcome once again to PediaCast CME. We are a continuing medical education podcast for healthcare providers.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 105.
We're calling this one Food Allergy Update. I want to welcome all of you to the program. So, we have a terrific episode for you today as we consider updates to food allergy diagnosis and management.
And it's a topic that impacts millions of families in the United States and millions more around the world. And because food allergies affect all of these folks, they also impact the medical providers who care for them. There are a ton of myths and misinformation for families to find online related to food allergies.
And they may even bring what they find to their doctor, which can result in more confusion all around. So, we're going to try and set some things straight as we explore food allergies, including best practices on the diagnosis and management and prevention of them. We'll also discuss the cause of food allergies and talk about how food allergies are different from food intolerances and food sensitivities.
Of course, in our usual PediaCast CME fashion, we have an expert guest joining us. Dr. David Stukus is the director of the Food Allergy Treatment Center at Nationwide Children's Hospital. He is an allergist and immunologist.
After listening to this episode, be sure to claim your free category one credit. Really easy to do. Just head over to the show notes for this episode at pediacastcme.org.
You'll find a link to the post test in the show notes. Follow that link to Cloud CME. Click on the materials tab.
That's important. And then taken past the post test and the category one credit is yours absolutely free. And we do offer credit to many pediatric professionals, including physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.
And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements. Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pediacastcme.org.
Also want to remind you the information presented in our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at pediacastcme.org.
So, let's take a quick break. We'll get Dr. Dave Stukus settled into the studio, and then we will be back to talk about food allergies. It's coming up right after this.
Dr. David Stukus is a pediatric allergist at Nationwide Children's Hospital and director of our Food Allergy Treatment Center. He is also a professor of pediatrics at The Ohio State University College of Medicine. He's joining us for an update on food allergies.
But before we dive into that, let's offer a warm PediaCast CME welcome to our guest, Dr. Dave Stukus. Thank you so much for visiting with us today.
[Dr Dave Stukus]
Oh, thanks for having me. It's my pleasure.
This is a topic near and dear to my heart, and I think we're going to have a lot of great information for your amazing listeners.
[Dr Mike Patrick]
Yeah, and we are really so happy to have you back. It's been far too long. You have certainly been on our podcast before talking all things allergy, and so we'll have to make sure it's not quite as long between now and your next episode.
So, we are talking about food allergies, and I think a great place to start is really with a definition because there are also food intolerances and food sensitivities, and sometimes we can get a little confused in our brain, which is which.
[Dr Dave Stukus]
And this is something I discuss with pretty much every family that walks in our door because they all think that their child has a food allergy, but oftentimes I recognize almost immediately that it's not an allergy, but maybe there's something else going on. So, when we talk about food allergy, this is when the immune system forms a response against a food and with allergies, they're reproducible. So, every single time you eat a food, no matter what form, you should have symptoms that occur.
For today's purpose, we're going to talk about IGE, mediated food allergies. So, these are reactions that are going to occur pretty fast after eating the food, typically within an hour. Food intolerances are very different.
So, this does not involve the immune system. This is difficulty digesting a food. This can come and go over time.
This may be associated with higher quantities of food. The most common example would be something like lactose intolerance. Somebody that can't digest lactose when they eat dairy containing lactose, it passes through their bowel undigested, makes them pretty uncomfortable, cramping, diarrhea, bloating, and things like that.
These are typically more delayed symptoms. And then we have the all-encompassing term called food sensitivities, which is actually not a clinical diagnosis. This is a marketing term that was invented by people trying to sell unvalidated food sensitivity tests or programs, or dietary, you know, whatever, supplements and things like that.
So, when we talk about food sensitivities, that really isn't a clinical diagnosis. So, I just want to warn people that to avoid that term.
[Dr Mike Patrick]
Yeah. Yeah. What about things like milk protein allergies that don't necessarily result in anaphylaxis, which I know I'm kind of jumping ahead a little bit, but just as we're defining these things and gluten, you know, with like celiac disease, I would imagine those also involve the immune system but aren't necessarily IgE mediated.
Is that correct?
[Dr Dave Stukus]
That's absolutely correct. Yeah. So, when we talk about the all-encompassing term cow's milk allergies, so this is typically an infancy, and it can invoke a whole host of things.
Typically, it's going to be the cow's milk-induced allergic proctocolitis. So, you have that infant who's doing well, and then you see some, you know, bright red blood in their stools. And a lot of times this can be attributed to ingestion of cow's milk formula, sometimes maternal diet while breastfeeding.
This is a benign condition, but it is, it does involve the immune system, and we typically just avoid milk, and it resolves often within just a couple of months. There are other things like food protein-induced enterocolitis syndrome, which causes delayed onset, profuse vomiting, and sometimes diarrhea. Also, immune mediated, but not from IgE.
And then with celiac disease, that's actually an autoimmune condition where, you know, when somebody ingests gluten, their body forms auto antibodies against their own tissues. So, avoiding some gluten is the treatment for that condition.
[Dr Mike Patrick]
Yeah. When you have one of these other reactions that's mediated by the immune system, does that increase your risk for having, for developing an IGE mediated response? So, if you have a baby, you know, who has a little blood in their poop with cow's milk, and then you switch them off, if they have milk later in life, could they have anaphylaxis or are they not related at all?
[Dr Dave Stukus]
Unrelated. And this is the point in my presentations to our colleagues where I put the slide up with the gel Coombs hypersensitivity classes. So, if we go back to medical school, you have your type one, two, three, and four hypersensitivity responses.
So, type one is what we're going to focus on today. IGE mediated hypersensitivity, potential for anaphylaxis. But most of these are going to be more type four, like poison ivy.
So, you brush against the oil on a poison ivy leaf, you're fine for 12 to 24 hours. Then you get the blistering rash. That doesn't increase your risk of having anaphylaxis to poison ivy.
So, it's the same idea here as well.
[Dr Mike Patrick]
And those other things are uncomfortable and a nuisance and annoying, and we want to avoid them, but they're not life-threatening like the IGE mediated responses are. And that's why we're focusing on these today.
[Dr Dave Stukus]
That's right. Yeah. There are some very rare forms of, you know, delayed onset food immune responses that can cause, you know, protein losing enteropathy and failure to thrive, but those are pretty darn rare.
[Dr Mike Patrick]
Yeah. Yeah. Now one would think since these are IGE mediated, so we know IGE is an antibody, it attaches to an antigen from a food and then goes to other cells that release histamines, and we'll get into all of that.
But since we're starting with an IGE antibody, you would think that you could just do a blood test and identify IGE antibodies to determine if someone is allergic to a particular food. And I know there are clinicians who do that. There are also big panels that you can run that just, you know, looks for a ton of different ones.
Are those suitable tests to diagnose a food allergy?
[Dr Dave Stukus]
When used in the proper context. So, they are not screening tests. We always want to use the clinical history of what happens when you eat a food.
The single best test is, you know, the dietary history. If you're eating a food and you're not experiencing reproducible symptoms, you're not allergic to that food. I don't care what the test shows.
So, you're right. So, can we detect IGE through blood testing? Absolutely.
Here's the problem, though. All that shows is sensitization and it doesn't diagnose allergies. So, there's now direct to consumer tests that you can order at home blood tests, get it sent to your home, send it off.
And, you know, these panels are widely marketed to pediatricians of, wouldn't it be great if you could tell your patient exactly what they're allergic to? Well, would, but you're never going to be able to get away from taking a detailed clinical history and you have to interpret the results in the proper context.
[Dr Mike Patrick]
And you're going to have some positive IGEs in there that aren't really causing a problem just because your body's making them and you're sensitized, but it doesn't mean that that's going to result in anaphylaxis. And then you may avoid foods you don't need to avoid, which, you know, there are folks that like their whole life, they think they're allergic to something and avoid it. And that takes a lot of time and energy and effort and also causes fear and anxiety in the patient.
That's totally unnecessary.
[Dr Dave Stukus]
100%. This is why we removed food allergy panels from our institution many years ago. We were able to demonstrate and publish in pediatrics that these are a real problem.
We don't want to order panels for these tests. When the old choosing wisely series that looked at the top 10 things that we're doing incorrectly in each specialty, number one on the list was literally don't order food allergy panels because it causes unnecessary harm and avoidance. All you're detecting is sensitization.
And one last thing, when you look at like the old NHANES trial for 10,000 kids measuring specific IGE, 40% of children and thousands and thousands of kids had detectable IGE to milk, egg, shrimp, and peanut, but only 5% are actually allergic. So, when you go by IGE alone, you're going to over-diagnose the vast majority of people.
[Dr Mike Patrick]
So, we really start with the clinical history and that's the gold standard. And then anything beyond that is just confirming what we already have a pretty good idea about based on the history. What is the time between contact with the allergen and the onset of symptoms?
Because is this something that happens always rapidly or is there sometimes a delay?
[Dr Dave Stukus]
There can be a delay, but almost always this was within one to three hours of eating it. So, we don't need to take a dietary history for the day before or the week before. And if you have somebody that has had hives lasting for days and days, that's not a food allergy reaction.
That's a different cause of those hives. So typically, it's going to happen within minutes, rarely longer than two to three hours later.
[Dr Mike Patrick]
And then what are the most common food allergens in children?
[Dr Dave Stukus]
Yeah, when we talk about IGE mediated food allergies, there's nine foods that account for more than 90% of all food allergy reactions. This would include cow's milk, hen's egg, wheat, soy, peanuts, tree nuts, finned fish like salmon, tuna, tilapia, and then shellfish like shrimp, crab, and lobster, and then sesame is on that list as well.
[Dr Mike Patrick]
And when we talk peanuts and tree nuts, is there any cross reaction amongst different nuts? Or are you allergic to specific ones only?
[Dr Dave Stukus]
There's a lot of foods that have the letters N-U-T in their name, but that does not mean that they're allergenic. So, peanuts are legumes. They grow on the ground.
That's where they're harvested from. Tree nuts grow on trees. There is no cross reactivity between these.
These are very different things. Now there's a lot of highly allergic individuals when they have multiple food allergies. They may be allergic to both peanuts and tree nuts because these are the more common causes of food allergy, but it's not like one causes the other.
And then even amongst the tree nuts, it's pretty unusual for somebody to truly be allergic to every tree nut. So, we know that walnuts and pecans tend to cross react with each other as do cashews and pistachios, whereas almond is kind of off on its own. So, we do want to be very careful about when we diagnose which tree nuts somebody's allergic to.
[Dr Mike Patrick]
And then what symptoms are we talking about? So, we say anaphylaxis. We have a lot of different types of listeners for our podcast.
We have physicians, of course, but we have other providers who listen. And so, I just want to make sure we're all starting at the same level of information. So, what exactly constitutes anaphylaxis?
Hives is the big one we think about, but there's more symptoms than just hives.
[Dr Dave Stukus]
Yeah. So, when we think about, as you eloquently described, when you have this IgE reaction, the IgE antibody is attached to mast cells in every tissue throughout the body and basophils, which are floating around our peripheral bloodstream. So, when the IgE binds the antigen and opens up those cells, the first thing that gets released is histamine.
So, a lot of the symptoms for food allergy reactions can be traced back to histamine. And it all depends on where it's impacting the body. Histamine in the skin can cause intense itching in hives.
A little bit lower can cause swelling, especially of the lips and the face. If you have histamine in your nose, you're going to get just like seasonal allergies, severe nasal congestion, sneezing, itching. Histamine inside the lungs causes bronchoconstriction and coughing, chest tightness and wheezing.
In the GI tract, you can have nausea and vomiting. You can even have severe abdominal cramping as well. And then in the blood vessels, it can cause dilation.
That's why people pass out from shock from anaphylaxis. So, anaphylaxis is any combination of more than one body system. The most common symptoms people experience from food allergy reactions would be hives on the skin, and sometimes they'll have vomiting.
And then with anaphylaxis, it can be any combination of those. But there's different degrees of anaphylaxis. Oftentimes it's very mild and self-resolved.
So, you develop hives, and you throw up once. That's anaphylaxis, but oftentimes that's all the reaction entails. Or you can have more severe symptoms where you have true difficulty breathing, especially if you have underlying asthma or particularly poorly controlled asthma.
That's when you're going to get more severe bronchoconstriction.
[Dr Mike Patrick]
So, you have hives with no other symptoms.
[Dr Dave Stukus]
Is that anaphylaxis? That is not. That's just hives.
Even if it's head to toe, the most itchy hives you can imagine. Hives are just hives are just hives.
[Dr Mike Patrick]
And you don't have to have hives. You could have two body systems, but not the skin, which is a little unusual, but it can occur, correct?
[Dr Dave Stukus]
That's absolutely right. Yeah. And with anaphylaxis, because it's a clinical diagnosis, we can draw a serum tryptase level in the first one to three hours after the onset of symptoms, but we don't want to rely on that because the results take a day or two to come back, but it's a clinical diagnosis.
So, when we educate our patients or when we're treating these patients acutely, we need to put this in the proper context. So, anaphylaxis from a food allergy is going to happen pretty soon after eating it. So, you know, people can have hives during viral infections.
So, if you have viral gastroenteritis and you're vomiting, have diarrhea, and you also have hives, that's not anaphylaxis. So, we want to always use that story and providing the diagnosis.
[Dr Mike Patrick]
Yeah. A lot of data points that we have to synthesize to come up with our diagnosis, right? What about processed foods?
So, you know, folks read ingredient labels, which is an important thing to do if you have a food allergy, but if a food is, if an allergen is in a processed food, does that make it less likely or more likely or not make a difference at all to cause anaphylaxis? Yeah.
[Dr Dave Stukus]
When you're in the United States, all of the nine highly allergenic foods that we discussed, if they're contained in a food, the label must clearly state contains. So, we teach people all the time to read labels every single time. So, if it says contains milk and you're allergic to milk, that is not safe to eat.
You know, there's other labels that we'll talk about in a second, but so if it says contains, we have to trust that and it's not safe. Now there's food derivatives as well. So particularly for folks who have soy allergy, there are things like soy lecithin that is used as a binding agent in many foods.
That's often very safe because that actually breaks down the food. A food antigen doesn't bind to the IgG and cause reactions.
[Dr Mike Patrick]
Very interesting. Are some food allergies likely just to go away on their own? Or once you have a food allergy, is it with you your entire life?
[Dr Dave Stukus]
85% of children with milk, egg, wheat, soy allergy tend to develop tolerance on their own, often by school age, by five or six. Whereas only about 10 to 20%, if you have peanut, tree nut, or sesame allergy, only 10 to 20% will outgrow that as they get older. So that can be more lifelong.
And we actually have adults that can develop new onset food allergy later in life, even after they've eaten a food for their entire lives. And we don't fully understand that. That's typically going to be more for like shellfish and tree nuts, but no, it can go away in many instances.
[Dr Mike Patrick]
And since it can go away, is that something that you test on a regular basis to see if it has gone away? Because if you're avoiding a food, you may not try it. And so, you don't know if it did resolve on its own.
So, if it's something, I mean, you may not do that for peanuts, tree nuts, and sesame seeds, but for the other, for milk and egg and soy and wheat and all those things, is that something that you test every now and then? Or do you just let it be?
[Dr Dave Stukus]
No, we absolutely, and for all the food allergens, because especially in young children, the immune system is very dynamic, and it often changes over time. So, we want to give every opportunity we can to help somebody identify if they've outgrown their allergy. I think there's a couple of major take-home points for your listeners.
One is don't use food allergy panels because you're going to ruin lives and over diagnose food allergy. We want to focus on clinical history. Two, if you wrongly diagnose somebody with food allergy, it's not going to a nice life, avoid this.
We're going to talk about management in a little bit, but it's also going to be, you know what, this is what you're allergic to at this point. Let's repeat testing typically once a year and see if this changes over time.
[Dr Mike Patrick]
And what kind of testing is that then? Are you doing the blood test, skin test, a food challenge? How do you do the annual, hey, let's see if you're still allergic to this?
[Dr Dave Stukus]
Yeah, oftentimes we'll do the skin prick test at the first diagnosis because I have them in the office. It's the point of contact. It takes 15 minutes right there.
But then we'll often follow the blood levels over time because we can actually track those numbers, and we get a scale from 0.1 to 100 kilounits per liter. And let's say somebody starts off at a level of 35, but a year later, it goes down to 12. We say, okay, this can help us with prognosis.
This may be going away. And then the oral food challenge is the gold standard. This is how we determine if somebody's actually allergic in the first place.
You can also get a better sense of like how allergic they are based upon how much they eat before symptoms occur.
[Dr Mike Patrick]
So, the oral food challenge, you do that in the office where you have treatment available. If they do have anaphylaxis, how long after they ingest the food, do you watch them in the office?
[Dr Dave Stukus]
Yeah, you really have to be equipped to treat an emergency in case it occurs. We also want to do a good pre-assessment of like why are we doing the food challenge. Sometimes it's to determine resolution or whether allergy is present in the first place.
Other times it's to try to figure out are they exquisitely sensitive to small amounts. And we basically just give them small amounts of the food and we double the dose every 10 minutes or so. If our desire is to determine if they're allergic or not, we want to go for at least a serving size or about four to six grams protein.
Then they hang out for typically another two hours afterwards. Just, you know, the last thing we want to do is have somebody have anaphylaxis or a delayed onset reaction in the car when they're driving down the road on the way home. So, it's a half-day affair.
And yeah, we have all the equipment available at our institution. We're very fortunate, especially at our Food Allergy Center. We do, you know, 800 to almost a thousand food challenges a year.
And this is the best part of our job. This is, you know, how we can help families the best. But that takes a lot of space, which we have dedicated space for, and it takes staff that have the experience in doing this.
[Dr Mike Patrick]
Yeah. Do the families have to bring in the food or do you supply the food?
[Dr Dave Stukus]
It depends. So, we stock, so we have all the milk, eggs, soy, we have tree nuts and peanut and sesame and stuff like that. If it's something cooked, we don't have a kitchen on site.
So, if we're going to do scrambled eggs or French toast, or if they want breaded shrimp or something like that, they have to bring it on their own. Okay. And your staff never goes hungry.
No, I'm- No, it's, yeah, that's, that's, I mean, of course, after the food challenge is over, right? Of course. Yes, that's right.
[Dr Mike Patrick]
That's right. One more question before we get into treatment, and that is genetics. Are food allergies inherited?
So, if you have, you know, grandma, grandpa has a peanut allergy, are you more likely to have one?
[Dr Dave Stukus]
Yeah, this is a common reason for referral and concern among parents. So thankfully, specific allergens are not inherited. So, there's no, you know, we don't pass a peanut allergy down from one parent to a child or anything like that.
However, allergies run families. There's a genetic predisposition. We don't fully understand why people develop food allergies as opposed to not, but oftentimes you inherit that likelihood that you are going to be allergic, and then there's a higher risk for that.
But even then, family history alone is not a very strong risk factor in children to develop food allergies. The strongest risk factor is, does that child actually have moderate to persistent atopic dermatitis, where it's affecting a large portion of their body surface area? They require, you know, prescription strength topical medications to treat it.
Those are the ones raising their hands saying, I'm at risk to develop food allergies, but you can also have food allergies without having eczema as well.
[Dr Mike Patrick]
Now let's actually, while we're on that topic with babies and peanuts, what is the current kind of rules for introduction of peanuts, and in particular in a baby who might have asthma or might have atopic dermatitis or eczema?
[Dr Dave Stukus]
This has been one of the greatest sort of triumphs in science over the last 20 years. You know, it is now well established, especially for peanut and egg, but really for all allergenic foods, is we want to let the babies eat. So, the best advice across the world, not just the United States, is around four to six months of age, once babies have already shown an ability and desire to eat solid.
So, start with the oatmeal and the rice cereal and the purees. Then we want to introduce all of the allergenic foods in age-appropriate forms into their diet. And more importantly, it's not like a little taste and then you're done.
Keep it in their diet consistently. Daily is great, but at least three times a week. That's our best way to try to prevent food allergies from developing.
We want to promote tolerance by having them eat it, expose it to their gut immune system, which is really powerful in that point in life, and try to get them to tolerate these foods.
[Dr Mike Patrick]
Are there babies in which you would not want to do that at home yourself because there could be a life-threatening reaction the first time they have it?
[Dr Dave Stukus]
Actually, no. So, when you look at all the evidence, and this is reflected in the most current anaphylaxis practice parameters or guidelines, it's extremely rare for infants to have severe anaphylaxis as their index food allergy reaction. I don't get patients because they end up in the hospital or ICU when they react to foods.
I get patients because they may get some hives and maybe they vomit once and parents say, that's not right, and they're reluctant to feed that food again. So, we want to reassure parents as much as we possibly can. We have parents, you know, we've done a really good job at scaring parents and feeding their babies collectively as a medical establishment, but we need to reverse that because the evidence shows that it's very safe to do, and if something arises, we can go back and figure it out.
Please don't tell families to drive to the parking lot of the emergency room before they feed peanut for the first time, or you don't need to prescribe an epinephrine autoinjector before they feed a food. It's something that they should enjoy, and it's a normal part of life, like let the babies eat.
[Dr Mike Patrick]
So, if they're going to have an anaphylactic reaction, you said that there are degrees of anaphylaxis, so the first time it happens, it's more likely to be mild versus as you have repeated exposures, then it could escalate and become a life-threatening reaction?
[Dr Dave Stukus]
It's possible, but there's a lot into that as well, such as cofactors and, you know, the amount that you eat and things like that, but the most common, even for anaphylaxis as the initial presenting reaction, is typically they get some hives, and they vomit once or twice. Again, as we discussed, that's anaphylaxis, but it's typically self-resolved, and then, you know, we can evaluate and figure out what's going on.
[Dr Mike Patrick]
As we start to think about management of food allergies, there's really, I guess, two prongs to this. One is managing anaphylaxis, and then there's also management of the food allergy itself in an effort to prevent anaphylaxis. So, let's talk about anaphylaxis first.
[Dr Dave Stukus]
How do we treat that? Yeah, so we want to educate everybody. So, one, clarify what are you allergic to, teach them how to read labels, communicate with food handlers, how to avoid accidental ingestion, and then we want to, you know, educate about how anaphylaxis can present.
So we go through the different symptoms that can occur, we put it in context. It can be really tricky, especially when kids have reflux, so they have chronic hives or eczema, and we want to counsel families like all of the symptoms that can occur from anaphylaxis can occur for other reasons as well. So just because they have hives, you don't have to think that they're having anaphylaxis.
And then, you know, once they identify anaphylaxis, epinephrine is the only effective therapy. So, we want to help close up the allergy cells and make the reaction stop a lot sooner. And most importantly, it makes kids feel better.
You know, thankfully, fatalities from food allergy reactions are extremely rare. We're talking like less than, you know, a dozen a year in the United States, and almost always it's, you know, adolescents and young adults, not school-aged children and infants. So, we want to reassure families that epinephrine is there because if accidental ingestion occurs, it's going to make them feel better a whole lot faster.
And that just reverses the effect of the histamines? Yeah, so everything, so epinephrine works on all those, you know, adrenergic receptors throughout the body. So, whatever's going on, it can help close up those skin cells that are dilating and causing hives and vasodilation and flushing.
It can help, you know, open up those airways if they're constricting, it can alleviate nausea. So, it's a great treatment and it works really fast and it's extremely safe, especially when given in the doses that are provided in available treatment options.
[Dr Mike Patrick]
So, since this is mediated with histamines, epinephrine is the treatment, not antihistamines? Because you would think, well, if a histamine is the problem, if I do an antihistamine, I'll block the symptoms that the histamine's causing, but that's not necessarily true, correct?
[Dr Dave Stukus]
Right. Antihistamines are great for hives, but they take a while to kick in. So, they take, you know, 15 to 20 minutes.
So, if somebody's actually having anaphylaxis, why would we make them suffer and wait that long? Epinephrine works so fast, and it works so well and it's so safe. So that's why we want to use it.
[Dr Mike Patrick]
You know, when kids have hives, oftentimes they come and go, you know, for a week. With food, with anaphylaxis, would you expect that once the hives are gone, they're gone? Or can the hives come and go for a few days?
[Dr Dave Stukus]
That's an important part of the diagnosis. So, if somebody comes in and they say, my child developed hives after eating this food and they're worried about a food allergy reaction, but those hives lasted two, three days, that's not a food allergy reaction. That's coincidence.
So, correlation does not equal causation. So, I hear you and I believe you, but I think this was just, you know, timing. We all eat every day, every, all day, every day.
So, it's going to event, you know, symptom onset's going to correlate with eating food. Food allergy reactions are almost always, even without treatment, gone within six hours. So, it's just, that's what happens here.
So, as the body sort of processes what's going on, it's not going to last for days and days.
[Dr Mike Patrick]
So, someone comes into my office or an urgent care center, emergency department, and they have, they ate a food and within an hour they had hives, and they vomited a couple of times. They come in and maybe they still have a few scattered hives. They're not vomiting anymore.
What do you do for those kids?
[Dr Dave Stukus]
That's a great question. And I'm going to talk about what to do and what not to do. So, what, what's the diagnosis, right?
So, did they have anaphylaxis, but now that's resolved, and they just have hives? Treat the hives. If you feel that they have ongoing anaphylaxis because of more than one body system, give them epinephrine.
But that's what we need to do at that point of care. So, a lot of anaphylaxis just resolves with or without epinephrine. We want to promote using epinephrine because it works, and it makes them feel better.
Here's what not to do. If you have that patient whose symptoms are resolving or they're already resolved, you don't need to give them steroids. Steroids do not treat allergic reactions, and they don't treat, they don't prevent biphasic reactions.
Biphasic would be reactions that resolve, but then symptoms come back again, you know, from one to several hours later. We've learned a lot about risk factors for that. So, if they have symptoms that have resolved with or without epinephrine and you can just monitor, and you don't need to monitor for four to six hours.
Those kids aren't going to have rebound symptoms. Maybe watch them for an hour or two. And if that family's, you know, well-educated and they feel comfortable, you can discharge them.
However, if they do require more than one dose of epinephrine or they require supplemental treatments, such as, you know, treatment with nebulized, you know, aerosolized albuterol or IV fluids because of, you know, hypotension, those patients need to be monitored for much longer and they may require supplemental treatment as well.
[Dr Mike Patrick]
In terms of the epinephrine, you know, traditionally we've used the auto-injectors and always either subcutaneous or intramuscular, you know, in the past. Now it's sub-Q, but there's nasal sprays now that are available as well. Is that correct?
[Dr Dave Stukus]
Yes, this is another exciting. So, there's so many things happening in the world of food allergies. So, if you have patients out there and they haven't seen a board-certified allergist or had a conversation about food allergy management in the last year, please get, you know, contact them and get them in because so much has changed.
We're about to talk about. But yes, now we have a nasal epinephrine device. It's actually the same little device that Narcan is delivered through.
So, it's a little plastic applicator. It has a two-milligram dose of epinephrine. So, that's from our auto-injectors, which are either 0.15 milligrams or 0.3 milligrams. And we just deliver it inside a nostril. You don't have to sniff. It just squirts it up and it can, you know, treat anaphylaxis.
It's only indicated for patients who weigh 66 pounds or more. It's given as two applicators and the shelf life is two and a half years as opposed to auto-injectors, which typically expire within 12 months.
[Dr Mike Patrick]
If I'm remembering correctly, 66 pounds is also the divider between using the epi, the junior version of the auto-injectors and the full-strength version. Is that correct? According to package inserts, but I think most allergists would tell you that we switch at 25 kilograms.
Okay, gotcha. And so, that's if a kid is big enough for the full dose auto-injector, then they're big enough to do the intranasal version. That's a great way to think about it.
[Dr Dave Stukus]
Yeah, and not everybody wants to. You know, the company has sample devices, and I show it to families and some are like, this is the greatest thing ever, especially if there's needle phobia involved. So, there's a lot of reluctance to use epinephrine because they're afraid of the needle and what that might feel like and this can replace that.
And stay tuned. If you'll have me back in the future, there's a company working on a sublingual epinephrine, which is like a little strip that goes under the tongue and absorbs through the mucosa. There's a separate nasal device that's being investigated as well.
So, exciting times to have options available. Yeah.
[Dr Mike Patrick]
And then, what about cost? As I recall a few years back, there was a big hubbub about just how much the auto-injectors were costing, and it was prohibitive for some families to have one that wasn't expired in their home. Has that improved and are the intranasal ones affordable for families?
[Dr Dave Stukus]
Great question. Yeah, there was price gouging going on a few years ago. It was terrible.
They were charging families $800 for these devices. So, a couple of things have changed. One is we now have generic epinephrine auto-injectors.
Some are the identical device as the trade name. Others are slightly different. So, that can lower the cost.
It really has changed year to year. So, it depends on your insurance company's formula and what they're covering. So, that's really unfortunate, but we are having to change devices every 12 months based upon what's covered.
Most of them are going to be more affordable these days. With the new nasal epinephrine device, a lot of insurance companies still aren't covering them, but they have a specialty pharmacy. We'll go through the prior authorizations and if it gets denied, then they will give you two devices for $199.
So, I talk to families, and I say, listen, if you're paying $100 for an auto injector that you have to replace every 12 months or if you want this for $200 that lasts two and a half years, you know, you're actually going to save money in the long run.
[Dr Mike Patrick]
Yeah, yeah. And it's good to have someone who knows the ins and outs of that because I feel like a lot of primary care docs, including myself, wouldn't necessarily know that. And so, oftentimes we do prescribe those, but really, we ought to have our allergy colleagues also involved in following along because there may be better options for families that we just aren't aware of.
[Dr Dave Stukus]
And yeah, and it's hard for us to even keep up with all this stuff. So, there's no way that anybody in primary care or other specialties can be, you know, that you can do it. So, we're happy to help in any way.
[Dr Mike Patrick]
So, the bottom line, anaphylaxis is treated with epinephrine. I mean, that's, and there's, you know, when you talk to families about, you know, when to use it, I'm sure that they're, and I know this from working in the emergency department, that there are families that are like, well, I didn't want to use the auto injector because I was afraid to use it. And that's why we just came to the emergency department.
Is it ever dangerous to use epinephrine when it wasn't necessary?
[Dr Dave Stukus]
No, I've done this myself. I thought it was a training device, but it was the real deal. And it was, I was kind of excited.
I've always wanted to, it's fine. It's, it's adrenaline. We all, we have this in our bodies.
So, if you're, if you're, if you're running or if you get excited or scared, that's what it does. So, the dose that's included in auto injectors has not been associated with any major adverse effects. So, even if you, if you're not sure if you should give it, we recommend that people give it because it's very safe to use.
Good to know.
[Dr Mike Patrick]
Before we move on to the prevention of anaphylaxis, so sort of management of food allergies, a couple other questions I thought of in terms of exposure to food allergens. One is, you know, you sometimes see on labels that a product may contain particular allergen, or it'll say this was processed in a facility that handles peanuts or something like that. So, it's not an ingredient, but they're saying, you know, there may be some allergen in this.
Is that something that, that people should watch for if you have a food allergy?
[Dr Dave Stukus]
Is that an issue? This is a good shared decision-making conversation with one's allergist because it depends on what people are allergic to, their prior reactions, how sensitive they are. And we, we have ways of identifying like exactly how much somebody needs to eat to trigger reaction.
But it's also important for them to know that those statements may contain process and facility shared equipment. They're not regulated at all, and they don't mean anything. More and more companies are putting them on there because they think that it protects them from a legal standpoint, but it does a disservice to the food allergy community because if you're really trying to find a safe food and you see these labels everywhere, and there's like two dozen different verbiages that are out there, it can be really confusing.
So, most people are not going to have any reaction at all to those sorts of labels. And there's a couple reasons why. One, very few of those actually contain allergen, let alone enough allergen to trigger an allergic reaction.
And two, most people with food allergy are not exquisitely sensitive to things like trace amounts and cross contact. So, you combine those two together and it can really open up a lot of options for people to eat.
[Dr Mike Patrick]
Yeah. Yeah. So, you know, they got rid of peanuts on airplanes, on many airplanes.
Was it, were, were the little bags of peanuts dangerous if, you know, a kiddo one row over had a peanut allergy? Is, were they going to get it through the air?
[Dr Dave Stukus]
No, this has been such, there's been such an overreaction towards safety over the last decade, but now we have really good evidence that shows that those sorts of exposures do not pose risk. There's actually a study done on airplanes. Go up in the air, open a bag of peanuts with the most sensitive detector you can possibly find.
And what they found was that you, for very briefly, have, you can detect the peanut dust to the level of the person's nose that's opening the peanut packet, but then it settles very quickly. So, we do want to recommend caution about using tray tables and armrests and stuff. And we always want people to take their own safe snacks and don't trust it when you're 30,000 feet in the air.
But just take like a, a detergent wipe and wipe down the tray table and the, and the handles, and you're going to be fine. And then make sure that anything you eat, read the labels and make sure you don't eat peanut, but we don't need to worry about somebody eating peanut near you.
[Dr Mike Patrick]
Okay. Very good. And then what about peanut oil?
Is that an issue for folks with peanut allergy?
[Dr Dave Stukus]
If you get the very expensive cold pressed peanut oil, that can be harmful, but very few restaurants use that because of the cost. So, for the vast majority of people, the commercial grade peanut oil that's used is safe to use. There's no protein in that.
So, that's another way that we can help open things up and make it more manageable.
[Dr Mike Patrick]
Okay. And that's something that if you were concerned, you could always do a challenge.
[Dr Dave Stukus]
I've done that. Yeah. So, I've had some, some highly anxious families that like, just, you know, don't believe, you know, what I have to offer.
And I said, that's fine. I said, go to your restaurant that uses peanut oil, bring it here and eat it here in the office. And it's great.
So, they have a little picnic, and you see just the weight lifted off their shoulders and they don't have to worry about it anymore.
[Dr Mike Patrick]
That's got to put a smile on your face when you help families because it improves the quality of their life so much to, you know, with doing that. And then what about baked goods? So, you know, oftentimes milk and egg may be ingredients, you know, like in a cake.
If it's baked, does that make a difference in terms of allergen exposure?
[Dr Dave Stukus]
Another huge advance is we now understand that 75% of children with milk and egg allergy can tolerate it when you use it as an ingredient in baked goods. So, that means anything that's in the oven. And the reason why is because for many of those children, they're reacting to really small epitopes or parts of the antigen or the allergen.
And when you bake it at high temperatures, like 325 degrees Fahrenheit, it unravels the protein. So, it's no longer recognized by IGE. Now, it's not 100%.
So, there are some children that do react, and they can have very severe reactions. We don't have a great way to assess that other than by eating it. So, that's why we do a lot of these challenges in the office.
And then once they tolerate it, they can often, you know, go on the ladder. And we used to think it was just milk or egg in a muffin or something like that or a brownie. But no, it's, you know, 75% of these kids can eat like quiche, which is insane, or pizza.
But the same principles apply because you're heating it extensively. So, we can work with families to try to figure that out and just make it so much easier to manage. It's interesting that those kids who can tolerate it also, it predicts they're going to likely outgrow their milk and egg allergy much faster as well.
[Dr Mike Patrick]
Oh, interesting. So, that's something that food, you know, allergists who take care of food allergies, you could say, hey, can I make an appointment to come in and eat muffin in the office and hang out for a couple hours and just make sure we're good?
[Dr Dave Stukus]
Yeah, absolutely. And there's also shared decision-making. There are occasions where this might be done at home.
So, let's say they've reacted to scrambled eggs four times. Every single time it's mild, self-resolved facial hives. We determine, yeah, you're actually allergic to egg.
Well, maybe, you know, if the parents feel comfortable, if they live a distance away, we can try the baked egg at home because it's unlikely that the reaction is going to be more severe compared to that. But this is when we get into the nuance and this is, you know, that's what I do every day.
[Dr Mike Patrick]
Yeah, absolutely. So, let's move on to prevention and sort of management of food allergies, preventing not the food allergy, but preventing anaphylaxis. One option that has been in the news for a few years now is oral immunotherapy.
What is that and where does it fit into the management process?
[Dr Dave Stukus]
Yeah. So, oral immunotherapy is, it's just like people who have received allergy shots for their severe pollen allergies. We've done this for over 100 years.
So, this is a desensitization process. So, with oral immunotherapy, we're giving somebody very small amounts of what they're allergic to and they're eating it every single day. The amount gets increased every two to three weeks, typically in the office setting, until they reach a maintenance dose.
And then that's their dose that they take every day for years and years and years. What we're finding is that for most people, it can increase their threshold that would trigger a reaction. So, it gives them sort of that bite-proof protection that a lot of families want.
For some children, it helps accelerate their development of tolerance, especially if we start this in the first couple of years of life. Unlikely we're going to do that when kids are teenagers, which means maybe we could cure their allergy. But you have to understand what's involved because if you're eating what you're allergic to every day, you could have an allergic reaction every day.
So, we have to take precautions. One is we want to make sure that there's a full stomach when you take your dose. Number two, exercise is a big co-factor.
So, we say no exercise for at least two hours after taking your dose. And then we also want to monitor. So, if they're sick with a fever or a cold or an illness, we want to hold doses that they are just doses.
This requires a ton of supervision. So, we don't want anybody doing this on their own. Allergists have to be equipped with understanding the protocols involved, how to counsel families and monitor for reactions and things like that.
But over time, this just makes it a lot more manageable. So, for some families, this is the best thing they ever did. For other families, it's the worst thing they ever did because their child is involved in multiple activities, and they can't possibly have them not play soccer or withhold from exercise.
Or some kids refuse to eat what they're allergic to. So, there's a lot of toddlers out there that just hate the taste of peanut. And even though parents desperately want this treatment, they're just refusing to eat it and it's making their quality of life even worse.
So, there's a lot of things to consider with this.
[Dr Mike Patrick]
Yeah. And I love the shared decision-making aspect of what you do. And we try to do that more and more even in the emergency department, you know, really just talking with families, letting them know what the options are, coming up with a decision together.
And I just, I love that. With the oral immunotherapy, at sometimes, it could potentially cure them by allowing them to become tolerant of the allergen or desensitized. But in other cases, it's really there just to try to prevent anaphylaxis if you had a small exposure.
So, you're not really necessarily giving them the oral immunotherapy with the end result of being so we can get rid of your allergy. It's more to make it less dangerous.
[Dr Dave Stukus]
Right. It's the exception that people may be cured from this. And really the only way to determine that.
So, while you're receiving your daily oral immunotherapy, you're desensitized and protected. Once you stop treatment, you just revert back to being allergic. However, in those young children, if we start it early and treat them for a while, and then if we decide to stop and then challenge them, that's how we only determine, that's the only way to really determine if they're, you know, no longer allergic or not.
For a lot of families, they don't care because they're just watching their kid eat what they were allergic to or what caused a reaction and they're managing it, and it decreases their anxiety surrounding it.
[Dr Mike Patrick]
Are there certain food allergies that are more likely to be cured with immunotherapy? You know, as, you know, milk or egg compared to peanuts, let's say.
[Dr Dave Stukus]
Yeah. So, not necessarily. We do want to be cautious because as we talked about, a lot of, you know, toddlers with milk and egg allergy, they're going to outgrow this on their own.
So, putting them on a potentially lifelong treatment with oral immunotherapy could be a huge disservice. So, we have to talk to families about, hey, once you start down this path, this is what this looks like, or maybe we just monitor for another couple of years. For those infants with peanut tree nut allergy and we start in the first couple years of life, those are the ones that maybe we can help make this go away.
But again, we don't want families thinking that this is going to cure their child's food allergy but certainly can make it more manageable.
[Dr Mike Patrick]
All right. And then there's been a lot of buzz about monoclonal antibody treatments for food allergies. These things are always tongue twisters in terms of how to pronounce them, but I'm going to say omaliz…
[Dr Dave Stukus]
Or omalizumab, but… Good.
[Dr Mike Patrick]
Oh, yeah. I'm going to forget that. So, what is this monoclonal antibody and what's its use?
[Dr Dave Stukus]
You're not going to say it again, are you?
[Dr Mike Patrick]
Omaliz… Okay.
[Dr Dave Stukus]
We're good. All right. So, omalizumab is a monoclonal antibody that's designed to bind to IgE.
So, it's highly specific. It has been used for over 20 years for other conditions such as allergic asthma, chronic urticaria, for people with nasal polyps. And then it was approved by the FDA, oh my gosh, in February 2024.
And it's approved specifically for the treatment of any IgE mediated food allergy and in conjunction with ongoing avoidance. And what the studies have shown is, one, it doesn't care what you're allergic to. So, if you have multiple food allergies, this is great because it will just protect you from all of them.
Two, what it can do is it can increase the threshold you need to eat to cause an allergic reaction, particularly anaphylaxis. And oh, by the way, now we're treating the whole person. So, if you're a person that has allergic asthma, environmental allergies, and food allergies, omalizumab can really help treat all of those conditions at the same time.
[Dr Mike Patrick]
So, this is an antibody that is attacking another antibody.
[Dr Dave Stukus]
That's right.
[Dr Mike Patrick]
It's like antibody inception.
[Dr Dave Stukus]
Yes, I like that, yeah. But this is great.
So, the biologics, these, well, one, it has a 20-year safety track record, which is great. There is a boxed warning because for reasons we don't fully understand, treatment for allergies can potentially cause an allergic reaction. But this is almost always in the first three doses.
So, we give the first three injections in the office, then we train people how to give this at home through an auto-injector. But otherwise, yeah, it's so specific. We don't see side effects like we see with steroids and other treatments like that.
[Dr Mike Patrick]
Yeah. Are there disadvantages to decreasing the number of IgE floating around by neutralizing them with another antibody? Is there a disadvantage to that?
[Dr Dave Stukus]
Yeah. So, theoretically, IgE also helps protect us against parasitic infections. So, there's a theoretical, but for most of us that live in first world countries, we don't come across those very often.
I do talk to families like, hey, if you're going to go swimming in a fresh body of water or something, don't drink the water, but that's good advice for all of us anyways.
[Dr Mike Patrick]
Yeah, yeah, yeah. There are all sorts of other reasons not to do that.
[Dr Dave Stukus]
Yeah.
[Dr Mike Patrick]
So, this has been a really fantastic conversation. One other thing that I wanted, before you head out, with the shared decision-making, do you have, since you do it so often, how do you go about facilitating that conversation? I think there's an art to it because in the back of your mind, you may know what you would do for your family, but you also know that alternatives are reasonable.
So, there's going to be times when you're like, no, this is the right thing to do and here's why. But there's other times when it is family dependent and risk-tolerant dependent. And so, how do you just go about having that conversation in an effective way with families?
[Dr Dave Stukus]
Oh, thank you for it. It's taken years of practice. So, there's two sides to this.
So, for our listeners, one is, as the experts, we need to discuss options. Here are the risks, benefits, expected outcomes associated with these three or four options. On the flip side, we need to figure out what each family's or patient's preferences and values are.
What's the most important thing to you? I want to do everything I possibly can to child doesn't have a reaction ever. Well, maybe OIT or oral immunotherapy isn't great for you because they're eating their food and that most kids do have some reaction at some point.
And we talk about that. I want to do everything I possibly can to avoid needles. Okay, Omalizumab is off the table because that's something given by injection.
So, we present the options. We have a conversation. There's a couple of important things.
One is, I want every family to know that they can change their mind at any time. I want them to know that they don't need to decide today. They can decide at any point in the future.
These options are not going away. What fits with you right now may not fit with you in the future. I also want them to know that every family has their own different approach.
So, if they're on social media, if they're hearing from family members, you need to do this, you need to do that. No, no, no. Ignore those voices in your life.
You need to decide what's best for you. What works for one family may not work for another. And then lastly, we have a whole handout that we give families.
I say, I expect you to forget most of this conversation. I'm going to give you this written information. Let's have you, let's revisit this.
Why don't you come back in in four weeks or send me a message through my chart and with whatever questions you have. So, it really is just like a welcoming conversation of here are the options. Let's make sure you understand them.
What's most important to you. You can change your mind at any time. There's zero pressure to get this right.
[Dr Mike Patrick]
Yeah, that's really smart and I'm sure appreciated so much by the families that you serve. Can you tell us before you go a little bit more about the Food Allergy Treatment Center at Nationwide Children's Hospital? What are you folks up to?
[Dr Dave Stukus]
Yeah, we're about to celebrate our fourth year. It's amazing. So, it's a dedicated space.
It's our Lewis Center facility, but it really encompasses all our allergy clinics at main campus and other satellites as well. And it's really a comprehensive approach to diagnosing food allergy and then offering management options. We have oral immunotherapy.
As I mentioned, we do tons of oral food challenges. We offer omalizumab. We have two psychologists on staff because there's a lot of anxiety that goes along with this diagnosis.
We often serve as a second third opinion for a lot of folks that have seen other allergists and maybe either weren't given these options or had panel testing done and things like that. It's as patient centered as it can be. It's great.
We have a dedicated staff, all like-minded, and most importantly, our approach is changing all the time, which is great because the science is changing. So, it's all evidence based, and I tell families routinely, I'm so glad you're here today. The conversation we're about to have, wouldn't have had six months ago.
So, let's talk about that. So, it's great. I love it.
[Dr Mike Patrick]
Yeah. And we're going to have a link in the show notes to the Food Allergy Treatment Center at Nationwide Children's, also to Allergy and Immunology at our hospital as well. Those will be in the show notes for this episode 105 over at pediacastCME.org.
We also have some interesting journal articles for folks to look at. One is the Food Allergy Yardstick, where does omalizumab, did I get it? Yes.
Where does that fit in? Omalizumab. I got to just keep saying this all day.
Another one is on actual guidelines on the diagnosis of IgE-mediated food allergy, and then anaphylaxis, a 2023 practice parameter update. And we'll put links to all of those things in the show notes for folks. So, once again, Dr. David Stukus, allergist and immunologist at Nationwide Children's Hospital and director of our Food Allergy Treatment Center, thank you so much for stopping by and talking with us today.
[Dr Dave Stukus]
Oh, thank you, Dr. Mike. As always, it's a pleasure and thank you seriously for having me on.
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thank you to our guest this week, Dr. Dave Stukus, director of our Food Allergy Treatment Center at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We are in the Apple Podcast App, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Of course, we also have our landing site at pdacastcme.org.
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