At least one thing is certain for anyone practicing pediatric medicine: you have at least one patient (likely several) allergic to something. More than a quarter of all kids in the United States have at least one allergy, including food, environmental and seasonal allergies.
A lot has changed in the field of allergies and immunology in the last decade – one of the biggest changes is the approach to introducing highly allergenic foods to young children. In the Talking Pediatrics episode, “Tis the season: Updates in pediatric allergy diagnosis and treatment,” host Dr. Angela Kade Goepferd talks to board-certified pediatric allergist and immunologist Dr. Nicole Chase about the latest clinical information for allergies in kids. Dr. Chase specializes in the treatment of kids with environmental allergies, food allergies, asthma, eczema, hives, chronic sinusitis, and other allergic diseases at St. Paul Allergy & Asthma.
Decoding food allergies in kids
Food allergies in anyone – especially kids – can be complex and concerning, often requiring major adjustments to lifestyles and environments just to function. When a child is thought to have a food allergy, they’re often put on a long path of testing, monitoring and treatments to make sure the allergy can be managed and the child is safe. This can also cause stress, guilt, and anxiety in parents and affect the entire family’s quality of life, and as clinicians we’re eager to help.
Previously, the approach to pediatric food allergies from the medical community was to eliminate any access to highly allergenic foods, especially for high-risk kids. But research studies found that is no longer the recommended approach. “I sometimes apologize to families and say, ‘If you’re confused, it’s us. It’s not you,’” said Dr. Chase. “We’ve learned so much in the last 5 to 10 years about food allergies. The current thinking now is that there is perhaps a window of tolerance that exists for [young] children.”
For low-risk kids, instead of waiting to introduce highly allergenic foods until age 1 or 2, the recommendation now is to introduce those foods earlier, when it’s culturally appropriate and age appropriate for the child. Low risk means there’s no history of moderate to severe eczema and they otherwise have no significant family history of food allergy.
Kids with a greater risk of food allergies are more challenging to treat. In general, most kids with moderate to severe eczema, the most common allergic reaction, don’t have food allergies.
Approximately 8% of kids in the United States have a food allergy, according to the Centers for Disease Control and Prevention (CDC). But it’s important to note: some adverse reactions to food are not allergic, and current diagnostic methods can be difficult to access, time consuming and require additional medical personnel, so the true prevalence of food allergies in kids isn’t completely understood.
When (and when not) to test for food allergies
Primary care pediatricians can help a family navigate understanding if their child has a food allergy the same way they would any other disease or injury: through education and building trust. It’s also important to strike a balance between the pros and cons of referring the child to an allergy specialist and ordering extensive lab tests.
“In a primary care setting, I always think about what question is this [allergy] test going to answer for me,” said Dr. Chase. “If a family comes in and says, ‘we’re worried and we think food testing is the answer,’ it’s really important to talk with them and educate them about the known risk factors. If the child doesn’t fit into those, the risk is actually quite low [and tests might be unnecessary].”
That said, Dr. Chase recommends also considering the parents’ need for some peace of mind about their child’s health and safety. “I also tell some people: I just need to know what’s going to help you sleep at night,” said Dr. Chase. “Perhaps doing a single test for a total IgE in a peanut level, maybe with a reflex to a component panel, if it’s positive, I think that that would be reasonable.”
Problems tend to arise when a parent has concerns about their child’s possible allergies and the clinician responds by ordering a big panel of tests with the intention of delivering comprehensive results. However, this approach provides extensive documentation about any degree of allergic sensitization, environmental allergies, eczema, etc. because even minor food or environmental artifact will appear in test results. So, a primary care pediatrician should consider if the degree of parental anxiety they are trying to alleviate might in fact be worsened by extensive tests.
The gold standard in testing for food allergies is the oral food challenge, a procedure where food is eaten under medical supervision to monitor effects and respond in case of an allergic reaction like anaphylaxis.
Options for environmental allergies
While many kids (and adults) suffer from mild seasonal allergies, some kids are just miserable and should see an allergy and immunology specialist. Before making a referral, however, pediatricians can first advise trying over the counter allergy medications that were previously available only by prescription.
Dr. Chase advises an intranasal steroids spray as the mainstay of treatment for allergies. The medication activates the DNA in the cells to decrease inflammation, decrease mucus production, decrease other cytokines that are associated with sneezing, etc. Over the counter antihistamines Fexofenadine, Cetirizine, and Loratadine are readily available and dissolvable. Olopatadine eyedrops are also very effective and now available over the counter. “When people have tried all of those kinds of things, or they either can’t take those medications or they don’t want to take the medications or, sometimes refuse to take the medications, that would be a good indication to think about consulting an allergist,” said Dr. Chase.
Kids with asthmatic symptoms exacerbated by environmental allergens (e.g., cats, seasonal, etc.) might benefit the most from allergen immunotherapy, or allergy shots. “[Allergy shots are] like an investment approach where you put a lot in up front, but the data suggests that people when placed on immunotherapy properly for the right allergens can have 15, 20, 25 years of benefit,” said Dr. Chase. “I think that’s especially true in patients with asthma where I routinely take kids either lower on their asthma medications, daily controller medications, or even off of them when we put them on allergy shots.”
New medications are coming soon
Dr. Chase is encouraged by the many new biologic medications recently available or coming soon to treat a broad range of conditions, from eczema and asthma to eosinophilic esophagitis. There is realistic hope these medications could change the trajectory of the allergic reactions and progression to other conditions in kids.
“We’ve learned about immune pathways in terms of allergic disease and we’re finding medications that were previously applicable for other disease states, whether in rheumatology or gastroenterology or whatnot, actually have applicability in the allergy space as well,” said Dr. Chase. “We’ve had some children on [the new] therapy, even off label. It’s unbelievable the amount of progress they make fairly quickly.”
Listen to the podcast or read the transcript of the full conversation here.
Alexandra Rothstein