Feed Peanut Butter to a Baby With Eczema?
What’s new in managing children with food allergies? Pretty much everything. Brian Schroer, MD, explains.
In the past, when a child was at high risk for developing food allergies, parents were typically given their marching orders for lowering the odds. These have included avoidance of allergenic foods such as, nuts and peanuts for up to three years, and even included suggestions for mothers to avoid these during pregnancy and breastfeeding.
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This advice and other accepted wisdom is being turned on its head by recent studies, as the allergy and immunology field scrambles to unlock the mystery of of why food allergies are still on a steep rise ― and respond with more than band-aids.
Brian Schroer, MD, of Cleveland Clinic Children’s Pediatric Allergy and Immunology Department, worked with Jaclyn Bjelac, MD and Mandy Leonard, PharmD, to summarize the latest research for the allergy and immunology community, pediatricians and general practitioners. In his paper, published in Current Opinion in Pediatrics, he paints the landscape of today’s best recommendations for diagnosis, avoidance and treatment of patients with food allergies and updates us on the state of immunotherapy.
By CDC estimates, food allergies affect eight percent of the children in the U.S. today. This is up over 50 percent from 1997. What’s going on? Theories can be confounding. One hypothesis points the finger at increasingly sanitized living conditions, and low incidence of many of diseases that used to plague the very young.
“Few babies die of meningitis due to E. coli or Listeria anymore,” Dr. Schroer explains. “The absence of such pathogens to fight may divert the immune system toward attacking innocent proteins instead. This idea, known as the hygiene hypothesis, may be one of several reasons food allergies are on the rise.”
A startling reversal in prevention advice has come on the heels of several studies, in particular the LEAP (Learning Early About Peanut) trial in 2015. It turns out that exposing high risk babies to peanut-containing foods ― versus avoiding peanuts ― significantly lowers the risk for a peanut allergy to develop. In babies who are deemed high-risk because of eczema or a previously diagnosed egg allergy, the National Institute of Allergy and Infectious Disease (NIAID) now recommends introduction of peanut between four and 11 months of age, following evaluation by their doctor.
Dr. Schroer also points to evidence that parents and doctors should not avoid giving certain foods based on a child’s eczema alone. “Eczema likely causes food allergies; food allergies don’t cause eczema.” In other words, avoiding certain foods in the hope that eczema will resolve is not very effective in many cases.
In addition, the article cites a study by Angela Chang, MD, et al., which shows evidence that avoiding feeding a baby certain foods to improve eczema may in fact put the baby at risk for developing allergies to those foods.
Are we testing too many patients and overtesting individual patients? New research steers physicians away from the practice of routinely testing siblings of food allergic children and children of parents with some type of atopic disease. Studies show that siblings are not much more likely to have food allergies than the general public. “There’s no reason to put a baby through a panel of skin prick tests (SPT) based on a sibling’s allergic disease.” In addition, using a full test panel that includes foods people are rarely allergic to is often not warranted.
The new NIAID recommendations are to test any child who has another known food allergy already or moderate to severe eczema requiring topical prescription-strength steroid creams.
Further, new evidence shows just how poor a predictor of allergic reactions allergy testing can be. Someone with a positive SPT or even a high IgE (sIgE) result may have no allergic reaction when eating the food. High IgE antibodies don’t necessarily correlate with a clinical reaction to oral intake of the food. Eczema alone can influence these blood test results.
These tests are good at ruling out food allergies with low false negative rates. But for children with positive SPTs but no known clinical reaction to the allergen, Dr. Schroer advocates food challenges in a controlled medical setting. “Too often, a doctor may draw conclusions from high blood or skin test results and say, ‘Why don’t you just avoid that food.’ But that’s a huge decision. We must realize there is a lot of fear that comes with thinking you may have a severe, potentially fatal reaction. That’s something you are going to think about at every meal, every single day of your life.”
Avoidance of known food allergies remains the gold standard and epinephrine pens the steady companion to anyone with food allergies. However, Dr. Schroer advises parents to balance the risks with the psychological aspects of growing up with food allergies. Sitting at a separate “peanut-free table” at school or avoiding play dates are not absolutely necessary for many children with food allergies, and the psychosocial risks are high. Therefore, studies suggest that physicians should ask their patients with food allergies about fear, stress and bullying.
Also among the new findings is that oral steroids are not an effective management tool for treating anaphylaxis or less serious reactions. Studies suggest that while one dose may be used, it is often over-prescribed and prescribed for too long following anaphylaxis. These studies may change protocol at the ED and beyond.
Using immunotherapy to “cure” the food allergy has been teetering on the cusp of clinical reality for nearly two decades. Why aren’t we seeing this widely used now?
With immunotherapy, patients are given small, but increasingly larger doses of the allergen in a medical setting and then eat that same quantity at home throughout the week. The build-up is repeated with greater quantities until most patients are able to be desensitized to the food. This means they can eat it regularly but need to eat the food every day to maintain protection.
While often effective in desensitizing patients, the problems with immunotherapy are numerous. Reactions at home can be unpredictable and adherence to eating certain daily doses to retain immunity is problematic for some.
“Immunotherapy is the best near-term hope for a ‘cure,’ but we have yet to establish protocols that researchers can broadly recommend to practitioners and their patients,” Dr. Schroer explains. “We just don’t know the full long-term benefits and risk.” These can range from anaphylaxis to the therapy, to chronic nausea and stomach pain to development of eosinophilic esophagitis, which causes trouble swallowing any food and can be progressive.
Food allergies can take a relentless toll on those afflicted, and their families. A child who feels particularly vulnerable, fearful, singled out as the focus of concern and special treatment is a candidate for lifelong anxiety and low self-confidence.
Physicians need to recognize that along with the diagnostic and educational components, they should teach families to recognize how the condition affects the allergic children in their day-to-day lives ― at school and at home. If it creates problems, Dr. Schroer suggests “the family should be referred to specialty counseling with someone who both understands food allergies and knows how to deal with those age groups.”
As serious as anaphylaxis is, Dr. Schroer, who has a son with a food allergy, guards against overblowing the dangers. “In some cases, the physician may go too far when it isn’t necessary for a patient to be that fearful. The toll on mental health can be severe and lifelong. Kids may need coaching to feel confident safely going out into the world and eating food.”