June 24, 2022
There is not a pediatric clinician among us who doesn’t have a patient with allergies, including food allergies, environmental allergies and/or seasonal allergies. On this episode, we talk with Dr. Nicole Chase, pediatric allergist and immunologist, about all things allergy including: current recommendations for food introduction, oral food challenges, pitfalls in “allergy testing” in primary care and what’s new and on the horizon for treatment of allergies with immunotherapy.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. There is not a pediatrician or a pediatric clinician out there who has not dealt with allergy concerns and kids. Whether it’s trying to sort through the severity and recommendations for a child with food allergies or trying to counsel a family about avoiding environmental triggers for allergy symptoms, keeping up to date on what’s new in pediatric allergy is beneficial for all of us.
Here to talk to us today about all things allergy is Dr. Nicole Chase. Dr. Chase is a fellowship-trained and board-certified pediatric allergy/immunology specialist who practices at St. Paul Allergy & Asthma. Dr. Chase has received numerous honors and awards throughout her career and specializes in the treatment of kids with environmental allergies, food allergies, asthma, eczema, hives, chronic sinusitis and other allergic diseases.
She is always eager to educate fellow clinicians on what’s new in pediatric allergy, and we are thrilled to have her on the podcast today. Nicole, welcome. I have heard you speak about pediatric allergy so many times. And one of the things I always really like about hearing you speak is how practical and relatable you are. Whenever I find people who really love what they do, I’m always curious about why. What got you into pediatric allergy?
Dr. Nicole Chase: I have to say that in all transparency, I didn’t fall in love with pediatric allergy, I fell in love with pediatric immunology. I remember I was a medical student in Milwaukee, and it was my second year, and I was sitting in the middle of a lecture that was being given by a heme-onc clinician who did bone marrow transplant.
And he was explaining this whole concept of how you could literally wipe out someone’s immune system if it was just misbehaving and give them a brand new one and literally cure them. I just was fascinated by this idea that, when you thought about it, you could have a cardiologist saying, “Oh, it’s the heart that really is the most important in a developing child” or, “Oh, no, it was the kidneys.”
But there are treatments for all of those things, but the immune system, it’s really the most fundamental part of the human body. I liked the idea of knowing that there was a specialty where you could work in collaboration with so many other specialties and still be able to help them, educate them in some way, even though they were their own experts in their field.
Dr. Angela Kade Goepferd: Yeah.
Dr. Nicole Chase: So I like all the disease mechanisms and pathophysiology behind bad disease. And I think that’s kind of where my focus has gone over time is to the immunology of allergic disease. I would call myself an allergist immunologist for that reason.
Dr. Angela Kade Goepferd: So speaking about wiping out kids’ immune systems and helping really improve people’s lives, let’s shift to just talking about food allergies. There is probably not many things that are more dramatic than a child who suffers from multiple food allergies and the ways that they have to adjust their life just to function based on that.
When I was trained about food allergies and kids 20 years ago, we were really restricting access to highly allergenic foods or whatever the case was. And that has really largely shifted. Can you tell us what should we be telling our patients and families in this moment in time with what we know about food allergies and kids?
Dr. Nicole Chase: Yeah. Food allergies are really just such a hot topic for so many reasons. And I feel like there’s a lot of guilt associated with food allergies as well. Not only from the point of view of parents, but also from providers.
For the longest time, we told everyone wait to introduce highly allergenic foods until age one or age two, and then there were studies that really proved that whole theory wrong in that what we’ve learned now is, the early introduction of highly allergenic foods, especially in children who are of high risk, it’s actually thought to be extraordinarily beneficial.
And so I apologize to families sometimes to say, “If you’re confused, it’s us. It’s not you.” We’ve really just learned so much in the last five or 10 years even about food allergies. The current thinking is that there is perhaps what I would call a window of tolerance that exists for children.
And the way we approach that now is, if you have a child that we would consider to be “Low risk,” quote, unquote, which is there’s no history of moderate to severe eczema, they otherwise have never had any type of significant family history of food allergy, highest is really a sibling, but even that is debatable depending on the food and has had no potential symptoms of reactions to foods.
The current guidelines are when it’s culturally appropriate for the child to go ahead and introduce solid foods, really just in age appropriate forms without regard.
I think that it gets a little bit harder when you see some of those kids that fit into those higher risk categories. And the most common one we see is eczema. So we counsel families that kids with moderate to severe eczema, the majority of them don’t have food allergies, but 20 to 30 percent will have at least positive testing, let’s say.
And so I think that this is where the leap study guidelines that came out in what, 2018 or so in the New England Journal of Medicine where these really are getting applied now where we actually evaluate high risk kids before we introduce some of these foods, just to see if they are developing sensitization and more or less to try and prevent these reactions that occur.
Dr. Angela Kade Goepferd: Speaking of the leap study in kids who are at higher risk, one of the things that I often get asked is about testing kids for food allergies. Whether there’s a family history of a food allergy or a parent is just highly anxious, they’ll sometimes come in and say, I want my child quote, unquote, “tested” for food allergies. Now, I’ve been practicing long enough to know that my answers should not be, “Sure, let’s go ahead and do that.” But could you talk a little bit about the pros and cons of doing any kind of food allergy testing for kids?
Dr. Nicole Chase: As a parent, I get it, right? We all are just trying our best to keep our kids safe. That really is everyone’s goal. When parents come in asking for testing for food allergies, you and I are in a different spot, right? When they ask me, I usually have gotten a referral from someone that there’s some kind of thought process behind it. Oh, the child’s maybe had some rash where they’ve eaten this food or the sibling has an allergy, or there’s a concern because of the eczema or whatnot. But I think in a primary care setting, I always think about what question is this test going to answer for me. And I think that if a family comes in and they say, “We’re worried, we think food testing is the answer.”
I think it’s really important to go back and say, “What are we worrying about?” So if the worry is that there’s a second degree relative who has a peanut allergy, I think that it’s really important to talk with the families and educate them about, “Here are the known risk factors. And if your child doesn’t fit into those, your risk is actually quite, quite low.”
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: Now having said that, I also tell people at some point, “I just need to know what’s going to help you sleep at night.” If the parent says, “There’s a relative that has a peanut allergy, I’m just so, so nervous.”And it really is impairing their introduction of the food, peanut in this example, then what I would say is perhaps doing a single test for maybe 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.
I think where we get into trouble is sometimes parents will say, “I’m worried about foods” and then clinicians will say, “Oh, okay. Well, let me allay that fear for you by ordering this big panel of food tests.” And what happens is it’s well documented that in kids who have any degree of allergic sensitization, environmental allergies, eczema, which drives their IgE levels up, you’re going to see artifact throughout any tests that you do, whether it be environmentals or foods.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: So the most common scenario I get is a referral from someone saying, “Oh, I don’t know. My ENT sent these labs because you have sinus congestion and they included these food panels. And now it says I’m allergic to milk. But gosh, I drank milk in my cereal this morning before they called me with the lab test result, where that’s an easy one to sort out. But at the same time, the degree of parental anxiety that we’re trying to prevent, we sometimes induce more of that with the testing.
Dr. Angela Kade Goepferd: Right. That makes a lot of sense. And I think at least in my practice in primary care, we’ve really tried to get away from doing much in the way of allergy testing or food testing and, correct me if I’m wrong, but the sort of mantra that I’ve been sharing with patients is if you’re eating it and you’re not reacting to it, then you’re not allergic to it.
Dr. Nicole Chase: Absolutely. That’s literally the best test there is. I mean, we have the option for specific IgE testing, so blood testing is used to be called RAST testing back in the day. We do percutaneous or allergy skin testing. But realistically we do all of those because we can do a lot of tests at once. We can assay search and molecular components in specific foods. But really if we were going to do this properly, we would just food challenge, every single patient who came in, it’s just not practical.
Dr. Angela Kade Goepferd: You mentioned oral food challenges. And I know that’s something that we’re doing a lot more of, especially because we have all these kids who, back when we were restricting their foods, they got labeled with food allergies. And so we’re trying to remove that from kids as much as possible. Who is a good candidate for oral allergy testing and who is not?
Dr. Nicole Chase: I have learned over time. And I, and I freely tell this to patients, that I think that at some point in time, every patient deserves the right to fail a food challenge. When we think about who is a good candidate for one, it’s usually the patient where either they have a clinical history of reacting to the food that either was distant or is dis-congruous with their current testing results. So let’s say they had a perioral rash when they ate egg for the first time as a baby, but their most recent egg skin testing was two or three or four millimeters of reactivity, pretty minimal. In that case, really the question we want to ask is this child allergic or not allergic? And we are having two dis-congruous results. So in that situation, going to the food challenge makes sense.
Dr. Angela Kade Goepferd: Okay.
Dr. Nicole Chase: I’ve had families where I can think of one child where the parent said to me, I know this child is not allergic to peanut. I’ve never fed it, but I just know it, like I know my own name.
Dr. Angela Kade Goepferd: Yeah.
Dr. Nicole Chase: And the child’s skin testing was above the threshold for which published parameters indicate that 95% of kids would’ve failed a food challenge. And that the patient was, I think he was 12 or so.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: And more or less I said to the mom, I think that this is reasonable. I’m going to tell you that my prediction is that this is going to fail. But at the same time, I don’t know what your sixth sense is about it. But at the same time, let’s give it a shot. And this child passed their peanut challenge.
Dr. Angela Kade Goepferd: Wow.
Dr. Nicole Chase: And I still can to this day, not explain it, but I think that there are lots of things in medicine like that, where the tests give us as close as we can get to the real answer. But sometimes you just need to actually eat the food to see if you’re allergic to the food. You know, if you’re doing food challenges and every single one of your patients passes, you’re probably not doing enough food challenges.
Dr. Angela Kade Goepferd: Yeah.
Dr. Nicole Chase: Because realistically, we should be using this in that kind of gray area where we are just not sure we can make a guess, but we’re not always going to be right.
Dr. Angela Kade Goepferd: So that mom who had that sixth sense probably was already giving her child Snickers. And so she told you, I know this kid is not allergic to peanuts. I’m being facetious, but so…
Dr. Nicole Chase: I don’t think so. Because I thought the same thing and the kid was like, no, I don’t want to eat it.
Dr. Angela Kade Goepferd: Okay.
Dr. Nicole Chase: And the mom said, “There’s no way.” This is the other part about just doing this for a while is you really start to learn that I try and make like a little bet in my mind.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: With every patient that I see, right. It’s like my positive predictive value. I try and think how certain of the test result being X, Y or Z am I because really it’s the statistics that you need to then interpret your results, but I’ve definitely been wrong. I mean, I think that allergies in general are really, really tough. And I think it’s one of these fields where the more you can have a trusting relationship with your patients and with your parents.
I think that in the end sometimes you’re right, sometimes you’re wrong, but it’s very, very validating to parents to just know whether the kid is allergic or isn’t allergic. Sometimes failing a challenge is the happiest day because then they just see what would actually happen if the child were to be exposed to the food accidentally. Some of the best challenges I’ve done have been a challenge where our whole goal was to open up the jar of peanut butter in the room and then have the child put some on their hand. And then we put some on their cheek and then put some on their lip. Now at that point, the child started to have a little bit of rash, little bit of redness on the lip. So we wiped everything off. We had washed in between. And then we decided to just watch and not give any medication because we were in the office and the family was in tears because they had been convinced elsewhere that even being near the open jar of peanut butter would pose a significant threat to life.
So I really do think that there’s a lot of, I don’t want to say bias, but there’s a lot of baggage that people come into the office with in terms of food allergies. And I really think that it’s our job to confront those head on.
Dr. Angela Kade Goepferd: Yeah. And I think some of that fear we’ve placed in them in the medical field because we’re really trying to get it through to families how serious a reaction could be. And you know, we’re really driving a lot of worries and families.
Dr. Nicole Chase: We are. I a hundred percent agree with you. And I think that we’ve really done a disservice to our patients by making this such a condition that people are so fearful about because in reality, these patients are trained and carry around an antidote with them all the time, which is epinephrine.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: I really truly believe that if food allergies a condition for which the treatment was never an injection, I don’t think people would have the same degree of fear about it. I think parents are almost universally terrified of the idea of having to give their child a shot, having to harm them in order to help them.
At our recent meeting, there were several companies that had posters, two of which were describing nasal spray varieties of epinephrine administration and delivery. And then one sublingual film epinephrine. And to me, there’s a lot going on with food allergy, oral immunotherapy, sublingual immunotherapy, all these things. I think that I’d rather wait for something that’s an actual cure. But to me, if you can tell a teenager, “Yeah, you can go out and you can be with your friends, just make sure you have your epi nose spray. And if you need it, you just take it. No big deal.” That’s so, so, so much less stressful.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: And also just really more of an empowering feel to the patients and to the parents versus them having to be worried about giving their life saving treatment. That’s kind of the crux of the issue to me.
Dr. Angela Kade Goepferd: No, and I think there’s been a lot of media dramatization of giving epi shots and it’s not been helpful for parents of kids who have food allergies, people who have food allergies in general.
I want to go back to the food challenges. What’s the best setting for those to be done in? Is that something that’s done in your office? I know we do sometimes those in our short stay unit here at Children’s. And how do you decide where to challenge a kid?
Dr. Nicole Chase: There is variability between providers and comfort level. We opt to do challenges in our office. We have a dedicated food allergy nurse who is in the room with the patient and the parent or parents. The entire time is monitoring vitals, is evaluating the skin, evaluating for any type of symptoms, is administering medications as needed. I do think that the field has more or less been trying to shift to more of this, even for other food related conditions like FPIES. Food Protein Induced Entercolitis, historically that was a disease state where we would only challenge kids with an IV in, in the hospital. And I feel like there are even now people pushing to say, “Hey, we have treatment options for this. Maybe this is something we could even start to do in the office.” I think some providers don’t have the capabilities or don’t have the comfort level.
And I think that doing that in a kind of a short stay unit or an observation unit at the hospital is appropriate, if you have it. I think that a huge problem is is that a lot of people don’t live near major metropolitan areas.
Dr. Angela Kade Goepferd: Sure.
Dr. Nicole Chase: And so if really their only obstacle to figuring out whether they have a food allergy or not is getting a food challenge, I think that it will become more and more necessary for those of us who are practicing a little bit outside of the main urban areas to offer these to patients.
Dr. Angela Kade Goepferd: Can’t talk to you about allergies without talking to you about environmental allergies. And I know that there are kids who suffer from mild allergies and we give them some Claritin or we suggest some Flonase and they do okay. But then there are those kids who are just miserable, and no matter what we throw with them are just having a hard time functioning. They can’t breathe, they have trouble sleeping. How can you help us with those kids? And how do we know which kids we should escalate to your level of care?
Dr. Nicole Chase: There are so many people suffering this time of the year. It’s always terrible to watch. I think that one interesting change in the field of allergy over the last couple years is that the majority of medications that we used to prescribe are now available over the counter. An intranasal steroids spray is the mainstay of treatment for allergies. It really is going to activate the DNA in the cells to decrease inflammation, decrease mucus production, decrease other cytokines that are associated with sneezing, et cetera. The over the counter antihistamines Fexofenadine, Cetirizine, Loratadine, and all of these are readily available and dissolvable. Liquid forms are easy to take for children and even eyedrops, olopatadine eyedrops used to be prescription and are just unbelievable and are now over the counter. So I feel like when people have tried all of those kind of things, or they either can’t take those medications or they don’t want to take the medications or, and sometimes refuse to take the medications, that would always be a good indication to think about consulting an allergist.
The other area where I think it’s really, really important is if kids have any degree of asthmatic symptoms, that seem to be exacerbated by allergens, whether that’s going over to the neighbor’s house where there’s a cat or the flare every time in August or when the state fair rolls around when people are extra wheezy. I think that in those patients, there’s really good data to support that actually treating the allergies is really helpful for intervening, not only in the kind of nasal ocular response, but also in the lungs and in the asthma. And that’s usually in the form of allergen immunotherapy, or allergy shots.
Dr. Angela Kade Goepferd: And for people who are not as familiar with allergen immunotherapy, can you just describe what a treatment course would look like for that? So we can maybe prepare patients for that.
Dr. Nicole Chase: I always tell people that, to be very honest, it’s a pain to do. It’s a lot of work. And in the beginning, really you are thinking about visits to your allergist clinic once or twice a week, probably for the first four to six months to just start from a very low dose diluted version of the allergens you’re allergic to in a solution and then escalate by concentration and volume until you reach a maintenance dose. At which point, then typically patients will come into the allergist’s office every two to four weeks. So once or twice a month.
Oftentimes we try and allow patients to titrate based on symptom control. So maybe they’ll come in every four weeks in the winter or every two weeks during the spring, if they’re miserable, but really the shots start to function as a medication for them. And the goal really is that by three to five years of that maintenance therapy, once or twice a month, patients really can begin to tell that they have been able to notice fewer symptoms, that they have been able to decrease or even stop some of the medications they previously were dependent on.
And then also they really can tell that there’s no kind of sensation of needing to go in for their next allergy shot. Even if they go a little bit longer than their four week interval. I tell people it’s a little bit 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. And 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.
Dr. Angela Kade Goepferd: So we’ve talked about a few interesting sort of newer things today. One was different forms of epinephrine that are now coming onto the market. We just spent a little bit of time talking about immunotherapy. What else is new in the world of pediatric allergy that you think pediatric clinicians would want to know about?
Dr. Nicole Chase: One thing I would love to just point out about allergy is that we don’t have an organ system. We don’t have a tissue, so we just kind of play everywhere. There are lots and lots of new biologic medications that are coming out. Some for eczema, some for asthma, some for eosinophilic esophagitis, and really we are trained in the care of patients with all of these conditions. So one that I would point out that is expected to have an FDA approval date of early June is a medication called dupilumab or Dupixent. This is currently approved for children and adults who either have severe eczema or severe eosinophilic asthma, six years of age and up. They are requesting FDA approval for children’s six months of age and up with severe eczema.
Dr. Angela Kade Goepferd: Okay.
Dr. Nicole Chase: Which we think this might be a real game changer for those children who just have miserable rash. And we’re very curious to see how this might change their whole trajectory in terms of the atopic march, where we think about kids having eczema. And then some of them may have food allergy progressing onto allergic rhinitis to asthma. And even to eosinophilic esophagitis. We are very curious to see if intervening in those very young children with eczema, if that actually can not only fix the eczema, but change their whole life trajectory.
Dr. Angela Kade Goepferd: That would be pretty remarkable. I know you’ve seen them and I’ve seen them. These kids that are just miserable with the amount of atopy that they have and the way that their bodies just are overreacting to everything. To be able to make a difference in those kids’ lives would be amazing.
Dr. Nicole Chase: Yes we’ve had some children that have been on this therapy, even off label. It’s unbelievable the amount of progress that they make fairly quickly. Now that we’ve learned about these immune pathways in terms of allergic disease, what we’re finding is that lots of medications that were previously applicable for other disease states, whether in rheumatology or gastroenterology or whatnot, that a lot of these medications actually have applicability in the allergy space as well. And so I think that we’re all really looking forward to learning more about small molecules and things like this going forward. And especially in terms of, can we intervene in children before they even start to develop any of these secondary features?
Dr. Angela Kade Goepferd: Well, Nicole, thank you so much for joining me today. I really appreciate it. I think one thing I’ve really taken away from today and hearing you speak in the past is there’s never really a wrong time to refer to a pediatric allergist. So thanks for coming and talking to us about some of the newer things and just some of the mainstays of good treatment when it comes to pediatric allergy and immunology.
Dr. Nicole Chase: Thanks for having me. I always like to tell people that I think allergists in general, we’re a really nice bunch and we never mind a quick phone call. So definitely reach out if we can be helpful for you.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.