Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, I'm joined by Dr. Aarti Pandya, Medical Director of the Food Allergy Center at Children's Mercy Kansas City. Today, we're exploring food allergy testing and diagnosis. Dr. Pandya, thank you for joining us today.

Dr. Aarti Pandya: Thank you so much for having me on your podcast.

Host: It's wonderful to have you. Now, when a family says, "I think it's a food allergy," what history or details can help you quickly distinguish from a true allergy versus an intolerance or a sensitivity or some unrelated symptoms?

Dr. Aarti Pandya: Absolutely. Food allergies are a challenging, often both diagnosis as well as problem that ails our community as well as our patients that we see. And they are typically seeking answers for, "Do I truly have something where this can be life-threatening and this can cause severe harm to me?"

So, it's generally what a family is coming in with mindset-wise. And so, to kind of accompany that with the proper history that distinguishes between a true food allergy, as you mentioned, versus an intolerance or sensitivity, there's a good set of questions we can ask.

Just one quick thing here. On true food allergies, this is typically mediated or driven by the immune system, whereas intolerances or sensitivities to foods will typically be driven independent of the immune system. So, that's an important mindset thing for us as clinicians to remember as we are asking questions about this particular topic.

Symptoms in particular can include hives, swelling, vomiting, diarrhea, trouble breathing, flushing, wheezing, presyncope, feeling lightheaded, loss of consciousness. In addition to having these symptoms, the timeline is crucial to making a correct diagnosis for food allergy.

What I mean by that is a food allergy reaction, truly one that's mediated by the immune system, is going to come on within two hours of ingestion of the food. And honestly, in most cases, within one hour of ingestion of the food. There are some rare exceptions to that. But when we talk about the majority of IgE-mediated food allergy or immune-mediated food allergy, that rule applies.

Host: That's wonderful to know about the timeline. What are some of the biggest testing mistakes that you're seeing in primary care, and how can pediatricians avoid over-testing, especially if an infant has never tried that food before?

Dr. Aarti Pandya: The biggest pitfall I definitely see with regards to food allergy testing is the performance of food panels when there is not a strong clinical history to suggest food allergy. So, what I mean by that is there are many conditions that individuals can present with where because they don't have a good treatment, let's say, or a good management plan, they are seeking, well, what internally is causing that? They come with that mentality to you. So, this can mean somebody who has atopic dermatitis or eczema that's not resolving, or somebody who's getting hives frequently. The assumption often on the family's end is, "Well, it has to be something I'm ingesting, otherwise why am I getting these types of skin rashes?"

And so, food panels are performed. So, what is a food panel? A food panel is a broad panel that tests for many different foods that don't accompany the clinical history. What I mean by that is with regards to a food allergy diagnosis, you're going to have a reaction to that culprit food every time you eat it.

And let's say you're taking milk as an example. So, you'll ingest milk, you'll develop a reaction. So in that particular individual, milk testing would be relevant. But if they're eating and tolerating peanut, or if they haven't put peanut in the diet, or if they haven't put shellfish in the diet, it's harmful to perform food allergy testing to foods that are not the culprit food.

These lead to five specific harms that I would encourage us to remember. The first is physical harm, where we actually develop loss of tolerance to a food. We were previously ingesting a food, but we started avoiding it because of a food panel testing, and that results in development of an IgE-mediated food allergy. Along with that part of physical harm, you can also develop a nutritional deficiency.

The second part is psychological harm. So individuals with true food allergies experience high levels of bullying, anxiety, and poor health-related quality of life.

The third is financial cost. So, we have increased costs of allergen-free foods and then increased healthcare costs too, which can result in more testing from the allergist's end to truly determine whether the individual has a food allergy or not. The fourth harm is going to be opportunity cost, which means delayed introduction of highly allergenic foods. So now, we miss a window of preventing food allergy because we don't put the food in the diet. Or second, you can eliminate less allergenic versions of the food for not a clinical reason. And so, that gets eliminated from the diet.

And then, lastly is healthcare disparities. So, there are high rates of false positive allergy testing among minorities. And so, that can lead to lower access to specialist care, et cetera. So, the food panel testing that I mentioned here, this can result in what we call false positives, where a test is positive, but the individual can tolerate a food. It's a flaw of the testing. And so, when we unnecessarily overly test for foods, we are resulting potentially in these five major harms.

Host: Thank you for taking us across the five major harms. That's really important information to know. So as a pediatrician, if I'm considering testing, what is your Test Wisely approach that you would recommend?

Dr. Aarti Pandya: I think one thing to keep in mind is we welcome, of course, pediatricians to perform testing. But if there's ever any uncertainty, the first thing in Test Wisely is to consider referral to a specialist as that referral can result in specialized testing that we perform and limit costs that come with over testing, and it narrows it down to exactly what needs to be tested.

So, that's the first thing. But if testing is performed on the pediatrician's end, then narrowing it down to just the culprit foods would be the best approach. In terms of interpretation of that testing, that can be very tricky and very difficult. I would strongly suggest, having a specialist that you can have a conversation with because there are so many different levels that occur in foods. Like, you can have a milk IgE level of 2 that one would inherently think accompanies a food allergy, and it could with the right history. But in the context of a different history, it may not. And it may be something on the specialist's end that we don't recommend avoidance for or we don't even deem as a food allergy. So, the best approach would be have a specialist that you can have those conversations with.

Host: When should a pediatrician refer to allergy and immunology? And what information would make that referral the most effective and efficient for your team?

Dr. Aarti Pandya: So, a pediatrician should always feel encouraged to refer to allergy and immunology if there is concern for food allergy. If there's even that concern for a food allergy, I think that is a great time to refer. If there's also conditions where there are symptoms like chronic hives or uncontrolled atopic dermatitis or eczema where someone is requesting food allergy testing, that's also an appropriate time for referral.

The thing that streamlines the referral and makes it very efficient is just knowing the reaction history for the food. And that's never expected necessarily on the specialist end because it takes so much time to dig into the exact reaction history for every single food that the individual is concerned about. But it can be helpful to know that.

Host: After diagnosis, what's the pediatrician's ongoing role? What do you want primary care to reinforce with families at follow-ups about safety, label reading and, most importantly, emergency readiness?

Dr. Aarti Pandya: The primary role I would say is communication if there is something that happens in the interim that doesn't get relayed to the allergist. For instance, there is an accidental exposure that results in a reaction. That is something that we would love communicated with us. And that is kind of what would aid our management for the patient in terms of the next steps.

In terms of reinforcement at follow-ups with regards to safety, label reading, emergency readiness, generally when someone has a true food allergy, IgE-mediated food allergy in particular, the emergency readiness means having an anaphylaxis action plan as well as an accompanying epinephrine device. So, that can mean an auto-injector or a nasal spray epinephrine device. Label reading, we typically want to avoid labels that say "contain" in terms of the culprit food. And then, in terms of the last thing with regards to safety, just informing individuals about the food allergy diagnosis. For instance, if you're out at a restaurant and eating, make it very clear that, "Hey, I have this food allergy." And so, there is a risk of cross-contamination that the restaurant or other area would need to know about. Those I would say are the most important.

Host: Wonderful. How do you explain the current options and how should families consider those current options?

Dr. Aarti Pandya: Firstly, there has been a surgence in terms of the options that are available for food allergy treatment. It's a very exciting time, to be honest with you, to be offering treatments for food allergy patients. In the past, we were limited for just avoidance. And now, there's so many things that are available, which makes it a very exciting time for food allergy.

I will tell you the conversations we have on our end and maybe what's easiest on the pediatrician's end to discuss. On our end as the specialist, we do talk about avoidance as a treatment option. There are immunotherapy options that are available, whether that be oral immunotherapy or sublingual immunotherapy. There are ongoing clinical trials across the country for other modalities of immunotherapy. And lastly, there is an injectable medication called omalizumab that targets IgE proteins that can also be used in treatment for food allergy. So, that is the whole gamut of what we offer on the specialist end.

There are nuances with regards to risks and benefits of each of those treatment modalities. So, we have a very, very detailed risk-benefit conversation when we're in the clinic as a specialist discussing these with patients. From the pediatrician's end, to simplify that, you can say that there are lots of new treatment options that have emerged for food allergy, and you would encourage discussing with a specialist to ensure that they know the full gamut of what is available out there In terms of how pediatricians should counsel families about early introduction and continued exposure, that is a great question. And I would say that is maybe the primary role that pediatricians can really play in to help both prevent food allergy and keep tolerance of ongoing foods in the diet.

So firstly, with regards to early introduction, generally the timeline of food introduction, which we say between four and six months of age, is when we start introducing allergenic foods. One thing as the specialist that we recommend is when introducing allergenic foods, try not to introduce multiple allergenic foods in one setting. The reason being is because if there is a reaction, it is a lot of work on the family's end, and there's a lot of fear on the family's end of backtracking to figure out what is the culprit food for the food allergy. So, what we generally say is one new allergenic food in the diet every couple of days. Continue doing it for a few days. Make sure there's no reactions prior to moving on to the next one.

And the other part about that is also counseling that in general practice out there is that food panels are not needed prior to introduction of foods for the vast majority of patients. Even testing is not needed for the vast majority of patients. And also, the majority of individuals do not carry things like epinephrine devices when introducing foods. So, those questions do come up even on our end too, and I know for sure come up on the pediatrician's end.

There's one nuance to consider, which there's a discrepancy between how this is done internationally versus in the US. So, it's one thing to keep in mind because the pediatrician should feel encouraged to counsel on what they feel is best based on the literature. So, one approach for introduction with regards to peanut allergy is following the trial that's called the LEAP trial and what that data showed about early introduction of peanuts.

So, the trial ultimately showed that early introduction of peanut served as a primary prevention of peanut allergy. However, there is two conditions that can result in potentially increased risk of peanut allergy. Those two conditions would be moderate to severe atopic dermatitis or egg allergy. So in those two demographics, there is potentially a role of peanut testing prior to introduction. And so if they meet that, that would be a time for a specialist referral. Beyond that, you would introduce the remainder of allergenic foods as we would recommend introduction of the remainder of foods. However, internationally, there is a discrepancy, like I said, in how peanut introduction is done even in those two conditions.

When I say discrepancy, I mean internationally, in other places around the world, there could be advocacy of just putting peanut in the diet without delaying that introduction even with testing because of that risk of false positives that come with testing. But I would encourage you, if you're leaning on that end, to just review the data yourself and make sure you feel confident on either option. And even on the specialist option, there is a wide variety of what we discuss with regards to peanut introduction in those more severe conditions like moderate to severe atopic dermatitis or egg allergy.

So to distill that down and make it simple, the best practice with early introduction of foods is to introduce at the time that you can introduce the majority of other foods in the diet when there's readiness for solid introduction. You would introduce one allergenic food at a time over a course of a couple of days. Don't put multiple allergenic foods in the diet at once. And with peanut introduction, there's two conditions to keep in mind. The first is egg allergy, and the second is moderate to severe atopic dermatitis. In those two conditions, there could be consideration of specialist referral prior to introduction of peanuts.

Host: Thank you. And my final question for you is the psychological aspect for new parents that are introducing foods to their infants. Anything else they should keep in practice or at top of mind about how to keep themselves regulated when they may not have these emergency readiness tools or medications on hand?

Dr. Aarti Pandya: That is something that I deeply both sympathize with as an allergist-immunologist and as a specialist in food allergy, and I empathize with as a parent. So, I certainly feel that from the parental end as well.

So, what I can say in general about that is there should be vigilance when you introduce foods. You know, we want to ensure that, especially with allergenic foods, we are watching our kiddos in terms of that timeline of when an IgE-mediated food allergy can occur, one to two hours after introduction of foods. Maybe don't consider introducing foods right before bedtime, as that's a vulnerable time for kids. They're going to go to sleep right after potentially, so we don't want a reaction in the middle of the night. So, potentially moving it up earlier in the day could be a great tool to bring peace of mind to parents.

And the third thing is food allergy in general is a rarer diagnosis. About 8% to 10% of the population has it. So while it is, of course, very scary to experience a food allergy reaction, the vast majority of the population does not have food allergy. It's even more rare to have more severe reactions in terms of food allergies. The majority of food allergy systemic reactions, whole body reactions, are on the milder end.

Many anaphylaxis self-resolves. So, that doesn't mean that we take it lightly. Of course, we want to keep vigilance. We want to be very mindful and conscientious when we're introducing allergenic foods in the child's diet. However, if there's anything concerning that comes up when you're introducing allergenic foods, just know that having access to something like an urgent care or emergency department facility is kind of the best way to go, and knowing that there are many specialists out there that are more than happy, willing, and ready to help treat your child's condition if you do end up with a food allergy.

Host: Thank you so much, Doctor, for anchoring us on food allergy testing and diagnosis, and your recommendations have been both clear and direct, which we love.

Dr. Aarti Pandya: Excellent. I really appreciate being on here and talking to you about one of my favorite topics, which is food allergy.

Host: Wonderful. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.