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Melanie Cole:  There's, no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. This is Kid's Healthcast by Weill Cornell Medicine. I'm Melanie Cole. I invite you to listen in as we discuss food allergies and anaphylaxis.

Joining me is Dr. Chandrika Sridharamurthy. She's an instructor in Pediatrics at Weill Cornell Medicine and an Assistant Attending Pediatrician at New York Presbyterian Weill Cornell Medical Center. Doctor, it's such a pleasure to have you join us today. I love this topic. Do we know what causes allergies or an allergic reaction as trying to keep our kids cleaner, safer by doing that, are we not really strengthening their immune system like we used to? I know this is possibly a theory, but do we know what actually is causing these allergies?

Dr. Chandrika Sridharamurthy: Yes, that's a great question. It's a common topic of discussion in the pediatric clinics. So, in general, an allergy happens when your immune system overreacts to a harmless allergen, such as a food protein, as you mentioned. And, since the job of the body's immune system is to identify and destroy germs like bacteria, viruses, that make you sick, it can also cause common allergic symptoms if it reacts to an allergen. So for example, food, household and seasonal allergies, they have different triggers and the symptoms can overlap, and the management can be different.

However, they're all caused by an overreaction of the immune system. Now I know that that's a theory that you mentioned, and really, it's the immune system overreacting and, certainly, when we will talk a little bit about, early introduction of certain types of foods that are known to cause allergies, it is really important to, introduce the immune system to those types of allergens early.

So certainly that does play a factor in causing allergies, food allergies are common as you may know, with 5.6 million children, it's estimated under the age of 18 have that. There's also seasonal allergies. So some of the common triggers are, you know, pollen, for example, and that's known as hay fever, seasonal allergic rhinitis. And so that's happens in the spring, summer and fall. Plants can release tiny pollen grains, and it can come from trees, weeds, and grasses. So these are sort of the different types of triggers that cause allergies, and there are many different causes.

Melanie Cole: What are the most common food allergens, doctor, among children nationwide that you see and are certain children more at risk for these kinds of allergies?

Dr. Chandrika Sridharamurthy: Yeah, that's a great question. So, you know, there are, eight most common food allergens that are known, milk, egg, peanut, tree nuts, soy, wheat, fish, and shellfish. And, the most severe reactions typically occur, to peanuts, tree nuts, fish and shellfish, which are all allergies that can last a lifetime. Children often outgrow allergies to milk and eggs, followed by soy and wheat as well. In terms of children who are more at risk for severe allergies, according to the Academy of Allergy, Asthma and Immunology, infants with a sibling or at least one biological parent who has allergic conditions, which are, as I mentioned, allergic rhinitis, asthma, food allergies, they can be at risk for developing food allergies, especially if they already have allergic symptoms. There's something called the Atopic March. And that refers to the development of eczema in infancy and food allergy, followed by allergic rhinitis and asthma. So these conditions can actually co-exist. And as one condition improves another can evolve. So as a general pediatrician, when I see a child who has eczema, I certainly want to make sure that I monitor this patient closely for the development of allergies and asthma and more importantly, if the child has severe eczema, despite appropriate medical management, I may refer to an allergist for further testing.

Melanie Cole: Well, as a parent, when we've got our little ones and they're just starting new foods, you know, it's such an exciting time getting them to try new foods, but it's scary, right? We hear about these allergies. So we're told when they're little babies to avoid peanuts and eggs. Is this still the case? We've heard about studies in Europe where they're saying, introduce some of these things a little bit earlier. Are we supposed to be doing that? Tell us a little bit about how parents should introduce new foods and if this is still the case that we stay away from some of these things,

Dr. Chandrika Sridharamurthy: That's a really great question. And as you can imagine, a very common question, in the office. So, you're right. guidelines have changed in recent years, based on new studies and evidence. So we are now recommending that allergenic foods, such as those that we mentioned egg, dairy peanuts, tree, nuts, fish, shellfish, that they, that they be gradually introduced during that same four to six month window that you know, that we introduce other foods. So for example, you know, fruits and vegetables, Studies have shown that in fact, delaying the introduction of these foods may potentially increase your baby's risk of developing food allergy. So, the short answer is yes, introduce these foods early, whenever it's developmentally appropriate to do so in your child and have that discussion with the pediatrician. The same rules apply for introducing vegetables and fruits, as well as, peanuts and egg, you know, introduce one food early and then wait a couple of days in order to see what sort of reactions, they may produce, but definitely introducing them early, is the guidance now.

Melanie Cole: Well, what's the reactions that they may produce? What are we looking for? I remember, I gave my daughter cherry tomatoes when she was probably two or three and around her mouth got pretty red and started stinging a little and we weren't sure what kind of allergic reaction that really was. Tell us what parents are supposed to look for. And we're really afraid of anaphylaxis. We've heard about this kind of allergic reaction as being terrifying, so tie all that together for us.

Dr. Chandrika Sridharamurthy: Yeah, absolutely. So, you know, food allergy symptoms are commonly seen in babies, as you mentioned, because we're introducing, the foods early and so on first exposure, we tend to see sometimes symptoms. There is some sort of reaction. But they can appear at any age, you know, when a new food is ingested. So in terms of symptoms, an allergic reaction, it can trigger symptoms in many different parts of your body. You mentioned the mouth, so certainly the face can be involved. there can be skin rashes or hives.

Sometimes you can have sneezing, coughing, runny nose, itchy eyes, some of the more severe reactions, you mentioned that anaphylaxis, difficulty breathing, stomach upset. You can also have nausea, vomiting, diarrhea, swelling of the mouth or face. So these are all more severe reactions. And it's important to note that if the symptoms are occurring, minutes after ingestion to a particular food, then you really do have to suspect food allergy, but sometimes, symptoms can occur hours later or days later. And those are likely not to be related to the food.

So timing of the symptoms is very important as well. You mentioned, in babies, it's challenging because they can't express symptoms to us. So we really have to be looking for these objective sort of symptoms, that I had mentioned. It's good to remember, that, also consistency is important. So for example, if you see the same reaction to a particular exposure, more than once, then that should key you into a potential allergen. And as you mentioned in the most serious of cases, something called anaphylaxis, which is a life-threatening reaction can occur. So anaphylaxis, you know, is it's a severe, potentially life-threatening allergic reaction. And that one often begins within minutes to an hour or two after a person is exposed to an allergen. And the most common reactions are to, foods, as we mentioned. It can also be to like insect stings, certain medications. Even latex can cause an anaphylactic reaction, in some people.

So, the most common symptoms, that you may see, especially in children are, on the skin. So itchy skin, flushing, hives, swelling of the deeper layers of the skin like around the face, lips, tongue, hands, feet, that can happen around in 80 to 90% of children. But that doesn't mean that an allergic reaction has to involve the skin. So when we're thinking about anaphylaxis, severe symptoms, should definitely be managed immediately.

So when I say severe symptoms, I mean, if it's affecting your lungs, so that includes shortness of breath, wheezing, cough, et cetera. The heart can be affected. So, if the child looks pale, blue, has a weak pulse or has dizziness, you know, the throat can be affected so that classic, feeling of the tightness in the throat, or the horse throat, trouble, swallowing trouble speaking. And the mouth can also be affected. So we mentioned, smelling of the tongues and lips and widespread hives, so the skin can be affected. And then of course the gut can also be affected. So repetitive vomiting, diarrhea. Those are severe symptoms and any one of those should be considered anaphylaxis and treated as such, immediately. Now, with anaphylaxis, you can also have mild symptoms. So if you have mild symptoms in more than one part the body, so for example, if your nose is affected itchy, runny nose, sneezing, the mouth can be itchy. The skin can have just a few hives or mild itch, the gut can be affected. So you can have some mild nausea and discomfort. If you have mild symptoms, you know, from more than one body part, then that should be treated as anaphylaxis as well.

Melanie Cole: Wow. You know, this is an exciting time for parents with food and introduction. But as I said before, it can be a little bit scary. Now, if children do develop allergies and as they're growing, we know they are allergic to certain foods or to seasonal allergies whatever it is, tell us some treatment options that today are available, whether they're home and lifestyle things parents can do, and then some of the things that you might recommend that kids carry around with them, or, you know, tell us a little bit about treatment options.

Dr. Chandrika Sridharamurthy: So, there are many different treatment options, as you mentioned. Based on the severity of, a child's reactions and the specific allergens, you know, so some of the common over the counter medications for allergies, you mentioned, seasonal allergies and things like that are, anti-histamine, so common names like Zyrtec, Claritin, Allegra, Benadryl.

There are also nasal spray forms of anti-histamine, so they can relieve sneezing and itching and the nose and eyes reduce runny nose and nasal stuffiness. And there's also nasal steroids. Corticosteroids like Flonase for example, is a common one. It's a type of nasal spray, and that helps reduce inflammation in the nose and can reduce like nasal congestion.

In terms of outdoor allergens and like lifestyle changes that can be made to reduce those outdoor allergens like pollen, you can keep your windows closed during pollen season that prevents it from coming into the house, bathing and shampooing your hair daily before going to bed, especially if the child is outside and then comes back in, that can help remove pollen from the hair and the skin and keep it off bedding. Washing sheets and bedding in hot soapy water once a week and changing and washing clothes after outdoor activities, those are some of the types of interventions that can be done to help reduce some of those, outdoor allergies.

Melanie Cole: What about at the schools doctor? How can the pediatrician help to bridge that gap with parents? If a child does have a severe allergy to wheat or tree nuts, whatever it is. How can you help them to work with the schools, whether it's in the lunch room, even school staff and bus drivers, knowing how to use an EPI pen, tell us how you help to bridge that gap?

Dr. Chandrika Sridharamurthy: Yeah, absolutely. And that's, a really important, discussion point, with children and families, who have severe allergies. I'd really like to stress that it's very important for anyone taking care of children with known severe food allergies to have training, regarding Epi pen use. o we talked about anaphylaxis. That is a severe life-threatening allergic reaction. So knowing how to administer epinephrin, is very important and, you know, in schools, food staff, bus drivers, transportation staff, everyone is part of that allergy management team because when we're taking care of children, it's important to know, to be trained in epi pen use.

So, that's definitely encouraged. And, you can work with your pediatrician to make sure that you have an anaphylaxis action plan which basically we'll go through the symptoms and signs of anaphylaxis. And when to use that epi pen, that's very important.

And we discussed some of the symptoms earlier, the severe and mild symptoms treatment should not be delayed if those symptoms are present because, that an certainly be a scary time and life-threatening, and here in New York, where I work, there are, guidelines that have been developed by the department of health, in conjunction with schools and pediatricians and allergists regarding the treatment of children with life-threatening allergies so that the schools have, a good guideline to follow in terms of how to treat these children.

Melanie Cole: This is such a great topic doctor, and as we wrap up, tell us some of the exciting game changers or exciting research that you know about. We've heard about desensitization, and maybe you could just give the listeners a brief overview of what that is, and then please offer your best advice for kids and allergies and anaphylaxis and what you want parents to know so that, you know, they're not as worried about their kids when they're starting to feed the little ones, newer foods kind of wrap it all up.

Dr. Chandrika Sridharamurthy: So you mentioned desensitization and, there was definitely a lot of exciting research happening in that field. So the idea behind desensitization is also known as like allergen immunotherapy is to basically weaken the body's response to the substance that's causing the allergen. So you want the immune system essentially to get used to, or become desensitized to that allergen. And, you may have heard of allergy shots for environmental allergies. This is the same sort of thought process behind that. It's important to note that when it comes to oral immunotherapy or food allergy desentivitation, that it's not a curative therapy, and, it's certainly exciting new research and sort of still ongoing, but it's still important to carry, that epinephrin, read labels closely and keep doing the things that are recommended by the pediatricians and the allergists. And there's a lot of exciting new research. So you mentioned, that desensitization therapy, there's also, research happening in, the field of, biologics, which are, interesting medications that can help, with asthma and eczema.

So hopefully all of this new research, you know, the hope is that it'll benefit many children and improve the quality of life for kids. So overall I would say in terms of allergies and anaphylaxis, I would say, have that discussion with your pediatrician and, if you have an allergist and have a discussion with the allergist about, offering new food. The new guidelines are definitely offer new foods, as early as possible and when it's developmentally ap propriate. Offer one new food, wait, two to three days and, see how the child responds. And that includes these highly allergenic foods, because the earlier it's introduced, we're seeing that actually has an important impact on future development of allergies. And with anaphylaxis, I would say, knowing the signs and symptoms, as we mentioned of anaphylaxis is very important and making sure that, the child, the parent, you know, the schools have access, to epinephrin and that the child is carrying. epinephrin with them wherever they go, whether it's camp, school, work, et cetera, that's very important, to know.

Melanie Cole: Doctor, thank you so much. This is really vital information for parents to hear. Thank you for joining us and Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

Thank you so much to our listeners. And that concludes today's episode of Kids HealthCast. Please remember to subscribe, rate and review this podcast and all the other Weill Cornell Medicine podcasts. For more health tips and updates like this, please follow us on your social channels. I'm Melanie Cole.