What topic would you like discussed? Text us!
Anaphylaxis is a a severe allergic reaction. How allergists manage anaphylaxis and how they advise their patients to manage anaphylaxis can mean the difference between life or death. That medical decision-making needs to be shared and have a foundation of evidence.
In this episode of the podcast, Dr. Alice Hoyt discusses the newest updates to the Anaphylaxis Practice Parameters, which were published in late 2023. You'll learn the data on:
- When and how to best administer epinephrine
- When you should go to the ER
- The likelihood of a severe allergic reaction occurring in babies after their first ingestion of an allergen
- When it may be safe to stay home
Don't miss this episode, and bookmark it - you'll want to come back to this one!
Looking for one-on-one time with a food allergist to finally get your food allergy questions answered? Sign up for Food Allergy Office Hours for Parents.
Are you a pediatric clinician and you want to stay up-to-date on food allergy information that's relevant to your practice? Join the Food Allergy Pediatric Hub.
Are you in need of an allergist in your area?
AAAAI Allergist Finder
ACAAI Allergist Finder
OIT Allergist Finder
Would like to become a patient? Reach out to the Institute!
Does your kiddo's school need help with medical emergency response planning? Check out the non-profit Code Ana.
This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:10):
Hello and welcome to the Food Allergy and your Kiddo
podcast.
I am your host, dr Alice Hoyt,very excited to be joined today
by one of my colleagues andfriends, dr Dave Stukas.
Dr Stukas, welcome back to thepodcast, sir.
Speaker 2 (00:26):
Well, hi, dr Hoyt, it's a pleasure to be here.
I'm excited.
Speaker 1 (00:29):
Well, good, I'm glad you're excited because there has
been understatement a lot ofexciting things going on in the
world of food allergy.
As you well know, and for thoseof you who are new to the kiddo
show, dr Stukas has been on ourpodcast before and he actually
(00:51):
hosts the podcast for theAmerican Academy of Allergy,
asthma and Immunology, anamazing organization of which I
am a fellow, as is Dr Stukas,and Dr Stukas is here today to
talk about the 2023 anaphylaxispractice parameters, um, which
is awesome.
So, dave, before we really likedive into what's in these
(01:15):
practice parameters, can youplease tell our listeners and
our viewers for those watchingus, um, on the video what is a
practice parameter?
Speaker 2 (01:24):
Yeah, how long do we have A practice parameter?
They're technically notguidelines, but essentially
they're clinical guidelines andwhat they do is they go through
for specific conditions and doan exhaustive search of the
literature so all of the peerreviewed literature surrounding
a topic, and then they they lookat the both for and against
(01:45):
certain questions or certaindisease states and they
formulate recommendations aboutbest ways to approach the
diagnosis and or management ofvarious conditions.
Typically there's a work groupof experts international experts
that go through all of theliterature and write everything
up and it goes back to the jointtask force on practice
parameters, which I used to be amember of for five years, and
(02:06):
we actually kind of editeverything together and make it
so that it flows nicely forclinicians to kind of follow.
So it is evidence-based,exhaustive, comprehensive and
current.
Speaker 1 (02:17):
I love it.
I love it.
Evidence-based I love it.
Yeah, when you look throughthese things, there's hundreds
of references.
It's amazing.
Speaker 2 (02:24):
Oh my gosh.
Yeah, I think 600.
You said joint.
Speaker 1 (02:27):
You said 600.
That's pretty outstanding Jointtask force.
Tell our listeners a little bitmore about that.
Speaker 2 (02:34):
Well, there's two professional organizations for
allergists, immunologists, inthe United States of America.
We have the American Academyand American College of Allergy,
asthma and Immunology.
So each organization appointssix members to the joint task
force and then they are eligibleto serve two separate five-year
terms.
So I served a five-year term.
(02:54):
Due to a lot of things excitingthings in my own personal
professional life, I opted todefer my second term towards
later in my career perhaps, butit was a wonderful experience
and there's great individualsthat really dedicate and
volunteer their time to putthese guidelines together, these
parameters, I should say.
Speaker 1 (03:09):
Well, thank you as a fellow allergist and as a food
allergy wife and mom, thank youfor spending your time doing
that, because I know thesethings take a lot of time to
really do them right, and I knowthat you guys definitely do
them right.
So we talked a little bit aboutwhat practice parameters are.
(03:31):
Why was there, why did thispractice parameter come about?
The anaphylaxis for 2023?
.
Speaker 2 (03:38):
Yeah, it had been several years since there was a
comprehensive document foranaphylaxis.
There was an updated one in2020 that really focused on
biphasic anaphylaxis, whichwould be an anaphylactic
reaction that resolves with orwithout treatment and then
symptoms come back again,sometimes hours later, and that
specific document really walkedthrough who's at risk to
(03:59):
experience that and what kind ofmedications would prevent that,
and so on and so forth.
So it was time just to providea much longer, more
comprehensive document thatreally went through some of the
newer evidence.
Speaker 1 (04:10):
And these parameters are super valuable to allergists
, of course, and to otherclinicians as well, but for our
audience.
Why do you think these are soimportant?
For our audience, the foodallergy moms, dads, family
members, to really know aboutthese parameters.
Speaker 2 (04:27):
Well, again, it goes back to their evidence-based.
There's so much outdated,incorrect information
surrounding food allergy,anaphylaxis, a lot of it
actually addressed in theseparameters and I think you know,
a lot of times we kind of saythe same things over and over
again just because it's whatwe've been taught or what we
once thought to be true.
But a lot of it's changed forthe better.
Um, these are.
I find these to be veryreassuring actually, Uh, but
(04:50):
it's interesting, cause there'sa bit of a paradigm shift when
it comes to anaphylaxis, aswe'll talk about.
So, uh, things don't have toseem maybe as dire as we were
once taught a few years ago inregards to this.
Now, of course, we want torespect it, as we'll talk about
and discuss, but it doesn't haveto be as scary as maybe
everybody's led to believe.
Not that long ago.
Speaker 1 (05:26):
Really.
What are your sort of biggestthree takeaways for food allergy
?
Speaker 2 (05:30):
families regarding these new updated parameters.
Yeah, three is tough, but yeah,I'll try my best.
Speaker 1 (05:34):
Okay, you don't have to limit it to three Cause.
Speaker 2 (05:36):
I think I can't, I think I can't so it so for those
watching, listening, theparameters cover a lot of ground
in regards to the updates thediagnosis of anaphylaxis,
anaphylaxis in infants and youngchildren, management of
anaphylaxis.
It also dives into diagnostictesting as well as mast cell
disorders and perioperativeanaphylaxis, so I think we can
(05:57):
probably skip a lot of that.
The top three for me one is isrevolves around anaphylaxis and
infants.
Uh, and that parameters reallyaddress that.
Uh, severe life-threateningreactions in infants upon,
especially upon first exposureto a food allergen are extremely
rare.
Speaker 1 (06:16):
Can you say it again?
Speaker 2 (06:19):
Yeah, so, uh, severe, life-threatening anaphylactic
reactions are very rare ininfants, especially the first
time they eat a food allergen.
So for all those parents thatdrive to the parking lot of the
emergency department before theyfeed their baby peanut butter
for the first time, the evidencewould suggest that it's
extremely unlikely, extremelyunlikely that your baby's going
to have a severe reaction thefirst time they eat.
(06:40):
That Anaphylaxis can occur, buttypically it's going to be more
.
They get some hives and maybethey vomit once and then they
feel better.
That's anaphylaxis.
So any combination of more thanone part of the body involved
in allergic reaction.
But for most people it'sself-resolved and relatively
mild.
We don't get patients asallergists because you know they
end up in the ICU the firsttime they eat a food.
We get patients because theyget a rash, we get some hives or
(07:02):
they get upset you know anupset stomach.
So that's what the evidenceshows and that's one of the big
take homes for me from these newparameters.
Speaker 1 (07:09):
I love that and you know, sometimes data comes out
and we're like huh really.
But that, no, that clinically,is really what we see, I would
say.
So I don't think that wasparticularly shocking.
What say you?
Speaker 2 (07:28):
No, I agree.
That echoes everything I'veseen, and you know I've talked
about this for over a decade.
When I educate pediatriciansabout how this is the typical
presentation for food allergy ininfants is they get some hives
and maybe they vomit.
It's misconceptions that theirairways are so small that
they're prone to swelling shut.
We simply don't see that,thankfully, which is very good.
(07:49):
There are misconceptions thatbabies can't tell us how they
feel, so there's some smolderingissues inside their body.
That's not the case at all.
If you're having an acuteallergic reaction, you should
look at a baby and be able tosee that they're uncomfortable,
they're not feeling well and yousee the symptoms of that
allergic reaction occurringbefore your eyes.
So there's no sort of thing aslike a hidden food allergy that
occurs or anything like that.
Speaker 1 (08:10):
I think that's just so valuable.
That's so valuable.
I think it's very valuable thatthis was not surprising to us,
that this is consistent with,clinically, what we see.
I think it's valuable to haveall of this written out and
really just the the referencesthere, the support there, the
evidence there that that this iswhat we see, that this is how
(08:31):
it goes to bring thatreassurance to families.
I think that is just so, soimportant.
So I I love that that was yourfirst thing.
That's awesome.
Speaker 2 (08:42):
Yeah, and of course there are families that do
witness you know they watchtheir baby have more severe
reactions.
So it certainly can occur.
I think the message is that itis much less likely than people
have been led to believe,especially in you know the.
The real the reality of thesituation is if we take, you
know, 95% of all babies, itdoesn't matter how you feed them
or when they feed.
When you feed them, they'renever going to develop a food
(09:04):
allergy, no matter what you doso.
if we're telling a hundredpercent of parents that you have
to drive to the emergency roombefore you feed your baby peanut
butter, that's a overlycautious approach.
That's a huge disservice tothese families.
Speaker 1 (09:15):
What would be your second, dave?
Speaker 2 (09:18):
Ooh, it's a combination and I love this so
much because I know I'm cheating.
But what it does is it kind ofwraps in our understanding of
individualized approach towardsfood allergy management and risk
.
And we now know that there aremilder forms of food allergy.
We also know that it's veryunusual for somebody to have any
reaction to trace amounts oryou know, especially severe
(09:40):
reactions to trace amounts.
Can it happen?
Yes, but for the vast majorityof people they have a higher
threshold than that.
So in the anaphylaxis practiceparameters it really addresses a
couple of key things.
So one not everybody needs tohave two epinephrine
autoinjectors prescribed.
For a lot of folks it's quitereasonable just to have one of
those devices because they'revery costly.
Most people go a whole yearwithout ever using them and they
(10:01):
just throw them away, and for alot of folks out there they're
just not at risk to have ananaphylactic reaction.
Another aspect along thoserealms is not everybody actually
needs to have epinephrineprescribed.
Now this gets very nuanced veryquickly, but you and I both
know there are children outthere that have a very mild egg
allergy.
So they've eaten scrambled eggssix times.
(10:21):
Every time they have mild,self-resolved hives, we do the
testing.
Yes, they're allergic.
They're eating baked egg allday and they're absolutely fine,
and they're very likely goingto outgrow this the next couple
of years.
And then the last part of thistrifecta within my number two.
It deals with some of thosefood allergy and anaphylaxis
plans that state if somebody atean allergen but don't have they
don't have symptoms that youshould give them epinephrine
(10:43):
immediately.
And that is just completelyfalse.
Uh, I don't know where thiscame from.
It was a highly conservativeapproach.
Uh, I get it.
It's better safe than sorry.
But here's the deal.
So, one, how do you know ifsomebody actually ate with their
allergy to?
Number two, how do you know ifsomebody actually ate what
they're allergic to?
Number two how do you know thatthey ate enough to trigger a
reaction?
Number three if you give themepinephrine which treats
anaphylaxis, it doesn't preventit.
If you give epinephrine beforethe allergic reaction actually
(11:05):
occurs, it might be out of theirsystem before they actually
need to use the medication.
And then, lastly, the mediantime of onset for anaphylaxis
from food is almost like 30minutes.
So if somebody ate somethingand you're not quite sure if
they're going to have a reaction, you have time to take a deep
breath and monitor and, you know, be in a safe zone to see
what's going to happen beforeyou even think about treating
(11:26):
them with epinephrine.
Speaker 1 (11:28):
Wow, that was a lot for your number two but I love
it.
I love it and it's all.
It's all.
It's all tied in together.
I completely agree with you,and those are all very big but
very important points that,again, would not be in this
parameter if they didn't havethe data to back them up and
didn't have the board-certifiedallergist reviewing the data
(11:53):
that backs this up, and I thinkthat you know you said it about,
you know it gets nuanced, andthat just highlights the
importance of having a boardcertified allergist who does
stay up to date on the latestallergy information so that you
and your child can have anevidence-based plan that not
(12:13):
just keeps him or her safe butalso improves your quality of
life.
If you've been told for adecade now that even smelling
peanut could potentially killyour child, that is not
evidence-based, that is not goodfor your mental health, and so
here it's just so lovely notjust to have the parameters but
to have you sort of likefleshing things out like this,
(12:37):
and I think that that all makesjust so much sense.
Speaker 2 (12:41):
For a lot of folks this is completely foreign.
I mean, these are foreignconcepts and they it's off
putting at first.
It can make people highlyemotional, actually, and say you
know how dare you suggest thatmy child's not at risk of having
a severe life threateningreaction if they are near their
allergen or take a small bite ofit?
But that's the reality of itand I think that we do families
a disservice if we don't havethat conversation with them and
(13:04):
help them understand thatBecause, as you mentioned,
that's what impacts their dailylife.
Speaker 1 (13:08):
No, that's absolutely right.
That's absolutely right.
I will say that I have noticedthat on at least the fair form,
the whole like give epi if itwasn't, if it may have been
eaten but no symptoms.
That's gone now, so that's niceand they've sort of retooled
that.
So another reason not to justsee your allergist once a year,
(13:35):
but whenever new things come out.
Just see your allergist once ayear, but whenever new things
come out, it's totallyreasonable to schedule a
follow-up with your allergistspecifically to ask very
specific questions about yourkiddo's food allergy.
You know, I think so much getsso much pressure gets put on
that like classic back-to-schoolallergy appointment, that
sometimes you're focused ongetting forms and these things
(13:56):
filled out that you don't get tojust like have a few minutes
where you're talking with yourallergist about some of the
newest data or newest treatmentsor whatever the case may be.
So families should never feel,should ever feel like oh well, I
don't have a good enough reasonto go in to the doctor,
especially now with telehealth.
You know you can.
You can have these telehealthappointments and get some very
(14:17):
good evidence based answers toyour questions.
Cool, dave, ok, you're pullingout some really good stuff from
these practice parameters.
What would you say?
How many points is your third?
It's your third point going tohave, for your third most
important thing for food allergyfamilies from the parameters.
Speaker 2 (14:38):
It's just one, but it's the big one.
So the new parameters containprovisions that if somebody
experiences anaphylaxis at home,they don't have to
automatically go to theemergency room or call 911 after
they use epinephrine.
And this is where you kind ofshocker, so what?
Speaker 1 (14:57):
this, say it again, so say it again.
You kind of shocker.
Speaker 2 (14:59):
So what this?
So you no longer have toautomatically call 911 or seek
emergency medical care If youuse epinephrine to treat
anaphylaxis at home?
And the reason why is because,well, there's a couple of
reasons.
So one the evidence again.
The body of evidence shows thatthe vast majority of people who
promptly receive epinephrine totreat anaphylaxis have complete
(15:20):
resolution of symptoms,typically within 10-15 minutes.
Most people feel better prettyfast.
So if you're at home in a verysafe environment, you have
access to more than oneepinephrine, you have a cell
phone and you can get care ifyou need it, use your
epinephrine and hang out andmonitor If symptoms are getting
better or going away.
You should be fine.
You can call your allergist ortalk to their office about next
(15:43):
steps and things like that.
But a lot of people either werenot using their epinephrine
because they didn't want to goto the emergency room, or they
were misinformed thatepinephrine was dangerous and
that just because you use it,that means you have to go to the
emergency room because of sideeffects and the needle and
things like that.
All of that's incorrect.
And what happens when mostpeople go to the emergency room
after they use their epinephrine?
Well, typically they just sitthere for six hours and they
(16:04):
receive a bunch of treatmentsthat they actually don't need,
such as steroids andantihistamines and Pepsid and
things like that.
Speaker 1 (16:11):
So like Benadryl, Dave, how do you feel?
Speaker 2 (16:13):
Yeah, like Benadryl.
You know how I feel about that.
Speaker 1 (16:19):
Alice.
Speaker 2 (16:19):
I'm sure you've read them.
I read these ER notes of apatient arrived, had
anaphylactic reaction at home tocashew, received epinephrine.
By the time they were evaluatedthey were asymptomatic.
We gave them Benadryl,prednisone for seven days and
Pepcid and had them monitor forfour hours.
Speaker 1 (16:36):
What are?
Speaker 2 (16:36):
we doing?
That's insane.
It's so outdated.
So that's where this comes fromand I think we can start to
have those conversations withfamilies.
I know I have for the lastcouple of years and this started
during the pandemic right.
We were afraid to send peopleto the emergency room.
We don't want to give themCOVID, especially before
vaccines are available.
So we started to actually learnhow to monitor at home and
treat them at home and have thatconversation, and that's what
(16:57):
the evidence supports as well.
Speaker 1 (16:59):
Yeah, no, I mean, I think that is such an important
point.
I will say the caveat ifthey're going to monitor at home
, I do like them to havesomebody there with them, but
otherwise, absolutely, if theyuse their epinephrine promptly
and they're improving and theyhave a second device with them,
(17:22):
um, it all makes a lot of sense.
Now, if they still want to goto the emergency room, you
absolutely can.
You absolutely can, um, buthopefully this will take away
some of those barriers toactually promptly using the
epinephrine Um, because the lastthing we want is not using it
or not using it promptly, andthen a kiddo is getting worse
(17:44):
and then you're putting thekiddo in the back of the car to
drive and then they're throwingup on the way to the ER and it's
just terrible, right, it's justterrible.
So we know that prompt use ofepinephrine is what stops an
allergic or a severe allergicreaction, anaphylaxis.
And you're right, I totallylove that.
The whole like, oh, if theymaybe ate it, no symptoms, then
(18:07):
give them epi.
I love that that is gone,because that has never made
sense.
I don't think to any of theallergists.
Speaker 2 (18:14):
Yeah, the dark secret with anaphylaxis, as you know,
is if you look at all of thestudies over the years, this has
been shown repeatedly 50% ofpeople having anaphylaxis never
receive epinephrine.
And what happens to those 50%of people?
They do fine Fatalities fromanaphylaxis.
They are tragic and they dooccur.
Thankfully, they are not nearlyas common as most people
(18:37):
believe them to be.
So we want to promote usingepinephrine early because it
makes people feel better a lotfaster.
Yeah, you're miserable.
You are so miserable you'rehaving an allergic reaction.
Use it because you feel better.
Speaker 1 (18:47):
Um so, that's absolutely right and that's
another reason.
Benadryl, the okay.
So like kind of before my time,they used to say, oh, we'll
give benadryl, if it doesn't getbetter, then give Epi.
Like that is absolutely wrong,that is not evidence-based,
because then not only are youdelaying use of epinephrine, but
you're giving Benadryl, whichis just an antihistamine.
(19:09):
And, as all my patients know,anaphylaxis is run by a lot more
than just histamine and it'snot the histamine that's going
to cause the fatal issues.
So you really want to get theepinephrine in promptly.
It's going to make the kiddofeel better because you're
really calming down thoseallergy cells so they stop
spewing out all of the stuffthat's causing all the reactions
and they help prevent all thosedifferent symptoms or causing
(19:31):
all the symptoms.
It's going to help stop thesymptoms as well.
As opposed to, an antihistamineis not going to be that
multifaceted at all, it's justgoing to be antihistamine.
Now I think you have pulled outamazing pearls for our patients
or our families listening on the2023 practice parameters and
(19:56):
for y'all listening to thispodcast.
If you haven't listened to thequad a eyes podcast on the
anaphylaxis practice parameters,where dr stukas interviews dr
golden, um, you definitelyshould, because it is a
fantastic listen subs.
It's a fantastic listen andthey do get in the weeds on a
few things and I love thatbecause it's two allergists just
(20:18):
talking about it, kind of likewe're doing today, dave.
So thank you so much for comingon the show and breaking that
down for us.
And where can people find thepractice parameters?
Speaker 2 (20:28):
You can actually just search them online.
So if you just look for allergypractice parameters, they pop
right up.
They're free for everybody.
I believe there's teaching,yeah, oh yeah, I think there's
teaching slide decks for some ofthe latest ones as well for
medical professionals out there.
If you want to actually learnmore, or even, you know, educate
those in your group or in yourcommunity.
So yeah, check it out.
Speaker 1 (20:48):
Awesome, dave, thanks so much for coming on the show.
Speaker 2 (20:52):
It's my pleasure.
Thanks for having me.
Speaker 1 (20:55):
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to
foodallergyandyourkiddoscomwhere you can join our
newsletter.
God bless you and God blessyour family.
Hello and welcome to the Food Allergy and your Kiddo
podcast.
I am your host, dr Alice Hoyt,very excited to be joined today
by one of my colleagues andfriends, dr Dave Stukas.
Dr Stukas, welcome back to thepodcast, sir.
Speaker 2 (00:26):
Well, hi, dr Hoyt, it's a pleasure to be here.
I'm excited.
Speaker 1 (00:29):
Well, good, I'm glad you're excited because there has
been understatement a lot ofexciting things going on in the
world of food allergy.
As you well know, and for thoseof you who are new to the kiddo
show, dr Stukas has been on ourpodcast before and he actually
(00:51):
hosts the podcast for theAmerican Academy of Allergy,
asthma and Immunology, anamazing organization of which I
am a fellow, as is Dr Stukas,and Dr Stukas is here today to
talk about the 2023 anaphylaxispractice parameters, um, which
is awesome.
So, dave, before we really likedive into what's in these
(01:15):
practice parameters, can youplease tell our listeners and
our viewers for those watchingus, um, on the video what is a
practice parameter?
Speaker 2 (01:24):
Yeah, how long do we have A practice parameter?
They're technically notguidelines, but essentially
they're clinical guidelines andwhat they do is they go through
for specific conditions and doan exhaustive search of the
literature so all of the peerreviewed literature surrounding
a topic, and then they they lookat the both for and against
(01:45):
certain questions or certaindisease states and they
formulate recommendations aboutbest ways to approach the
diagnosis and or management ofvarious conditions.
Typically there's a work groupof experts international experts
that go through all of theliterature and write everything
up and it goes back to the jointtask force on practice
parameters, which I used to be amember of for five years, and
(02:06):
we actually kind of editeverything together and make it
so that it flows nicely forclinicians to kind of follow.
So it is evidence-based,exhaustive, comprehensive and
current.
Speaker 1 (02:17):
I love it.
I love it.
Evidence-based I love it.
Yeah, when you look throughthese things, there's hundreds
of references.
It's amazing.
Speaker 2 (02:24):
Oh my gosh.
Yeah, I think 600.
You said joint.
Speaker 1 (02:27):
You said 600.
That's pretty outstanding Jointtask force.
Tell our listeners a little bitmore about that.
Speaker 2 (02:34):
Well, there's two professional organizations for
allergists, immunologists, inthe United States of America.
We have the American Academyand American College of Allergy,
asthma and Immunology.
So each organization appointssix members to the joint task
force and then they are eligibleto serve two separate five-year
terms.
So I served a five-year term.
(02:54):
Due to a lot of things excitingthings in my own personal
professional life, I opted todefer my second term towards
later in my career perhaps, butit was a wonderful experience
and there's great individualsthat really dedicate and
volunteer their time to putthese guidelines together, these
parameters, I should say.
Speaker 1 (03:09):
Well, thank you as a fellow allergist and as a food
allergy wife and mom, thank youfor spending your time doing
that, because I know thesethings take a lot of time to
really do them right, and I knowthat you guys definitely do
them right.
So we talked a little bit aboutwhat practice parameters are.
(03:31):
Why was there, why did thispractice parameter come about?
The anaphylaxis for 2023?
.
Speaker 2 (03:38):
Yeah, it had been several years since there was a
comprehensive document foranaphylaxis.
There was an updated one in2020 that really focused on
biphasic anaphylaxis, whichwould be an anaphylactic
reaction that resolves with orwithout treatment and then
symptoms come back again,sometimes hours later, and that
specific document really walkedthrough who's at risk to
(03:59):
experience that and what kind ofmedications would prevent that,
and so on and so forth.
So it was time just to providea much longer, more
comprehensive document thatreally went through some of the
newer evidence.
Speaker 1 (04:10):
And these parameters are super valuable to allergists
, of course, and to otherclinicians as well, but for our
audience.
Why do you think these are soimportant?
For our audience, the foodallergy moms, dads, family
members, to really know aboutthese parameters.
Speaker 2 (04:27):
Well, again, it goes back to their evidence-based.
There's so much outdated,incorrect information
surrounding food allergy,anaphylaxis, a lot of it
actually addressed in theseparameters and I think you know,
a lot of times we kind of saythe same things over and over
again just because it's whatwe've been taught or what we
once thought to be true.
But a lot of it's changed forthe better.
Um, these are.
I find these to be veryreassuring actually, Uh, but
(04:50):
it's interesting, cause there'sa bit of a paradigm shift when
it comes to anaphylaxis, aswe'll talk about.
So, uh, things don't have toseem maybe as dire as we were
once taught a few years ago inregards to this.
Now, of course, we want torespect it, as we'll talk about
and discuss, but it doesn't haveto be as scary as maybe
everybody's led to believe.
Not that long ago.
Speaker 1 (05:26):
Really.
What are your sort of biggestthree takeaways for food allergy
?
Speaker 2 (05:30):
families regarding these new updated parameters.
Yeah, three is tough, but yeah,I'll try my best.
Speaker 1 (05:34):
Okay, you don't have to limit it to three Cause.
Speaker 2 (05:36):
I think I can't, I think I can't so it so for those
watching, listening, theparameters cover a lot of ground
in regards to the updates thediagnosis of anaphylaxis,
anaphylaxis in infants and youngchildren, management of
anaphylaxis.
It also dives into diagnostictesting as well as mast cell
disorders and perioperativeanaphylaxis, so I think we can
(05:57):
probably skip a lot of that.
The top three for me one is isrevolves around anaphylaxis and
infants.
Uh, and that parameters reallyaddress that.
Uh, severe life-threateningreactions in infants upon,
especially upon first exposureto a food allergen are extremely
rare.
Speaker 1 (06:16):
Can you say it again?
Speaker 2 (06:19):
Yeah, so, uh, severe, life-threatening anaphylactic
reactions are very rare ininfants, especially the first
time they eat a food allergen.
So for all those parents thatdrive to the parking lot of the
emergency department before theyfeed their baby peanut butter
for the first time, the evidencewould suggest that it's
extremely unlikely, extremelyunlikely that your baby's going
to have a severe reaction thefirst time they eat.
(06:40):
That Anaphylaxis can occur, buttypically it's going to be more
.
They get some hives and maybethey vomit once and then they
feel better.
That's anaphylaxis.
So any combination of more thanone part of the body involved
in allergic reaction.
But for most people it'sself-resolved and relatively
mild.
We don't get patients asallergists because you know they
end up in the ICU the firsttime they eat a food.
We get patients because theyget a rash, we get some hives or
(07:02):
they get upset you know anupset stomach.
So that's what the evidenceshows and that's one of the big
take homes for me from these newparameters.
Speaker 1 (07:09):
I love that and you know, sometimes data comes out
and we're like huh really.
But that, no, that clinically,is really what we see, I would
say.
So I don't think that wasparticularly shocking.
What say you?
Speaker 2 (07:28):
No, I agree.
That echoes everything I'veseen, and you know I've talked
about this for over a decade.
When I educate pediatriciansabout how this is the typical
presentation for food allergy ininfants is they get some hives
and maybe they vomit.
It's misconceptions that theirairways are so small that
they're prone to swelling shut.
We simply don't see that,thankfully, which is very good.
(07:49):
There are misconceptions thatbabies can't tell us how they
feel, so there's some smolderingissues inside their body.
That's not the case at all.
If you're having an acuteallergic reaction, you should
look at a baby and be able tosee that they're uncomfortable,
they're not feeling well and yousee the symptoms of that
allergic reaction occurringbefore your eyes.
So there's no sort of thing aslike a hidden food allergy that
occurs or anything like that.
Speaker 1 (08:10):
I think that's just so valuable.
That's so valuable.
I think it's very valuable thatthis was not surprising to us,
that this is consistent with,clinically, what we see.
I think it's valuable to haveall of this written out and
really just the the referencesthere, the support there, the
evidence there that that this iswhat we see, that this is how
(08:31):
it goes to bring thatreassurance to families.
I think that is just so, soimportant.
So I I love that that was yourfirst thing.
That's awesome.
Speaker 2 (08:42):
Yeah, and of course there are families that do
witness you know they watchtheir baby have more severe
reactions.
So it certainly can occur.
I think the message is that itis much less likely than people
have been led to believe,especially in you know the.
The real the reality of thesituation is if we take, you
know, 95% of all babies, itdoesn't matter how you feed them
or when they feed.
When you feed them, they'renever going to develop a food
(09:04):
allergy, no matter what you doso.
if we're telling a hundredpercent of parents that you have
to drive to the emergency roombefore you feed your baby peanut
butter, that's a overlycautious approach.
That's a huge disservice tothese families.
Speaker 1 (09:15):
What would be your second, dave?
Speaker 2 (09:18):
Ooh, it's a combination and I love this so
much because I know I'm cheating.
But what it does is it kind ofwraps in our understanding of
individualized approach towardsfood allergy management and risk
.
And we now know that there aremilder forms of food allergy.
We also know that it's veryunusual for somebody to have any
reaction to trace amounts oryou know, especially severe
(09:40):
reactions to trace amounts.
Can it happen?
Yes, but for the vast majorityof people they have a higher
threshold than that.
So in the anaphylaxis practiceparameters it really addresses a
couple of key things.
So one not everybody needs tohave two epinephrine
autoinjectors prescribed.
For a lot of folks it's quitereasonable just to have one of
those devices because they'revery costly.
Most people go a whole yearwithout ever using them and they
(10:01):
just throw them away, and for alot of folks out there they're
just not at risk to have ananaphylactic reaction.
Another aspect along thoserealms is not everybody actually
needs to have epinephrineprescribed.
Now this gets very nuanced veryquickly, but you and I both
know there are children outthere that have a very mild egg
allergy.
So they've eaten scrambled eggssix times.
(10:21):
Every time they have mild,self-resolved hives, we do the
testing.
Yes, they're allergic.
They're eating baked egg allday and they're absolutely fine,
and they're very likely goingto outgrow this the next couple
of years.
And then the last part of thistrifecta within my number two.
It deals with some of thosefood allergy and anaphylaxis
plans that state if somebody atean allergen but don't have they
don't have symptoms that youshould give them epinephrine
(10:43):
immediately.
And that is just completelyfalse.
Uh, I don't know where thiscame from.
It was a highly conservativeapproach.
Uh, I get it.
It's better safe than sorry.
But here's the deal.
So, one, how do you know ifsomebody actually ate with their
allergy to?
Number two, how do you know ifsomebody actually ate what
they're allergic to?
Number two how do you know thatthey ate enough to trigger a
reaction?
Number three if you give themepinephrine which treats
anaphylaxis, it doesn't preventit.
If you give epinephrine beforethe allergic reaction actually
(11:05):
occurs, it might be out of theirsystem before they actually
need to use the medication.
And then, lastly, the mediantime of onset for anaphylaxis
from food is almost like 30minutes.
So if somebody ate somethingand you're not quite sure if
they're going to have a reaction, you have time to take a deep
breath and monitor and, you know, be in a safe zone to see
what's going to happen beforeyou even think about treating
(11:26):
them with epinephrine.
Speaker 1 (11:28):
Wow, that was a lot for your number two but I love
it.
I love it and it's all.
It's all.
It's all tied in together.
I completely agree with you,and those are all very big but
very important points that,again, would not be in this
parameter if they didn't havethe data to back them up and
didn't have the board-certifiedallergist reviewing the data
(11:53):
that backs this up, and I thinkthat you know you said it about,
you know it gets nuanced, andthat just highlights the
importance of having a boardcertified allergist who does
stay up to date on the latestallergy information so that you
and your child can have anevidence-based plan that not
(12:13):
just keeps him or her safe butalso improves your quality of
life.
If you've been told for adecade now that even smelling
peanut could potentially killyour child, that is not
evidence-based, that is not goodfor your mental health, and so
here it's just so lovely notjust to have the parameters but
to have you sort of likefleshing things out like this,
(12:37):
and I think that that all makesjust so much sense.
Speaker 2 (12:41):
For a lot of folks this is completely foreign.
I mean, these are foreignconcepts and they it's off
putting at first.
It can make people highlyemotional, actually, and say you
know how dare you suggest thatmy child's not at risk of having
a severe life threateningreaction if they are near their
allergen or take a small bite ofit?
But that's the reality of itand I think that we do families
a disservice if we don't havethat conversation with them and
(13:04):
help them understand thatBecause, as you mentioned,
that's what impacts their dailylife.
Speaker 1 (13:08):
No, that's absolutely right.
That's absolutely right.
I will say that I have noticedthat on at least the fair form,
the whole like give epi if itwasn't, if it may have been
eaten but no symptoms.
That's gone now, so that's niceand they've sort of retooled
that.
So another reason not to justsee your allergist once a year,
(13:35):
but whenever new things come out.
Just see your allergist once ayear, but whenever new things
come out, it's totallyreasonable to schedule a
follow-up with your allergistspecifically to ask very
specific questions about yourkiddo's food allergy.
You know, I think so much getsso much pressure gets put on
that like classic back-to-schoolallergy appointment, that
sometimes you're focused ongetting forms and these things
(13:56):
filled out that you don't get tojust like have a few minutes
where you're talking with yourallergist about some of the
newest data or newest treatmentsor whatever the case may be.
So families should never feel,should ever feel like oh well, I
don't have a good enough reasonto go in to the doctor,
especially now with telehealth.
You know you can.
You can have these telehealthappointments and get some very
(14:17):
good evidence based answers toyour questions.
Cool, dave, ok, you're pullingout some really good stuff from
these practice parameters.
What would you say?
How many points is your third?
It's your third point going tohave, for your third most
important thing for food allergyfamilies from the parameters.
Speaker 2 (14:38):
It's just one, but it's the big one.
So the new parameters containprovisions that if somebody
experiences anaphylaxis at home,they don't have to
automatically go to theemergency room or call 911 after
they use epinephrine.
And this is where you kind ofshocker, so what?
Speaker 1 (14:57):
this, say it again, so say it again.
You kind of shocker.
Speaker 2 (14:59):
So what this?
So you no longer have toautomatically call 911 or seek
emergency medical care If youuse epinephrine to treat
anaphylaxis at home?
And the reason why is because,well, there's a couple of
reasons.
So one the evidence again.
The body of evidence shows thatthe vast majority of people who
promptly receive epinephrine totreat anaphylaxis have complete
(15:20):
resolution of symptoms,typically within 10-15 minutes.
Most people feel better prettyfast.
So if you're at home in a verysafe environment, you have
access to more than oneepinephrine, you have a cell
phone and you can get care ifyou need it, use your
epinephrine and hang out andmonitor If symptoms are getting
better or going away.
You should be fine.
You can call your allergist ortalk to their office about next
(15:43):
steps and things like that.
But a lot of people either werenot using their epinephrine
because they didn't want to goto the emergency room, or they
were misinformed thatepinephrine was dangerous and
that just because you use it,that means you have to go to the
emergency room because of sideeffects and the needle and
things like that.
All of that's incorrect.
And what happens when mostpeople go to the emergency room
after they use their epinephrine?
Well, typically they just sitthere for six hours and they
(16:04):
receive a bunch of treatmentsthat they actually don't need,
such as steroids andantihistamines and Pepsid and
things like that.
Speaker 1 (16:11):
So like Benadryl, Dave, how do you feel?
Speaker 2 (16:13):
Yeah, like Benadryl.
You know how I feel about that.
Speaker 1 (16:19):
Alice.
Speaker 2 (16:19):
I'm sure you've read them.
I read these ER notes of apatient arrived, had
anaphylactic reaction at home tocashew, received epinephrine.
By the time they were evaluatedthey were asymptomatic.
We gave them Benadryl,prednisone for seven days and
Pepcid and had them monitor forfour hours.
Speaker 1 (16:36):
What are?
Speaker 2 (16:36):
we doing?
That's insane.
It's so outdated.
So that's where this comes fromand I think we can start to
have those conversations withfamilies.
I know I have for the lastcouple of years and this started
during the pandemic right.
We were afraid to send peopleto the emergency room.
We don't want to give themCOVID, especially before
vaccines are available.
So we started to actually learnhow to monitor at home and
treat them at home and have thatconversation, and that's what
(16:57):
the evidence supports as well.
Speaker 1 (16:59):
Yeah, no, I mean, I think that is such an important
point.
I will say the caveat ifthey're going to monitor at home
, I do like them to havesomebody there with them, but
otherwise, absolutely, if theyuse their epinephrine promptly
and they're improving and theyhave a second device with them,
(17:22):
um, it all makes a lot of sense.
Now, if they still want to goto the emergency room, you
absolutely can.
You absolutely can, um, buthopefully this will take away
some of those barriers toactually promptly using the
epinephrine Um, because the lastthing we want is not using it
or not using it promptly, andthen a kiddo is getting worse
(17:44):
and then you're putting thekiddo in the back of the car to
drive and then they're throwingup on the way to the ER and it's
just terrible, right, it's justterrible.
So we know that prompt use ofepinephrine is what stops an
allergic or a severe allergicreaction, anaphylaxis.
And you're right, I totallylove that.
The whole like, oh, if theymaybe ate it, no symptoms, then
(18:07):
give them epi.
I love that that is gone,because that has never made
sense.
I don't think to any of theallergists.
Speaker 2 (18:14):
Yeah, the dark secret with anaphylaxis, as you know,
is if you look at all of thestudies over the years, this has
been shown repeatedly 50% ofpeople having anaphylaxis never
receive epinephrine.
And what happens to those 50%of people?
They do fine Fatalities fromanaphylaxis.
They are tragic and they dooccur.
Thankfully, they are not nearlyas common as most people
(18:37):
believe them to be.
So we want to promote usingepinephrine early because it
makes people feel better a lotfaster.
Yeah, you're miserable.
You are so miserable you'rehaving an allergic reaction.
Use it because you feel better.
Speaker 1 (18:47):
Um so, that's absolutely right and that's
another reason.
Benadryl, the okay.
So like kind of before my time,they used to say, oh, we'll
give benadryl, if it doesn't getbetter, then give Epi.
Like that is absolutely wrong,that is not evidence-based,
because then not only are youdelaying use of epinephrine, but
you're giving Benadryl, whichis just an antihistamine.
(19:09):
And, as all my patients know,anaphylaxis is run by a lot more
than just histamine and it'snot the histamine that's going
to cause the fatal issues.
So you really want to get theepinephrine in promptly.
It's going to make the kiddofeel better because you're
really calming down thoseallergy cells so they stop
spewing out all of the stuffthat's causing all the reactions
and they help prevent all thosedifferent symptoms or causing
(19:31):
all the symptoms.
It's going to help stop thesymptoms as well.
As opposed to, an antihistamineis not going to be that
multifaceted at all, it's justgoing to be antihistamine.
Now I think you have pulled outamazing pearls for our patients
or our families listening on the2023 practice parameters and
(19:56):
for y'all listening to thispodcast.
If you haven't listened to thequad a eyes podcast on the
anaphylaxis practice parameters,where dr stukas interviews dr
golden, um, you definitelyshould, because it is a
fantastic listen subs.
It's a fantastic listen andthey do get in the weeds on a
few things and I love thatbecause it's two allergists just
(20:18):
talking about it, kind of likewe're doing today, dave.
So thank you so much for comingon the show and breaking that
down for us.
And where can people find thepractice parameters?
Speaker 2 (20:28):
You can actually just search them online.
So if you just look for allergypractice parameters, they pop
right up.
They're free for everybody.
I believe there's teaching,yeah, oh yeah, I think there's
teaching slide decks for some ofthe latest ones as well for
medical professionals out there.
If you want to actually learnmore, or even, you know, educate
those in your group or in yourcommunity.
So yeah, check it out.
Speaker 1 (20:48):
Awesome, dave, thanks so much for coming on the show.
Speaker 2 (20:52):
It's my pleasure.
Thanks for having me.
Speaker 1 (20:55):
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to
foodallergyandyourkiddoscomwhere you can join our
newsletter.
God bless you and God blessyour family.
Popular Podcasts
40s and Free Agents: NFL Draft Season
Daniel Jeremiah of Move the Sticks and Gregg Rosenthal of NFL Daily join forces to break down every team's needs this offseason.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.