Managing pediatric food and seasonal allergies during COVID-19

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Today, I'm at the Forefront Live UChicago Medicine Comer Children's pediatric specialists. We'll discuss the best way to manage food and seasonal allergies. Does the COVID 19 pandemic impact allergies? When do patients need to be concerned about a baby's symptoms that could be food allergies? And how to video visits work when allergy health care is needed? Dr. Christine Ciaccio and Dr. Timothy Sentongo will answer your questions, and that's coming up right now on At the Forefront Live

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start out and have each for you introduce yourselves, and tell us what you do here at UChicago Medicine. And Dr. Sentongo, you're on set, so we'll start with you.

Hello, my name is Dr. Timothy Sentongo. I'm Associate Professor of Pediatrics at the University of Chicago. I also direct pediatric nutritional support, and I also direct pediatric gastrointestinal endoscopy. So my areas of interest are really nourishing children who are ill and, obviously, helping children with gastrointestinal problems tolerate their foods and grow. Thank you very much.

Perfect. And Dr. Churchill?

Hi, I'm Dr. Christina Ciaccio I'm an associate professor of pediatrics and medicine at the University of Chicago. I also serve as the section chief of allergy/ immunology and pediatric pulmonology. I also direct the food allergy program and have an interest in caring for both children and adults with food allergy, asthma, and other allergic diseases.

So let's jump right into the questions. We're going to start off with kind of from general COVID 19 questions. And Dr. Ciaccio, I want to start with you on this one. Are there symptoms of food or seasonal allergies that mimic some of the COVID 19 symptoms. And, if so, what should parents be aware of?

That's a great question because this can get confusing, particularly in a high pollen season like we're having right now. So you-- many people, many of your viewers probably know that the tree pollen and grass pollen counts are both very high and can mimic an upper respiratory infection. There are some key differences, though, that I would recommend paying attention to. One, first and foremost, is that allergies do not cause a fever at any time.

So if you have a fever, that is a reason to suspect an infectious illness and to contact your doctor about what to do. You should also not feel short of breath from allergies unless you have asthma, as well. Allergies, however, are very specific in that it causes a lot of itch, so if your eyes are swelling and are very itchy or if your nose is itchy and sneezing, that's really more indicative of an allergy than it is of COVID.

So Dr. Sentongo, you are a nutrition expert, and I imagine you also work with patients who have food allergies. What should parents be aware of in that area? And do parents need to worry about COVID 19 for their kids, because we've heard a lot in the news reports that maybe that COVID 19 situation is-- well, it's more severe for adults-- but kids can get it as well, correct?

Yes, kids can get COVID 19. And from everything that we've heard and learned from places where COVID has preceded us is that children, fortunately, are not as symptomatic as adults. Children may present as maybe a runny nose and some loose stools, and it might not be severe enough for the family to even go and see the doctor. The tip off might be that there might have been a family member who was sick with COVID. Therefore, that might mean that the child may have gotten COVID.

But, clearly, it's like an acute symptom. It's a child who was previously well. And then there's now new developmental of maybe a runny nose, a slight cough, and loose stools. But many times, it doesn't get to the level of going to the doctor in children.

We do want to remind our viewers that we are taking your questions for our experts. So just type them in the comments section, and we'll try to get to as many as possible over the half hour of our program. And let's launch into some of the questions that we've already received.

Food allergies and intolerances, in general in children. Kind of curious because it seems like we hear much more about that than we used to. Are they on the rise, and do we know what causes that? And I'm not sure, Dr. Ciaccio, if you want to take that one or start with that one?

Sure. This is a complicated question. We think, and most of our data is, about what we term IgE-mediated food allergy, which means that if a child eats a specific food, within 15 minutes, they'll develop respiratory distress, swelling, hives. And we do think that food allergy has been on the rise since the 80s. And it's very unclear, yet, why that is.

At the University of Chicago, one of our research programs is looking at how are the bacteria in our gut may influence this. And if some of the things in our modern society have changed the bacteria that live inside us. And maybe that's one of the reasons why some of these things are on the rise.

But, unfortunately, we just don't know yet. So we're doing our best to manage food allergies in kids. And we're coming a long way with new treatments and with a lot of different research that is helping us better understand exactly what's going on.

Another question from a viewer. Can inflammation from allergies make you more susceptible to COVID infection? And Dr. Sentongo, I don't know if you want to take that one?

Not really. COVID infection really, across the board, could catch anybody who's exposed to it. So we do know that there are more-- if you have actually more serious illness like your immune suppression-- you're immune suppressed-- or have a lot of chronic medical problems, weakness of your muscles-- then you're going to be sicker. So once again, it's regardless of what your previous medical health is, you could catch COVID. And the symptoms to get the point of seeing a doctor tend to be related to if you have any pre-existing medical condition.

Another question from a viewer. We're getting a lot so far. This is great. We're off to a good start. Can you discuss IgG versus IgE allergies and how to proceed when you suspect more of an IgG reaction? How to pinpoint what's the trigger, how to avoid medication, and that sort of thing. And Dr. Ciaccio, you want to take that one?

Sure, another excellent question. So an IgE-mediated allergy, like I mentioned, the symptoms are very specific. You eat a food, and within minutes you have a severe reaction. There's lots of food intolerances, and it's different per person. And, unfortunately, no matter how hard we've tried, we've never been able to find a good test that can reliably tell us food that you're intolerant to.

There is IgG or IgG for testing on the market for food allergy, but time and time again it's shown us in research that it just doesn't work. It doesn't point us in the direction of what may be causing symptoms of food intolerance. So what I recommend to my patients, and it is the only validated way of determining a food intolerance, is to keep a food diary and go avoid foods that you think you may be intolerant to for about two weeks and see if you have a difference in symptoms. Unfortunately, we just don't have anything more sophisticated than that at this time.

Another question from a viewer. My son is having some splotchy redness around his mouth after eating peanut butter on three different occasions. He's only 9 months old. How should I proceed? Is he too young to have a true peanut allergy? And I have a question, because is he too young to be eating peanut butter? Is that accurate, Dr. Sentongo?

Actually, the times are changing. And I'll defer more to Dr. Ciaccio. Previously, we used to recommend delaying introduction of several foods. But right now, there's a new understanding that children who are prone to allergies seem to do better in the long-term if some foods are introduced, obviously, sooner.

And I would imagine that the serving's really more of the texture of the food that would determine. But I wouldn't imagine the child would be eating a large serving size. So we are now open and encouraging families to introduce a variety of foods even sooner to their infants. So that's now becoming less unusual.

Is nine months too early to have a peanut allergy, though?

Nine months is-- maybe I'll defer that to Dr. Ciaccio.

OK. Dr. Ciaccio, you want to take that one?

Yeah, absolutely. No, nine months is not too early for a food allergy. In fact, we see food allergies develop at pretty much any age. And we have good evidence now that, like Dr. Sentongo mentioned, if you are at high risk of developing a food allergy, and that would include children with eczema or another food allergy to egg, for example, early introduction at four to six months of age of a peanut product-- and we do recommend thinning it so, of course, infants don't choke-- is absolutely appropriate. And we recommend they get it on a regular basis, and that's highly effective in preventing a food allergy.

If your child is having redness around their mouth when they're getting peanut, I do think it's probably time to talk to your primary care doctor or an allergist and just make sure everything's OK. And it is a reasonable path forward to keep introducing peanut. Of course, we're hoping very much to keep peanut in children's diet prevent the long-term outcome of maybe at five or going to school age with a severe anaphylactic peanut allergy. But it's a little bit nuanced. And I think, depending on your family history, it's worth talking to a doctor.

Well I'm glad you brought that up, Dr. Ciaccio, because this allows me to talk a little bit about video visits and some of the telehealth. And you and I were actually talking before the program a little bit about this, that it's something that UChicago Medicine and Comer Children's is using extensively right now.

And you've had a great deal of success. You were relaying some of that experience with me before the program. Do you want to talk a little bit about that, and maybe kind of allay some of the fears that parents might have that are worried about bringing your children-- bringing their children, rather-- to the hospital?

Absolutely. About 70% of our visits right now are being done via video. So patients, the families, can be at home together. It is also possible if one parent's at work and one parent's at home for them both to come into the video chat separately so we can make sure everyone's included in the visit. And that's done a few things.

One, sometimes it really just is a talk with the physician, and that's all that needs to happen. In fact, that happens quite a bit. The video visit is extremely effective at delivering care.

It also has helped reduce the number of patients in our clinic. So we don't have full waiting rooms now. We're able to maintain social distancing, and we're able to, in a very safe way, bring the families who need to be the seen in person back to their rooms, very much minimizing any risk of developing a COVID infection. So we've been very pleased how things have been able to progress forward. And I think that we have been able to continue to give care to our patients who have chronic diseases. Of course, we don't want to neglect those during this time, either.

Absolutely. And Dr. Sentongo I'm curious from your standpoint, as well. The use of televisits or video visits, how is that working for you? Are you pretty pleased with how that's going so far? And also, the one thing I would like you to talk about as well, is if patients really do need to come in to Comer Children's, for example, it's very safe here for them to do that. Would that be correct?

Yeah, that is very correct. And I'm also very, very amazed and pleased at the way video visits have played out, because many families do actually work and understand them very well. It takes a bit of an arrangement before the visits to make sure that the settings and the passwords are correct because, again, it's confidential information between the physician and their patient. But patients and families are really very appreciative of them.

And in the encounter, we do let families know that there's a possibility that some assessments may need to be done in person. Anything that needs to be done in person, the visit is coordinated, as Dr. Ciaccio has mentioned, is a walk pathway into the hospital and to the clinics to ensure that there's actual good social distancing. The appointment is set up so that there's minimal waiting, and the encounter happens. So both options are available, but, obviously, right now in this era of social distancing, video visits are the way to go. And they are working out, amazingly, very well.

That's fantastic. And, you know, it was interesting because I had the opportunity to go into Comer-- I think it was last week-- and, again, people are being very cautious. They're taking all of the proper precautions. And as one of the physicians told me in that program, it's probably safer to be here in the hospital than it is, you know, just about any place else you could be right now because of the efforts to keep everything clean. The social distancing, everybody's masking in the hospital, and being very, very careful.

So let's talk a little bit about some of the-- here's a new question. I want to throw this one at you. So what are you hearing from your patients about the use of, I think, it's Palforzia for peanut allergy now that it's been a few months since FDA approval? And I don't know which one of you would like to take that one.

I can take that. We're using that in our clinic. Palforzia is the first FDA-approved medication or treatment for food allergy. So we're all very excited to see that happen last January. And what it is is it's a method to desensitize or do an oral immunotherapy for children who have peanut allergy. It's specific to peanuts, so it doesn't cover any other food.

But what we do is we actually start feeding children a very small amount of peanut that's below their level of reactivity, below the amount that we think would cause a reaction. And we have them eat that every day, and after about two weeks, they come back and see me again. And if everything looks good, I have them eat just a little bit more. And they eat that amount for two weeks, and that goes on and on for about six months.

And after about six months, we find that we can have kids, even with severe peanut allergy, eating a peanut every day. And what that allows is a layered protection. So your family can feel safe going to a baseball game that has peanuts or buying foods that say, this product is manufactured in a plant that has peanut. Those very difficult precautionary labels that we really don't know what to do with.

It's worth seeing that it's not a cure. We don't expect that your child's peanut allergy will go away completely. It's a layer of safety, but it really is a very nice layer of safety for our families to feel confident sending their kids back to school and to overnights and other things that every kid wants to participate in.

And I want to talk about milk allergies in just a moment, because we've received quite a few questions. But, going back to Dr. Sentongo, your comments about Comer, we have some video that we took when we were there last week. And it kind of shows a little bit about what the situation is like inside Comer right now. And, again, it's very safe and you can get an opportunity-- here's Comer right here.

It's a beautiful facility, first of all. And the work that's done there is fantastic. But we'll go inside in just a moment, and you'll kind of see-- the parents who are watching this will get an idea of what precautions are being taken right now. And one of the things that I noticed immediately when you do enter is that they will stop and greet you and check to see if you have any symptoms, potentially, of COVID because they want to make sure that, again, the patients are protected and all of the family members that are there.

So it's really-- you know, it's well-run. And it's a very, very safe place to be. I don't know if you have any thoughts on this as we're watching this.

No. I think it has been well-thought through exactly, as you said, to regulate how people come into the hospital and to make families also be assured that we are also thinking about them first. We understand that they're ill, but we also want them to come to a safe environment for them. And also for us.

So I really credit our infectious disease team, control team, who have thought through this. I know they meet regularly to fine-tune and clean up any bottlenecks that arise as more and more people come through this way. So I really think it's a very, very strength for the institution.

Yeah, I was amazed when I was there. It's-- you know, the patients are moving through. They're keeping separated just as they should be, and it seemed like it was working really well. And the patients seem to be in a pretty good mood as they were going through it because, of course, they understand that this is very important.

Can we talk about cow's milk for a moment? The question we had, and I thought-- we've got several, actually about milk allergies-- but one is, how can parents protect infants from developing an allergy to cow's milk? Which, I guess, is the most common food allergy for children? And I'm not sure which one of you would like to take that.

I'll take a shot at it.

Sure.

So, first of all, I think it's a very, very important question because cow's milk allergy, actually, is a concern and babies, many are fed milk. Therefore, that's the one food they're being fed, and all of a sudden, you're having difficulties feeding your baby. So allergies are on increases, Dr. Ciaccio has mentioned.

A couple of things that we do know that seem to reduce a risk of an allergy manifesting or developing in an infant, obviously, increasing nursing, breastfeeding because that seems to be one of the most-- children who get breastfed tend to have fewer allergies than those who are not. They do have allergies, but the overall on a comparison basis it seems to be less severe. There's a protective effect on breast milk.

Then, secondly, we now know about introducing foods a bit sooner. Because, previously, people delayed introducing a variety of foods when children were much older, like nine or ten months. But right now, between ages of four to six months, there's now a move to begin exposing infants to more foods. We know they won't eat a large amount, but just introducing a different texture and the process used in using a different food, that seems to have a protective effect.

Are there good milk alternatives for children that have the allergy?

Oh, yes. Yes, there are alternatives. If a mother cannot nurse and child gets diagnose with a milk allergy, we end up feeding them with our pre-digested formula. These are formulas that have all the same protein and nutrient levels as milk, but the protein is pre-digested, meaning that the protein is broken down into smaller fragments which are unable to make the child develop an early manifestation.

And there are different varieties of those formulas. Some are much more extensively pre-digested than others. And I would say most of the time, I would say, we're effective in nourishing the child. And, obviously, if the allergies persist, then they work with my colleague Dr. Ciaccio to figure out the extent of the allergies and whether desensitization is even an option.

So Dr. Ciaccio, you spoke about Palforzia here just a moment ago. Is there any research that is indicating that that could expand to other types of nuts?

Yes, absolutely. That's ongoing right now, several other foods, in fact. We have an egg desensitization program open and, we are anticipating a multi tree nut-- so that would be things like walnuts, pecans, cashews, pistachios-- yet this year. And milk is certainly on the radar and will be coming soon. We already have some options for desensitization for some other foods. So please contact the clinic if it's something that you're interested in hearing more about.

That's great. Another question from a viewer. What test is best to determine if a child has asthma or allergies? My daughter's two years old and takes Flovent daily, but I feel the medication does not help control her symptoms, which are frequent runny nose, itchy eyes, some cough, and particularly after running around or exercising.

You know, I think the best testing for the allergy component is something called skin prick testing. And this is where we take a dilute concentration of actually pollens and things like dog dander or dust, and we just make a very small prick on a child's back. It doesn't break the skin. It doesn't draw blood. It doesn't really hurt it's just a very small pinch feeling.

And we watch it for the next 15 minutes. And if that turns into a hive, that gives us an indication that your child has some allergies. There's also an option to do blood testing. It's not quite as good as skin test, but it's pretty good.

And, certainly, in the age of COVID, we have been doing quite a bit of blood testing. We actually can mail lab slips to families, and they can go to any lab they're comfortable with. And that can certainly give us some useful information.

As far as asthma goes, there's a breathing test. But in the time of COVID, we actually have not figured out a workaround for this just yet. So most asthma testing is on hold for the immediate future.

Another question from a viewer or a request. Can you discuss EoE and when formal scoping and testing is warranted? Don't know which one of you want to take that one.

EoE, basically, it's an observation for eosinophilic esophagitis. Eosinophilic esophagitis is a formal food allergy that mainly affects the food pipe, the esophagus. That's the tube between your mouth and your stomach when you swallow your food. It goes across your chest through the food pipe called the esophagus.

Now, in this condition, people have an allergy to something in their diet or something in the environment that causes inflammation in the esophagus. And when that happens, they have pain, they may be vomiting, they don't want to eat. And that's how they come to attention.

And it's diagnosed based on a good history. Sometimes maybe a family member with the same condition. But, ultimately, they may need to have a test called an endoscopy.

An endoscopy is a camera test which is like a special tube which is done under sedation. The child gets sedated by an anesthetist who's experienced in doing that. And then we insert this scope in the mouth through the back of the throat and down in the esophagus and we can take a look and take a biopsy of it.

So, once again, there are many treatment options for it, but one of them, obviously, is a full elimination. And the importance of it, obviously, is that it makes children have a lot of chest pain and vomiting. And the treatment involves eliminating foods most of the time.

Another viewer would like to know if you would recommend holding off on starting OIT during the COVID pandemic.

That's a great question. So far we have not, during the COVID pandemic, started OIT. Although, we have several patients who are already on OIT. And just last week, we started updosing again, and just in the next two weeks, we are planning to start new OIT again. And we're going to play it by ear.

There may be times when we have to stop, and we can't updose for a month or two again. But what we know from the literature is as long as your child is getting exposed to the food, that allergen, through the process of oral immunotherapy, that even if we can't go up on schedule, they're still going to get continued effects on their immune system. So I wouldn't think of it as a waste. I think that it's still effective at different concentrations. We're still going to shoot for that goal of, in the case of a peanut, a full peanut, but we may not be able to get there in a six month time frame. It may take a little bit longer.

Another question from a viewer. I'm not sure if my toddler should be tested for COVID 19, or if it's allergies. I've treated them with a Zyrtec, and it's helped with some congestion, but my toddler still struggles. This sounds like a good opportunity for at least a video visit, possibly bringing the child in, but I'll let one of you answer that.

Sure, I'll take that. I do think it's reassuring if Zyrtec helps. And, in general, since we don't have treatments that we'll give to mildly ill patients with COVID at this time, there really isn't a strong need to actually get testing to prove you have COVID one way or the other, as long as your child is breathing OK, and you're able to control a temperature, if a temperature's involved. Then it's OK to stay home and keep watching.

Of course, if your child is starting to struggle to breathe or develops a fever that you're having trouble controlling or is prolonged, by all means, please make a visit right away. But, again, the fever is really specific for infection and not for allergies. So if you see a fever, I would not be suspicious of allergies.

Dr. Sentongo, Dr. Ciaccio, we are out of time. I appreciate both of you doing this. You both did a wonderful job. We'll have another At the Forefront Live next week. Please remember to check out our Facebook page for our schedule of programs coming up in the future.

Also, if you want more information about UChicago Medicine take a look at our website at UChicagoMedicine.org. If you need an appointment, you can give us a call at 888-824-0200. And, remember, you can schedule your video visit by going to the website. There's also a very helpful video there that tells you exactly what you need to do and how to prepare. Thanks again for being with us today, and I hope you have a great week.

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