Baby Has Skin Reactions to Milk, Egg and Peanut: What Should I Do Next? with Carina Venter, PhD, RDN

Carina Venter (1s):

And one easy thing you can do is just to put a little bit of Vaseline or any other barrier cream around the lips before you feed them so that you don't get the skin contact because it's the skin contact that causes the rashes or the flare

Katie Ferraro (14s):

Hey. There. I'm Katie Ferraro, registered dietitian, college nutrition professor and mom of seven specializing in baby-led weaning. Here on the Baby-Led Weaning Made Easy podcast, I help you strip out all of the noise and nonsense about feeding, leaving you with the confidence and knowledge you need to give your baby a safe start to solid foods using baby-led weaning. What if your baby tries a new food and then gets a rash on their face? or, what if you're doing one of the allergenic foods early on in infant feeding, let's say cow's, milk or egg or peanut? Those are the three most common pediatric food allergies.

Katie Ferraro (54s):

But what if your baby gets hives and the baby's not in distress, they're not showing any other signs of allergic reaction and the skin stuff goes away on its own. Can you then reintroduce that same food to your baby and do you do it at home? Or do you need to wait to see an allergist? Or, what about even testing for food allergies in babies? Some doctors say wait until one, but others test right away. Well, my guest today is incredibly well equipped to answer all of these questions for you. Carina Venter is joining me today. Carina is a PhD dietitian who is a researcher, an academic and an educator specializing in infant feeding and pediatric food allergy. As one of the world's leading pediatric food allergy researchers, Carina has been so gracious to be on our podcast a number of times in the past about food allergies and teaching everything from how to use an egg Ladder to reintroduce egg to babies who have egg allergy and the research behind, or a lack of research behind the recommendation to wait three to five days between trying new foods, Carina does tons of research about the benefits of diet diversity for babies.

Katie Ferraro (1m 49s):

So on a personal level, for me, as the creator of the original 100 First Foods baby-led weaning program where we help your baby eat a hundred foods before turning one, this idea of diet diversity is so appealing and I'm always closely following Carina's publications and her research since she really is on the forefront of reshaping how we teach parents to introduce foods, and in particular allergenic foods to their babies. So with no further ado, I want to welcome Carina Venter who's here today to talk about a real life baby that I've been working with in my practice who had skin Reactions to milk, egg and peanut, and then her suggestions about what the family should do next. So here's Carina Venter again. This episode is Baby Has Skin Reactions to Milk Egg and Peanut: What Should I Do Next.

Carina Venter (2m 36s):

Hello Katie, very nice to see you again.

Katie Ferraro (2m 39s):

Now I learned so much from being a part of your and Miriam's pediatric food allergy course for dietitians I got to do throughout the course of the year. Before we get into today's topic, could you just share some background on what projects you're working on right now? Cuz I haven't chatted with you in a while. What is it that's going on in your world of infant feeding or pediatric food allergy that has you really excited?

Carina Venter (2m 59s):

Yeah, so I always find that I, when a question like that, I feel I really have to focus to give you a focused answer. But basically a lot of my research is currently focused on the maternal diet in pregnancy and so I've developed a healthy eating diet that's associated with less allergy outcomes in the infant, significantly less. So I'm currently working on a grant proposal to actually test this diet approach. And then in infancy we are doing some exciting work on maternal diet during breastfeeding and breastfeeding composition and how that relates to infant food allergy. I'm also working on a study with Richie Gupta, the pi, where we are introducing eight common food allergens in the first year of life to see if we can reduce all food allergy outcomes in infants.

Carina Venter (3m 49s):

And then because I'm really interested in the microbiome, I have got a few smaller studies ongoing in children with and without food allergy, with and without Eczema to look at their gut microbiome, their skin microbiome and how their disease as well as their diet intake relates to what we see in the skin and the gut microbiome I think that summarizes it.

Katie Ferraro (4m 10s):

Is that, oh, that's all. And then didn't you just write a textbook in the meantime as well?

Carina Venter (4m 14s):

Yes. We've also written a textbook: "Nutrition Management of Food Allergy for Healthcare Professionals." They showed the, the cover of the book at least this weekend at the Academy of Nutrition and Dietetics conference. And we are hoping it will be launched by the end of the year, if not really early 2023.

Katie Ferraro (4m 32s):

Are you happy with the book cover? I know as someone who has published textbooks, you don't get a lot of say in it and sometimes they get way off the mark.

Carina Venter (4m 39s):

I love the book cover, I love the content of the book. That chapter on allergy prevention that I wrote contains everything I know about prevention. So I think it's gonna be a really, really helpful guide.

Katie Ferraro (4m 53s):

I have to tell you a funny story. I, I don't teach at UC San Francisco anymore, but I did for many years and I co-wrote a book on medical nutrition therapy for nurse practitioners. So I co-wrote it with an NP who was also a dietitian and McGraw Hill was our publisher. You know, we pitched the book, we wrote the whole thing. You know how book writing is, it's a labor of love. You get through the whole process and it was in our contract, but we did not have final say over the cover. The cover that came back was a picture of a, a white lady sitting at a desk with a white lab coat on and food models on her desk and she was holding an apple and I was like, you could not have a more stereotypical book cover picture of what some man who knows nothing about nutrition thinks nutrition is about.

Katie Ferraro (5m 37s):

And to be honest, it was so disappointing because we put so much energy into the book, but you know, people look at the cover and we never got to change it again. And I was so mad about it.

Carina Venter (5m 47s):

Oh my goodness. I think my worst nightmare would be a Dietitian with a white lab coat or perhaps a kitchen coat if I could call it that with a hairnet on, because I've often been told that I shouldn't call myself a dietitian because dietitians are people who works in hospital catering facilities with hairnets. And so I, I think we've come a long way since that was the, the typical view of a dietitian. So I would, I would really not be happy with that cover that that looks like that.

Katie Ferraro (6m 18s):

I think you should keep calling yourself a dietitian because you're doing very, very important work in the world of nutrition.

Carina Venter (6m 23s):

I definitely call myself a dietitian, actually on that note, I asked my professor in England one day, what else can I call myself if I can't call myself a dietitian? And he looked at me for quite some time and then he said, I think you should just call yourself a Dietitian because I've never heard of anybody that's that proud to be a dietitian. So keep going. So that's what I'm doing.

Katie Ferraro (6m 44s):

Well today we're here to chat about skin reactions to food and then what they mean or do not mean with regard to food Allergy. And in particular we're going to focus on milk and egg and peanut. So parents get concerned when they're introducing new foods to their babies, especially these allergenic foods. And then of course, particularly if that baby has a skin reaction. So Carina, are there situations where a baby could have a skin reaction to a new food that is not indicative of a true food allergy? Like basically when is skin involvement only like not really a big deal or something not worth worrying about?

Carina Venter (7m 16s):

You know, it happens all the time, particularly reactions around the mouth and on the face, you know, babies get like little perhaps one or two isolated hives with no other symptoms. They get red rashes around the mouth, they get red flashy cheeks. Quite often the babies will have these symptoms, perhaps more so the red flushy cheeks and then you know, five, 10 minutes later it's gone. The baby doesn't seem to be distressed with it. I think you know, if you have a few hives with red flashy cheeks and their eyes start streaming and baby is clearly distressed by rubbing their eyes or pulling their teeth, that's the point where you think this is a food reaction. But just the common appearance of red flashy cheeks and perhaps red, red lips or red around the lips is not Foods related.

Carina Venter (8m 4s):

We particularly see this in children with eczema and one easy thing you can do is just to put a little bit of Vaseline or any other barrier cream around the lips before you feed them so that you don't get the skin contact because it's actually the skin contact with the food. And particularly so in babies with baby-led Weaning, you know, it's the skin contact that causes the rashes or the flare and if you could have the barrier then you won't actually see these symptoms at all.

Katie Ferraro (8m 31s):

So when the skin involvement the hives or the rash when it goes away on its own and it's not accompanied by another sign or symptom of food allergy, is it safe to say to go and try that food again?

Carina Venter (8m 44s):

Oh yes, definitely, definitely. You know, and classically it'll happen to foods containing tomato or containing berries, particularly strawberries when children start eating tomato ketchup on their food that you know, those foods touching the skin or even without touching the skin are known to cause these flares. And most definitely I would advise the family not to be concerned about it and continue to feed the foods.

Katie Ferraro (9m 9s):

So this baby that I've been working with lately and kind of the reason why I emailed you to see, could you come back on and talk about this, had probably the most severe eczema I've ever seen. I've worked with a lot of babies, but I mean this is when you describe textbook severe eczema, not the run of the mill eczema that all babies have and her eczema wasn't just present in early infancy, it was persistent even past the six month mark. And this is to the point where the baby literally, I worked for her for her first 10 days of solid foods and then after that even baby scratching, she's so distracted at mealtime, she cannot concentrate on the solid foods because she's constantly scratching. So full body eczema that not resolving with typical with steroids, dermatology, et cetera.

Katie Ferraro (9m 50s):

Not surprisingly when we tried egg, which was the first allergenic food that we did, she had full body hives. So severe eczema plus a skin reaction to egg. What would you advise to the mom of this six month old baby for next steps as far as egg reintroduction goes? Because mom was reticent of course to try egg again if it had caused hives.

Carina Venter (10m 9s):

Okay, I just first want to take a step back a baby with full body eczema that's particularly uncomfortable and itching. We really need to get back to the dermatologist or get a referral to a dermatologist to make sure that the child is optimally treated. We can ask simple questions about just how much ointment do they use a week. We also have to remember that ointment is probably the choice of moisturizer we we want to use because many of the creams have got preservatives in that can actually cause even more irritation to the skin. So really go back to the dermatologist, make sure the correct cream or ointment is prescribed that the mother is using it optimally and that whatever steroid is prescribed is used as recommended as well and that you get advice on frequency of bathing the baby and perhaps adding something to the bath water as well.

Katie Ferraro (11m 3s):

So getting the skin under control is really important.

Carina Venter (11m 5s):

But definitely we need the skin under control. So once we have the skin under control, we now have a child with severe eczema and an egg Allergy and we know that children with severe eczema, and I've even published it myself, are at increased risk of having IgE mediated food allergy. And then the child with eczema plus or minus egg Allergy and the child with egg allergy plus or minus eczema is at risk of developing a peanut allergy. So this is a case where I will not say to mom, just try it again and see what happens. They need a referral to an allergist and the allergist will do testing definitely to egg in combination with the history of reaction to the egg where we have the hives and common flushing, full body flushing off of the skin, which we call flushing of the eczema, but it's probably just flushing off the skin irrespective of the eczema.

Carina Venter (11m 57s):

So we have those two symptoms, we have the history of reaction to egg that will be followed by skin practice. The million dollar debate here is whether the allergist will then test for peanut. I work with many different allergist across the world, so I'm not speaking to anyone particular allergist and I would say it's, it's almost fifty-fifty, 50% of allergists will test to see what the peanut result is. And then they will either introduce the peanut in hospital if the skin or the blood test was positive or at home if it was negative, the other 50% will probably say babies are highly unlikely to get anaphylaxis. So we're just gonna go ahead and introduce peanut at home.

Carina Venter (12m 39s):

But definitely I wouldn't like to continue with egg intake or even start peanut intake without at least a consultation with an allergist.

Katie Ferraro (12m 49s):

So what we did was after she had the reaction, took pictures, the skin stuff resolved on its own. And by the way she had no other, no difficulty or labored breathing, no vomiting, no diarrhea, no swelling, no change in demeanor like she had hives and then they went away. But obviously egg and coupled with the severe eczema, you're thinking yes, this baby's at higher risk for certain food allergies. So we go back to the pediatrician who she's in our town, I know who the pediatrician is and he said test her for every food allergy. And of course our audience is very familiar with, we've had you on Marion, Ruchi Gupta, Dr. Stukus telling everyone do not test for a food that your baby has not reacted to. So my assumption is that pediatrician's knowledge of food allergy is is not great.

Katie Ferraro (13m 30s):

So she went to a different allergist who specialized in the allergist, said listen, try peanut at home. So we get the green light to do the peanut and the baby did have a similar reaction. So about five minutes after we tried peanut, the Puffworks peanut puffs for babies, no other ingredients in there, the baby had the Puffworks peanut puffs, about five minutes later she started to get hives on her knuckles, inside her wrist, in her elbow, neck, and then all along her stomach; again completely chill baby just hanging out on the couch. Fine, they go away on their own. But now she's reacted to egg and she's reacted to peanut and she's got this severe eczema. So my recommendation is go, you know you need to go back to your allergist because this is replicable.

Katie Ferraro (14m 13s):

If you did this again, that's what would happen again. We really suspect food allergy, this isn't your run of the mill, "Oh you had a hive and it went away on its own." Would you agree?

Carina Venter (14m 22s):

I totally agree. This is really the time where you need to get the allergist involved because now of course it's the question about the the other food allergens. Are we going to introduce them? Are we going to test, you know the tree nuts are particularly now relevant. Are we going to try cashew and walnut? Are we going to test for them again? I think you know, there's no right or wrong answer about the testing or trying at home. Like I said, the doctors have different opinions but I think there is one wrong answer in this whole situation and this is if you are testing and you get a positive test and now you tell the family to wait with introduction or wait with a food challenge because you're not able to do food challenges for 6 to 12 months.

Carina Venter (15m 4s):

And so what we now have is a big time lag in introducing that particular allergen and also the subsequent allergens. I've just recently published a paper showing that peanut and egg introduction opens the gates; once the parents are happy with Peanut and egg introduction, introduction of the other allergens just follow naturally. So if we actually put a stop gap on peanut and egg without any good reason, the other allergens won't follow. But in this particular case we now need an allergist to really verify allergies or not, but it definitely sounds like allergies.

Katie Ferraro (15m 43s):

So then how do you feel about when she went back to her pediatrician for her nine month check, the doctor just said, well you know we don't test babies before one so just don't feed them any allergens until after one. And then she comes back to me and she's like, "Katie what? What do I say?" I said, "Well to withhold all of the other allergenic foods, the only thing you're going to do is potentially increase the risk for food allergy because you're removing that potentially protective effect of early introduction of the other foods." I get egg and I get peanut, but I don't want parents to be scared off of all allergenic foods because baby reacted to one or two.

Carina Venter (16m 18s):

No, I mean I often say let the babies eat. You know I think we really have to relax about allergens and don't consider them our enemies because really they are our friends and the sooner We can get them in the diet, the bigger the chance is that they will polarize opposed to causing allergies. And so the first thing is "we don't test babies before nine months or one year." There's no reason to actually state that. We can test babies from the day they're born. You know, we probably don't go to that extent. But in the LEAP study they clearly showed that before four months of age when they actually did blood tests to these babies, they were already sensitized to particular peanuts;

Carina Venter (17m 1s):

well not all children, but some of the children. So babies start producing, you know, IgEs from a very young age, they may even be born with high specific IgE or total IgE levels. And in the allergy clinic if we do have a referral of a 1, 2, 3 month old baby, we will taste appropriately not panel testing. I know Dr. Stukus has made that point very clearly, but test them to whatever particular food we we think is a concern at that young age is probably gonna be hopefully just milk but, and then you do need the skill of an allergist to really interpret lower level tests in those young babies that may mean a lot, you know generally speaking we say skin prick test is positive if it's equal or above three millimeter, but in young babies we drop that equal to above three millimeter to whatever we consider to be appropriate for that age group.

Katie Ferraro (17m 54s):

Are there protocols for those age groups though? Like are there published guidelines about the skin prick test results being applicable to younger aged babies?

Carina Venter (18m 3s):

I know of a few book chapters and then there's studies coming out of Europe in particular where we looked at predictive cutoff points for specific IgE and skin prick tests and we compared the cutoff points for younger children versus older children. So children under two versus children above two. So yes they, these published data, I'm not aware that they've been incorporated in any particular food allergy guideline but most definitely regional papers and review papers mentioning these.

Katie Ferraro (18m 33s):

Okay so that same baby, all this stuff that was happening with egg and peanut starting solid foods, the eczema ongoing, that was at six months of age. So babies eight months of age and I actually, again I'm friends with the mom, she's in our town. We went to lunch the other day we were doing a YouTube video about taking babies to restaurants so go out with her and her, her baby and the mom was, the Eczema is still very persistent like you know what's going on, her eczema is still not going away. And mom said, you know, I've been really kind of, you know, not happy with the results from traditional medicine because her stuff's not going away with the steroid treatment. So she started seeing a functional medicine person, so a nonmedical doctor, non-Dietitian and the mom is my friend. So as a Registered Dietitian myself, I'm talking to her about the importance of like any advice you're getting about feeding your baby really needs to be coming from credentialed feeding professional.

Katie Ferraro (19m 18s):

And this one really steamed me because the functional medicine person told mom that the baby's liver is blocked. Okay, I just wanna clarify, she's eight months old, her liver is blocked and that she needs supplements to clear her skin. So she walked away with all these recommendations of cod liver oil and these other supplements to resolve food allergies and mom is now stopped doing topical eczema skin treatment in lieu of supplements that, I mean I can tell you from having just dined with this family, it's not working, the baby still has very bad eczema. How do you deal with that as someone who is a researcher and a credentialed professional, people turn around and like telling parents that their liver is blocked and that's why she has eczema and food allergies?

Carina Venter (19m 55s):

Well I think there's a number of things there. First of all, the baby's liver is clearly not blocked. However, if this baby miraculously did have a blocked liver, I would not use cod liver oil in this baby, which we know has got extremely high levels of vitamin A & D. So I would say that's definitely not the case. I personally never use cod liver oil in babies because of the high vitamin A and D levels. If I feel that there's a particular need to supplement omega three fatty assets, then I will use either a fish oil supplement or I would use an algae oil supplement. I find that the algae oil supplements are much better tolerated by babies than the fish oil with the the aftertaste.

Katie Ferraro (20m 36s):

And just to clarify, the cod liver oil, your reservations would be the high levels of vitamin A and D because those are fat soluble vitamins that could potentially build up to toxic levels in the baby's liver, is that correct?

Carina Venter (20m 46s):

Most definitely, yeah.

Katie Ferraro (20m 47s):

Which is ironic because the recommendation if you're told that the liver is blocked, which is not true and then recommended a supplement that could potentially have, you know, dangerous levels of these fat soluble vitamins stored in the liver, like it's asinine that that's a recommendation that a parent is getting.

Carina Venter (21m 1s):

Yeah, so, so that definitely doesn't make sense. The only time that I would recommend omega-3 fatty acids is if I feel very strongly that the diet is deficient in omega-3 fatty acids opposed to treating eczema. Now it's very interesting cuz I was up till about 12 o'clock last night and then again from five o'clock this morning I received emails from one of the lead atopic dermatitis researchers in the world and he wanted to understand why when we supplement omega-three fat acids to children or adults with atopic dermatitis, why don't we see that all the studies find an improvement in atopic dermatitis?

Carina Venter (21m 41s):

Because from a basic science level, it does make sense that we give omega three fatty acids, eczema improves. Unfortunately that's not the case and that's another systematic review that I published and we don't understand why we don't get very clear and consistent messages. So at this point in time I'd like to say I hope that in future we'll find that supplementation with a lipid, it may not necessarily be a omega-3 fatty acid, but that a lipid improves atopic dermatitis. But at this point in time we just do not know what supplements we need to prescribe orally to improve atopic dermatitis. So I I would not agree with, with any of that advice given, I would just really go back to the basics, treat the skin, trust the dermatologist.

Katie Ferraro (22m 29s):

If a baby has skin reactions only to food, like we're talking a neurotypical healthy baby skin's intact and they try egg and there's some hives around or some atopic dermatitis, some stuff on their face and it goes away on their own, no other signs of anaphylaxis, what should the parent do as the next step?

Carina Venter (22m 49s):

I think, you know, if it's just a few isolated hives around the mouth or like I said rashes around the mouth or the face, I would probably recommend, you know, to, to try it again. It's very rare that we see only two hives causing a a food reaction or you know. But again, if it's like quite a few hives all around the baby's cheeks or or chin, then I would get concerns as well. But it literally is, you know, fear reaction, one or two hives, it goes after 10 minutes, I would definitely suggest to try the food again. I wouldn't then go and give a whole egg and see what happens. But you know, perhaps one or two teaspoons and and and see what happens.

Carina Venter (23m 29s):

But that is definitely in the baby where it's a very happy healthy baby, beautiful still skin, no wheezing, no other concerns with other food. As soon as the story get complex like they have some eczema or they may have, you know, a family history of allergies or they might have a reaction to another food and they get hives to another particular food, I would be more concerned and definitely contact the allergist. But many babies just have a few rashes from eating a food and it it goes away and next time they tolerate it perfectly fine.

Katie Ferraro (24m 5s):

And while I know the thought of your baby having an allergic reaction to food can be scary. You said it earlier, but I think it's so important. Death from anaphylaxis in infancy is incredibly rare to the point where it's kind of even hard to find in the literature and not to discount the seriousness of true food allergy, but the likelihood that your child is going to die from you trying egg a second time after they had a skin reaction that went away on its own with no other signs or symptoms is actually very low. Would you agree?

Carina Venter (24m 34s):

It is actually, I, we actually wrote a pro-con debate paper about this, you know like do babies get anaphylaxis on early introduction of allergens? And so obviously the con side who said that they can get anaphylaxis clearly had one or two case studies that they could reference. But the majority of the data really points to no anaphylaxis. We are unaware of any anaphylaxis to the introduction of peanut. Egg is the tricky one because in the studies where they actually fed really young babies uncooked eggs, so it was pasteurized egg white, we had two cases of severe symptoms and depending on how you define anaphylaxis, which is another nice debate we have in the allergy world, we could say that two babies had either anaphylaxis or severe reactions, but nobody's gonna feed a baby raw eggs.

Katie Ferraro (25m 28s):

I was just gonna say who designed a study protocol where you fed a baby, I know it's pasteurized but uncooked egg white, like that's not applicable in real life.

Carina Venter (25m 35s):

Yeah, so exactly. So when we talk about feeding babies normal food, I'm unaware of anaphylaxis during the weaning process using family foods.

Katie Ferraro (25m 46s):

So parents are so scared understandably about introducing allergenic foods and we're all working in the field of feeding to help parents understand and interpret the research that shows us really the only tool we have for lowering your baby's risk of food allergy down the road is early introduction of these allergenic foods in infancy. So do you have any parting words of wisdom for parents when their baby does have a skin reaction to a food that may or may not be a sign of true food allergy? What can they do?

Carina Venter (26m 10s):

I think, you know what I normally say to the parents, first thing is let the baby touch the food and then touch the skin. Because you know, even with milk you get babies who touches the milk, it goes on their arms, it go on their cheek and they get hives everywhere. You've touched the milk but you give it orally perfectly okay. So really find out about the touching. Then I would also find out about how often have they given the food? Have they tried it again? Do they have concerns with other food? I will if let's say it was egg, I would say what happens when you feed your baby strawberries? You know, do you get some flushy cheeks? Because that often also shows that it's probably not that big a reaction, but I think it's hard to to pin it down.

Carina Venter (26m 55s):

I think if one, two, more than two hives, I'd be concerned, anything less than that, especially if it goes away, I wouldn't be too concerned. And that's also published in the Practical Food Allergy guidance. If there's swelling of the lips, that's a concern. If they start to scratch their eyes, that's a concern. If they start pulling their tongue out because it they have these oral itching symptoms, that's a concern. But really a happy healthy baby with a few red blotches that goes after five to 10 minutes, We can definitely keep giving the food.

Katie Ferraro (27m 27s):

Well thank you for sharing your time and your expertise with us in this interview. Carina, tell our audience where they can go to learn more about the work that you and your team are doing.

Carina Venter (27m 36s):

So I have my own website, which I really need to update a little bit. It's called Carina Venter, one word online. I do have information there about early introduction of allergens, little bit of information about the symptoms of food allergy, so you can look at that. Then of course, food allergy research and Education, which is the fair website, have a lot of information on early introduction, what symptoms of allergies look like. And then also the Center for Food Allergy and Asthma Research, CFAAR in Chicago, if you search that they have a lot of information about weaning babies, you know, concerns about food allergies, managing food allergies if your child has a food Allergy.

Carina Venter (28m 22s):

And we actually presented just all day practical information and handouts this weekend at the Academy of Nutrition and Dietetics conference.

Katie Ferraro (28m 30s):

Well, wonderful, thank you so much. I'll link all of those resources that you mentioned as well as some of the previous episodes that you've been on for parents concerned about egg. You did a whole interview teaching about the egg Ladder for reintroduction of egg, and I'll put those all in the show notes for this episode on blwpodcast.com.

Carina Venter (28m 45s):

Thank you.

Katie Ferraro (28m 47s):

Well, I hope you guys enjoyed that interview with Carina Venter. She is one of my favorite people in the infant feeding space, so incredibly knowledgeable, right on the cutting edge of all of the research and all of the papers coming out. That's really helping to reshape the way we look at introducing allergenic foods to babies. So all of Karina's resources, including the previous episodes that she's been on, some of the other papers that she mentioned, I'll link them all up at blwpodcast.com/274. Thanks so much for listening and I'll see you next time.