Ron Sunog (1s):

Feeding peanut protein, infants early and often decreased their risk of developing peanut allergy. Starting under age 11 months, eating two grams of peanut protein, three times a week. Page five was protective against peanut allergy.

Katie Ferraro (15s):

Hey there I'm Katie Ferraro, registered dietitian, college nutrition professor and mama 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 competence and knowledge you need to give your baby a safe start to solid foods using baby led weaning.

Ron Sunog (45s):

Hey guys, welcome back. Talking about food allergies today. I have one of my absolute favorite guests of all time, Dr. Ron Sunog returning to talk about something a little more specific this time.

Katie Ferraro (56s):

If you guys know Dr. Sunog, he's a pediatrician. He also specializes in food allergies in infants. He wrote the book called Eat The Aight. It's all about how to feed your baby. The big eight allergenic foods. Those are the eight foods that account for about 90% of food allergy, fabulous book, a wealth of information about food allergies. But today's going to talk specifically about what do I do if my baby has an allergic reaction? Cause a lot of you guys get it by now. I got to do these allergic foods early and often I get that. I know how to do them safely, but what if your baby does have a reaction? Dr. Sunog is going to go ahead and answer all of those questions for you. Again, his book is called Eat The Eight. You can find that at eattheeight.com.

Katie Ferraro (1m 38s):

I'm also going to go ahead and link up all of the resources that he talks about in today's episode on the show notes for this particular episode, and that's at blwpodcast.com/58. So with no further ado, I want to welcome Dr. Ron Sunog, pediatrician and food allergy expert. Well hello, Dr. Sunog. Thank you so much for being back on the podcast. You are the first repeat guest cause you are the allergy guru and I'm so excited that you are here today.

Ron Sunog (2m 7s):

I'm honored. Thanks.

Katie Ferraro (2m 8s):

All right. So our parents know and caregivers who are listening that we've kind of gotten through, you got to introduce the potentially allergenic foods early and often. So they understand the importance of that. But what I'd like to focus on today is talking a little bit about what should parents be prepared to do in the event that baby does have a reaction to food, any general guidance for us?

Ron Sunog (2m 31s):

You know, first I'll just say the chance of reaction is low. So when introducing new foods in general, there's no reason to be anxious about that, but the chances in zero, some children, some infants will react. I would have Benadryl at home available. And I would recommend that prior to introducing solids, you talk to your pediatrician about that, you know, specifically when to give it and what the dosage should be.

Katie Ferraro (2m 56s):

Okay. Can we talk a little bit about Benadryl because parents hear about that and people often talk about baby Benadryl, but then when you go to the store, there's no such thing as baby Benadryl. There's children's Benadryl. The recommendation on the package is don't use for kids under two. So parents are like, I'm not going to do any of this allergen stuff cause I don't even know what I would do if they had a reaction. Can you talk about children's Benadryl and its use in infants?

Ron Sunog (3m 18s):

Almost every bottle of Benadryl you'll see will be the same dosage, 12.5 milligrams in five ml, which is about a teaspoon. There is a one brand I found that's a different concentration. I've never heard of it prior to looking it up and I've never seen it anywhere. So the common Benadryl you'll find specifically if it's main Benadryl or the generic batch of hydrazine, there'll be 12.5 milligrams in five ml. Like all called medications, they are not recommended in general in children under six. And I would agree with that in general, when you're talking about treating colds, there's generally no use for that. And it's considered more of a contraindication in children under two.

Ron Sunog (4m 1s):

So again, it shouldn't be used routinely also, although Benadryl can make you drowsy, it should not be used for sleep and children. So I would avoid that. And it is actually interesting that in children and young children, it often does not sedate them and in fact can make them hyper. So it's not a good idea in any event. So now when we're talking about children two and under or one and under again, I think it's worth having at home in case you need it. And I think for specific dosing at that age, again, talk to your pediatric provider when you go to your visit and talk about specific dosing. But I think it's a good idea to have at home, have on hand in case you need it.

Katie Ferraro (4m 41s):

I also usually remind parents that the Benadryl dosing will be based on your baby's weight. So it is a good idea to know your baby's weight. And if you're not able to go to the pediatrician, it is something that they will sometimes share over the phone. Okay. Based on this weight, here's the recommended dose just in the event that there is a reaction.

Ron Sunog (4m 60s):

Absolutely.

Katie Ferraro (4m 60s):

Okay. Dr. Sunog, could you share a little bit about which foods would babies be more likely to have a reaction to?

Ron Sunog (5m 8s):

You can react to most anything, but there are eight foods that cause the vast majority of reactions they are known among allergists and pediatricians as the big eight. And I'll just go over them and I can give me the approximate percentage of the amount of allergy they cause in children. Number one is peanut about 25% of food allergy in children is to peanut and about 21% to milk about 17% to shellfish, 13% to tree nuts, about 10% to egg, 6% to fish, 5% to wheat, almost 5% to soy. So those are the big eight. There is a ninth that's close to the big eight.

Ron Sunog (5m 49s):

That's sesame. Sesame allergy has become somewhat more prevalent in the last few years. At some point we may be talking about a big nine, but it's still referred to as the big eight.

Katie Ferraro (5m 57s):

And I know that the name of your book is Eat The Eight. We often talk about the big eight plus SB if they really change it in sesame. Because, cause I know like in Canada, isn't sesame one of the big nine they're already there? If we change it in the US, wuold you have to change the title of the of your book?

Ron Sunog (6m 11s):

Yes. In my, in my book, I even suggested assessment comes on. It goes from EPA to a notch deny.

Katie Ferraro (6m 17s):

Awesome. All right. You're prepared. I love it. Would you recommend, or would you give us the list of the big eight allergens? And you were saying like in what order and peanut was first, is that a ranking infants or did, was that all children? I know sometimes the, data's hard to say which one's the most common cause are we talking about kids or kids under one?

Ron Sunog (6m 34s):

That's all children.

Katie Ferraro (6m 35s):

Okay. So is it different for infants? Like for six to 12 month olds, is milk allergy more prevalent than peanut or is the list pretty much in the same oder?

Ron Sunog (6m 44s):

Yeah, that's interesting. So I would think that it would be somewhat different for infants just based on what infants are going to eat. So for example, shellfish and fish allergy, I think generally comes later if for no other reason, then children can eat that later. Milk is something that infants will get exposed to either through formula or certainly, you know, later in the first year of life through foods like yogurt and cheese. So it'll depend partly on being exposed to the food, trying to prove.

Katie Ferraro (7m 13s):

And I think what's also hard when you're trying to interpret that data is a lot of it is based on self report. So what a parent might think an allergic reaction is versus what may have actually happened. It might be a little bit different, but regardless, we do know that the majority of food allergies come from those eight foods plus sesame. When it comes to the reactions, I was wondering if you could give us some tips for like, what are the signs that parents and caregivers should be looking out for to see, gosh, is my baby having an allergic reaction to this new food that I'm presenting to them?

Ron Sunog (7m 43s):

I'm going to start by saying that a very serious or life-threatening reaction is going to be rare. So even, you know, children who, who have reactions is infants and, and more importantly, it's more rare during infancy than it is later in life. So your risk at that age of a serious reaction is unlikely. But the reactions include possibly an itching, rash. The rash can be hives. It can be around the mouth or elsewhere. There can be some swelling, facial swelling, vomiting, difficulty breathing, a sort of a fussiness.

Ron Sunog (8m 24s):

And, you know, as it progresses in bad cases and infant or child can lose consciousness, but that would be a severe case and truly rare.

Katie Ferraro (8m 33s):

And when you mentioned that the signs of anaphylactic reaction, as you were describing them are rare in infancy, is it also the case? I think I remember this from a previous conversation that not only is it less common in earlier, so it's an advantage to introduce it earlier, but that the reaction is actually less severe early on. So like a further incentive to do these foods early would be that the reaction is potentially less severe. Is that correct?

Ron Sunog (8m 56s):

Yeah, that is correct. First I'll say, you know, regarding the word anaphylaxis, people do use that in different ways. Technically anaphylaxis is simply having any two of those symptoms, so more than one symptom. So for example, if a child has rash and vomiting, that is technically anaphylaxis, but if it doesn't go any further, that is certainly not life-threatening. When people hear the word anaphylaxis, they think of something much more severe. And again, it can be, but in most cases are not. So yes, during infancy, the chance of anaphylaxis is lower and the chance of fatal anaphylaxis is lower.

Katie Ferraro (9m 31s):

Do some reactions go away on their own or will all require some sort of medical intervention.

Ron Sunog (9m 36s):

The short answer is yes, my guess is a lot more go away than we're aware of. Because for example, an infant can have a reaction that consists entirely of just fussiness. So, you know, infant can try a food, can just be fussy from it and that goes away. And you can imagine that parent is likely not going to seek medical attention or report it to anyone, but yes, they can go away on their own.

Katie Ferraro (9m 60s):

Okay when you mention some of the reactions I know recently on Instagram, they're doing a lot of awareness about food allergies. And there was a mom who she had tried like 50 new foods with her baby. And she has an older child. Who'd had, has a number of food allergies, including most of the tree nuts, but also mustard seed, which I thought was interesting. I know that's not as common, but I certainly hear about it more frequently than I used to. But this baby is on her, like 56th food, the baby. So the younger sibling had a reaction and it was to tilapia. So the mom had actually tried fish previously, which was interesting. And the baby's hands got really swollen and the family is black and the mom was sharing pictures and she was telling, she was like, you know, you need to do a better job of showing how reactions actually look different on different skin tones.

Katie Ferraro (10m 46s):

And she said on my baby, I don't see anything on her skin, but a second is the hand starts swelling. I noticed that because my first daughter had that with reaction. I was just curious if you see that sometimes where the reaction occurs, not on the first, but on subsequent exposures. And then second question, for babies of different skin colors does the reaction look different?

Ron Sunog (11m 6s):

So I'll answer the second one first, absolutely different skin color rashes can be easier or more difficult to see, so that absolutely can be an issue. I'm sorry. Repeat the first question again.

Katie Ferraro (11m 19s):

The other question was, is it usually the case in your experience, you work in this field day in and day out that a baby is having the reaction on the first exposure like that baby, it had salmon, no problem. But then with tilapia, subsequent exposure they had a reaction.

Ron Sunog (11m 32s):

Yeah. So there's sort of two parts to that. One is having had one kind of fish does not guarantee you won't be allergic to any fish. Certain foods overlap where if you're allergic to, you know, for example, cashew, your odds of being allergic to pistachio are higher. So that's one thing. So that's not a particular surprise that a child had one kind of fish and then react it to another if there's no overlap, let's say. As far as a having had a reaction on a first ingestion of a food. So technically you, you really shouldn't have a reaction on first exposure to anything, but that is something that gets reported, right? So, so what explains that in the answer is unknown exposure.

Ron Sunog (12m 16s):

And what that means is what you think your infant is eating for the first time, there might have been some very small amounts, let's call it even microscopic in some other food, or they were simply exposed in the environment. Most pointedly like a, I talk about a lot in my book, APA exposure through the skin. So if there's food in a house, there can be residue of that food in the dust, in the house and the child, can get, an infant can get exposed that way. So when they're then eating the food for the first time, they've actually been exposed to it before,

Katie Ferraro (12m 46s):

Because I know parents will say, that's not true. The first time my baby had, an example eggs, they blew up. They had all these rashes, vomiting, etc. What Dr. Sunog is saying is that may not have essentially been the first exposure. So just be aware of that, because I think sometimes, especially with the less commonly consumed foods like shellfish, parents will try crab and they're like, all right, knock that off the list we did crab once the babies had it, they're not allergic to it, but that might have truly been the first exposure where we wouldn't anticipate seeing the reaction. So we encourage parents to feed these foods early and often. And I was wondering Dr. Sunog, if you could just expand on that because when parents hear early and often, their next question is how much over what period of time of these different allergenic foods should we be feeding?

Ron Sunog (13m 28s):

That takes me back to the base study. The leap study back in 2015, showed that feeding peanut protein to infants early and often decreased their risk of developing peanut allergy. So the specific data from that study showed that starting under age 11 months, and then eating a peanut food, two grams of protein, peanut protein three times a week on page five was protective against peanut allergy. So that's very specific information talking about peanut again specifically, is that the exact right amount? Well, that study proved that that amount worked with less work with, you know, something less than two grams, three times a week work.

Ron Sunog (14m 10s):

We don't know. And I can promise you if you need the results of a study to prove it. We will never know because no one's going to repeat that study with less peanut protein. And then as far as other foods go, there are no specific amounts that anyone can point to from a study. Studies have shown that early introduction of other foods decreases the risk of food allergy, but the, how much, how often, hard to say, which is why most people say early and often

Katie Ferraro (14m 38s):

It's like purposely ambiguous. It's frustrating as a parent, especially if you're like type a like me and you want to know the number of grams and how often, but I love it. You're just reminding us. You're not missing anything. That guidance is not out there.

Ron Sunog (14m 49s):

Right. It's unknown. So my recommendation would be, you do your best with it. You try to introduce a lot of foods. You try to feed them repeatedly. You don't get the idea. You know, you mentioned earlier, you know, child eats crab. They didn't react, cross it off the list, it, number one, you can't cross it off your list and say, my child will never be allergic to crab. And number two, if your intent is to decrease their risk of developing allergy by feeding it early, it's not a one and done thing.

Katie Ferraro (15m 16s):

Don't forget the often part of early and often. So you mentioned the leap study. So that's learning early about peanut allergy. And from that study, we've kind of had a shift in what we now know constitutes high risk for peanut allergy. So would you mind sharing, what is it that makes a baby at high risk for peanut allergy based on that, and other reasons research?

Ron Sunog (15m 41s):

When you're studying anything, you need a population that's selective enough that you're going to see results without having to test thousands or tens of thousands of people. So the leap study wanted to find a population of infants, where they knew that their risk of developing peanut allergy was relatively high, so that if kids got peanut early, during infancy early and often, and they didn't develop peanut allergy, somebody couldn't say, well, the odds are so low anyway. So they took kids who had either egg allergy or severe eczema because those infants with those conditions are at significant risk of developing peanut allergy. And we know that if they don't eat peanut early, that something like 20% will develop peanut allergy.

Ron Sunog (16m 27s):

And then they took those kids and fed them peanut and 80% fewer had peanut allergy when they ate peanut as infants and again, early and often important point on that in terms of high risk, only about 3% of all kids are going to have either severe eczema or egg allergy or both.

Katie Ferraro (16m 47s):

Are there in case you guys missed. It was severe. I know everybody's baby has eczema. Parents hear eczema, they stop listening to everything else. They're like, yep, that's my baby. We're high risk for peanut. I'm not doing this, especially until COVID is over. And I see a lot of parents unnecessarily delaying the introduction of these potentially allergenic foods and to kind of put the guidance in other words, if you look at all of the major health bodies, their recommendation is including the American Academy of Pediatrics, is that there's no benefit to delaying the introduction of these foods. We used to think, oh, if you wait until after one to do egg whites, your baby will have a lower risk. We now know none of that is true, no benefit to waiting. So you should be doing it early and often if you're not already convinced to do so.

Katie Ferraro (17m 30s):

So Dr. Sunog, I want to switch gears and talk more to, and again, I identify as a type A parent like very nervous about introducing new foods and allergenic foods. And especially in the time of COVID, when we don't have such regular access to medical care, you don't just saunter into the pediatrician's office like you used to, and you graciously did a whole separate episode for us on, is it safe to allergenic foods during COVID and you guys, I'm going to link to that episode in the show notes for this episode, because I think it's important to listen to it because the guidance is a little bit different if you can't go to your pediatrician. And so if you go to the show notes for this episode, it's at blwpodcast.com/58. I'll link to Dr.

Katie Ferraro (18m 11s):

Sunogs previous episode about COVID. But right now, okay, parents want to take precaution, should they get an epi pen? Like my baby's not at high risk, but I'm thinking about doing peanuts. Can I call my pediatrician and get an epi pen? Just in case there is an anaphylactic response?

Ron Sunog (18m 24s):

So again, the short answer, no. So speaking of the high-risk kids, so it seems like a dilemma, right? You've got a high risk infant, and you know, if you feed them peanuts, there's a certain chance they're going to react. And again, they could react on that first known exposure because there's probably been unknown exposure. And what I mean by that is if this child, particularly, they have eczema, if there's peanut in the household and something like 95% of households have peanut butter, there will be peanut in that infant crib in the dust, you can almost guarantee it. So you've got a high-risk infant and you know that they have a high risk, less than 50%. Like I said, about 20% of reacting to the first time you give them a peanut food, but here's the dilemma.

Ron Sunog (19m 11s):

If they're in the 80% who won't react on that first ingestion of peanut, if you don't give them peanut through infancy, as they get older, they have a higher chance of becoming peanut allergic. So you want to give it to them. So what do you do? Well, one choice is to just give it to them. I'm not saying I recommend that, but there are experts who do because of something we spoke about earlier. And that is what is the risk they're going to have if they should have a reaction, a very serious or life-threatening reaction. And the answer is almost zero. Okay. So even though there's a significant chance, they'll react because they're high risk, there's an almost 0% chance it's going to be life-threatening. Experts recommend What I agree with is those infants should be tested first.

Ron Sunog (19m 53s):

In the age of COVID, how do you do that? Well, you have two choices. There's a skin test and a blood test. The skin test is scratch test. You can still do that. That'll be done at the allergist's office. Talk to your pediatrician, you know, presumably send it to the allergist. So that's one way to do it. But if you want to avoid the office because of COVID, although my guess is you're not seeing a lot of COVID patients in allergists office like you might in the ER, for example. You can do a blood test. Again, you would have to go to the lab and going out and about there is certainly some risk, but I, I would say, you know, that can be done safely and you get a lab test. And so if you show that your infant is not allergic, even though they're high risk, you absolutely should give that infant peanut food early and often.

Katie Ferraro (20m 38s):

Okay. What about for parents? The ones who ask, okay should I go and drive up in front of the emergency room and test the potentially allergenic food there with the notion being, if there was a reaction I'm right next to emergency medical, is that advisable for not even your high risk, just your general run of the mill parents?

Ron Sunog (20m 56s):

For your not high risk, there is of course, some risk of allergy of allergic reaction to peanut or any of these foods, but the risk is so low. And again, the risk of something serious happening that you can handle by say, driving to the emergency room after it, you know, the reaction, I would not advise it. And I would say, you know, there isn't any expert who advises that foods. You should think of foods as being safe to introduce at home.

Katie Ferraro (21m 25s):

I want to circle back. If you don't mind, one more time. Could you do a run-through of the signs of an allergic reaction and maybe talk about which ones are more indicative of a reaction or not? Like I see parents, the baby tried tomato. There's a topical rash around the face. It goes away in an hour and they think their baby is allergic to tomatoes. So could you maybe just clarify what the signs of a severe allergic reaction are versus the mild one?

Ron Sunog (21m 50s):

Severe is when you see a lot of swelling and rash, particularly not around the mouth is so it becomes sort of a full body event along with any difficulty breathing and vomiting that is more concerning. If it's rash alone, that's generally not that concerning. In any of these events, you should call your doctor and, you know, potentially be evaluated, certainly with the severe reaction you should. And the severe reaction, if you give an infant food and they start vomiting and having difficulty breathing, you can go to the emergency room. In terms of really mild events, something that comes up pretty frequently is this thing called oral allergy syndrome, which is a local reaction, just the mouth, lips and that reaction almost never spreads to anywhere else.

Ron Sunog (22m 41s):

And it occurs with eating certain foods, lots of fruits and vegetables that have overlapping allergenic qualities with certain environmental allergies. For example, if you're allergic to Birch tree pollen, you could react when you eat an apple or cherries and other foods. That's very localized. Again, almost never progresses to something more severe. And that's a different thing. Certainly a parent would not be expected to differentiate between these things at home and really just look at how, how sick does my infant. Well, and again, if it's difficulty breathing, vomiting, go to the emergency room.

Ron Sunog (23m 21s):

If it's rash, call your doctor

Katie Ferraro (23m 22s):

You're a pediatrician, so you know, but I get messages all the time. Like my baby had eggplant. I know it's the nightshade family. I know it's potentially related to this one. As like at, at this point, you really should be consulting an allergist, not a dietitian to ask about how food allergies manifest, because just because you're allergic to one thing in one family doesn't necessarily mean you'll be to another and like with tree nuts, we see so many babies who are allergic to some tree nuts, but not all, again, as with many things in child development, each baby is unique. So it is always a good idea to be assessed by the appropriate professional first-year pediatrician who may then refer you to an allergist who then specializes in food allergies for children. So Dr. Sunog, thank you for all this fabulous information for parents who want to learn more about using food to introduce early and often and help prevent food allergy, where can they go to learn more?

Ron Sunog (24m 10s):

You can certainly go to my book, Eat The Eight. It has a lot of information about the wrong advice we gave before, the right advice we give now and why. And it talks about foods that infants most commonly react to and what those reactions are. And, you know, I try to talk to pediatricians about this and encourage them. In fact, interesting, I have a new nurse practitioner at my office and just talked about it yesterday and it was all news to her. So I'm always happy to spread this information to, to people who haven't heard it.

Katie Ferraro (24m 43s):

And I think it's important because I work very often with parents who will say, and then they will literally state the exact same guidance, which was what I learned when I was studying to be a dietitian 25 years ago. And I said that that information that your pediatrician just provided you is at least 25 years old. And we now know that we actually do the opposite. Cause we used to wait much longer to introduce these allergenic foods. And that's one thing I love about your book Eat The Eight is that you go through the history of the guidance and the recommendations and that how for many years, a lot of it was just based on folklore and we passed it down, wait until for example, one year to do egg white. But now we're looking so much more at the evidence that guides these recommendations, but it is important that pediatricians are up on that as well.

Katie Ferraro (25m 27s):

So thank you for educating, not only parents, but our pediatricians as well. And you guys, you can grab Dr. Sunog's book at eattheeight.com, he has a lot of other fabulous resources on his site for introducing these foods early and often in order to prevent food allergy. Again, that's eattheeight.com and I'll link up everything we talked about today in the show notes at blwpodcasts.com/58. Dr. Sunog thank you so much for taking the time to answer all of our parents and caregiver questions about what we do if our babies have an allergic reaction.

Ron Sunog (26m 4s):

My pleasure.

Katie Ferraro (26m 4s):

Well, I hope you guys enjoyed that conversation with Dr. Sunog all about what to do if your baby does have an allergic reaction. I just absolutely love speaking with him. I could like stay on the phone with him forever and pick his brain because he has such a calming way of really clarifying what the data says, what the science says, what the guidance is, and then what we should be doing. Like there's no nonsense when it comes to Dr. Sunog. So I'll definitely have him back to do future allergy interviews. But in the meantime, if you want to check out his materials, he's a really a wealth of knowledge. Again, he's a pediatrician who specializes in the introduction of food allergies. His book is Eat The Eight, it's preventing food allergies with food and the imperfect art of medicine. If you go to eattheeight.com and spell out E I G H T , that's where you can find his book and a bunch of other resources, but I'll go ahead and link that up on the show notes for this episode, which is that blwpodcasts.com/58.

Katie Ferraro (26m 55s):

Thanks for listening guys. Bye now.