David Stukus (59s):

The window will start to narrow as they get older in regards to those who are going to develop food allergy. So we do want to try to promote this as early as possible. If you haven't introduced a certain food by 9, 10, 11 months of age, that doesn't mean you shouldn't do it. It doesn't mean your child's going to have an allergic reaction. The first time they eat it.

Katie Ferraro (1m 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 competence and knowledge. You need to give your baby a safe start to solid foods using baby-Led Weaning. Tell me, how's it going with introducing allergenic foods to your baby? No pressure, no judgment. Just checking in today to see if you are trying to get these allergenic foods into your baby early and often.

Katie Ferraro (1m 54s):

And it's important, even though my feet kind of boring and not maybe the sexier side of introducing solid foods, but we've got some good data to support this idea that the introduction of allergenic foods early and often for Babies can help prevent food allergy down the road. But I wanted to take a little bit of a closer look at this idea of the prevention window. And so I'm so grateful that Dr. David Stukus is back on the podcast to help us understand a little more about this timeframe for Babies. And particularly When Does the Food Allergy Prevention Window Close? So my guest, if you're not familiar with his work, or you've never heard him speak before is Dr. David Stukus. And he is an absolute joy and a pleasure to chat with because he not only knows everything about food allergies, but he also has an incredible way of summarizing the data and the current guidelines to put it into practical and applicable recommendations that parents and families can use.

Katie Ferraro (2m 48s):

So he's a pediatric allergist who specializes in food allergies. He's the director of the food allergy center at nationwide children's hospital. And he's also an internationally recognized expert and authority in food allergies. If you're on Twitter or Instagram, he's at allergy kids, doc. And again, I know the allergy stuff can be a little bit dry and sometimes it can be scary, but I'm so grateful for experts like Dr. Stukus, who are willing to share their time, come on and answer our questions. And today really helped clarify what can sometimes be confusing recommendations about the timeframe for introducing babies to these important allergenic foods. So with no further ado, let's welcome Dr. David Stukus, who will be talking about When Does the Food Allergy Prevention Window Close?

David Stukus (3m 35s):

Well, thank you so much for having me back. It's great to be here.

Katie Ferraro (3m 37s):

I never want to take advantage of your expertise, but anytime questions come up, I'm like we got to ask Dr. Stukus to come back and gotta ask him to come back. So I know you've been here before helping our audience learn about, for example, we did an episode on the limitations of food allergy testing, and it's one of our most downloaded episodes because it blows parents' mind that like up to 50% of food allergy positive results are actually false positive. So, but to back it up for listeners who maybe have not heard from you before, could you give us a background of your work and what you do as a pediatric allergist?

David Stukus (4m 3s):

Oh, absolutely. So I'm more than just a pediatric

Katie Ferraro (4m 5s):

I know, sorry. You're so much more than that.

David Stukus (4m 7s):

Oh, no, I didn't mean that. I meant more just that I really just focus now on just food allergy, which is, it has changed my whole career. We opened our food allergy treatment center at my institution nationwide children's hospital in Columbus, Ohio a year ago, we just celebrated our one year anniversary. So this is all I do now. But as a pediatric allergist, immunologist, you know, I received specialized training in treating all sorts of allergic conditions, whether it's food, allergy, asthma, environmental allergies, eczema, medication allergies, and Alyssa. But now all I do is focus on food allergy, which has been amazing for me because I am seeing all of the little tiny nuances in regards to how food allergies can present and how we can manage them. I promise you and your listeners, this is not one size fits all.

David Stukus (4m 49s):

It is not set it and forget it. Our approach to food allergies has changed dramatically just in the last few years, because the evidence has evolved.

Katie Ferraro (4m 57s):

I know it's hard to get excited sometimes about things like allergies. I think it really is such an exciting time to be working in this field because we have more and more data that's really kind of paving the way. Whereas it used to feel like in the, like, I don't know, 20 years ago when I was studying to be a dietician, we're just kind of like grasping at straws in the dark. It felt like just don't feed your baby egg until one. Well, why not? Well, we don't really know, and there's really no research, but it just feels right. It's like we don't do that anymore. There's so much more evidence to support the guidelines today regarding food allergy introduction.

David Stukus (5m 24s):

No, there are. And you know, I liken this to where we were with asthma 10, 15 years ago. We're the same place with food allergy and where we are with asthma now is we know that there it's not just one size fits all. There are many different types of asthma and there's different approaches to therapy and prognosis and management. And we are just on the cusp of that with food allergies. Are there people out there with very mild food allergy? Yes, there are. There are people that, you know, no matter how much you feed them, they're not going to have anaphylaxis. And there are people that are exquisitely sensitive. If they eat trace amounts, they could have a life-threatening reaction. Now we're still trying to figure out how to best identify those nuances to help those families navigate it. But you're right. A lot of what we did in, in regards to introduction guidelines was just based upon experts at the time thinking what was the best approach, which made sense at the time, we don't want to second guess, you know, ourselves for decisions we made two years ago.

David Stukus (6m 13s):

Cause we all do the best we can with the evidence available at the time, but we absolutely have to allow ourselves to adapt and change our approach as the evidence evolves and accumulates. If we've learned nothing else over the last couple of years of living through this pandemic evidence evolves, that can be really hard for people to understand. And, you know, from a healthcare professional standpoint, we have to acknowledge how hard that is as well. And we have to be able to say like what I do every single day, almost every single exam room, listen to the conversation we're about to have now would not have taken place five years ago because the information we're going to discuss now didn't exist then. So I think we just have to acknowledge that it's okay to kind of change and change can be hard.

Katie Ferraro (6m 52s):

Especially from kid to kid, we have some families that I was just working with a mom who had a ten-year gap. Baby has food allergies. And she was like, this is so different from what we even did 10 years ago. And that's what we're here today is talking kind about timing and using food to prevent food allergy. And we know that there's pretty good data and updated current guidelines that support this idea of early introduction of allergenic foods to prevent food allergy. And we know, and we're always teaching parents, listen, there is no benefit to withholding introductions of these foods to your babies. But I wanted to ask you about this idea of the protective window for when introducing foods can help prevent food allergy closing somewhere around the 11 month age started to hear more about this kind of 11 month where's this info coming from.

Katie Ferraro (7m 33s):

And is that truly when the protective window does close for Babies?

David Stukus (7m 37s):

Yeah. So before I talk about that, I think it's really important for all of us to acknowledge that there has been a culture of fear created around the food allergies over the last couple of decades. We're a part of it, the general public,

Katie Ferraro (7m 49s):

The commercial supplement companies, if I may are a huge part of it,

David Stukus (7m 53s):

No everybody's afraid to feed their babies. As you take a thousand babies born today, 920 of them, no matter what you do will never develop food allergies. Think about that. So if all of those thousand families are treating their babies as is, if they're ticking time bombs, that they're gonna explode the first time they eat a food, that's a disservice to the vast majority of those families. So we just have to, first of all, acknowledge that the vast majority of children will never develop food allergies, no matter when you feed them. That being said, we have learned through excellent evidence, both through observation data and through randomized controlled trials where we actually take two groups of children at a very young age and give half of them, allergenic foods like egg and milk and peanut and things like that.

David Stukus (8m 33s):

And the other half we avoid introducing until a certain age and we see which groups develop food allergy. And there are differences in those who start eating foods early in life, as opposed to those who wait. Now, as far as these specific numbers, I really want everybody to understand that a lot of this is made up to a certain degree of when you design these research trials, you have to come up with some endpoints. You have to, otherwise you can never answer the question. So a lot of the observational data, or even the introduction studies, you just have to pick a time point, the pivotal leap study, where they actually demonstrated for the first time that the earlier we introduced peanut to infants and keep it in the diet can dramatically reduce the risk of developing peanut allergy. They just chose the age range of four to 11 months.

David Stukus (9m 14s):

That's what the researchers looked at initially. And they went from there. A similar study called the EAT study, looked at multiple different allergenic foods. They went down to three months. So there's a range here and it's not like the day your baby turns, 11 months of age, something switches in their immune system. It's not black or white. There's huge variability, but we can take our understanding of these different studies and then group them together to offer guidance to families.

Katie Ferraro (9m 37s):

So what do you do for parents? Because you are always working with parents in the clinic setting in a research setting, and it's like, they're scared about introducing these new foods and we try to show them the, you know, the only thing that you have control over as far as reducing your baby's risk for food allergy is to introduce these in a timely fashion. Sometimes the parents have babies nine and 10 months old and they had maybe done peanut or have maybe done egg. Is it still possible for them with older infants to get the protective effects of quote unquote early introduction? Or did you kind of move them along at a, maybe a little bit more quicker pace without panicking them? Of course, I'm just curious. Cause there's parents of older babies listening for sure.

David Stukus (10m 11s):

Yeah. It goes back to what I mentioned before. The vast majority of children will never develop through dollars no matter what you do. So yes, there's still a window of opportunity. Now we do know that the earlier we introduce and keep it in the diet, that's the, it's not just a little taste and then you go six months without giving it again. We want to have it actively included in the diet. That's our best bet to try to prevent food allergies from developing. It is advised to start between four to six months of age, which is just when most infants start to demonstrate the ability and interest to eat solid foods. That's when we typically introduced purees and cereals and things like that. So we want to make sure they can chew and swallow before we do it. So that's just the window. Some infants may not be ready until they're a little bit later, but the window will start to narrow as they get older in regards to those who are going to develop food allergy.

David Stukus (10m 53s):

So we do want to try to promote this as early as possible, but that being said, if you haven't introduced a certain food by 9, 10, 11 months of age, that doesn't mean you shouldn't do it. It doesn't mean your child's going to have an allergic reaction. The first time they eat it, there are other risk factors we can take into play. Does your child have moderate to severe persistent eczema? Not just little patches here and there that pop up, you know, over time is truly persistent eczema despite using a good deal of the skin care regimen, potent topical corticosteroids, things like that. Is there a family history of food allergies as your child developed food allergies, allergies to other foods? And the thing that I say to parents is that, look, if you're scared about this and you're worried about food allergies, let's do everything we possibly can to prevent that from happening. Let's keep this from introducing into your life because this is a life-changing experience, but it's also important to acknowledge that nothing that we do in medicine is 100% effective, nothing.

David Stukus (11m 42s):

So there are children that despite early introduction will still develop food allergies. We don't fully understand why, but the pathway towards preventing food allergies, the vast majority is to introduce it early and keep it in the diet.

Katie Ferraro (11m 54s):

And also I think we should remind parents who came on a different episode, talking about this kind of tendency and proclivity in some healthcare settings to over test for everything. And if you guys are interested in testing and episode 125, Dr. Stukus was here talking about why our false positive results in food allergy testing so common. And the answer is not to go blanket test for every single food out there because you never test for a food that your baby has not reacted to. Is that still your general thoughts? Dr. Stukus

David Stukus (12m 20s):

From a medical standpoint, I've actually changed since we last spoke. Oh

Katie Ferraro (12m 24s):

Good. Then you're back.

David Stukus (12m 25s):

And I say to them, I say, listen, from a medical standpoint, there's really no indication to do any testing. The best test is what happens when you eat the food. If you're eating a food without having reproducible symptoms, you're not allergic to that food. If you've never eaten a food, I can't predict whether you have a reaction to that food, just because you have an elevated skin test, a blood test, it doesn't diagnose you as having food allergies. So for medically speaking, there's no indication to do any food allergy testing. And then I say, but I'm talking to you. You're a human being. You're a parent. Do you have fears? You have concerns. So if there's a role for limited testing, I'm happy to do that with you. As long as we got to go into it with the understanding together that just because there's an elevator result, it doesn't mean we have to avoid the food. In fact, I'm going to say, come back into my office as soon as possible or even today. And let's feed that food under supervision because your child may be sensitized for tolerance.

David Stukus (13m 9s):

And if we avoid that food, they're the ones who go on to develop allergy. If the tests are negative, that's great. Go home and feed all these foods at the same time, which is one more important point. I really can't emphasize enough. There's emerging evidence. It's not clear cut, but emerging evidence that diet diversity matters. So the more foods that we introduced to babies and keep it in their diet from an earlier stage, that's associated with decreased risk of developing food allergies. And why is this important? Because there's a lot of people out there still saying one new food every five days or one day food every seven days. So let's do the math. If you do one new food, every five days, that's six new foods a month. And then over six months between six and 12 months, that's the only 36 new foods. Whereas if you give it because most children will not develop food allergies, you get multiple foods either on the same day or within just a couple of days, you're going to significantly expand their diet.

David Stukus (13m 56s):

They're going to love to learn, you know, different textures and different tastes and different foods. There'll be healthier, have more nutritious options. And you'll also lower the risk of developing food allergies at the same time. So I really want to emphasize that point as well. And I see you smiling. So

Katie Ferraro (14m 9s):

I know, well, I, you know, I can't help myself the whole research about diversity. The underpinning of my a hundred FIRST FOODS approach for baby Led Weaning is helping babies learn to eat. We follow my five step feeding framework. We do five new foods a week, including one allergenic food. Every week, it's 20 foods a month in five months, your baby has achieved a hundred foods with all the different textures with the high iron foods. We've gotten all the allergenic foods in and then we're working them and continually offering them to babies. So we're getting those foods in early and often. And I was smiling when you said diet diversity, I'm actually in an advanced food allergy course for dietitians taught by Carina Venter and Marion Groetch. And we were just looking at the diet diversity data out there. And it's so nice to be able to focus on all the foods babies should eat, right, as a dietitian specializing in baby-led weaning.

Katie Ferraro (14m 50s):

I want parents to walk away thinking, gosh, look at all these foods that my babies can eat instead of which historically, you know, and no offense to pediatricians and physicians, but more than 90% of them have never taken a dedicated nutrition class. And so we run into this problem of many physicians still perpetuating these age old myths of waiting three to five days between foods. And we're actually seeing that that could potentially be doing more harm than good because there's certainly no need to wait. So we want you to be inspired to try all these foods with your babies, including the allergenic foods.

David Stukus (15m 18s):

It's a paradigm shift. You know, all of us know pediatricians and parents. We don't want to harm our child. Nobody wants that, but we also have to be able to understand, oh, wait a minute. What we once thought was true is no longer true. Even the kids who present with their initial allergic reaction, it's often just rash and they might bomb at one time. Very rarely do they have respiratory compromise with the throat swelling shut. And if you're truly concerned about it, instead of waiting five days between foods, just give a small amount, wait five or 10 minutes, not 5% days, give a little bit more, nothing happens a little bit more, a little bit more, a little bit more go slowly. And then if symptoms do occur, they'll generally be more mild. And then you'll have an idea, you know, not to give any more of that food.

Katie Ferraro (15m 54s):

And Marianne's coming on later in the month to talk about FPIES, which is a very unique and distinct subset of potential food allergies. We remind parents that with the vast majority of food allergies, if your baby is going to have a reaction, it will occur within minutes and up to no more than two hours following ingestion. So this idea of like, I'm going to try a strawberry and then three days later, the cost of the stool looks unusual. I wonder if they're allergic to strawberry, that's just not how it works. And so there really is no need to build in this three to five day window, which is just slowing down our babies from doing what they want to do, which is try a bunch of new foods while they're under this flavor window. So I want to ask you if it's okay to go to the opposite end of this protective window for food allergies, the age at which we start the introduction of allergenic foods and a lot of practitioners just let it kind of rolls off the tongue four to six months, four to six months.

Katie Ferraro (16m 41s):

But the physiological changes in differences that occur in babies from four months, till six months of age are really different, right? Like two months to you and me, not a big deal, but in the developmental lifespan of a baby, what they can do at four months is significantly less than what they can do at six months. And so we generally don't recommend starting anything except breast milk or formula, or offering that to baby until six months of age, because they're not sitting up relatively independently and they don't need anything from a nutritional standpoint. So outside of like the very, very high risk for peanut category, which we know there's benefits to introducing peanut prior to six months for those babies for everybody else, is there really any data to support the idea that earlier introduction of allergenic foods at four months, is that hard and fast?

Katie Ferraro (17m 22s):

Yes. More protective than starting at six months of age for foods like egg and milk.

David Stukus (17m 27s):

Yeah. That's where it gets tricky. And as we sort of talked about at the beginning of there's, these different cutoffs are different studies. So the earliest one was the eat trial where they went down to three months of age. And if you look at the study overall, they didn't see a significant difference. And those who started eating it three months versus six months. But if you look at the group that actually could adhere to the number of foods and how much they ask them to eat, there was a difference, especially for egg and peanut. But to your point, that shows that I think 70% of the children weren't able to eat all of that food starting at three months of age. So they just weren't ready yet. But in fairness to the study, I mean, they're talking to like egg whites and like Sesame paste and fish and things like that. So yes, it's a window. And this is one of the most common things that I hear from parents of, you know, comparing your child to another child or to other siblings.

David Stukus (18m 9s):

The developmental milestones are this broad range of not days, months for some. And it's all normal. Some children may be ready to eat it for months. Others may not be ready until six months, but I don't want anybody out there sweating or thinking that if you don't do it by a certain date, that you're not going to achieve the outcome one, you have to go by what your baby is showing as far as the readiness stage.

Katie Ferraro (18m 29s):

And we don't want you to feel any undue pressure to do something your baby's not ready for yet. Right. We always talk in feeding about meeting your baby where they're at, but we also just like these ideas to be on parents' radar, because let's say you're not paying attention between six and 12 months, and now you've got 15 or 18 month old and you haven't tried any of these allergenic foods. We know that that's not ideal either,

David Stukus (18m 47s):

Right? No, you're absolutely right. So there there's, you know, as with everything in life, there's, there's a happy medium. I think of everything as a bell-shaped curve, right? So the vast majority of people fall in the middle, then we have our outliers. The vast majority of infants will be ready to eat solids probably around 5, 6, 7 months. I think there's the two window group there. Some, a little bit earlier. Some might not be ready until a bit later. Does that mean that they're abnormal? No. It just means that they're outliers within the normal spectrum. And then, you know, figuring out where your baby lies, it's, it's up to you and your baby and hopefully guidance from pediatrician. I do want to caution everybody out there from the stories that you read on social media. And you know, I, I look at this stuff sometimes it's almost horrific to me because one to touch on your point earlier, a lot of people were saying, well, this is what my allergist told me.

David Stukus (19m 28s):

And I say, well, that was either outdated or it's been proven incorrect. So yes, they told you that, but that was five years ago and things are different now. Or the second thing is what we, we think of as like these echo chambers and bubbles. When I post things about FPIES, it seems like everybody on social media has a baby who has FPIES

Katie Ferraro (19m 45s):

Any baby who's ever vomited has have FPIES

David Stukus (19m 47s):

Whoa, no, no, no. I mean, this is all I do for a living. And you know, we see thousands of patients a year. We diagnose FPIES like 10 to 15 times. So it's very rare. Is it out there? Yes. But you know, just because your baby hasn't symptoms, it doesn't mean they have that diagnosis.

Katie Ferraro (20m 2s):

I just want to point out that we had to wait to do our FPIES episode. I think it's going to be episode number 230. So it was like, we need 229 other data points before we even talk about it because your baby is very, very unlikely to have FPIES. But again, sometimes the power of social media, like I love parents can see babies, eating meat and eating food based versions of all these allergenic foods. And I love that. But on the flip side, they hear about something like FPIES. And if they don't truly understand it, they think any vomiting incident is an indicator of FPEIS. And then they are unnecessarily withholding, huge categories of food and important food. So we don't want that to happen to you, but we do have enough pies episode coming up soon.

David Stukus (20m 40s):

Excellent.

Katie Ferraro (20m 41s):

So, Dr. Stukus thank you so much before I let you go. I'm just curious, any interesting projects that you're working on, anything coming out soon, you're always kind of on cutting edge of food allergies and pediatrics. So just interested to hear what's inspiring you these days.

David Stukus (20m 52s):

Yeah. So with the launch of our center, I'm honored to serve as the director. So I have to get all of our clinical operations up and running and I have my dream list of things to do, but we didn't even wait. Like we out of the gate, we just adopted the approach we always have. So we truly have this holistic approach to treating food allergies. It's not just a voice. We have a nice life. We address psychosocial concerns. We address anxiety. We do these proximity challenges where people, honestly, this is the most powerful thing I've done. They legitimately think they're going to die. If peanut butter touches their skin and they're gripping the chairs in fear and you know, there's myself and we have a psychologist involved and we show them, we can say, we can take away the, what if scenarios and show you. It doesn't mean you're not allergic to it, but it shows you the casual exposure is not going to cause any symptoms at all.

David Stukus (21m 35s):

Or if they do occurrence a mild rash. So we're doing a lot of that. We're going to be starting our oral immunotherapy program very soon as well. It took us a little while to get our logistics in a row, but want to do it right. So when they should, that's right. And we've already started our clinical research. Charles we're, we're involved in one right now and we already have two more ready to go. So we are just, we're doing everything we possibly can to help the families in our community and beyond. And it's an honor to do so. It really is.

Katie Ferraro (21m 57s):

Well, thank you again for sharing your time and all your expertise with us, tell us and our audience where they can go to learn more about your work there as a pediatric allergist, specializing in food allergies.

David Stukus (22m 6s):

Yeah. So you can, I'm pretty active on social media. You can find me both on Twitter and Instagram under the handle @allergykidsdoc if you're not sick of my voice, I also serve as the social media editor for the American academy of allergy asthma immunology. And I'm the producer and host of their podcast series conversations, more of allergy where we have excellent deal experts from the world of allergy, talking about all kinds of things. So check me out online

Katie Ferraro (22m 29s):

And I will link to your podcast as well as all of your social handles and your website on the show notes for this episode, if you guys can find at blwpodcast.com, Dr. Stukus thank you again, always a pleasure to speak with you.

David Stukus (22m 40s):

Likewise, thank you so much.

Katie Ferraro (22m 42s):

I hope you guys enjoy hearing from Dr. David Stukus. He's one of my favorite people, certainly in the food allergy world. Cause I hate to break it to you and food allergies. Aren't always that interesting to parents, but he has such an incredible knack for taking what can be sometimes scary and confusing information and putting it into, I hate to say bite size, but bite size bits of information that parents and families can really use. So I'm going to go ahead and link to all of doctors, do disses resources, as well as his podcast and his social handles. There'll be on the show notes for this episode, including some of the other interviews that we've done. If you want to explore a, kind of more of his take on infant feeding with regards to allergenic foods, we've done a number of different interviews together over the years. That'll all be on the show notes for this episode, which you can find at blwpodcast.com/227 Thanks so much for listening.

Katie Ferraro (23m 28s):

And if you haven't done an allergenic food this week, go to your a hundred FIRST FOODS list, pick out one of the allergenic foods and make it a point to introduce that food early and often get it in your repertoire and keep moving forward with those allergenic foods. See you later, guys.