In this video, Theresa Bingemann, MD, reviews recent literature about early-introduction foods to prevent food allergy, some of the most common food allergies, and outgrowing food allergies. Dr Bingemann also spoke about these topics during her session titled “Food Allergy–Non Treatment” at ACAAI Annual Scientific Meeting 2022.

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Theresa A. Bingemann, MD, is an Associate Professor of Pediatrics and Medicine and the Program Director of the Allergy and Immunology Fellowship at The University of Rochester (Rochester, NY).

TRANSCRIPTION:

Dr Theresa A. Bingemann: My name is Dr Theresa Bingemann. I am an associate professor of pediatrics and medicine at the University of Rochester, and I'm also the program director of the Allergy and Immunology Fellowship there. So the goal of my session was to look at the literature over the last year and see which articles had the most impact on clinical care. And so the first two articles I chose had to do with early-introduction foods. We know that early-introduction can help prevent food allergy, and so people understandably are looking for the easiest way of doing that. However, the paper that I looked at was trying to figure out how much allergen is in each of these early introductory foods. And it turns out that the foods they looked at, some had one allergen, some had multiple allergens, but it didn't really matter which one it was. There was significant variability in the amount of allergen.

So the important point with respect to that is if you're trying to prevent something, we really need a little more data on the amount of allergen and how frequently it needs to be given to hopefully do that. The next article I had chosen had to do with actually allergic reactions to early-introduction foods. Parents buy these foods with the idea of hopefully preventing allergic reactions and some may. Most of the parents had introduced the foods between four and nine months. And in this paper from Mount Sinai, there were 12 infants who had reactions either to the early introduction food or to the food in its natural form after consuming the early introduction food. And so there were 12 infants out of about 1,200 that were being evaluated for food allergies. So we can't make a lot of conclusions, but the point is, when you're having shared decision-making and discussing this with patients, you need to consider the fact that these early introduction foods may not prevent allergy and acknowledge the fact that it is possible to have an allergic reaction to them as well.

I moved on to sesame allergy. The reason I picked this was you may know that sesame is now the ninth most common allergy in the US and you may have heard that the FASTER Act was past this past year that come January of 2023, sesame is going to be labeled on foods in the US. And so I wanted to look at whether the testing we had, what was the best test to predict whether someone would outgrow this allergy or not, or how would we know when we want to do a food challenge to test that. And so the first group looked at sesame-specific IgE testing. They looked at skin testing to sesame with the commercial extract, and they also looked at skin testing to tahini, which is a sesame paste. And what they found was is that skin testing to either the sesame extract or to tahini performed far better than the specific IgE testing when it came to predicting whom we should do food challenges in and who is likely to react or not to sesame.

And in fact, for the commercial extracts at a wheel size of 5.25 millimeters, it was pretty good. I believe the sensitivity was about 80% for predicting who would react. And for the tahini at a wheel size of six millimeters, it predicted with 100% accuracy reactivity. So it was really some good information as we're seeing more and more patients with this allergy.

The next sesame paper I looked at had to do with can we predict who will outgrow their sesame allergy? And so they took, I think it was 190 consecutive patients over four years in their practice and they wanted to find out, okay, who's going to outgrow and who isn't? And what they found was if kids were symptomatic earlier, so less than 10 months of age, they were more likely to outgrow. The kids that had the smallest skin-prick test wheel size to sesame extract, that's what they tested with in this study. So less than seven millimeters at presentation had a greater likelihood of outgrowing.

And those that also had a milder reaction, typically those with one body system also had a greater likelihood of outgrowing. The other factor that they found that was associated with an increased likelihood of outgrowing was not having a nut allergy. So the encouraging thing was that some kids are outgrowing. We haven't had a lot of natural history data, so this was useful. The other thing they showed in this study was when they did the food challenges, they did their first set of food challenges with sesame seeds. And a number of patients with sesame allergy may actually tolerate sesame seeds as they did in this study. However, the patients that tolerated sesame seeds were then given sesame paste, which is the tahini again, and about half of them reacted. So we know that a number of patients that tolerate sesame seeds may not tolerate more concentrated forms of sesame.

So then from there I decided to pivot to two adult studies. There is a delayed food allergy called food protein-induced enterocolitis syndrome that is recognized not as often as it probably should be, even in pediatrics. But basically what happens is someone eats a food and then they typically have delayed GI symptoms one to four hours after consumption of the food. So it's often missed because we're used to people reacting right away. And the kids that have this can also have... So repetitive vomiting and lethargy and pallor, and it can be kind of frightening for parents. It has now been recognized that this occurs in adults as well. However, the presentation in adults is a little different. Most adults, and it depends slightly on which study you look at, present predominantly with abdominal pain and diarrhea and then nausea and vomiting.

Interestingly, some of the studies have now also reported chills and shivering, and so things that we haven't really thought a lot about in the pediatric literature. The most common foods that adults react to are fish and shellfish. And one of the papers showed there are some associations where when some people react to some of the cephalopods, they may also react to finfish more frequently than those that didn't. And they also showed that adults that reacted to milk were more likely to react to egg. So some interesting associations that we hadn't seen previously. And then lastly, the papers also looked at, does this ever resolve in adults? And it turned out a portion of the population, I believe it was about a sixth of the population, actually did outgrow their allergy. And the interesting thing was the median time from when the individual had last had a symptomatic exposure to the food was about 15 months. So not all that long, all things considered. So it is encouraging to see that this will resolve for some adults.

So I would say the big takeaways are when considering an early introduction food, you need to consider the amount of allergen related to the food is actually in there to see if it's enough to prevent. You should recognize that it is possible that someone might react to these early-introduction foods and they may fail to lead to prevention. It's also important to recognize that when we're doing testing, we want to make sure we're using the best test to assess for what we're looking for. And so in this case, we know that sesame extract skin test as well as tahini skin test performed better than the specific IgE testing to sesame.

And then reassuringly, it's nice to know that some people will outgrow their sesame allergy and they'll likely tolerate sesame seed before they'll tolerate tahini. And then lastly, of course, that food protein-induced enterocolitis syndrome does occur in adults predominantly with abdominal pain and diarrhea and then possibly nausea and vomiting. And we should think about this and that most of the time it's going to be to fish or shellfish and that it may actually resolve in some people.

Well, thank you for having me with you today. I hope you found this information informative, and I hope you have a great day.