Dr. Melanie Makhija, MD, Allergist and Immunologist at Ann & Robert H. Lurie Children’s Hospital, and Associate Professor of Pediatrics at Northwestern University, talks about a new treatment for severe food allergies.
Interview conducted by Ivanhoe Broadcast News in April 2022.
Have food allergies become an epidemic in this country?
DR MAKHIJA: Yes, absolutely. Food allergy has become an epidemic in this country. We’ve seen an increase in the prevalence or the rate of food allergies over the last three decades. Food allergy happens in about eight percent of children, that’s all food allergens, not just peanuts, but eggs, milk, soy, wheat, tree nuts, fish, shellfish, and sesame are the most common. You can have a food allergy to any food.
Do you think it’s just because we’re diagnosing it better, or is it that for some reason we’re getting it more?
DR MAKHIJA: We’re actually seeing more of it.
Why is that?
DR MAKHIJA: That’s a Nobel Prize-winning question. We believe that we’ve probably shifted our gut microbiome. All the bacteria and different organisms in our gut, we believe that there’s been a shift and it makes us more prone to recognizing things that we’re not supposed to be allergic to as allergic.
Is there not a lot of treatment out there for it other than staying away from peanuts?
DR MAKHIJA: Yeah, exactly. For right now, the general recommendation for food allergies is to avoid the allergen, even in small amounts or cross-contamination. We give patients a prescription for auto injectable epinephrine, which is an emergency medication. We also give them an emergency action plan, so they know how to use their emergency medications and when to use them.
As a kid, it can probably affect a lot of things, right?
DR MAKHIJA: Yes, absolutely. Birthday parties, school, everything. Food is so important.
What is OIT?
DR MAKHIJA: OIT is oral immunotherapy. Oral immunotherapy is basically giving the patient the food they’re allergic to, starting in very minuscule doses and then, gradually increasing the amount. The goal of oral immunotherapy is to trick the child’s body into thinking they’re not allergic so that if they have an accidental exposure, they’re less likely to have a reaction. And if they do have a reaction, it’s a less severe reaction.
Now, that hit the news with peanuts, right? Are they doing anything else now with that?
DR MAKHIJA: It has been FDA approved for peanut, and there are trials going on looking at a multiple food oral immunotherapy product. There are people who do oral immunotherapy that’s not FDA-approved to other foods. But there are other foods in the works.
Is it true that a lot of people don’t know that OITs exist? – I was not part of this study
DR MAKHIJA: Yes, OIT became FDA approved in the middle of the pandemic. So, I think that the awareness is a little bit less than what we would have seen otherwise. COVID, in terms of medical news, was at the top of the headlines, the top of the news stories, understandably so.
Did you find that it hit some demographics a little bit more than others?
DR MAKHIJA: The food allergy population tends to be well-educated, and I do think that it hit a more internet-using, technologically savvy population, more so than others.
Can you tell us about your research?
DR MAKHIJA: I run our Oral Immunotherapy Program here at Lurie Children’s where we have patients who get desensitized to the allergens, they are allergic to, but primarily to peanuts through the FDA-approved product. I run clinical trials. We do research for all different treatments for food allergy that are being developed now.
Are you guys worried with the OITs that people will try to do this themselves?
DR MAKHIJA: Yes. It’s a concern of mine because when we do oral immunotherapy in clinic, we start with 1/600th of a peanut. So, it’s a very tiny dose. It would be very hard to measure at home. And we still see reactions. I think it’s important to work with an allergist and work with somebody who is familiar with the treatment and can monitor the treatment over time.
What is on the horizon with your clinical trials for people with food allergies?
DR MAKHIJA: Even if oral immunotherapy isn’t right for a child, there are a lot of different treatments being developed for food allergies. It’s an exciting time in the food allergy world. If, unfortunately, you have a food allergy, there are things that are being worked on like a – there’s a peanut patch that’s being developed. There is a sublingual immunotherapy. So, if you if you can’t do the oral immunotherapy, sometimes you can start with a little bit of the food under your tongue. There are biologic treatments which are injectable medications. The hope is that one day we’ll have a treatment that doesn’t involve eating the allergen, that’s more general and can treat multiple or various different food allergens.
Why is everything focused on peanuts? Is it just because more people are allergic to peanuts?
DR MAKHIJA: Peanut is a prevalent allergen. In children, the most common allergens are milk, egg, and peanut. Most kids outgrow the milk and egg allergy. So, even though they’re everywhere and it’s a huge problem, they’re a little bit more manageable because parents know that eventually, about 80 percent of kids will outgrow them. Peanut is a persistent allergen. Less than 20 percent of kids will outgrow their allergy. So, it has been the focus.
Are you born with an allergy or is it something that you develop?
DR MAKHIJA: We don’t know the answer. Often, allergies are discovered right after a child eats the food for the first time. So, we’re seeing a lot of four to six-month-olds who have just had an exposure to egg or peanut for the first time and have a reaction. But there’s a big study that suggested that if you introduce the food early, and that’s why we’re introducing peanut to babies, that we can prevent allergies in a lot of kids. My understanding is that there are a portion of kids who have an allergy, if not when they’re born, very early on. And then, there’s a portion of kids who develop allergies in those first few months of life as their immune systems are developing. But it’s not fully understood.
Is there a way to introduce foods to children that will prevent food allergies?
DR MAKHIJA: We used to recommend avoiding foods until the kids were older – like, don’t give your kid peanuts until they’re one or even three because of a choking hazard. And there were all kinds of recommendations. We realized that those were not the correct recommendations. The recommendation now is, for peanut and egg, there’s good evidence to suggest that if your child is at high risk of an allergy – if they have eczema when they’re a baby or they have a parent or sibling with food allergy – introducing peanut and egg early, between four and 11 months, and a lot of pediatricians recommend between four and six months, that you may actually prevent an allergy to those foods. For other foods, it’s not as well understood yet. There are studies going on. It’s hard to feed babies shrimp and fish and all these different allergens together. But the general thought is that introducing early is better.
Are there any other risk factors for kids like eczema?
DR MAKHIJA: Yes. So, if you have a parent with a food allergy or sibling with a food allergy, you are at higher risk. Also, if there’s a strong family history of, like seasonal allergies, asthma, any allergic conditions, you may be at higher risk of allergies.
Has there been anything coming out of the clinical trials that you’re working on that is surprising to you?
DR MAKHIJA: The most surprising piece to me is that with oral immunotherapy, kids seem to tolerate it well. And overall, even if they’re eating a small amount of the food, like one peanut’s worth of protein a day, when you do a food challenge, often they can tolerate much more. So, people worry that with oral immunotherapy, you’re going to have to eat, like, 20 peanuts every day and it’s overwhelming. And if the kids don’t like it, it can be a problem. But even if they’re eating one peanut a day, if you do a food challenge, they may tolerate 10 peanuts. So, that was surprising and exciting.
How long do these kids have to stay on the oral immunotherapy?
DR MAKHIJA: The recommendation is that they keep peanut in their diet for as long as they want to remain desensitized. So, we’re still trying to understand what that means. So, do they just have to keep a small amount in every single day? Can it be every few days that they have to take it? That’s still being understood.
If you stop taking peanut for, like, a year, does that allergy come back?
DR MAKHIJA: You’re likely to redevelop your allergy.
Is it permanent?
DR MAKHIJA: Yes. It’s likely to come back and you’re allergic again because it’s a desensitization. We don’t have a cure, yet. That’s the ultimate goal. We’re just not there yet.
Who would best qualify for OIT?
DR MAKHIJA: Oral immunotherapy isn’t great for everyone. If you have asthma that’s uncontrolled, it’s not a great treatment. For the FDA-approved product, it’s approved for kids right now, ages four to 17. There are trials looking at children as young as one year of age, so, hopefully, it’ll be approved for littler ones soon. Oral immunotherapy is not just eating peanut protein every day, it involves taking it around the same time every day with food. There are some restrictions that can be hard for children. So, they can’t exercise for three hours after they take their does; that is the recommendation by the FDA. They have to take it with food. And they can’t jump into a sauna or a hot tub because anything that gets your heart rate up can make you more prone to reaction. They also have to be careful if they’re sick, if they have a fever or vomiting or diarrhea, we recommend holding their doses.
How long do the doses last?
DR MAKHIJA: The doses are given once a day, every day. The recommendation is to stay on peanut protein indefinitely. But at some point, a lot of patients will switch to eating a peanut or may want to eat more than one peanut. So again, we’re still understanding the longer term.
Can you tell us about Adelina?
DR MAKHIJA: Adelina’s an eight-year-old girl who has a peanut allergy – peanut was her only allergy. Her mom wanted to not worry if she went to a birthday party or to a school event where there might be peanuts. So, she was able to be desensitized. She came in and did an initial escalation day, which is kind of the first day where you eat five doses of peanuts, starting with that 1/600th of a peanut. And then, we watched her, and she came back and then, started building up every two weeks, so, gradually increased the amount of peanut protein she was eating. And she’s now eating one peanut’s worth of peanut protein every day and has been doing well on OIT overall.
Is OIT enough to prevent a reaction if Adelina goes to a birthday party and there are peanut cupcakes and peanut butter cookies?
DR MAKHIJA: It’s not enough for her to be able to just pick up a peanut cupcake and eat it. But if she were to accidentally take a bite of something that had touched the peanut cupcake, she’s less likely to have a reaction. And if she did have a reaction, she’s less likely to have a severe anaphylactic reaction.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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