Anna Nowak-Wegrzyn, MD, Professor of Pediatrics, Director of Clinical Research at the Jaffe Food Allergy Institute, Department of Pediatrics at Gravis Children’s Hospital, Icahn’s School of Medicine, Mt. Sinai, New York, New York, talks about food allergies in children and a grant study using oral immunotherapy in children that are not super allergic.
Interview conducted by Ivanhoe Broadcast News in November 2018.
Your expertise is in food allergies?
Dr. Nowak-Wegrzyn: I am a pediatrician by training as well as an allergist immunologist with a special expertise in food allergy.
It seems like this generation has more food allergies than ever before, is that the case? Do we have more allergies or it just being diagnosed a little bit more?
Dr. Nowak-Wegrzyn: You know that is a great question; definitely for peanut allergies we know that there is absolutely a huge increase. Over the past twenty years there was tripling of peanut allergy prevalence in young children. Right now it’s about two to three percent of all of the kids in the United States that are being diagnosed with a peanut allergy. As far as other food allergies are concerned we don’t have such clear evidence that they have increased over the years. But what has happened which I can tell you is that even though there’s no evidence that there are more milk or egg allergies, we have more children that have very severe allergies to those foods. Before they would out grow it when they were two or three, certainly by school age. Now we have a lot of teenagers and young adults that now are seriously very allergic to milk, in addition to adults who are allergic to peanut and tree nuts. So it’s surreal, it’s not a perception, it’s happening.
Do we know why?
Dr. Nowak-Wegrzyn: That’s a million dollar question, we know parts of it like bits and pieces. Probably it relates to our lifestyle, for instance food allergy is a huge problem in the developed countries, societies like the US, Canada, UK, Australia, and all other countries of lower prevalence. There’s something about our lifestyle that sets us apart and it’s the food we eat, how we feed our babies, how much antibiotics we’re using. All of those pieces or factors are very important. The more simple, natural lifestyle, the fewer allergies there are.
What are some of the symptoms, does it range? Because when we think food allergies my mind as a mom always goes to those very severe allergies. Is that always the case when a child has food allergies? Walk me through some of the signs and symptoms.
Dr. Nowak-Wegrzyn: The term food allergy is a very general term. It basically tells this is an immune system that mediated a reverse reaction to food. You can have people that show immediate symptoms and the worst sort of manifestation is anaphylaxis. Somebody could potentially have a horrible asthma attack, a drop in their blood pressure, they could die from it. But it’s a small percentage of those people who actually have such a severe allergy. Other kids will have hives, some swelling or sneezing, maybe coughing but it’s not as bad. Then we have children that have a food allergy, which mostly manifests as skin rashes; like eczema, sort of a very itchy skin eruption. Then you have children who have food allergies that manifest with chronic diseases of the gut. You have user entervagvitis, food protein user entercolitis, or proctocolitis. It really spans different sort of disorders but also within each disorder there’s a spectrum, you have people who have more mild symptoms and then ones that are very extreme. Those are really the most challenging patients to treat.
What are the treatments?
Dr. Nowak-Wegrzyn: Right now we are still at the time where the standard of care is strict avoidance of the food. We cannot really offer, and we don’t have a cure for food allergies, so our best bet at this point is avoid it; eliminate it from the diet and hope the child is going to eventually outgrow it. As they get older most of the foods and most of the mild food allergies are going away. It’s a function of the maceration of the immune system, of the gastrointestinal track they just sort of start to tolerate the food spontaneously but the ones that have very serious manifestations of food allergy; especially peanut, tree nuts, and now a subset of patients; kids with milk, egg, and wheat allergy, they are not outgrowing it spontaneously, they will need some kind of treatment. There’s a lot of interest right now in new immunotherapies for food allergy.
Is that something that you are looking at here and what is oral immunotherapy for food allergy?
Dr. Nowak-Wegrzyn: Immunotherapies, one of the treatments that we are looking at, there’s been an explosion in the last couple decades. Twenty years ago there was nothing but just avoid it. Right now there’s so much going on in the field of food allergy research, looking for therapeutics. All people are getting allergy shots, they get allergy shots because they’re allergic to bee stings or they’re allergic to dog dander or pollen, so basically we expose them to small doses of allergen and then over time the immune system builds tolerance to it. This has been tried before with food allergy but because there are so many side effects people can get very serious allergic reactions so shots are not really being given for food allergy. We’re looking at alternative ways of delivering this allergen and because we eat food, right, oral delivery is ingesting the small amounts of food and gradually increasing the amounts, which is called oral immunotherapy, sort of came into play. And it’s very logical right? It utilizes the natural pathways of tolerance because the vast majority of people who eat the food they don’t have reactions right? So overall it’s probably eight percent of those who are just very unlucky and develop food allergy.
We talked to Kristina and she talked a little bit about the path you’re taking with peanut immunotherapy for her son. Can you walk me through what you do and how you monitor the child to see how their body is reacting to it?
Dr. Nowak-Wegrzyn: This is a slow process obviously it has to be very, very carefully done and under supervision and not every child would be an appropriate candidate for it. At this point this approach is still investigational, it’s not an FDA approved treatment, but it’s generating a lot of interest and obviously a lot of hope for the parents, for the children. We start from a tiny amount of peanut in a child that we know that is truly allergic. In the case of the baby that we’re talking about, she had a food challenge to peanut and she demonstrated symptoms at that challenge. We know that for sure she’s allergic, so we’d like to offer some treatment for her. Basically it starts with a tiny amount which she takes under supervision during the visit, and then she takes the same amount every day at home pretty much at the same time, and she’s closely observed by her mother or parent. Then she comes here every couple of weeks and we increase the amount that is given to her. We want to learn from her to see who are the best candidates, is it the right thing to start this kind of treatment when it’s a little child or whether it’s better to wait until they are older. We’re still investigating this.
So far anecdotally what have you seen, have you seen in this case Juliet is able to tolerate that buildup?
Dr. Nowak-Wegrzyn: What we have seen is that we can help a lot of children with peanut allergy, but also other food allergies to increase their threshold or sort of help them tolerate a larger amount of food so they can now safely eat different foods that may contain small amounts. We don’t worry that if she’s around some other child and she grabs a piece of cookie that she’s going to have a horrible reaction. We know that this can be accomplished for most children. The big unknown is can we cure her of her peanut allergy, this will require many years of treatment. The treatment is a daily treatment so it is quite difficult in the long term. For a baby this may not be a bad approach because her parents control what she does, how she eats. For older children; teenagers, young adults, this may be a little bit more challenging for them so maybe other treatments will be much more appropriate, for example vaccines that are being developed or biologic treatments.
What is the theory and hope for the oral immunotherapy? As you said, you don’t know at what age it might not no longer be a problem but what is the hope? Is this something on the horizon?
Dr. Nowak-Wegrzyn: Yes, absolutely. We are hopeful that there will be an FDA approved product as soon as next year, which will allow this treatment to be offered to many children across the country. What we struggle with is really trying to identify the patients that are the best candidates. Based on their age but also on the severity of the allergy because unfortunately the ones that are most allergic, they really struggle with this treatment. They have a lot of side effects, it’s unpleasant enough that they decide to stop the treatment. But there is a big subset of those that have sort of a mild to moderate allergy that they do well, and it’s just a commitment to the long term dosing. After several years you can get to the point that you could stop taking peanut every day and they would still be protected if exposed sort of casually.
The study that you’re doing is that just peanut allergens or is it other food allergies?
Dr. Nowak-Wegrzyn: We are a big food allergy center so we have a lot of clinical trials that are going on, each sort of protocol is a different program, a different scheme. But we’re studying peanut, we are studying tree nuts, milk, wheat, egg, and there’s also protocols that are looking for children that have multiple food allergies to see whether we could offer sort of a mixed multiple food treatment. Because one in three children with a food allergy are actually allergic to more than one food, and if your child is allergic to peanuts they’re also very likely to be allergic to tree nuts. When you think about this very long-term treatment, daily treatment for years on end, then you probably need a lifetime to address each additional food so this is very important.
You had mentioned the FDA will hopefully approve a drug or treatment next year?
Dr. Nowak-Wegrzyn: Yes, there are two products in development right now. One is for all immunotherapy and the other one is for patch immunotherapy, both for peanut. It’s just natural; peanut is such a big problem. And most children don’t outgrow it, it doesn’t go away with time and it’s a very strong allergen so even a tiny amount can produce a serious reaction so it’s a natural first choice for treatment.
One of the questions I had asked Kristina, she has no known food allergies, her husband has no known food allergies, none of her parents or relatives have food allergies, yet she has two children with food allergies. What does that suggest, does that give us any kind of indication as to cause?
Dr. Nowak-Wegrzyn: Definitely as you mentioned before this is a fairly new phenomenon, we haven’t had many patients with food allergy before. So a couple of things here, one is that parents, I don’t remember exactly Kristina’s story but I think her husband has eczema; a type of dermatitis. If you have one parent with some kind of an allergic disease, it can be eczema, asthma, or allergic rhinitis; the child has at least one in three chances of having some allergic disease. It doesn’t follow sort of path like if the father has allergic rhinitis the child will have allergic rhinitis. A father can have a pollen allergy but the baby will be allergic to milk or peanut. If you have two parents, you have seventy percent at least that a child will have something. Really when you look carefully at the parents, the parents tend to be atopic; so they have something, they are allergic to cat dander or pollen or they had eczema as a child. True food allergy in that generation was very uncommon. Also another thing about Juliet is that I think her both parents were born outside of the country. So she’s really the first generation born in this country and many studies have shown that when parents immigrate they are protected sort of by whatever environmental factors from the old country. But the babies that are born here they don’t have this protection. They really can show this full genetic potential to develop food allergy, actually they have more allergies than kids that are born of American born parents.
Is there anything I didn’t ask you that you want to make sure that people know?
Dr. Nowak-Wegrzyn: I think that it’s very hopeful, we are very excited, we’re very happy now that we just received this big grant study of peanut oral immunotherapy in children that are not super allergic. Because a lot of these studies are focusing on those that are extremely allergic, we feel like we’re getting a very skewed readout of the potential of this therapy to help people. Obviously those that are the most sensitive will be also more difficult to treat. The majority may actually have a much better outcome that we’re sort of reading from these studies, but it’s still something that we are learning. We don’t understand the long-term consequences of exposing somebody who is allergic to the food, forcing it upon them. A lot of children, some of them love it they’re very happy, some of them really don’t like it because they have this natural aversion to the taste and the smell of the food. It’s not an easy treatment at this time, but it’s an option and there’s so much more going on with modified vaccines for peanut in particular because it’s a big target. The vaccines would be much more convenient. To me if I had peanut allergy, I would rather take an injection in my doctor’s office once a month rather than taking the food every day. There’s also this big area of biologic treatments, which have been used in bowel disease, and autoimmune disease, that are now coming for early stage clinical trial for food allergy. It’s a very exciting time and we’re hopeful we’ll be able to offer so much more to our patients in five years time.
END OF INTERVIEW
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