One thing that has become very clear in the 3-4 months that I have been wrestling with Violet's eczema and potential food allergies is that I am not alone. So I was grateful to have the opportunity to chat with Dr. Wayne Shreffler (Director of the Food Allergy Center at Massachusetts General Hospital) about allergy prevalence, prevention, and daily practice. We only had a short window of time but covered quite a bit. The following are key takeaways that I wanted to share with you. Thanks to everyone who has weighed in about allergy struggles via Twitter and Facebook!
1. With eczema, consider variables other than food allergies. One frustrating thing about Violet's eczema is that it hasn't been as simple as eliminating a food (or, many foods, as is our case) and seeing the eczema recede. Dr. Shreffler confirmed that indeed, there are other variables to consider: "There's good evidence that eczema is not only driven by allergens...for example, data suggest that for many kids staph bacteria drive the eczema. Or that some kids' skin is more easily irritated by physical stimuli such as heat, scratching, and different fabrics. This isn't just a fight against allergies or food allergies...there's some data that suggest that only 40-50% of kids will in the end prove to have a food allergen triggered by eczema. That's important to keep in mind."
2. Care for the skin first. The National Institute of Allergy and Infectious Diseases (NIAID) recommends that kids with eczema should be evaluated for food allergies (typically milk, egg, wheat, soy, peanuts...the relevant allergens in 90% of kids) if they fail to improve with standard therapy (e.g., topical cortical steroids). However, Shreffler recommends: "As a first step, make sure you're addressing everything you can to take care of the skin. I'm a fan of frequent baths immediately followed by moisturizer and also recommend avoidance of detergents, use of antihistamines for some, and not being too afraid of topical anti-inflammatories. Also, for some kids, avoidance strategies like double rinsing clothing makes a big difference."
3. With season allergies, first try simple treatments. Dr. Shreffler and I discussed different seasonal allergy medications (such as Zyrtec, Allegra, or Claritin) which do not prevent allergies, but do appear to be very safe. However, they can cause sedation, or paradoxically in some result in hyperactivity, and Shreffler recommends starting with simple interventions first: "Some very simple allergen avoidance practices can be helpful...wearing sunglasses, wearing a hat, washing your face and hands frequently [since the face is a major attractor of allergens], and changing clothes when you come in from outdoors."
4. Treat topically when possible. I really appreciated Dr. Shreffler's focus on simple solutions (e.g., #2 and #3). In addition to recommending topical treatment and avoidance when possible, he referenced immunotherapy, including the use of oral administration, as a topic of increased research and practice: "There are studies coming out showing the effectiveness of oral immunotherapy [same concept being studied for food allergies] as an alternative to allergy shots -- though this is not widely available yet."
5. Consider early oral exposure. As we've experimented with eliminating foods in Violet's diet, one thing that has bothered me all along is that no particular food elimination has made her eczema disappear, and I'm concerned that we're preventing her from building up tolerance to various mild food allergies. Dr. Shreffler confirmed these concerns, noting that studies have shown that delayed introduction of some foods (e.g., milk, eggs, fish) is related to higher risk of allergies, and that some of these studies are partially responsible for overturning recommendations to wait on introducing peanuts until a child is 3 years of age. He also shared about a study that compared the rate of peanut allergies in Israeli vs. UK Jewish communities. The prevalence of peanut allergies was found to be 10 fold lower for those living in Israel -- where a popular early feeding food is the nut-based Bamba -- compared to those living in the UK. This has led to a large interventional trial of actually giving peanut flour to babies as a preventative strategy. However, it is not yet known whether this works.
6. Think critically about testing and results. As a former scientist, I appreciated Dr. Shreffler's critical approach to allergy studies (not surprising given his research background...he has a Ph.D. + M.D.): "Testing for allergies is tricky. Food allergy tests tend to pick up too much, whereas environmental tests often miss things (e.g., dust mites, pets, staph)." Shreffler also shared that studies that have tried to identify whether there is a link between diet while pregnant (e.g., avoiding nuts) and child allergies have been problematic in experimental design and are currently not conclusive.
7. Keep in mind that siblings can differ. We've certainly found this to be the case, as Laurel has no allergies whatsoever, and Violet clearly is dealing with something. On Facebook, one father expressed the following concern: "Our older son had milk, soy, egg white and peanut allergies, all of which resolved themselves by his second birthday. Now we have a second little boy who will be moving to solid food in the next few months. Our doc told us that he has a 40% chance of having the same allergies. We are nervous about trying out these foods and wonder if it makes sense to request RAST and skin testing before we give him any solids." Dr. Shreffler shared that the NIAID guidelines say that there's an increased risk for food allergies across siblings, but that he thought the rate was more in the 15-25% realm. "I generally skin test the second child for allergies such as fish, nuts, and eggs, but don't recommend delaying solid foods longer or not introducing milk. If the family wants to take a more relaxed approach, I am totally supportive of that."
In short, allergies clearly are tricky. First, there is the issue of wanting to not delay foods (#5 and #6) and the very real concerns parents have about potential allergic reactions. To further complicate matters, it's entirely possible that something other than food allergies is involved. Shreffler said, "One of the big problems in this field is that most kids outgrow food allergies and many are sensitized and actually never truly allergic. You can get the impression that different therapies look great, but you really need to do the right controls: bring in a group, prove that they are actually allergic, then test with immunotherapy. Sensitization/positive tests do not necessarily mean allergy."
I hope these tips are helpful as you navigate potential allergies in your family. I found this conversation with Dr. Shreffler insightful on many levels. It was affirming of skepticism I have about the flat-out elimination approach to food. It gave me hope that perhaps Violet is not actually allergic to various foods and we will slowly start reintroducing items soon, starting with foods we've eliminated and not seen any improvement in her condition (we'll use the same method we did when we started her on solids...introduce one new thing at a time and wait 3-4 days to see if there's an averse reaction). And it also is making me consider environmental factors and simple prevention methods all the more.
Thank you Dr. Shreffler for taking the time to chat and address questions from the community! Let's all keep chatting and supporting one another on this topic!