This Webinar was recorded on February 14th, 2023

Is there a genetic tendency to develop allergic diseases like rhinitis, asthma, and atopic dermatitis? Or is there something in the environment that causes these?


  • Dr. Tina Sindher

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Sponsored by the American College of Allergy, Asthma and Immunology

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Andrea: hello, everyone, and thank you for joining us today. We have a few housekeeping items. I am Andrea Jensen, the interim director of education for allergy and asthma network. All participants will be on mute for the webinar. We will record today’s webinar and it will be posted on our website within a few days so you can listen to it again or please feel free to share it with your colleagues. You can go to our website and school all the way to the bottom of the page and find our recorded webinars and also any of our upcoming webinars. This webinar will be about one hour and that includes time for questions. We will take those questions at the end of the webinar but you can put your questions in the Q&A at any time. We have someone monitoring the chat. If you have questions or if you need any help, kris will be there to help you out. We will get to as many questions as we can before we conclude today’s webinar and now, we will begin. Today’s webinar will discuss if there is a genetic tendency to developing allergic conditions like rhinitis, asthma, dermatitis, or food allergies. Is there something in the environment that causes these? We will go ahead. There we go. Allergy and asthma network is a grassroots organization that was started over 35 years ago by a mom who knew that other moms like her needed resources and support. Our mission is to end the needless death and suffering due to allergies, asthma, and related conditions through outreach, education, advocacy, and research. Today’s webinar will be recorded and it will be available for minimal cost. You will receive an email within a few days after the webinar with resources about food allergies, environmental influence, and genetics. With that email, you will find a link to download your certificate for attending today. Today, it is my pleasure to introduce our speaker, Dr. Tina Sindher. She joined the Center for allergy and asthma research at Stanford University in January of 2017. She is a clinical associate professor of allergy and immunology in the Department of medicine division of pulmonary and critical care medicine. She divides her time between research at the S&P Center and outpatient clinical care of pediatric allergy and immunology patients. She completed her pediatric residency at Albert Einstein College of medicine, Children’s Hospital, in Bronx, New York, and her fellowship in allergy and immunology at Children’s Hospital of Philadelphia in Pennsylvania. She is a principal investigator of several clinical trials addressing atopic conditions and is the director of clinician training at the S&P Center. She is the director of oral immunotherapy clinic at Lucile Packard Children’’s Hospital, LPC H, within the outpatient pediatric clinics. Her interests lie in food allergy and research involving strategies for prevention, diagnostics, and novel therapeutics. Thank you for being with us today. We look forward to you sharing your unique perspective in treating those with a variety of allergic conditions.

Dr. Sindher: thank you so much for the kind introduction and for inviting me here today. As Andrea mentioned, we are going to talk about food allergy and whether there’s a genetic cause versus environmental and what our research shows so far. As many in the audience have heard many times now, the prevalence of food allergy has been rising. Not just in the United States but across all continents. Food allergy has become a global issue. This rising burden has prompted more research into not just treatment and diagnosis but also the why. If we better understand the reasons behind increasing food allergy, perhaps we can take steps to prevent it. There are numerous factors that have been implicated to date in the development of food allergy. Most of these are environmental exposures early in childhood. Sufficient levels of vitamin D, a diverse microbiota, and oral allergen exposure collectively support the development of tolerance as in not being in an allergic state. Allergic sensitization is promoted through continuous exposure, reduced diversity of the microbiome, and vitamin D deficiency. Diminished Mike Road biome diversity — microbiome diversity are thought to interrupt the regular thorium mechanisms of oral tolerance. With the latter as in vitamin D deficiency also contributing decreased epidermal barrier function. That is the skin. Environmental exposure to peanut antigen is highly associated with the risk of clinically confirmed peanut allergy down the line. But the genesis of food allergy is a very complex process. We have not yet found one thing that can cause it. There are lots of influences which include the genes, the host, the individual person’s immune responses, function, and environmental factors. Increased use of antibiotic use, nonrational births, ultra sanitary lifestyles, less time spent outdoors, and the resulting so-called modern microbial community structures of the gut and the skin which begins at birth have been implicated in aberrant immune system maturation and the development of food allergy. As early as 1995, the trend of increased rates in family was noted. The investigators found that allergy was more common in successive generations. Peanut allergy was reported by .1% to grandparents, .6% of aunts and uncles, 1.6% of parents, and 6.9% of siblings. The authors found that peanut allergy is more common in siblings of people with peanut allergy and therefore, there was the search for inheritance and the genetic contributions. In another study, the investigators looked at 75 pairs of twins where at least one twin had peanut allergy. The investigators found that identical twins were nearly 10 times more likely to both have peanut allergy compared to nonidentical twins. As I have alluded to, it is not just genetics alone but rather the interaction between existing genetics and environmental exposures. In 2021, Clark at all — et al. conducted a survey in Canada to look at the effect of demographic characteristics on food allergy. Canadian born children of Southeast and East Asian immigrant parents had higher reported food allergy than children born to Canadian born parents. This suggests an interplay between genetic processes and environmental exposures. The author suggested that early life environmental exposure such as climate, diet, and microbial exposure exerts a differential effect on food allergy development, possibly depending on the existing genetic background. Recently, I was speaking to a researcher from Australia and they have found similar findings in Australia as well where food allergy was higher in their immigrant population of folks from Southeast Asia dissent. — descent. A genetic mutation in the skin that has been well studied is mutations. In a population-based study, children carrying at least a one SLG loss of function mutation were at increased risk of developing peanut allergy. If they had high environmental peanut exposure around the time of birth. For each unit increase in peanut death concentration in infancy, there was a six-foot increase in school age peanut sensitization and a 3.3 fold increase in school-aged peanut allergy. As we look into some of our studies and have multisite studies ongoing, this is one of the factors we are collecting. We are looking at environmental peanut dust in the household as we look at long-term outcomes and whether or not they develop food allergy. Although there is a lot of evidence that there is a hereditary component to food allergy, our understanding of genetic causes for food allergy is still in its infancy. Several genes have been found to be associated with higher risk of developing food allergy such as stat6, CD14, SLG, IL-13, and other epigenetic modifications but we need to be careful in interpreting this, such as these genes are associated, not causative. This is just a signal but not defined, confirmed genetic link. Food allergy development is complex and is due to a combination of many different factors. Genetic, epigenetic, environmental. So it is very important to continue our exploration of the process behind food allergy development. So currently, there are three known strategies of food allergy prevention that are being explored. Some birth cohort studies show that enriched infant formulas make — may play a role in prevention of food allergies and displays on existing signals showing that breast-fed babies have a lower risk of food allergy so they are trying to see how enriched infant formulas can provide that same protection for those who are unable to breast-feed. There is no also increasing evidence that early life allergen exposure through the skin causes food allergy whereas early oral exposure causes tolerance. And this theory is known as the dual allergen exposure hypothesis. The newer studies have shown earlier exposure to foods considered allergenic may be protected and can reduce the risk of food allergy later in life. So as I speak to my patients in my outpatient clinic and we are discussing food allergy prevention, I talk about the six d’s. Diet, early dietary diversity, dirt, playing outside, being exposed to a plethora of allergens and exposures. Dogs, early life exposure to dogs have been shown to be protective. And vitamin D, a lot of children have vitamin D deficiency because of decreased time spent outdoors. So that is also something that can be protective. And then dry skin and detergents are thought to be worse for development of food allergy. I will speak about dry skin shortly. But early dry skin and eczema can lead to increased risk of food allergy down the line and then detergents are thought to actually break down or contribute to our barrier breakdown of the skin that can also increase the risk of allergen exposure through the skin ahead of allergen exposure through the gut. So dual allergen exposure hypothesis. For years, it was thought that children became sensitized to food allergens by exposure through the gut. Early consumption. There is now increasing evidence that early life allergen exposure through the skin causes food allergy whereas early oral exposure causes tolerance. In the last five years, several studies have been demonstrated — have demonstrated oral tolerance induction to allergenic foods in high-risk children. So essentially, it’s a race against time. You want to increase early oral consumption while decreasing cutaneous exposure to allergens. Increasing evidence on timing of the introduction of solids in development of allergic diseases have been underway. We have all heard of the LEAP study published in 2015 which has led to our current changes in guidelines with early exposure to peanut, but in this study, peanut allergy was five times more likely in children who avoided peanut during infancy. And in the EAT study where multiple different allergens were introduced, the authors Thomas rated the introduction of multiple allergenic foods in infant diet was possible and may be protective towards preventing food allergy down the line. The effect of oral tolerance induction appears to be allergen specific. So you really are protected against the foods you ingested and you may still have increased risk against the foods you are not ingesting. In the LEAP study, early peanut consumption did not lead to prevention of tree not or Sesame allergy. Since food allergy develops early in life, there is a narrow window of opportunity to induce tolerance with the oral introduction of multiple foods. In the population-based study in Australia, 3.1% of children already had challenge proven peanut allergy by the time they were 12 months of age and 9% were egg allergic. Introduction of multiple allergenic foods into the diet of young infants is challenging. In the EAT study, the adherence rate for introducing six allergenic foods into the diet was only 42%. Meaning it was really hard to do for regular families. There is a need for alternative approach to prevent food allergy, not just early introduction alone. There is evidence that dietary diversity in infancy reduces food sensitization and allergic asthma, but the results for atopic dermatitis, eczema, and allergic rhinitis are mixed. A systematic review found that breast-feeding was protective for allergic asthma. However, the evidence for atopic dermatitis and allergic rhinitis was weaker with no effect on food allergy. Other methods such as vitamin D supplementation has produced mixed results. There is little evidence for the role of prebiotics, and while meta-analyses in individual studies show some benefit from probiotics, these studies have had issues such as objective evaluation of outcomes, design, blinding, so these studies are hard to put together in the real world. And then this brings us to the concept of atopic March. Over recent years, the focus on atopic dermatitis has increased because it is associated with an increased risk of developing food allergy, asthma, and allergic rhinitis down the line. The term atopic March is used to describe the progression from eczema to other allergic diseases. So there have been numerous studies that have shown this connection of the atopic march and development of food allergy. In the ALSPAC study, an losing, cresting skin rash was an independent factor for the development of a peanut allergy. — particularly within the first three months of life, severe atopic dermatitis markedly increased the risk of food allergy. In the health nuts study from Australia, children with early onset severe atopic dermatitis had a 50% rise in challenge proven egg, peanuts, and sesame seed allergy by 12 months of age. In the LEAP screening study, there was a dose-dependent increase in food sensitized station with increasing SCORAD levels. It stands for scoring atopic dermatitis. Higher rates of food allergy in those with higher SCORAD levels in children aged four months to 11 months of age. Duration of infantile atopic dermatitis prior to treatment with proactive topical steroid has also been shown to increase the risk of food allergy for each month that passes where the eczema is not under control. This evidence suggests that shortening the duration of eczema by reducing inflammation reduces the opportunity for exposure to environmental food allergens and thereby preventing sensitized station and subsequent food allergy so in this strategy, by treating eczema early, we are blocking the way antigens can interact with their immune system through the skin. In this — and this slide reflects the shift in our guidelines for managing food allergy. Prior to 2015, in the U.S., the recommendation was complete avoidance of peanut and tree not until one year of age and avoidance of seafood until three years of age. As a strategy to reduce food allergy. And this is when the thought was that early introduction by ingestion is what is leading to the increase in food allergy. The LEAP study which was published in 2015 showed that P analogy was five times more likely in children who avoided peanuts. In the study published in 2016, it showed that children who remained in the study and consumed the recommended amount of a variety of allergens had a 67% lower risk for developing food allergy. Based on these data, in 2017, the American Academy of pediatrics reversed its previous guidelines and recommended early introduction of peanut protein. In 2019, they issued clinical reports citing strong data for early introduction of all foods. As we go through prevention strategies and what is causing food allergies, I did want to add a patient story where they were treated for food allergies. So even if at this time we were still working towards effective prevention strategies, but treatment opportunities are also out there and being explored. So one patient story I wanted to highlight was the story of Fis cher and his family. At six months of age, he was rushed to the hospital for anaphylactic shock after eating a wheat pizza biscuit. Now, he’s 10 years old and a recent graduate of our combined food trial which combines multiple food allergen immunotherapy with Biologics onboard and after completing the trial, he wrote to us saying because of this trial, I feel like a totally different person. He can now eat small portions of multiple foods he was allergic to, no more canceled play dates because the other parents were too nervous to host Fischer. No more missed opportunities for vacation in remote locations because they were too far from the hospital. No more constant anxiety around food. This trial improved the lives of everyone in our family, says Fischer’s mom. She said, at first, she was scared to have Fischer eat small amounts of the foods. But she was quickly reassured. What makes the program so special is not only the wealth of knowledge from the staff but the breadth of resources available. These include fully equipped hospital grounds, a psychologist, and innovative technologies such as a food challenge virtual reality headset. All of these may increase the patient experience and increase the chance of success in the program. Now, Fischer is looking forward to eating an English muffin and going fishing for crabs and shrimp. Foods he could not even touch before. To the center staff, he says thank you so much. I just have to say thank you. You have changed my life. Now, I am not isolated, I am not anxious. Just thank you. I wanted to highlight this case mostly to show that food allergy impact not just the individual but their family. And apart from the dangers of an allergic reaction, increased mortality and morbidity, it also plays a big impact on quality of life, so as we look into new treatment opportunities, we strongly highlight the shared decision-making and kind of eliciting what the concerns of patients and their families are and really meeting them where they are needed most. That is the end of my presentation. Thank you so much. I don’t know, Andrea, if you wanted to take over?

Andrea: high there. Can you hear me now?

Dr. Sindher: yes, I can.

Andrea: apparently, my headphones decided to quit working. OK. I will get close to the mic so everyone can hear. I think this was a great presentation because this gives a lot of hope to families. There can be a lot of concerns. In my family, we all have allergies and asthma and that was my biggest concern that was in us being genetically defective and passing things onto our children. But I was struck by the side you have that topped about the environmental exposures, especially in Canada. So I think that is important for people to understand. For those who may have missed that at the beginning, do you mind going over that a little bit more? It can be environmental as well.

Dr. Sindher: sure. Absolutely. Let’s see.

Andrea: sorry to make you — Dr.

Sindher: no worries. No worries at all. Were you thinking of this slide or this one?

Andrea: you are — you talked about in Canada, probably back at the beginning. I apologize for all of you that are joining us. We are going a little bit backwards now. But really, yes, this is a site and I think this is important to talk about. It is not just genetics, which was my fear when I was having kids 31 years ago.

Dr. Sindher: absolutely. Thanks for bringing this up, Andrea. Based on these findings, the authors actually suggested that it wasn’t just genetics. It’s early life environmental exposures such as climate, diet, microbial exposure. This overlay on the existing genetic background that may increase the risk.

Andrea: wonderful, wonderful. Another question we have is someone asked, when you talk about early introduction, what exactly is the age window?

Dr. Sindher: yes, yes, that is a fantastic question and you know, before — I trained in pediatrics. We say the guidelines are for months to six months but what I told families is some infants show readiness at an earlier age and some little later so I know this, you know, it is hard to follow these guidelines but I really urge my families to read your baby’s cues, and if they look like they want to try foods and they want to take a lick, go ahead and start introducing a variety of foods paid with the studies, there’s a focus on specific allergens, the high allergenic foods. But really, what the data is suggesting is dietary diversity so as many different things as you can have your infant drive, it’s going towards an improved microbial diversity and decreasing long-term food allergy risk.

Andrea: I think that is important — an important point. So many of us were taught don’t feed them anything. Only breast-feed and then only give them rice cereal and about — for about six month and now, that has been completely flipped on its head, completely opposite, and it can take a while for people to make that shift, especially if there is someone my age might be having grandchildren, which I am not. For a lot of people to make that switch and say this is how I raised my children. I am glad to see so many school nurses on the line that can help us kind of get that word out. We also have some questions. They did want you to review the six D’s for food allergy prevention. They also asked are there any home remedies that are helpful?

>> yes. I preemptively ended up on the slide here. So the six Ds is dietary diversity early in life, low in processed foods and sugars, dirt. In my mind, I like to combine the dirt and vitamin D together, just thinking of it as increased time spent outdoors. Just keeping in mind that when we are seeing dirt, we don’t mean unhygienic or filth. There is a difference. Just kind of being outdoors and being exposed to different kinds of environmental exposures. Dogs — children with dogs in the home and we think this is because the dog goes outside and brings in different antigens on its feet and fur is what may be providing that benefit. Cats on the other hand can increase risk of asthma early on. And then dry skin. A lot of our current research is showing that minimizing dry skin in aggressive treatment of eczema may become protective against developing food allergy. Just kind of moisturizing with thick unscented creams can really help. Detergents. We found what makes some popular detergents so effective is they have these — that break down the dirt but they can also break down our own kind of skin barrier. If you are smelling the detergent, that fragrance, they are ingesting some of that and going through your mucosal layers. That may be contributing food allergy development. What I recommend to my families is doing, you know, an extra rinse in the washer and minimizing fabric softeners and things like that. And a couple brands that are more better for sensitive skin and are unscented and may be an official — unofficial in terms of food allergy development down the line.

>> thank you, thank you. We did have a question on the chat and I believe she just answer that so perfect timing once again. I do like how you mentioned doing an extra rinse cycle and our family were always very careful to make sure any detergents we use are unscented and it makes a big difference. Ever since we have eczema and all those other fun things. Another question we have is does Mom breast-feeding and eating allergens, does that expose the baby?

>> yes, we highly encourage diverse diet in mother as well. We are actually enrolling pregnant moms and then following the child after birth for three years of age. We are collecting all this information. We are trying to understand what the moms diet is during pregnancy, what the diet is during breast-feeding. And the baby’s diet as they are getting older and older. We are trying to better understand Accra biome and how that may be playing a role. — understand microbiome and how that may be playing a role. Yes, definitely have a diverse diet. At the same time, even though the data is promising, it has not shown a huge kind of siding pointing towards food allergy prevention so there is more to this so stay tuned.

Andrea: understand, yes. This is part of the important work that you do is research and we know that things are changing all the time. Another question we have in the chat is could you discuss the protocol you use to introduce eggs? There’s a lot of attribution — there’s a lot about peanuts but what about eggs?

Dr. Sindher: one of the reasons peanuts are studied so much even though there’s many other allergens is because peanut is one of the few among — and tree nuts — that kind of persistent long-term whereas egg and Derry, 80% of children outgrow it before three years — dairy, 80% of children outgrow it before three years of age. It’s hard to tease out what is just natural, naturally developing tolerance versus the intervention making a difference. That being said, you and the peanut is the best study, in the trial, Egg and Daria were also introduced and found to be protective as well. I think of it as whatever the family’s diet is, just slowly incorporating those foods into the babies diet. Joking proof and easy to consume for the baby but not really withholding any of these so-called highly allergenic foods.

Andrea: wonderful. A little bit follow-up, when you talk about not getting them foods could potentially choke on, we have a photo of the little baby in the highchair and he was having those little puffs. Perfect right there. We don’t normally say brand names but you can just explain a little bit more what that is.

Dr. Sindher: absolutely. In the U.K. leap trial, he is one of our collaborators for one of the food allergy prevention studies we are actively doing right now. What he noticed is that babies in the U.K. had a higher rate of peanut allergy whereas in Israel, peanut allergy was much, much lower. So he kind of looked at what they were doing, what were the Israeli babies doing? And he found that a very common early childhood snack is something called Bamba, and it’s epos, like in the U.S., it’s made out of peanut. And babies were ingesting these as early as six months. Incorporating it into their diet. They have lower risk of developing peanut allergy down the line so in the LEAP trial, that is exactly what the researchers did. They looked to babies that were sensitized, meaning their skin was positive as well as bloodwork showing that they were already on the path for potentially developing peanut allergy and in one group, they fed the babies bamba, and in the other group, they did standard of care, and they found the babies who ingested bamba were five times more likely to not develop food allergies. Five times less likely rather. So after that study, it has become very popular and is not available on Amazon. So that is a great way of introduction. Another thing I used to do with my children was I would just come as I was making purées, I would put in all the nuts in the purée into applesauce, so that they could ingest it that way as well.

Andrea: excellent. I love those examples and that will help some of the families that are curious a little bit about that. Someone asked. Hang on tight because we have a lot of questions in the chat. Someone is asking why would cats cause an increased risk?

Dr. Sindher: risk of asthma. We see that a lot, something about the cat dander is considered to be high risk for developing asthma and difficult — even difficult to manage asthma. The risk is not so tied with food allergy per se and again, these are all associations, not causation’s. For instance, if I have a child, has no eczema, has no asthma, I am not worried about the cat in their household. I’m only concerned if the eczema is becoming harder to manage and control and their asthma flares are difficult to manage with high potency inhalers and they are still requiring multiple courses of steroids so these are all again just kind of additions to an existing kind of predisposition the child has. So I don’t want you to think that if you have a cat, you must remove the cat to prevent food allergy. It’s only those at high risk who are already suffering from cat allergy.

Andrea: all right, thank you, thank you. Cat dander is a lot stickier than dog gander as well. — dander as well.

Dr. Sindher: it stays for years.

Andrea: that can make the difference. We have something that was interested in the work you are doing and I’m wondering if there is a chance to have a child engage in some sort of research program. Are there places around the country that are doing this, that are asking if there’s anything important? are there other places in the country that are doing research such as yours?

Dr. Sindher: for instance, the seal trial, where we are enrolling infants up to three months of a two have already developed either dry skin or eczema and in this study, in one group, we are aggressively treating with one kind of moisturizer, another group with a different kind of moisturizer, and a third group, standard of care. We think that early more striation can reduce — moistur ization can reduce that, but we cannot make that recommendation for everyone. For the trial, we are working with our colleagues at the University of Chicago and national Jewish Hospital in Denver. We just enrolled a site in Cincinnati and we are working with our colleagues in the United Kingdom. One way to look up studies around you is going on clinical and basically any clinical trial that is occurring have to be registered on that website and you can put in different search terms and look for studies around you and your you.

Andrea: thank you. That is great information to know that this is a way we can pay it forward. Not only can it help our children and grandchildren but they can pay it forward for others down the road. Following in our footsteps. Someone asked, can a child outgrow a food allergy?

Dr. Sindher: yes, they can, and that is one of the research questions we are asking. Because when we test an infant, a baby, you know, and they are allergic, some of them naturally outgrew their food allergy and what is it about their immune system that allows for that to happen? So we are trying to look at those who naturally outgrow their food allergy and see what is going on in their immune system so we can better understand and by better understanding, we can help with the guidance we gave so if our testing shows that you are more likely to naturally outgrow, we will say stay put and keep checking in and we can keep testing whereas for — if our testing shows you are not likely to outgrow it, we might recommend, you know, embarking on oral immunotherapy earlier than we normally would. Also, if you can identify those who do naturally outgrow, that can potentially help us with new treatment strategies for more kind of individual based care.

Andrea: excellent, excellent. A follow-up would be a little bit on the flipside of this. We know that people can develop food allergies at any time even as an adult.

Dr. Sindher: that’s right. We are seeing that more and more we are adults — we used to think of food allergies as a childhood problem and not something that you would see in adulthood except for shellfish which seemed to occur out of the blue for adults and we are looking into that and have a shrimp allergy study kind of in the works for adults. But we are seeing that not just a shrimp but other foods as well , more and more adults are developing — we call it de novo food allergy where they did not have a problem with it. Through these research trials where we are collecting blood, we are trying to understand, you know, the immune responses and not just the IGE and the B cells but also the T cells and all these interactions that are occurring in our immune system to see if we can better understand what is it that is contributing to this and what can we do about it?

Andrea: that’s brilliant and there’s so many things to look at. Really, thank you for all of your research and for helping people because there is so much out there and there’s so many tiny little details. So we have another question in this one is actually about milk. His milk when we want to wait until the child is 12 months or cannot be introduced sooner question marked –sooner?

Dr. Sindher: go ahead and introduced sooner in the form of yogurt because we have actually found that yogurt, because of its — kind of the microbial properties, it is considered a probiotic or even prebiotic, so it would be great to introduce yogurt early on.

Andrea: OK. We have had a few questions, people just wondering about how does what mom eat, how is that related to when mom is expecting and how does that affect the baby? If mom eats certain allergens, will that expose the baby? Is there a chance the baby could develop a food allergy for something that the mom ate while she was allergic to a certain food?

Dr. Sindher: these are such excellent questions and there are more unknowns in this than what we already know. Part of the trial, we are also collecting some breastmilk as well to understand how mom’s diet, by the time it gets to the infant, what does the antigen look like? What is the antigenic load? So far, the data hints towards diversity in diet of mom to be protective and does not hurt, and if mom is allergic, the child has an increased risk of food allergy, but this is a really — I guess what you are hearing is we don’t know all the nuances. All we can say is, you know, dietary diversity is helpful. And because there is a chance of a genetic predisposition for food allergy, you can sometimes do everything right and by the book and we still end up with allergy, so don’t give up hope. We will continue to look and explore and ask these questions and these questions are great because it kind of helps us design our next studies and what the — where information is still lacking.

Andrea: I appreciate you saying that because often times there can be so much mom guilt. Was it something that the mom did while she was expecting or early on in life? They can do everything right and kids can develop allergies and asthma and food allergies. That is the luck of the draw sometimes. Another question we have is for kids that suffer from atopic dermatitis without food allergies, what are the chances they can develop a food allergy later on in life, even elementary or middle school?

Dr. Sindher: that is a great question. I would say if the child has atopic dermatitis early, if they are actively eating the foods, I am less worried. But if they are — if they have eczema, in my mind, that child is always atopic, meaning if for whatever reason our to withhold that allergen for a prolonged period of time, there is a chance that they will develop a food allergy so what I would recommend for, you know, for families with children with eczema is making sure that all these foods are always in the diet and before embarking on any type of elimination diet to really working with your allergist and doing testing to see if there are sensitized nations — when I say center salutation — sensitiz ation, it shows that you are allergic but if you are consuming the food, you are still keeping that clinical reactivity at bay. I’m very aggressive with my recommendation to make sure that food remains in the diet and if we have to do and elimination diet — I have lots of patients and we are pursuing an elimination diet — we do talk about the risk of developing food allergy my kind of eliminating that food for a while.

Andrea: OK, excellent information. Someone asks that they say I have several people in my family with a soft shellfish allergy such as shrimp, crab, etc., developed later in life. Is this common phrase to food allergy? Is there a way to get more information about the research study about shrimp that you mentioned?

Dr. Sindher: yes. Shrimp was actually one of the, you know, earlier on, early to thousands, we used to think that shrimp allergies, seafood, shellfish allergies is the only one that presents in adults. As far as adult food allergy goes, it was the most common where someone can be totally fine with it while growing up and then develop it out of the blue as an adult. Some of the research studies — they are trying to look at just that. Those who had lifelong allergy versus those who developed this down the line. In terms of current existing food allergy studies — so we just wrapped up our motif study and this was a diagnosis based study kind of trying to explore different diagnostic strategies for those who responded really well to treatment with oral immunotherapy and then in terms of upcoming trials, Baylor — Dr. Carla Davis is putting a grant together in Stamford will be one of the sites as well as a few other sites in the country looking at treatment of shrimp allergy in adults with the biologic known as — on board. So it is not active yet but if you look on clinical, it is a great way to kind of explore studies in your area and you can put search terms for exactly what you are looking for.

Andrea: thank you. That is great information. Some people in the chat have wondered is that something covered by insurance, being part of a clinical trial?

Dr. Sindher: yes, so clinical trials actually do not use insurance and usually, because this is a trial, there is, you know, some studies will have something called blinding which means you don’t know what treatment you are receiving and your provider does not know what treatment you are receiving, just so we can have an unbiased outcome and we are looking at the results, but the majority of clinical trials — I don’t know of any that go through insurance and all the care through these trials are free of care. Sorry, free of charge. So no financial — there are no financial obligations from the participant standpoint.

Dr. Sindher: right.

I think that is good — Andrea: right. I can do that is good information for people who have not been part of a study before. This is a little bit different. It does not go through insurance. Completely separate. Funding is separate so there will not be a charge but there will be a benefit of helping those around them. With being part of a study. So one question we have — I think if — thank you for being so patient in answering so many of these. I don’t think we will get to every single one but I will try it. Someone says they ate peanut butter all the time as a child and as an adult, they are allergic so any explanation for how that happens?

Dr. Sindher: it depends on what their symptoms are. For instance, you know, could be that — I’m going to speak in generalizations because I do not know the person it’s Pacific clinical history but what could have happened — two things. One thing could be that they were sensitized meaning they always had the specific IGE antibodies that recognized peanut and by keeping peanut in the diet, they kind of subdued those allergic cells and maybe there was a period of time where peanut was no longer in the diet and that kind of prolonged elimination either knowingly or unknowingly may have skewed the skills so to speak in putting them into the more allergic outcome, clinical outcome. The other thing that could happen, and we see this a lot, is something called oral food allergy syndrome or pollen food allergy syndrome where if someone has pretty strong environmental allergies, when they eat specific foods, they can cross-react with the pollen allergens so we do see this in some of our — those with hayfever and seasonal pollen allergies where peanuts can induce kind of an oral itching but it will not progress to a life-threatening allergic reaction, and that is where kind of working with an allergist to do the testing kind of identifying which kind it will be. One thing that helps us do this is we have something called component testing which any allergist can actually do in the lab, just order the blood. It looks at specific markers in the peanut and some of those markers are more correlated with true allergic anaphylactic type symptoms where some of those are more associated with the oral food allergy syndrome so based on those labs, I might recommend, you know, in my clinic, maybe during the oral food challenge, just to be sure, it would help us tease out whether it’s a true analogy and that means it can progress towards anaphylaxis versus oral food allergy syndrome where you can Fritos with an antihistamine and keep symptoms at bay.

Andrea: that is an important distinction to it I’m glad you spoke about that. I’m having an oral food challenge next week. And so it is hard to tell — is it really an allergy or is it something else? To actually do that food challenge is an important part of what you do. Thank you for talking about that. Someone is asking — lots of questions about allergies and some of these allergic connections. So can someone outgrow an animal dander allergy?

Dr. Sindher: we have not seen folks outgrow animal dandruff allergy. We have seen — you know, when we think about atopic march, we see eczema starts up early and then we see asthma and food allergy go hand in hand and then allergic rhinitis or environmental allergies developed later and a little more persistent. What we have seen, kind of like the concept of allergy shots and oral immunotherapy, repeated exposure to a specific animal may reduce the symptoms in certain folks, but based on our current testing strategies, it is hard to predict.

Andrea: OK. And for those who may not be as familiar with immunotherapy or allergy shots, my kids did those for five years so I know them very well but for those that don’t understand a little bit of the concept behind it, do you have time to explain that briefly?

Dr. Sindher: sure. Allergy shots, subcutaneous immunotherapy, we basically try to identify what your environmental triggers are. It could be grass, it could be animal dander, cat, dog, mold. Different kind of trees. We put together a vial that contains extracts of all of those triggers and then we do shots, we inject them, we build it up over time and with each shot, you go up just a little bit so you are basically training your immune system with gradually increasing dosing to basically ignore that allergen if it does come up.

Andrea: OK.

Dr. Sindher: so after five years, we hope that environmental triggers will no longer be bothersome because your immune system now knows to recognize it and ignore it.

Andrea: and that is what generally happens as has happened to my children. The allergies are still there but they can go to a friends house that has cats or dogs. Thank you for expanding that. Yes, this goes on — this question has a little bit to do with what you talked about, the oral — sorry, just lost the word, got long COVID brain.

Dr. Sindher: immunotherapy?

Andrea: that brain fog we all have. I will be the question. I am allergic to cherries. I have an adult allergy. when I eat them raw, I have symptoms but not if they are cooked or canned. I have the same thing with peaches. What is the difference between raw and cooked?

Dr. Sindher: yes, yes, yes. This is a perfect example of oral allergy syndrome where basically, in the uncooked — it should be the skin of the fruit that can trigger — it cross-reacts with your existing environmental pollen allergies. As you are eating it, your mouth seems to think you are ingesting the pollen protein and triggers a mild — it should be mild — itching and sometimes a little bit of throat itching, mouth itching, that should not progress to a more severe reaction. What happens is when you cook it, you change the protein component, you denature it by the high heat, and that takes away that cross-reactivity so your body no longer sees it and thinks that it is the pollen that it is ingesting.

Andrea: in other words, you are saying since it is Valentine’s Day, people can go have a cherry pie or peach pie, right?

Dr. Sindher: that’s right, if it is baked, then some of our patients — let’s say they love. carrots — if they have raw carrots, it triggers oral itching for they will boil it ahead of time, keeping it in the fridge, and much on it later. It is the raw fruit and veggies with the skiing on that can trigger these symptoms and by cooking and kind of removing the skin, it can minimize those symptoms. Andrea: that is a brilliant tape and this is the first time I have heard this so you can actually cook that and let it cool and then eat it a little bit later when you want it cold. OK, excellent, excellent. Last question I think we have time for. Someone asked will cooking tree nuts in foods — is it the same thing as cooking with fruits?

Dr. Sindher: in terms of denaturing the protein? There have been studies looking at boiled peanuts and roasted peanut. It doesn’t seem to play a big role, meaning if you are allergic, you can still have a reaction to it. Same with the oral allergy syndrome. For those that are having that kind of cross-reactivity, because the peanut protein is — it’s not as susceptible to kind of changing its shape when cooked. Folks can continue to have symptoms. Andrea: OK, OK. Do you mind going down to the very last slide? We could be her all day but I know you need to get back to your patients. If you are able to — yes. Speaking of long COVID, as I mentioned that, many of us have that and have brain fog and all sorts of other fun little side effects, but we will have a webinar and this will be on March 9 and it is called long COVID, how does it impact asthma and asthma control? Thank you, Dr. Sindher. I can listen to you countless times and still learn something every time. For everyone who joined us, if you would like to go back and listen to some of the questions and answers and the entire presentation, this will be recorded. This will be on our website within a few days so you can listen to that again. For those of you who want credits, will be available as well. So thank you a million times, Dr. Sindher. When I grow up, I want to be smart like you and have a brain like you.

Dr. Sindher: oh my gosh, well, thank you so much for the very kind words and for inviting me. Thank you so much.

Andrea: this has been such a help to everyone. We need to get this information out to more people and thank you, everyone, and have a great day.

Dr. Sindher: have a great day. Goodbye.