Managing Atopic Conditions: Prevention & Treatment of Food Allergy in Infants (Recording)

This webinar was recorded on November 19, 2025

Food allergies now affect nearly 8% of children in the United States, with incidence continuing to rise and increasing the risk of comorbid atopic dermatitis, asthma, and allergic rhinitis. Understanding effective prevention and treatment strategies is essential for optimizing patient care. Join us as we discuss current knowledge and emerging perspectives on the prevention and management of food allergies in infants, within the broader context of atopic disease. Dr. Kim will discuss evolving evidence, highlight key considerations in clinical practice, and explore approaches that support both families and healthcare providers. The session will emphasize evidence-informed strategies that can be applied across diverse clinical settings to improve outcomes for infants at risk of or affected by food allergies.

Speaker:

Edwin Kim, MD, MS

Dr. Edwin Kim is an Associate Professor of Pediatrics and Chief of the Division of Pediatric Allergy and Immunology at the University of North Carolina School of Medicine. He also leads the UNC Food Allergy Initiative, a research program dedicated to developing innovative therapies for food allergies and advancing understanding of the mechanisms that drive their development.

This Advances webinar is in partnership with the American College of Allergy, Asthma, & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for the Advances webinars.

All attendees will be offered a certificate of attendance. No other continuing education credit is provided.

Sponsored by the American College of Allergy, Asthma and Immunology

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.

 I’m the education program manager at the allergy and asthma network. I’m delighted to welcome you to this accredited webinar. We have an excellent program plan focusing on managing atopic conditions. Just a few housekeeping before we get started. Everyone will remain on mute for the remainder of the webinar to minimize distractions. We will record today’s session and it will be uploaded to our website within a day or two. You will be able to access this recording as well as all previous webinars recorded on allergyasthmanetwork.org I . Our webinar is scheduled for an hour. Please feel free to submit questions at any time to the Q&A box at the bottom of your screen. One of our team members will be monitoring that question-and-answer box as well as the chat to see if you have any questions or technical issues that we might be able to answer throughout the presentation. This webinar is brought to you in collaboration with the American College of allergy can and smoke, and immunology. It offers–American College of allergy, asthma, and immunology could you can create a free account and earn attendance credits through the portal. All attendees will receive a certificate of attendance. Zoom will email you that link as well as supplemental resources that go along with the material. Today’s presentation is titled “Managing Atopic Conditions – Prevention & Treatment of Food Allergy in Infants.” Food allergies now nearly 8% of children in the United States, with incidents continuing to rise and increased risk of comorbid atopic conditions such as asthma. Understanding the effects of prevention and strategies is essential for optimizing patient care. It is my pleasure to introduce today’s presenter, Dr. Edwin Kim. Dr. Kim will emphasize evidence and strategies that can be applied across diverse medical settings to improve outcomes for infants at risk or affected by food allergies Dr. Edwin Kim is an associate professor of pediatrics and chief of the division of pediatric allergy and immunology at the University of North Carolina school of medicine. He also leads the UNC food allergy initiative, a research program dedicated to developing innovative therapies for food allergy and advancing and understanding the mechanisms that drive the development. With that, I will hand it over to you, Dr. Kim, for your presentation. “Managing Atopic Dr. Kim, I think you are still on mute.

Dr. Kim: I am on mute. After all these years, you figure I will be better at this, so I apologize. Very happy to be here and talk on this topic, which is super important to me personally as well as professionally. I have disclosures here. I consult for several companies involved in the food allergy space, particularly around developing therapeutics as well as preventive-type measures as well. All right. Learning objectives. First we will try to explain the evidence of food introduction as a strategy for preventing food allergy. Number two, to differentiate among current and emerging treatment options for food allergy. We will touch briefly on oral and epic cutaneous as well as biologic therapies. Finally, incorporate shared decision-making. It will only be a couple slides but probably be the most important slides of the presentation. Just to start out, I kind of hinted, it is so exciting to be in a food allergy versus when I came out of training 12 years ago because now the approach to food allergy is transforming. What do I mean by that? First of all, one of the things I want to make a point of that all the people on this call recognizes delayed introduction of allergens just doesn’t work. There was this mantra of wait until age 14 milk, H2–H on– age one for milk, age two for egg. That that is a way to protect our kids from food allergy. You see in the graphic on the left that it hasn’t worked. Unfortunately now it is commonly referred to food allergy is an epidemic with 32 million Americans potentially having food allergy, and importantly with kids, the concept of one in 13 children and another way to think about is to kids in every U.S. classroom potentially having food allergy, it is bonkers to think about that. So yeah, food allergy, delaying introduction has not helped. 

How about once they become allergic? Also what we have found is when they are allergic, historically what we told them is here are instructions, here is the epinephrine autoinjector. We will keep you safe in that way. We also have learned, or may be seen more out loud now, is avoidance is not good enough if you are allergic. The food allergy labeling consumer protection act as well as the FASTER act. They require labeling of the top nine allergens. Milk, egg, wheat, soy, unit, tree nuts, fish, shellfish, and sesame. It is going to call out specifically the most important or likely allergens. Unfortunately, what everyone also recognizes some ultimately that is the advent of what we are calling PAL, precautionary allergen labels. These are more commonly seen. They are voluntary and importantly not regulated in any way. In the U.S. there is an estimate that 17% of all products in the U.S. supermarket has some kind of precautionary allergen label. You see an example in the bottom of this corner where you see it says contains wheat, soy, egg, and milk, very clear. But then it says “may contain traces of tree nuts.” Are they in a there or are they not? That is where families with allergies have challenges. Perhaps maybe most important, and again, I am very — I guess I don’t want to say excited, but I think it is very important that this last bullet has come to life more recently. Avoidance by itself is not denying. Avoidance, we know it leads to fear, it leads to social isolate decision. 

There is a restriction of daily activity. In all of this leads to — and all of this leads to lower quality of life. Even if you have a reaction once every couple of years, every day these are kids and families living in fear, they are scared about where they’re going to go to eat or what activities are say. Even the process of having to think through that creates a level of burden and stress that can really wear on family. I think it is really important that we are talking out loud about this and thinking how treatments cannot only protect against allergic reactions, but potentially quickens this as well. The great news is things are changing, we don’t have to just wait for food allergy to happen anymore. It is not this idea of passive just wait for something, just hope nothing bad happens. You can actually do something. First I will talk about a paper that everyone is very familiar with. This is the learning early about peanut allergy study, the LEAP study. This looked at four- to 11-month old children that at high risk of peanut allergy. The idea of this study was, OK, rather than wait for food allergy, which is what we talk about not working, the idea was what if we get them the food super early before they have a chance to become allergic. 

The idea was ingesting at least two grams of peanut three or more times per week starting at four 11 months of age– four to 11 months of age. What we have seen way back in 2015 is that this dramaticalyy reduces the rate of — dramatically reduces the rate of peanut allergy. In the group of kids where they didn’t introduce peanut and continue to avoid it, 17% of high risk became allergic to peanut by age five. Compared to the ones that intentionally started to eat the food early, eat the peanut at four to 11 months of age, 3.2% of those patients became allergic. Did completely remove peanut allergy? Note, but it is — no, it is clear from the bar graph that much less kids became allergic. A slide that maybe you all have not seen is they continued to follow these kids. This was super exciting and 2015 — by the time they reach age 5 — there was a question of, well, when you let go of eating that regularly, do they then flip to become? The middle part of the screen is the LEAP-ON sets. They took the peanut away for a year and they look to see where it looked like the peanut allergy was prevented. What you see is on the left that age five LEAP data, and in the middle, when you’re off of peanut — one you’re off of peanut, and the same. — when you’re off of peanut, and the bar graph looks essentially the same. All of these kids who were prevented didn’t suddenly become allergic, which was very encouraging that what we were doing was making a lasting difference. On the fire — on the far right is the LEAP-trio study. 

They reintroduced peanut and set eat it when you want and let’s see what happens at age 13. The great news here is that the percentage of patients who are not allergic, the green bar, none of those patients or very few of those patients, or no new patients became allergic. All the way up to age 12, 13, suggest that this early intervention lasts into adolescence. Further evidence that this is so, so, so important that we get in there, in particular the kids at high risk, but really all kids in getting that message out there that we can do something about food allergy, peanut allergy, and try to prevent that. What about the other foods? Peanut, we’ve got a lot of data and a lot of groups are starting or have been trying to introduce peanut. There was a study that was run in parallel called the EAT study. This looked at three-month-old patients that were exclusively breast-fed and they tried to look broadly across multiple foods. Not just peanut, but milk, peanut, egg, sesame, fish, wheat, following them through age three. This is a much broader study than just doing peanut. Really important that we do this to get a sense if there is something special magical about peanut, or if this invention is possible for all the other foods people can become allergic to. 

This is data from the EAT study. What I have at the top is boiled down. The effect was not as dramatic, but it does look like the early introduction of the other foods was beneficial as well. One of the reasons that it was probably not as dramatic was like I hinted at, the protocol was — we are trying to program in the early introduction of these foods and making sure that those foods are in the diet, and that is a lot of different foods that are there. Only 42.8% of the patients are able to do kind of what the protocol asked for in this early introduction cohort. Hard to really make dramatic conclusions from data when less than half of your patients can do what we are asking them to do. But even with that 42.8% adherence, when you get to age three we did see a decrease, specifically when we looked at egg allergy and peanut allergy. Immunologically there is not reasoning that the foods would be different from peanut as far as prevention is concerned. There is some supporting evidence — not perfect, but some evidence that, yeah, we can prevent not just peanut, but egg and the other foods with early introduction. So what should we do? I think the key point I try to make with families is at this point there is really no benefits to delaying introduction. There is no — the idea of I’m going to wait until like it is three or four or five, that is not going to increase the chance that it is going to prevent the allergy. Again, culturally that might make sense and that is a different story, but from the immunological and preventing food allergy, there is no benefit to delaying introduction. We do think that the skin is the portal that allows for these kids to become allergic. The ones that avoid it, we think that the skin is the likely — they get exposed to the food likely through the skin that allows them to become sensitized. Skin care and management of atopic dermatitis is important in early infancy. 

Whether that is moisturizers, topical steroids, whatever works with your allergist and primary care, but we think that will be very important. And what we have just been talking about, early introduction of these allergenic foods. The data is very clear for peanut and promising for the other foods that we can try to prevent the onset of allergy to peanut, egg, and other foods. All right, so what if we feed them early and you still saw the 3% or so — what if some of them still become allergic? Then what? The nice thing is now we don’t have to just sit back and wait. We don’t have to wait for something bad to happen. There are approved treatment options that are available. You see press releases for two of the options available in the clinic. We will talk a little bit about each of these. First let’s talk about oral immunotherapy. Many of you may be familiar with what this is, just to make sure we are talking about the same thing, a term I started to use a lot more of is the idea of exposure therapy. Some of my patients like to use that term, and it makes it easier to understand. The concept of oral immunotherapy, or any immunotherapy, is gradually increasing ingestion of the food to increase that person’s threshold. So how much food it takes to trigger a reaction. It tries to increase that and thereby prevent allergic reactions. Typically when we do it it involves a month-to-month — multi-month bill the process. And then it is followed with the regular likely daily ingestion of the actual food itself as what we call our maintenance steps. –maintenance dose. There is an FDA-approved formulation for peanut that you saw a second ago. But supermarket foods are increasingly used off label to treat for the others with oral immunotherapy as well. At the bottom of the screen you see what the protocol might look like. Starting from low doses up to what they determine for the peanut, FDA for the peanut product, the maintenance is 300 milligrams, and that his continued daily for however long the patient is going to be treated. The great news is that study after study after study has shown that OIT can work. OIT can desensitize, it can decrease the threshold that it takes to trigger reaction and provide the level of protection. On the left you see the first double blind study in immunotherapy. You see the Phase 3 study that led to the FDA approval of the product in 2018. 

Over and over we have seen that peanut oil and immunotherapy can work. The point of this particular dog is looking at those young kids. — particular talk is looking at those young kids. Is OIT feasible — a study on like to talk about is the IMPACT study, sponsored by the immune tolerance network. This looked at oral immunotherapy, peanut oil immunotherapy coming in one- to four-year-olds. What this study found is, yeah, it works. OIT provides superstrong to sensitization. — superstrong desensitization. Just looking at the patients that were able to complete the entire treatment, what you find is that for the kids that were getting the peanut oil immunotherapy, 84% of these kids were able to eat a full serving size, 54 grams of peanuts, 16 to 20 peanuts at the end of the 2.5-year treatment, vs. 3% getting placebo. Please evoke, we are talking — placebo, we are talking about a 2.5-year treatment for toddlers. How many are outgrowing it? Clearly very few, versus 84% of the kids on the peanut oil immunotherapy were able to reach this essentially service I threshold. Above that, what that is counting as anyone who wasn’t able to finish the treatment, whether they got tired of it, whether they had side effects. All of those kids were considered to have failed. If you think of it in that way, 71% of everyone that came into the study that got the peanut oil immunotherapy were able to get this desensitization, versus 2%. What was super important with this particular study was the idea that, OK, these young young young kids, their immune systems are still developing. Perhaps we can get a longer-lasting benefit. Tolerance is what we are hoping for. In the case of this paper, we call it remission. For the first time we found that in this case after two and half years of treatment, if we took the treatment away, if we took a peanut exposure away for six months, what happens? Do they flip back and become immediately allergic? Some do, but when 1% of these kids six month later were still able — 21% of these kids six month later were able to eat five grams of peanut without symptoms at all, versus the one kid who likely outgrew peanut alone on his own in the placebo group. Glass half-full site is that OIT can have this potential for a long-lasting benefit. Glass half empty would be, well, a lot of these kids become reactive during that six-month p eriod. Once that became reactive, pretty much every single one of them at the entire five grams and had symptoms of the very end, suggesting that they did lose some but they didn’t flip back to becoming just as allergic as they were pretreatment. It looks like there is some level of lasting, maybe not permanent, but lasting benefit that comes. We have talked about age. 

This figure on the right from the same paper tried to look at can we predict two other kids more likely to get this lasting benefit. Long story short, what they found was one important factor is how old you are when you start the immunotherapy. What they found was that the one- to two-year-olds have the highest chance of the six-month remission. Does that mean we can’t treat a three-year-old or four-year-old or seven or 12? No, absolutely not. Many studies show OIT can work in these groups. If you do get in super early, it actually after the kit is diagnosed at age one, age to come at can have more lasting benefit. Thinking about age, biomarkers support this concept of starting OIT young. There is this window of opportunity. We know a lot of kids when they first become diagnosed with peanut allergy, the IGEs may start at a low level and then over 3, 4, 5 years, that IgE level will increase. This figure, if we look on the far left, this is grafting peanut IgE. I will have you focus on the dark blue, green, and red lines. Dark blue are the kids who got the six-month remission. Red are the ones who were able to get the full serving size on the treatment but then had symptoms after the six-month. And then green ones are the ones who had some benefit but never got to the full serving size. What you see is those lines separate nicely with the dark blue, the ones that got remission from other once it started with the lowest IGE. Green ones had the highest when they started the therapy. It doesn’t seem to suggest that if you catch them early before IgE has a chance to increase, you can have a longer-lasting benefit. Interestingly, when you look at the light blue line that supports the same concept. That is the lessee program. What you see for the placebo is their IgE doesn’t stay the same, but over the two years on the treatment, it does increase naturally. Even for the kids that don’t get the remission come if you can get in and prevent it from skyrocketing, maybe there is a long-term benefit. The window of opportunity concept is very important to these young kids. Now, again, that is not the end-all, be-all. OIT is not perfect. Under the big problems is it comes with a lot of risks. It is an exposure therapy. You’re giving these kids what they are allergic to — in this case peanut. In this study, the study way back in 2019 demonstrated that looking at kids getting peanut oil immunotherapy compared to the ones avoiding it, not surprisingly they have an increased chance of anaphylaxis, increased frequency of anaphylaxis, and then an increased requirement to treat the symptom with epinephrine. None of that is necessarily surprising, because we are giving them what they are allergic to. 

But at the same time if you think — if you put — if you have a parent of an allergic it or you have allergy yourself, understand that this treatment can protect you but it can lead to the thing that you are trained to avoid. The reaction does become important. For some families that is too much of a risk to overcome. Other families do see if I have the potential to get, my goodness, a whole serving size level of desensitization, or potential for a six-month remission, this level risk is important to keep in mind that it may be manageable. It is important to keep that in mind. But I think recently, in particular once the FDA approves the oral immunotherapy and it becomes more widespread over the last few years, what we recognizes is that the risk we can manage, but what you also notice is not everyone can do OIT. The administration of OIT itself can be difficult both for patients, but also for allergy officers, providers as well. Number one, the dosing restrictions that come with OIT can make it hard to do. OIT should be given on a full stomach. The child should’ve had some sort of meal before that. Exercise and hot showers for some patients can potentially trigger allergic reactions to what should otherwise be a safe dose. There is guidance to try to avoid those two activities for couple of hours. If patients are sick, if they have fever, they can become reactive when they wouldn’t otherwise. Those factors right there alone, thinking about your own families, can you find that window of time? If you try hard enough, yeah, a lot of families can, but it may not be easy. If you have the kid coming home and has some sort of instrument or homework or whatever it may be, or say you have a family that, again, you are living in two different households, how do you find this time? 

Families can do it, but other families may not. We know that specific to peanut, a lot of the kids, the taste, the texture, the smell, it’s pretty rough. Asking that same gift to try to eat this on purpose every single day, some kids are able to overcome this and do it, others maybe not. It is important for us to recognize that. In particular when we think of the youngest kids, you have “good leaders,” where you give them what you want and they will eat it right away, but some don’t eat as well. If you have to do peanut and it takes 30, 45 minutes, and you have to do everything all day, it may not be feasible in the long term. Also separate from the dosing, the actual visits to the office can make it quite difficult as well. I should do the letter diagram. 10, 11, 12 visits to the allergens office within the first six month of treatment. The family circumstances, work schedules, school schedules can make it really tricky. For some families, they may not be able to go into the office to meet the protocol days. Also, again, you may be lucky enough where you live in New York City or even here in Chapel Hill where I live or we have many allergists around us. Great, you can find an allergist. What if the nearest allergist is a two-hour drive away? Can you do a one-time visit? Maybe. But every six months, or couple times a year after that, it becomes trickier. Not everyone may benefit from YG because they can’t actually do it. — not everyone can benefit from OIT because they can’t actually do it. Something we have studied a lot at the University of North Carolina, an alternative to be considered to OIT. The potential for sublingual immunotherapy comes from extremes we have had for sublingual immunotherapy — what we’re talking about is the idea that we are giving the actual food, or in the case of pollen, the actual allergen in a liquid form that is diluted in this sticky glycerin preservative. The thought is that the sublingual accesses the immune system, these cells underneath the tongue. Those will take up the allergen and then promote the tolerance we are looking for. So back to the kids. Maybe we are doing sublingual for adults. But how about for little kids, toddlers? Can we do it, does it work? We were able to do a study that was 20 funded by the national institutes of health — this is the peanut man Arthur B sublingual trial. — peanut immunotherapy sublingual trial. We did it with elementary school-age children, six to seven years old. In this case we encoded 50 peanut-allergic children ages one to four years old. We treated them with formula grams of peanut in the form of SLIT compared to placebo for 36 months. 

One peanut kernel is approximately 300 milligrams, and that is the dose that the FDA approves for the immunotherapy product. Four milligrams is far, far, far less. We think that is where the safety comes from. Does it work? One of the nice things with sublingual is across all three of our studies, we have not had the exercise restrictions, mealtime restrictions with this compared to the oral. And for this particular protocol we were able to shrink the time in the clinic down to five monthly visits and included some of dosing that patients can do in their own home and not have to come in the office, hopefully finding the happy medium of observed doses and education with the allergist, but not having to come into the office. We found was, yeah, with these young toddlers they can do really well. They have got high thresholds with this. First of all, there is 50 kids and the median age of 2.2 years. Really young kids in the study. What we found were similar to what we talked about with the impact study. Patients able to finish the treatment, if you count them all as failures, in this case the entire 4.4 grams, I still think of this is essentially a serving size for a young kid at his age. 60% were able to eat the 4.4 grams, vs. none of the kids in the placebo after the three years of treatment. If we only counted the kids who are able to complete the treatment itself, nearly 79% of the kids were able to actually eat that 4.4 grams of food, vs. non-placebo. Really strong benefit with them easily serving of milligrams sublingual. Exciting outcome we have seen. And similar to the impact study we wanted to see, are these immune changes that come with sublingual, today lasted to some extent? We were — do they last for some extent? In this case we took away the peanut treatment for three months to see if that benefit lasted. For many of the patients, it actually did. What we found work 48– were 48% of those patients were able to eat the 4.4 grams. If you count all the kids you finish the treatment, 63% of the kids were able to the serving size three months after stopping the treatment. Do I think this is a cure? No, just like with the impact study, if you give it enough time, their activities probably coming back. But this is a great sign that it is not overcome it last for a while thousand even if you miss a few weeks or even a month or two, the majority of the benefit is likely still there for these patients, which is really reassuring for these patients. How about the age concept? We talked about the impact of younger is better. We look at that in this study. On the left side what you see is when we split it up into one- to two-year-olds, starting at two give you a stronger chance of getting the serving size desensitization. Even with the three heaven month remission — three-month remission, not as clean as the left side, but one to two-year-olds have a stronger rate of getting that remission. 

Further evidence that not just with OIT, but even with sublingual, if we can get in there early when the kids are still one to two years of age, it may be easier to do the treatment with the potential to have a slightly longer-lasting benefit for those kids as well. Let’s talk about another treatment that is in development. Sublingual could be a nice option for some families with — rather than OIT. Epicutaneous immunotherapy is really exciting. Still in development, but the potential is strong. Essentially this is a medicine patch for peanut allergy. It includes 250 micrograms, the equivalent of 1/1000 of a peanut. Overly small exposure to the peanut. It is on a patch that is applied daily to the back. The most common side effect is, not surprising, skin irritation. We are exposing the skin. The concept is you put it on for 24 hours and then you rotate across on the back to manage and minimize any sort of irritation or ditch that the patient may have. — itch that the patient may have. Thankfully severe reactions and reactions that are treated with epinephrine were rare with this treatment as well. A lot of potential on the safety second and it is easy to see how easy this would be to administer. Does it work? Toddlers do seem to achieve significant desensitization with the peanut patch. This is called the EPIT study, 362 toddlers ages one to four years, and the median age is 2.5 years. 1/1000 of a peanut apply to daily for 12 months in this case. 67% of the one getting the peanut patch met the responder criteria, vs. 35 — oops, that is a typo — 33.5 — sorry, never mind, it is correct. CD7 –67% of these kids are responders. It doesn’t suggest that the younger kids do better– does suggest that the younger kids do better than the slightly older kids with peanut thinking about the side effects, the irritation that may happen on the skin. Do any patients discontinue treatment or are not able to complete treatment? nine 8 out of 244 patients withdrew because of the side effects. 

There are some kids where this is not the right treatment as well. But the potential for benefit is very big, with really good safety and simple use. For the last bit of time let’s talk a little bit about biologics. It has been a in the news. If you have been to the allergist office you have had this conversation. Why do we even need to have this conversation? Daily treatment with anything is difficult. Daily treatment with exposure therapy is going to be hard to sustain for some families. The dosing restrictions with OIT, like I mentioned can pick and very difficult for some families. What we know with immunotherapy is right now immunotherapy is food specific. Peanut immunotherapy won’t treat your egg allergy. Unfortunately, 40 to 50% of our patients are allergic to multiple foods. If we try to treat multiple foods, it becomes exponentially harder. Either more risky or more burdensome. One benefit of biologics is they potentially should be able to treat multiple foods simultaneously, because they are hitting the immune system at a point before you go to the specific foods. Biologics don’t include the food itself. 

There is no food exposure. There is no risk of reaction or through diversion as we are talking about with OIT. And then the added treatment plus, benefit plus, is that some of these biologics may be able to treat the other allergic diseases simultaneously with the food allergies. If you have a patient that has comorbid eczema, the biologic may have the potential to treat both. These are why are we talking about this kind of stuff. The one we have studied the most is going to be on Melissa about– omalizumab. The cells bind to the allergens of this tries to grab the IgE and take it out of circulation. One really nice thing with this is this is not a new drug encompasses been around for quite some time. Originally approved in 2003 for allergic, asthma 2014 for chronic your Zakaria –chronic urticaria. It is a shot, it is an injection, so when we are talking about these young kids, toddlers, it is a shot potentially two to four weeks. That in itself may not make it right for every kid out there. The main study we will talk about is what is called the OUt MATCH study. This looked at patients ages one to 55 and they had to peanut, number one, and then allergic to at least 2 other foods of the list of milk, egg, cashew, walnut, hazelnut, and wheat. Had to be allergic to peanut plus two other foods. In particular what I will focus on, this is the study summary, which is quite complicated, three stages with an extension. When I will focus on is the simple stage I, omalizumab vs. placebo. This is the primary outcome from the study. What you see in the graph is going to be the gold bars are going to be one treatment with omalizumab and the blue will be placebo. She did on the far left is the primary food. 

Peanut is the key for that everyone had to be allergic to. 67% of patients were able to beat at least one gram of peanut — each more — eat at least one gram of peanut after the treatment. If we go down the line and look at the other foods, cashew, egg, milk, wheat, you see there is a clear difference. The gold bars demonstrate that omalizumab can treat all of the different foods significantly better than what you might get with Lane old avoidance with the placebo. What is important is a couple of things will number one is going to be the thresholds for success for the peanut is one gram, vs. for the other food two grams. There is a slight difference there. It is noticeable that caches have a lower number. All of the other foods are high 60 to 70%, pretty uniform. One of those that we are trying to understand, is there something unique with cashew? Is the dose wrong? Clearly better than placebo, but different than the other foods. Something we are paying attention to and trying to investigate. This is a figure that was in the paper as well. I like to look at these papers because this particular figure, here it shows every individual patient as opposed to the bar graphs that are lumped together. It is pretty easy to see that can met all of the orange lines are pointed upwards. Some higher than others, but it seems that the vast majority of patients are getting improvement when they are on the therapy. That is number one. Number two is when you see the black bar, these are the median levels. What you see is the levels that patients are achieving, not just a little bit. The median levels for these foods are very high. For the peanut the group started at the median threshold, 44 milligrams to treat your — to trigger a reaction. By the end that goes all the way up to four grams. Egg, milk, the other foods come these are up to six grams and four grams. Cashews stand as improved for sure, but only 444 of them. Something unique about cashew perhaps. There are a few patients that don’t respond. Graybar bars that go downwards. There are some that are fairly flat. In the study it looks like 14% of patients didn’t really improve with peanut. That is important. It is a good product but it doesn’t look like it is a perfect product. Important conversations that most patients will do well but some will not respond. In the last couple minutes I will talk about one other biologic that we see a lot in the clinic. Dupilumab actually blocks — this actually blocks IgE class switching, blocking cells from making more IgE. It is proved all the way down to six months of age. It is approved for eczema down to six months of age. 

It is not just eczema, but for asthma, polyps. It’s medicine that seems to be effective across multiple allergic diseases. It is given by an injection, a shot similar to omalizumab. The subcutaneous injections. One nice thing is it is approved from use. Looking across atopic dermatitis, eczema, one thing they found across all of these studies, IgE goes down for these patients. If you can drive down the IgE, could it work for food allergy? Two studies were done. Unfortunately the final answer is not very impressive. If you look at 24 weeks of dupilumab on its own, it did decrease the IgE as we had hoped or expected. When we went to the food challenge to definitively show it’s better, only two of the 24 patients were able to eat one peanut after. Keep in mind when we’re are talking about oral immunotherapy, we are talking about serving sizes. Even with omalizumab we were seeing patients one to four or five grams. Not very impressive with the short 24-week treatment period. On the right what they look at is what about dupilumab in conjunction with OIT. Driving down IgE at the same time as OIT, couldn’t make it safer or better. There was small improvement. Passing the food challenge, light blue is going to be on the combo of dupilumab plus OIT v s. placebo and OIT. When you look at the maintenance phase, that difference becomes even smaller. There is some improvement in the food challenges, but not a dramatic one at this stage. An early sign that dupilumab may have some benefit, but may be somewhat limited in what it can provide. To wrap up in the last couple minutes, what is the best approach? Number one, I think everyone hopefully recognizes there is clearly no one-size-fits-all for food allergy. Every situation will be different. On the side of how does food allergy impact the patient — for some kids it may affect the ability to go to this school, may affect nutrition. Every kid is going to be affected differently with it. But also what is the food allergy look like. 

How many foods are they allergic to? What other comorbid stuff do they have? There is going to be no one-size-fits-all treatment at this point. Peanut oil immunotherapy, there is no FDA-approved version. Omalizumab is approved by the FDA. They are both available for patients ages one and older. For those patients we have tried to prevent becoming allergic, these are approved options covered by insurance that could be available in the clinic. Both of those have really good looking data for these young toddlers as well. Sublingual, no FDA-approved formulation at the moment. Epicutaneous immunotherapy is in phase three studies and hopefully will be something that the FDA will judge on in the future. Each of these different treatments, OIT sublingual, subcutaneous, omalizumab, each has a different degree of desensitization, different degree of safety, as well as the difficulty of doing the actual treatment itself. This is where the shared decision-making is going to be really important. Early train to get it how does food allergy impact that particular family and that particular patient, and which of these different treatments can help them get there the best. The key piece in my mind is starting with how is the food allergy impactig the family and then coming to the treatment of regret which ones may best switch of the trip — and then figuring out which ones may best help them get there. We have talked about humans and how we don’t have to be reactive, we can be proactive. Avoidance is still and will always be an option. 

One thing I think is important now is I think of it as an option. It is not one of those where we are all forced into avoidance. My particular kit with food allergy, omalizumab, maybe that is an option. Maybe OIT is an option. What is the pros and cons of avoidance? To think of those as options, and in my case I will say that maybe when Mike is going to go to kindergarten, that is when I think it will be most practical for May. To be able to have that decision is essential. And so food allergy is in a paradigm shift. Really exciting for us. Like I just mentioned, we used to just be reactive, we would sit back and wait and hope we would not become allergic, and if we became allergic we hoped we would not have an allergic reaction. Those days are gone and my mind and how it is about being proactive. How do we prevent it in the first place? If we don’t prevent it, that’s fine. How do we protect against reactions, how do we allow our kids to more normalize and be there with the other kids like they should be? Prevention and treatments are possible. And there is a lot more coming. Avoidance may be OK because there is more stuff coming. We have been very fortunate weather there is been a lot of ongoing research — where there has been a lot of ongoing research and those close and those close in developing as well as those all little more distant. I see a lot of innovation coming ahead. All right.

Ruthie: thank you so much, Dr. Kim, for that excellent presentation. You provided the audience and myself awesome and important information on food allergies. I see some hands up, so please feel free to submit those questions through the Q&A box. We do have some questions we will get started with. The first one is what is your recommendation for families with three or four generations of anaphylactic food allergy reactions?

Dr. Kim: Three or four generations of food allergic reactions. In trying to guess what the reader or the question is coming from, situations where people are allergic to different foods can definitely be problematic. You may have a parent that is allergic to peanut but the kid that is allergic to tree nuts. How in the world who do you manage those? nine Especially with treatment, that can create a complication of how you introduce peanut to the young infant when the parent themselves is allergic to that. I don’t have a great answer to that. Families have been creative, whether they separate it out with other family members to do that, or just coming up with different strategies. This is a situation that is tricky. I think one thing that is very important as a reminder is when it comes to allergic reaction, it is important to that the majority of significant — it really will take ingestion to have larger allergic reactions as well. Any way that you can be very careful with what the other person is allergic to, watch what is on your hands, that will go a long way to protecting also being exposed to the allergy itself wasn’t some patients are going to be more sensitive and those cases will need an allergist to figure out the best strategy. I hope that is getting at the questionnaire asking about. — question they are asking about.

Ruthie: Yes, thank you for that. How do you prevent IGG-mediated reactions?

Dr. Kim: If I’m understanding this question as well, one of the number one side effects is a recurrence of stomachache, sometimes vomiting, and some proportion of patients, they may have another disease, inflammation of the actual esophagus, the feeding to. If that is allowed to continue, it can cause inflammation, even swelling, and strictures where it becomes really permanent and difficult to swallow. In those cases at the moment this is a place where I do think the alternative immunotherapies can be superduper important. There are some strategies with oral immunotherapy that can overcome this. But for those that don’t want to try the therapies, that is what the sublingual or epicutaneous immunotherapy may be safer versions. As well as the biologics. Biologics don’t include exposure to the foods themselves. Those may be a safer option for this particular patients, where they may be concerned about or even have risk factors for the side effects.

Ruthie: Thank you. Another question for you, what are the main criteria to say that an infant is a high — at high risk for food allergy?

Dr. Kim: That’s a wonderful question, trying to understand what makes someone high-risk. We sort of use that terminology twofold. Number one is when I was using it, I’m thinking about, first of all, from the research point of view. The research point of view, trying to figure out who are going to be more likely to become allergic so we can clearly demonstrate we can make a difference. If you have something for 1% of people become allergic to try to show a difference there will take thousands and thousands of kids to show it is only half a percent. From a research point of view, one of the reasons we try to identify who is high-risk, but what are the factors we think of? Within the LEAP study in particular would thought about atopic dermatitis, in particular ones that are harder to treat. For unique topical steroids — where unique topical steroids or interventions like that seem to be risk of developing food allergies. What we saw is egg allergy does seem to increase the chances that the same kid will be allergic to the peanut. We know the family history definitely matters. If you have one family member that is allergic, or one parent that is allergic, we estimate a 40 or 50% chance of some former allergy. If a parent is allergic that jumps up to 80%. Interestingly, we have not seen risks within siblings. But those are some of the risk factors we think about. Ruthie, and one more question before we end. How do you count sole parents or caregivers when they are anxious about introducing peanut, egg, or other allergens at home?

Dr. Kim: It is very, very difficult, not just for patients or families, but the other providers. It wasn’t long ago we were saying don’t get it, wait until age three for peanut because we want them to be more mature, we want them to be communicative because peanut may be more severe and allergic reactions may happen. Thankfully we have growing amounts of data to really support that this is safe to do. What we are seeing is that the youngest kids, six-, seven-, eight-month-old kids — your allergist can help you and perhaps the introduction can happen in the form of a challenge. Somewhere where it is a safe space that this can be done. There are a lot of groups that are out there that can provide support for this as well. There may be multiple patient advocacy groups and larger groups like allergy enhancement network that may — larger groups like Allergy & Asthma Network that have resources as well. We know that it is effective in preventing the allergies, and between your allergist, there are resources that can help because it can be a scary thing and that is OK. It is completely understood that people are going to be nervous about that. It is right to ask for support.

Ruthie: Thank you so much for taking the time to answer our audience’s questions, and again, for an insightful and informative presentation, Dr. Kim. In a few days, Zoom will email all of the attendees a link to the recording as well as oppose webinar evaluation. Feedback is very important to us, so take the time to fill that out and give us feedback and any suggestions you may have. Our final webinar for 2025 will be on December 4, rhinosinusiti s, nasal polyps, and asthma, what to do about that. It will be presented by Dr. Andrew White. Please register and join if you can for that. Attendees are invited to join the discussion on advancing diagnostic techniques, contemporary treatments, and surgical interventions, and the role biologics in managing cases. On behalf of the Allergy & Asthma Network, thank you again for your participation and registering. We look forward to seeing you in our upcoming webinar next month and next year. Have a wonderful rest of the day, and thank you so much, Dr. Kim. Have a good day.