An estimated 6 to 8% of children in the United States have a food allergy, or roughly one in 13 children. For families to best navigate a food allergy for their child, it’s important to understand the signs of an allergy, typical and atypical food allergies and the differences between food allergy and intolerance.
Stacie Jones, M.D.
, director of the food allergy program at Arkansas Children’s Hospital Research Institute (ACRI) and a professor of pediatrics at the University of Arkansas for Medical Sciences (UAMS), works with a large team of physicians, nurses, registered dietitians and research coordinators to help adults (in the UAMS adult allergy and immunology clinic) and children with food allergies. Researchers are still trying to determine why someone can suddenly develop an allergy.
“True food allergies are typically not subtle, and not something that most people have to be on the lookout for all the time. What we want to do is calm the fear factor and say, be aware. Be attentive, but don’t be paranoid and don’t look for everything,” Jones said. “Have really great communication with your provider, your primary care physician or advanced practice nurse, and then get in to see an allergy provider when it's important to tease through the details.”
In its research program, the team sees children with food allergies working to find new therapeutics to combat life-threatening and life-altering food allergies through treatment or prevention. The team also sees various conditions besides food allergies, including asthma, chronic hives, hay fever, allergic rhinitis-type symptoms and immunodeficiency disorder.
“We have a large clinical program that also feeds into our research program that is funded nationally, and we’re really excited about this work. We’ve been doing it for more than 25 years here, and I really hope to continue to be pacesetters in this field,” Jones said.
In observance of Food Allergy Awareness Week, May 14-20, Jones shared her insights regarding food allergies.
What typical food allergies would you see in a child that comes in?
Food allergies can be manifested in a lot of different ways. The most common type is what we call IgE or immediate-type of food allergies. Those most commonly in children are milk, egg and peanuts and tree nuts. We talk about the “big nine,” and that’s milk, egg, wheat, soy, peanuts, tree nuts, fish, shellfish and sesame. Those cause about 90% of food allergies. There are more rare types of foods that can cause food allergies, but those are the big ones. Kids and adults that have those allergies will have everything from a life-threatening severe allergic reaction to very mild, maybe even mild rashes or GI types of symptoms that cause abdominal pain or vomiting.
What is something about food allergies that not many people would know?
The most common are the immediate-type reactions, where you eat a food, and you have symptoms that go with that. But there are also problems where children have delayed reactions where maybe there’s a disorder called the Food Protein Induced Enterocolitis Syndrome (FPIES). Those children don’t really ever have skin rashes. They have repetitive vomiting after drinking a formula for instance and show up in the emergency room because they’re having a lot of very abrupt symptoms that are delayed for several hours. So sometimes those are a little bit harder to pin on a particular food. There are even types of food allergies where you just see hives alone, or maybe just vomiting alone or isolated symptoms, so it can be a real spectrum of diseases.
Children can get rashes out of nowhere, causing some parents to wonder, “What have they eaten recently that was new? And is that the cause?” How long is a delayed reaction? How long is the length of time before it can’t possibly be a reaction from food?
There is a standard kind of directive that we live under. For those immediate-type reactions, we think of having a food and having symptoms temporarily related to that food within a two-hour period. Most kids that have the immediate-type of food allergy can react within 30 minutes to an hour, but it can be delayed up to two hours. The other types of disorders may be as late as four to six hours. Commonly, we have new moms, in particular, they get very worried because they see hives the next day, and they gave their children maybe a peanut or strawberries the day before, and that’s probably not related.
It drives you crazy because you so want to protect your child. And that’s when it’s really helpful, the tools that we give people — we say to write it down. Think about what they ate, think about all those things, but write it down and get the timeline and then talk to your doctor. A lot of those things you can get reassurances just by having that discussion and not absorbing it all yourself as a new mom or as a new dad. Children do turn red. They do have rashes and hives and things that are not related to food.
Are food allergies always present at birth, or do they develop later in life?
We think of food allergy as along the atopic march or the allergic march
. Children that develop allergies often will start off with some eczema or atopic dermatitis skin rash that is chronic and begins in infancy or early infancy. That pairs often around the same time, or food allergy will come just after that. Then we go on in a little bit older children in early school-age years, they’ll have some asthma or allergic rhinitis, hay fever types of symptoms, and that’s how this march goes. Children are born with that food allergy, but they often, we think, have a predisposition based on the fact that maybe they were born into a family that has a lot of allergies or asthma, or maybe even food allergy. They inherit that propensity or that genetic background to develop allergies, but why it happens in some kids and not in others, jury’s still out. That’s a lot of the work we’re doing right now.
Sometimes blood tests can reveal a child has a food allergy. Does that automatically mean they have to avoid that food?
One of the messages that we really feel strongly about is if a child is tolerating it, whatever that food is, it stays in their diet because that is something that we know is helpful and helps that immune system say, “Hey, this is safe. I don't have to react and have a problem.”
That allergy profile is potentially there. We call it sensitization when it's just test results. If that child is eating peanuts and he has a positive test (for peanut allergy) and has no problems, we want it to stay in the diet. Because if you take the food out, all of a sudden, the problem can arise, and the immune system may develop its armies and on the next exposure say “Oh, you know this is now bad for me.”
Be aware and ask questions to your pediatrician. Say, “Why are we doing the tests, we have the foods in the diet, and we're doing just great?” We need more and more awareness for families and providers that are out there doing these tests about how to interpret them. And what we love is when they call and say, “Hey, I've got this. What do I do?” Let us help you.
What are the first symptoms that appear when you have a food allergy?
Eighty percent of people with a food allergy will have a rash or hives, itching, flushing of their skin. But that means 20% of people don’t, and so that’s one thing that is hard to recognize sometimes when that rash or that skin itching doesn’t happen. It can be as simple as a rash that is not simple for a child or a parent, clearly. Or the first reaction might be a severe allergic reaction, where that individual has trouble breathing or has throat tightness, head-to-toe rash, vomiting and the whole spectrum. That’s where it becomes very scary, and the difference might be that the child that has a rash and hives may need to be treated at home and then follow up with their doctor, where the more severe reaction needs to get into the emergency room quickly for treatment.
How do you tell the difference between a reaction you can watch and see and a reaction that requires immediate emergency care?
With a minor rash, we’re going to say, “Slow down, watch, give some antihistamines and see how things are going.” Once it starts progressing or once we have symptoms like throat tightness, wheezing, difficulty breathing or repetitive vomiting, that child, adolescent or adult needs to get emergency care. Hopefully, if that person already has food allergy, they have injectable epinephrine. There are many different devices now, EpiPens, Auvi-Qs, and they would take that injection, call an ambulance and get to the hospital.
One thing really to point out is how rapidly things can change. We talked about a minor symptom, like a rash, but that rash can progress very quickly to a more severe reaction in a matter of minutes. Especially if we know that patient has food allergy, be attentive to signs and symptoms. One of the things we haven’t talked about is the food allergy allergic plan or anaphylaxis plan. That’s a detailed written plan as to which symptoms require very quick action and seeking emergency attention. That’s something we recommend for everyone to have.
Why should a parent consult a pediatric allergist or immunologist versus one who typically deals with adults?
The main thing is to have someone that really understands food allergy and the nuances. We believe in pediatric allergy that there are differences in children compared to adults; children are not little adults. The nuances of atopic march or allergic march that we talked about and how allergies are manifested, whether it’s asthma or food allergies in children, look very different. So having someone that has experience with children and teens to know how those diseases change over time, I think is really important and something that I think for here our group adds a lot to the field and to the state. We also have really great colleagues that are our affiliates and our partners out in the community that do a wonderful job too. And we really need everyone on board taking care of these children.
What are some of the ways food allergies would present differently in a child versus an adult?
Well, I’ll reverse it — in adults, it is uncommon to have new allergies. Not impossible, and certainly there are adults that haven’t eaten a food for most of their lives and suddenly have a food that they have problems with. But typically, the lifelong food allergens are peanuts, tree nuts, fish, shellfish and sesame. Most of the more common childhood allergens like milk and soy, and egg and wheat, most kids will outgrow by the time they’re teenagers. Only about 10 to 15% of people will actually retain those allergies into adulthood. So those are just nuances. A lot of adults believe they have a food allergy when they don’t. They have an intolerance.
What is the difference between a food allergy and intolerance?
An intolerance often has to do with the type of food, or a great example is that there will be people that think they are milk-allergic when actually they’re lactose intolerance. They can consume a lactose-free milk, but a milk allergic person is still going to have trouble with that lactose-free because it’s about the protein in the milk. So that’s an example of an intolerance that is often a threshold-related thing rather than actually needing to get rid of the entire food group in their diet.
Is it possible to prevent food allergies?
We have national guidelines that came out in 2017 that we’re still working to implement that really indicate from a big study that was done that if we can get, for instance, peanut into an infant’s diet in the first four to six months, that it will prevent them from developing peanut allergy. And that’s a huge fact. The study that was done, it was about an 80-fold difference in the number of children that developed peanut allergy versus the ones that did not. That is something that we would really like to continue to have pediatricians, and family doctors offer input as part of their well-child visits to go ahead and begin to get these foods in.
To learn more from Stacie Jones, M.D., watch the full interview here.
Groundbreaking Studies in Food Allergy
The Arkansas Children’s Research Institute is currently involved in about 15 to 20 clinical trials related to allergies and immunotherapies, said Stacie Jones, M.D., director of the food allergy program at Arkansas Children’s Hospital Research Institute and a professor of pediatrics at the University of Arkansas for Medical Sciences.
“We’re studying everything from new versions of patch studies, where a child puts on a patch to desensitize or to protect from their allergy, to we have a new tablet that goes under the tongue. We have some injectable therapies that are more like vaccines. There’s one called a peptide therapy that’s getting ready to start, and that, so far, has a tremendous safety profile. Because in the other things we talked about, we are using the allergen to treat, and we’d love to get away from that,” Jones said. “There’s just a wealth of new therapies. We call them biologics, where we’re impacting the immune pathways that cause the allergies, so we’re really impacting their whole allergic profile. And I would say we have seven or eight different types of therapies going on right now. And we love having families call us about this.”
One current study focusing on prevention is the SUNBEAM study
. It aims to identify prenatal and early childhood markers of high risk for food allergy, atopic dermatitis, or eczema and the biological pathways that lead to these conditions. The observational study of children from birth to age 3 years will examine the origins of allergic disease. Jones said 12 centers around the country are involved.
“We are in the process of enrolling 2,500 mothers and babies and their fathers. We’ll be following those babies initially for three years and probably much longer. This is a large study funded by the NIH (National Institutes of Health), and it’s going to gather information including genetic information and environmental information and information about what you feed your child and how you raise that child,” Jones said. “At the end of that, we hope we’ll find targets that we can actually use to prevent food allergy and eczema down the road. So, it’s a data-gathering study right now, but it is the biggest of its kind. It’s never been done in food allergy. And so down the road, I think we’re going to see some real ways that we know what caused food allergy and how to intervene early and prevent that.”
In 2022, results of the groundbreaking clinical trial relating to peanut allergies called the IMPACT trial
, funded by the NIH, were published in The Lancet
. While the care guidance for children allergic to peanuts is to avoid them, the trial found that peanut oral immunotherapy given to children 1 to 3 who were highly allergic to peanuts desensitized most to peanuts and induced peanut allergy remission in one-fifth of the 143 children who participated. ACRI was one of five U.S. academic medical centers involved in the trial. Jones served as the protocol co-chair.
Before the trial, the child participants were so highly allergic to peanuts they'd react to about a 10th of a peanut. Those who responded well to the study could be off peanut therapy for six months, consume over 16 peanuts, and have them in their diet regularly.
“One of the things about this trial and others that are on the hills is that it provides really strong protection for children at risk of anaphylaxis or severe allergic reactions due to peanut allergy. I think it’s going to help pave the way for other trials. As a matter of fact, we think now about age in clinical trials related to food allergy when we didn’t necessarily think about that,” Jones said. “So, I think it is changing the way we think about when to intervene and how to keep those children safe. It is not 100% ready for primetime yet, but we’re working on the details of what that looks like. These are big teams that do food allergy research, so we need to figure out now how to get this into the real world and to provide this therapy for families. I think it changes the face of how we look at treatment protocols down the road.”