The new AAAAI podcast is about Palforzia–surprise surprise. It was recorded just three days after the introduction. Like all these podcasts the host is our friend Dr. David Stukus. Appropriately the interviewee is Dr. Andrew Bird from Dallas who contributed a piece to this website five years ago called Food Allergy Testing in the Coming Age of Prescription Immunotherapy. Dr. Bird wrote at the time, “The response from the medical community must be to ensure that patients are appropriately diagnosed and diagnostic methods are used intentionally in patients with a history supporting a role of immediate reactivity following food ingestion.” Five years later, that remains a key concern as this first-ever drug enters the market and is clearly explained, as are such issues as cost, dosing, maintenance, overall efficacy for certain patients, reactions, goals of treatment, and why patients choose to discontinue treatment. There’s also forthright discussion of the pros and cons of offering the treatment for allergists and shared decision making in choosing to start the treatment or not.
David Stukus
Who’s Ordering Food Allergy Blood Tests?
Dr. David Stukus has had a busy year publishing research as well as bylined articles, and most of all his weekly “Bad Joke of the Week” as part of his active Twitter feed @AllergyKidsDoc. He has shared his thoughts with us about the role of Primary Care Providers and allergy treatment before, so it was particularly noteworthy the other day when he popped up as lead author of a study in Pediatrics called “Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists”. Employing data from Nationwide Children’s Hospital in Columbus, it revealed some eye-opening, but not quite surprising, statistics. The authors looked at all the NCH data for 2013. Notably, 45.1% of serum IgE (sIgE) tests ordered by primary care physicians (mostly pediatricians) and some nurse practitioners were panels of multiple allergens, compared to just 1.2% by allergists. Given our preoccupation with over diagnosis of food allergies and the consequences for personal, family, and public health, we decided to catch up with Dr. Stukus and ask what it all means. — Henry Ehrlich
AAC: Thanks Dave, and welcome back to our website. First, please tell us why you did this study. It’s a broad worry in the allergy community. You cite Dr. Andrew Bird who also did a piece for us. Is there some specific reason, a particular patient or group of patients that got you thinking? Did you see consequences in your own specialty practice?
Dave: Thank you, Henry, for the opportunity to return to your wonderful site and audience. The idea for this study originated from patients being seen in our office every day. We routinely receive referrals for evaluation of suspected food allergies in infants and young children, many of whom already had serum IgE testing performed. Sometimes they have foods taken out of their diet based upon these results. Many times, parents are told to withhold introduction of new foods based upon these tests. Rarely, we see patients develop a new allergy to a food they were eating regularly without problems but produced IgE towards; the food is removed based upon testing and then, when reintroduced weeks or months later, they develop a new allergic reaction to that same food they were previously eating without problems. So, yes – this felt like it was a big problem but had not previously been objectively assessed or characterized on a wide scale, which is what we sought to do.
AAC: You point out, “Compared with allergists, PCPs ordered significantly more sIgE tests for foods associated with a low prevalence of IgE-mediated food allergy, such as strawberry, beef, corn, and tomato.” Do you have any insight into why these tests are ordered? Do patients/parents ask for them? If so, do you get such requests in your practice and how do you handle them?
Dave: I think there are different reasons why testing for unlikely causes of food allergy occur. First, clinicians may have misunderstanding regarding the signs/symptoms of IgE mediated food allergy, the role of IgE testing, and common causes of IgE mediated food allergy reactions. Symptoms due to certain foods, such as heartburn from tomatoes, may be misattributed to IgE mediated allergy, thus prompting testing to be performed. Second, many parents/patients request testing for wide ranges of foods due to concern over symptoms they may be experiencing or “just to make sure I’m not allergic”.
I routinely have requests to perform food allergy testing for unlikely causes of food allergy or towards large numbers of allergens. In these cases, I spend a lot of time taking a detailed history, discuss the proper use and limitations of IgE testing, and offer suggestions for other causes of their symptoms. 99% of the time, I can avoid testing when it’s unnecessary. This takes a lot of time in digging out the details from the patient and also time to explain how testing works and doesn’t work. Rarely, I’ll still end up testing for limited foods, hoping that seeing a ‘negative’ result will provide enough reassurance to positively impact a parent/patient.
AAC: One element that your data raises is the role of the calendar in the life of an allergic child. Namely, that allergies develop after exposure, they aren’t there from the beginning. You mention “the Childhood Allergy Profile, which was only ordered 2 times during the study period by allergists, compared with 383 orders from PCPs. This profile contains 5 aeroallergens (cat, dog, dust mite, cockroach, and alternaria) that rarely cause clinical symptoms in infants (under) 12 months of age who may be suspected of having food allergies.” Don’t these tests come with “black box warnings” or something to discourage inappropriate use? Don’t doctors read them?
Dave: These tests not only lack any type of warning label or best practice alert, but are also aggressively marketed by laboratories to clinicians. IgE panels may be presented as a convenient way to find out all the things a patient may be allergic to, with one easy test. If a clinician lacks the understanding or expertise in the interpretation of IgE tests, then this may seem like a great idea. Unfortunately, when the results are reported with a big exclamation mark next to even the slightest elevation in level, or with pre-assigned arbitrary classes designating ‘severity’ (which is completely fabricated, by the way), then providers may be prone to overdiagnose food allergy based upon results.
AAC: You itemize the costs attached to the tests, and they can be pretty hefty. But where does the money go? Do doctors profit from ordering more tests or does it go to the laboratories and the manufacturers? Insurance companies are frequently demonized, rightly in my opinion, for denying testing and treatment, but isn’t there an algorithm for fishing expeditions?
Dave: The way our healthcare system is designed in the United States, the ordering clinician does not profit one penny from ordering these laboratory tests. Unless, of course, they also have equity in the laboratory used to process the sample. The money goes towards the laboratories that run the testing protocols and also to the companies that design and offer the assays. I’ve heard anecdotes of insurance companies refusing to pay for IgE testing if the same test was already performed within the past 12 months but I don’t actually know if this is true, from a patient perspective.
AAC: You mention the “Choosing Wisely” program, which seeks to discourage unnecessary tests. We also wrote about this a few years ago. Do you get the feeling that this campaign has had a tangible benefit in the intervening years? Is it actively promoted? Do you as a regional leader in this field exert special influence?
Dave: I think the Choosing Wisely program is fantastic but unfortunately, I do not believe it has reached it’s intended audience on an appreciable scale. It takes decades for clinical guidelines (see: NHLBI asthma guidelines) to actually change the behavior of practicing clinicians. Primary care physicians are fantastic due to their long-standing relationship with patients and ability to monitor/diagnose/treat literally hundreds of conditions. However, due to time constraints, it is impossible for a primary care doc to keep up with all the latest and greatest research or clinical guidelines from every subspecialty. For every allergist, such as myself, shouting from the mountain tops to stop the use of indiscriminate IgE panels/testing in the evaluation of food allergy, there is a gastroenterologist shouting about the risks of long term use of proton pump inhibitors, or a cardiologist shouting the latest advice regarding diet and exercise.
I think there are many ways to reach primary care providers and ultimately change behavior towards best practice and evidence-based management. One way is to publish research in widely read peer reviewed journals. I’ve received numerous positive messages from pediatricians and allergists alike since our study was published, which demonstrates at least some benefit from this approach. Social media is another avenue to utilize for spreading evidence-based information but this will be limited to the reach of the content originator and by size/involvement of the intending audience. Grand rounds, presentations at national meetings, and posts such as this one are other ways to help with dissemination.
As for your last question: Do I exert special influence? Unlikely, other than I may have access to platforms that others may not…such as your website. But, I’ll let others decide that…
AAC: My favorite factoid from the current study is the demarcation between older and younger PCPs in ordering the tests. To wit, those in practice for more than 15 years order more tests than those who have practice less. This is an encouraging trend. Do you think that the word is getting out to younger doctors? If so that bodes well for the future. It seems to me that older doctors are at a disadvantage here because they were trained in an era when food allergies particularly weren’t as well known as they are now and demand for testing is probably rising. Do you think a concerted effort at reaching older doctors might be in order? What can be done for them?
Dave: I agree that it is not an even playing field. We know that food allergy prevalence has increased relatively recently, over the past two decades. Physicians in practice for more than 15 years likely received little, if any, training to recognize or diagnose food allergies. The growth of allergy/immunology fellowship training programs, involvement of academic allergists in residency training programs, and newer manners of education, such as online learning may all improve the education and understanding of physicians with less experience.
Before we try to target physicians in practice for x number of years, we will need to better understand their preferred manner of ongoing adult learning, their receptiveness to new research and ideas, as well as their willingness to change their clinical practice.
AAC: The big problem here is the demographics of the allergy specialty. Consciousness of allergies is rising while training programs decline and the supply of new ones isn’t keeping up with the retirement of old ones. This dictates that more allergy treatment will be done by PCPs, and by the way they aren’t doing very well either in terms of replacement either. You practice in the middle of a state with lots of rural communities that must be struggling to maintain access to primary care. Any thoughts on how we can leverage the expertise of doctors such as yourself?
Dave: I think we evolve with the times! Telemedicine is the first thought that comes to mind. This is being implemented more and more, offers reimbursement from insurance companies, and is being refined and better understood on a continuous basis. Social media is another exciting avenue for dissemination of evidence-based information.
AAC: Thanks for your time, as ever.
Dave: It is my pleasure – any time. Thank you for all of your interest and help in spreading the word!
David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma and food allergies, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children’s Hospital Department of Pediatrics Junior Faculty Award in November 2013. Dr. Stukus has been an active member of the medical advisory team for Kids with Food Allergies since 2009 and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Lastly, Dr. Stukus actively engages with food allergy support groups and participates in social media on twitter through @AllergyKidsDoc.
Nut-Free Schools: The Good, The Bad, and The Ugly
By Dr. David Stukus
I couldn’t believe it had come to this. I was the first allergist this family had seen for their 10-year-old son, who had a peanut allergy. They came to see me as a last resort before pulling their son out of school. He had attended public schools since Kindergarten, all of which were “nut free.” However, he was about to start fifth grade at a new school, which was not. Both parents were extremely anxious about his peanut allergy and potential for life-threatening reaction at school, where he was outside of their watchful eye. They requested that I “force” the school to ban all nuts to allow their child to safely attend. After much discussion, it turned out that they had never received counseling about food allergy management, risks, and expectations. I’ll spare the details, but after a productive discussion (and several subsequent visits), they decided to allow their son to attend his new school, without changing its policy. You’ll be happy to learn that he has done great ever since.
Nowhere is the epidemic of food allergies more contentious than in our nation’s schools. This is where the health problems of an average of two children per classroom run headlong into the “right” of children to eat “America’s favorite food” or other staples of the typical diet, where education professionals must learn emergency medical skills and school nurses are becoming a luxury, and so on.
Current estimates are that 5-8% of children have at least one food allergy, with roughly 2% having allergies to peanut or tree nuts. But while these are the battleground allergens, milk, egg, wheat, soy, fish, and shellfish collectively account for > 90% of all food allergy reactions. Many people do not realize that any food allergy can cause a severe allergic reaction. Although milk, egg, wheat, and soy allergies tend to improve or go away with age, 80% of children with nut or seafood allergies will never outgrow their allergy. The severity of reactions can progress over time and cannot be predicted based upon any test result, or even prior history.
Compounding the school dilemma is the fact that food allergens can represent a threat even when they are not ingested. Because even trace amounts of peanut protein introduced through cross contamination from a shared baking sheet or utensil can provoke a life-threatening allergic reaction in some children, management of food allergies requires constant vigilance at every snack and meal to ensure the food doesn’t contain or didn’t contact any food allergens. Casual contact through touching the food or a surface where the food previously touched can also cause reactions, although these are rarely life threatening, and mostly cause localized hives or swelling. However, transfer of the food from hands to the eyes or mouth can trigger a more severe reaction. Food allergy reactions can occur to some foods through inhalation as well, but the majority of these are when the food is being cooked on the stove top and releases vapors into the air, such as frying fish. It is exceptionally rare for a food such as peanut to cause a life-threatening allergic reaction by merely being in the same room or vicinity without ingestion occurring, but minute amounts may travel on hands and clothing. The exact route these proteins travel may never be known in each case.
Given the prevalence of peanut and tree nut allergies, risk for reaction with every exposure, and multiple routes of exposure, some schools have adopted nut-free policies to try to minimize the risk with their students. This can be a highly charged political and emotional discussion from both sides, and may provoke strong sentiments from families who don’t have children with food allergies. The decision to make a school nut-free affects everyone. Below are some of the things to consider for both sides of this argument.
The Good
Given the large number of students spread throughout multiple different classrooms and moving through various locations throughout the school day, it can be extremely challenging for school personnel to provide constant supervision for students with food allergy. Younger children in particular naturally explore their environments more with their hands and even mouths. Having peanut/nut containing products in the classroom increases the risk that they will accidentally touch or ingest these foods. Having a policy in place that is communicated to all students and school personnel about being a nut-free facility can reduce the number of potential exposures and risk for reaction. This can also bring about a sense of community and promote well-being for all students, acknowledging the challenges that children with nut allergies face every day.
Each school differs in regards to their physical layout and meal preparation/lunchrooms. It may make a lot of sense for a school that serves lunch in the classroom to restrict all nuts to minimize risk of exposure. However, schools that have separate cafeterias and do not allow snacks/meals in the classroom may prefer to implement nut-free cafeterias instead. Each circumstance is different and the age of the students, specifics to the school, and understanding/preparation from the school personnel all must be taken into consideration when deciding whether to go nut-free.
The Bad
There is no evidence that demonstrates nut-free schools protect against allergic reactions. In fact, the opposite may be true. At least one study has shown ongoing reactions to peanut/tree nuts in nut-free schools! How can this be? If you discuss with school nurses and administrators, many of them will tell you that nut-free policies are not enforceable. Despite repeated notifications to families and provision of policy statements, children without allergies may still unintentionally bring nut containing foods to school for lunch. Unless you search every single bag every single day, there is no way to enforce this rule with 100% certainty. Peanut butter is a great source of relatively inexpensive protein and many families rely on peanut butter and jelly sandwiches to feed their children at lunch.
In addition, having a policy about being nut-free may inadvertently cause students with food allergies and school personnel to have a false sense of security and let their guards down. One study shows that accidental exposures happen at higher rates than in schools that allow nuts (and both are far below the rates at home). Labels may not be read every time. Perhaps the students forget to ask about ingredients in the lunch line. Perhaps parents neglect to send injectable epinephrine with their child, feeling secure that they will not be exposed to nuts. One must always consider unintended consequences, which in this instance includes potential for being unprepared to recognize or treat an allergic emergency.
Many who advocate against nut-free schools discuss the need to prepare children with food allergies for living in the ‘real world’. They will always need to follow all standard precautions when visiting public places, other people’s homes, or when traveling. Implementation of nut-free policies within schools may hamper their ability to practice and learn critical self-management strategies that will help them navigate their way through the rest of the world. Counseling the family in the anecdote with which I began this post taught me as much as I taught them about the responsibilities that fall on every food allergy family. Fortunately, they learned and their son has benefited.
The Ugly
Parents of children without food allergies may not understand the real risks involved or the serious nature of living with a food allergy. They may not understand that there is no safe amount and every snack or meal needs to be scrutinized. Poor awareness and recognition of these facts can lead to intentional or unintentional emotionally charged exchanges with families living with food allergies. Animosity may grow towards the select few who force a policy that affects all. Occasionally, conflict erupts that brings out the very worst in parents, who view new restrictions in a political context of ever-more intrusion on personal liberties.
In addition, making a school nut-free does not protect children with other potentially life-threatening food allergies such as milk, egg, wheat, soy, or seafood. Parents of these children may feel as though their child’s needs are not being met and excluded from the communal feeling of the school banding together to protect some children, but not others. This can turn into a slippery slope very quickly.
Lastly, several studies have shown that 25-30% of children with food allergies are subjected to bullying at school. While having nut-free policies won’t change the fact that a student may already have food allergies, it may bring their allergies to the forefront for those with bad intentions to exploit.
Conclusion
Regardless of a school’s decision to adopt nut-free policies or not, everyone within the school should receive annual training and education regarding the recognition and management of food allergies. The Centers for Disease Control published excellent free guidelines in 2014 that provide in-depth discussion of many of the issues raised in this article, in addition to recommendations for ways schools can best accommodate and protect students with food allergies.
You may note that this article does not make any recommendation one way or the other whether schools should adopt nut-free policies. You may also note that no professional medical organizations, including the allergy specialties, have made formal recommendations regarding this topic either. It is simply too complex to apply blanket statements that should be adopted by everyone. While debate can carry on regarding the merits of nut-free policies, no one can argue that there is a lack of evidence for both sides of the argument. Individual 504 plans for children with food allergies can help provide thorough, written communication regarding provisions the school can make to ensure the safest environment possible.
The approaches by schools and families with food allergic children may vary. However, at the end of the day, what matters most is that children with food allergies be able to attend school with their peers, not be secluded from any activities, and learn in a safe environment while minimizing risk of accidental ingestion of their food allergens.
David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma and food allergies, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children’s Hospital Department of Pediatrics Junior Faculty Award in November 2013. Dr. Stukus has been an active member of the medical advisory team for Kids with Food Allergies since 2009 and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Lastly, Dr. Stukus actively engages with food allergy support groups and participates in social media on twitter through @AllergyKidsDoc.