Transcript: Food Allergies & Breastfeeding

Jacqueline Kincer  0:38  

Welcome back to The Breastfeeding Talk Podcast. I'm your host, Jacqueline Kincer. And today I am excited to bring to you a very special guest. Dr. David Sukus is someone that I followed on Instagram for a little while and I was actually super sad when he came to my city to give a talk at a conference and I missed it. I sort of fell out of the loop of in person events during the pandemic and so when he came I was so mad at myself that I did not know he was coming to speak. But that's okay because I got to chat to him on the podcast. 

 

So if you don't know who Dr. Stukus is, he's a professor of pediatrics in the Division of Allergy and Immunology at Nationwide Children's Hospital, and the Ohio State University College of Medicine. At his institution he serves as the Director of the Food Allergy treatment center, and Associate Director of the pediatric allergy and immunology fellowship training program. Dr. Sukus is a member of the Board of Regents for the American College of Allergy, Asthma and Immunology, the social media editor and host of the podcast series for the American Academy of Allergy, Asthma and Immunology, and is one of 12 invited members for the Joint Task Force for practice parameters for allergy and immunology. 

 

You can find him on Twitter and Instagram at allergy kids doc, we've got that linked up in the show notes for you where he has amassed over 45,000 followers. What I love about Dr. Sukus is that he just brings us back to a sense of reality. He is so clear on the science and the evidence. His podcast is phenomenal for anyone who wants to nerd out and dive into the world of allergy. So what we're gonna be talking about today specifically, is food allergy and allergies related to babies and breastfeeding. There are so many myths and misconceptions. And I will be the first to admit that I fell victim to those things over the past years. You know, these last two or three years I've really become enlightened about just overall scientific studies and principles and things. I think there's a lot of misinformation out there and disinformation out there. And sadly, even clinicians can fall victim to it. So Dr. Sukus is really a light at the end of the tunnel for a lot of us. 

 

You may not like everything that he has to say. But nevertheless, what he has to say is true and incredibly helpful. If you are a mom who's wondered, Is my baby's reflux or skin issues or diaper issues related to something I'm eating this episode is for you. He clarifies so much. And I also will say that I think he's just very encouraging, getting to know him chatting to him before and after the episode, I would say he's just a really compassionate human being who just wants to see the best for our children and our babies. So without further ado, here's my chat with Dr. Dave Stukus. 

 

Welcome to the show Dr. Stukus I'm so excited to have you here to talk about allergies and food issues and babies and breastfeeding. I followed you for a while on Instagram. And I just find your posts so incredibly informative and educational, and setting the record straight and then recently started listening to the podcast that you host. So I'm thrilled to have you here. And I'd love for you just to say hello to our audience. We've got a mix of moms and professionals who listen to the show. Tell us where you're from. Tell us what you do. 

 

Dr. Dave Stukus  4:18  

Yeah. Well, thank you so much for inviting me. This is going to be great. And I'm honored to be here. I think that hopefully our conversation will provide some insight and some help to folks listening. I am a pediatric allergist and immunologist. And what that means is that after going to medical school, I specialize in pediatrics for residency, and I did an extra two years as a fellow in allergy and immunology. Then I became board certified. And I've been in clinical practice for Oh boy 15 years now. And my career has has shifted a little bit as my interests have changed. I've been at Nationwide Children's Hospital in Columbus, Ohio. For the last 11 years. I actually did my residency here, and 20 years ago. 

 

And over the last 11 years I fell in love with asthma. That's why I got involved in allergy immunology in the first place. Because I kept seeing all of these children admitted to the hospital coming to the ER and I said, this is such a common condition, why can't we control this. And then I learned about all the different heterogeneity of it and the immunology behind it and all the nuances. And then I realized a few years ago that where we were with asthma 10, 15 years ago, is exactly where we are with food allergy, which means we are on the cusp of offering very personalized individualized care. We're using fancy terms like phenotyping, and endo typing to understand the immunology behind people. And I've learned in clinical practice that you can take 100 children with peanut allergy, and they're all different in different in unique ways. So there is no one size fits all approach when it comes to any of this stuff. And I'm sure we're going to talk about that. And now, I'm the director of our food allergy Center at Nationwide Children's Hospital which reopened oh my gosh, 18 months ago. And that's all I do is I get to spend all my time helping families who have concerns about food allergy. In addition to that I do a lot of work and research and quality improvement. I'm involved in our professional organizations, and it keeps me busy and out of trouble.

 

Jacqueline Kincer  6:05  

Wow, yes, that is amazing. I think your body of work is so incredible. And so needed, obviously, you know, one of the reasons why I asked you to come on the show was specifically food allergy. And how common you know, I've seen that come up in our, you know, our practice, where, you know, so many moms will think that there is an issue that's going on. And sometimes it's not, or pediatricians are often very confused about this. And then there's many people that, you know, really don't know what to look for. And we're spotting it sometimes as clinicians. And it's certainly not an issue where, you know, I'm able to diagnose or fully assess or examine, but there are some signs that I can spot and then try to make that appropriate referral. And so there's so many myths and misconceptions out there, I think, even if you're an adult, but especially when we're talking about children and babies. So I'd love for you to talk about that specifically with breastfeeding. You know, I find it really hard when moms are sort of led to believe that their breast milk is somehow bad, right? And that's often just a misunderstanding and miscommunication. And so, you know, how many times have I seen it where, you know, a pediatrician says, oh, let's put your baby on this specialized formula to see if breast milk is the culprit? Well, there's a lot of reasons why you might see a reduction in symptoms with that. And it doesn't always indicate, you know, an allergy, there could be something else going on, depending on how the baby's being fed, right, feeding a baby at the bras versus the bottles are totally different mechanical experience. So sometimes we see that but I'd love for you to, you know, tell me what you're seeing when it comes to breastfed infants.

 

Dr. Dave Stukus  7:48  

Yeah, if I may, let me let me state a very a couple of very important concepts. And I think that'll set the stage for everything. Number one, all of the symptoms that can occur due to food allergies can occur for completely unrelated reasons. So it gets very confusing. Number two, causation is not the same as correlation. And there are many parents, the human mind is programmed to ask questions. And if we see something going on with our child, we are going to ask why is this happening? We want to find the answer because it makes us feel really good about ourselves and the world we live in. But more often than not, there's a correlation there and not an actual causation. And then lastly, our understanding of food allergy has evolved so rapidly in just the last few years, that even if we all uniformly believe something to be true five years ago, there's a chance that our understanding has changed. So even if you were told something, and and you know, it takes years for all this to get into clinical practice. So our well intentioned, wonderful pediatricians and internal medicine doctors and other specialists, it's impossible for them to stay up to date with all the evidence, it's impossible for me to stay up to date with all the evidence, but that's part of what I do. 

 

And then I had the chance to educate all of them. So it's not right or wrong. It's we do the best we can with the information available at the time. But we now know enough to know that when it comes to breastfeeding and maternal diet, there are very few indications where a mother has to stop eating a food because it's harming their baby. And we need to be really thoughtful about why we tell mothers to stop eating foods, what the expected outcome is in their baby. And as well we have to discuss what's the harm to that mother and baby if she stops eating certain foods as well. Because it's not a no risk proposition. And you know, there's a lot of well intentioned people that say, well just stop eating this and then we'll see what happens. Well, you stop eating that, and then you see no change. So then what happens we'll take this out of your diet, and that of your diet, and then you're avoiding 12 foods. And then one other last concept we can get into more details is babies undergo such dramatic maturation and change early in life that if they had symptoms at four weeks of age, you could feed them the same exact thing every day. And those symptoms may be completely different by eight weeks of age. So we have to account for what's going on inside the baby at all times as well. So they kind of threw a lot at you but hopefully it sets the stone

 

Jacqueline Kincer  10:00  

My gosh, it's deep, but I love it, it outlines exactly where we're gonna go in this conversation. And, you know, I think the first two things you said about, you know, symptoms can have multiple causes. And, you know, we really made it make sure we're targeting the right the right cause that we're finding out doing that due diligence as clinicians, right, and as parents not sort of becoming a runaway train of oh, this is definitely it, because my friend had a baby with the same problem. And they did this and that fixed it or, you know, whatever it might be right on, and that correlation does not equal causation. So you had mentioned about infant maturation, and maybe that's a good place for us to actually start. So let's talk a bit about that, you know, the infant immune system, digestive system, anything you think is relevant there to this topic.

 

Dr. Dave Stukus  10:46  

Yeah, to go back to what you said, nobody should ever compare their child to any other child. Each child has their own unique human, it's their story. And I see this all the time of parents whose youngest child doesn't do what the older siblings did. So therefore, they think something must be wrong. But from my end, I get to see 1000s and 1000s of children. So there's a normal variation there. And everything that we deal with in health and medicine, there's a bell shaped curve, most people fall within the middle ground, but then we have the extremes on both ends, there are people on the extremes, those are the rare exceptions, but they are absolutely out there. And it's still part of the normal distribution. So when it comes to babies, things changed dramatically, you know, keep in mind that they are inside a water environment where they're literally attached to another human being for nine months. And then they come into the world and there's bright lights, and the air is very dry, and they're they're cold. And they're, you know, they're forced to fend for themselves. 

 

So everything changes dramatically, as they adjust to the new environment. This has to do with them feeding for the first time. So their gut has to get used to eating things, whether it's, you know, formula or breastfeeding, this has to do with the ambient environment, so their skin can be very dry, they're going to get all kinds of rashes, this doesn't mean that they're having allergic reactions, this is just their skin getting used to not being inside water, or the amniotic sac, I should say. And then, you know, their immune system is going to change dramatically as well, because a lot of what they start out with in life, they have their own baseline immune system, but they also get very passive antibodies from mother. And as they get older, in the first few months, a lot of that kind of goes away, then they start to develop their own immune system and ramp that up. So they don't have immune deficiency. They're not fragile little creatures on the firstborn, it's just their immune system is still developing and changing. And then the cool thing with the immune system is, as it interacts with the world that we live in, it's very dynamic. It's like going to the gym, our immune systems love to exercise. So as the immune system encounters different forms of bacteria and viruses and germs and things like that, it is going to adapt, it's going to change, it's going to become stronger. Same thing goes with foods, if you haven't been exposed to certain food before, you know, eating it promotes tolerance. Whereas if we avoid it for prolonged periods of time, that's when we may develop risk for having an allergy. So it's just important to understand all these dynamic influences are going on on a steady basis as you're really in the first couple years of life.

 

Jacqueline Kincer  13:06  

Oh, wow. That's, that's magnificent, you know, I'd love to touch on what you said about skin and the baby's skin adapting from this, you know, completely wet environment to now a dry environment. That's not always the same temperature and all of those things. What's going on with baby acne? Is it caused by hormones? Is it caused by an adaptation to the environment? Is it a food allergy issue? Is it some combination of those depending on the baby? I have? I have so many questions that I honestly do not know. You know, it's not my it's not my area, right? I don't treat that you know, but it pops up where moms will say, Oh, he has a bit of baby acne that's from the hormones or he has baby acne. He has like cow's milk protein allergy. And I'm like, Well, it probably isn't, you know, so black or white? Yeah,

 

Dr. Dave Stukus  13:54  

I can tell you definitively, it's not due to food allergy. So here's what we know about acne and adolescence, you know, all of us have had acne at some point, I still get acne every once in awhile, it's because of all of our pores can be clogged by the oils and the sebum and things that our body naturally produces. Sometimes bacteria gets involved in it, it interferes with it, and you get more of a post like reaction and there's inflammation and all kinds of stuff like that. But you know, diet is in regards to acne is highly controversial, even in adolescents and adults. And I know the internet will tell you differently, but the evidence, yes. So you know, baby acne is I we don't know, is it just a normal part of the skin as it sort of exfoliate? And it's maturing? Is it partly due to hormonal influences? You know, regardless, it's an it's, it's fine. It's a benign condition. It improves over time. Some babies have been more severe than others. I guess a cousin to that would be something that we call seborrhea where kids get really dramatic flaking of their scalp, and it can be really dramatic. It doesn't bother them at all the babies are completely fine. But parents we don't want to look at our precious newborns and see this on their scalp. Not always improves. The time as well. So some people just have more dramatic examples compared to others. But the last thing we want to do is really make drastic changes based upon these normal newborn experiences.

 

Jacqueline Kincer  15:11  

Yes. And so what you're really referring to there with a scalp is what we commonly refer to as cradle cap. Yep. Right. So yeah, I know, there's, I know, some moms will say it's like a guilty pleasure. They're nursing their baby, or they're holding them and they're sleeping. And they like, I just, I just can't I just pick out it and I pick it off.

 

Dr. Dave Stukus  15:28  

Oh, so satisfying. Yeah,

 

Jacqueline Kincer  15:31  

kinda, you get the comb, and you, you know, get it out if they have some hair and whatnot. Yeah, kind of feels good.

 

Dr. Dave Stukus  15:38  

Big chunk off there. Oh, I get it.

 

Jacqueline Kincer  15:41  

Oh, my gosh, we're hilarious creatures as humans, it's so funny. I'd love to talk about two, I don't know, you can kind of take this whatever order you want to also but you know, there's that idea, right of, you know, the gut, you know, there, there's amniotic fluid, the babies in the womb, and they're getting nutrients through the placenta and all of that. Now they're out in the world, and they're going to really be putting their digestive systems to use and what's going on in those first few days? Maybe you can touch on that. And, you know, is there some significant difference between breast milk and formula?

 

Dr. Dave Stukus  16:16  

Well, yeah, there's differences in regards to the nutrients that are involved, as well as you get all kinds of benefit from breast milk with, you know, passive transfer of antibodies and other parts of the immune system and things like that. I do want to say, though, and I know you, you know, this better than anybody, but there's a lot of guilt that's involved with mother, there are some others that simply can't breastfeed for whatever reason, my wife struggled, struggled with our son is now 13. And we were both in tears. And we've been down this path, it's so hard, but there are some women that just can't do it. So I like to make this a guilt free zone. But when possible, you know, best Smoke does offer, you know, significant advantages compared to cow's milk based or soy formula. So just the nutrients involved. But, you know, I actually just saw, I saw a console not too long ago, where they were concerned that a breastfed baby was having too many stools, and they were too liquidy. They thought it was something that the mother was eating or some form of allergy. And as a pediatrician, I simply said, that's normal. They're not eating solid food, they're not going to poop, they're not going to have well formed stools, until they really start eating solid foods or until they mature a little bit further. 

 

So you know, it's normal for babies to do that, for the first several months of life, and then things are going to change dramatically, once they start eating different foods. It's not because they're allergic to it or intolerant to they don't have a food sensitivity, it's just normal part of eating, you know, different nutrients and fiber and stuff like that. And then the other thing is your infant behavior, we don't fully understand colic, and, you know, colic it, it can be very severe. And boy, when we have newborns and they're not sleeping well, and we're not sleeping well and we're exhausted and, and they're screaming their head off, we want to do anything we possibly can to help them. And that makes us susceptible to people selling snake oil, this is where Grifters come into play. And this is where people will offer unvalidated non evidence based treatments or cures or approaches and your spend a lot of money and waste a lot of effort, you know, trying to help your baby and then these people are there to take advantage of folks like that. And it's not just for for parents of newborns is anybody that has a condition with no known cure, or cause or things along those lines. So I just want to recommend caution when it comes to that as well.

 

Jacqueline Kincer  18:22  

Yeah, absolutely. You know, I think some things that come to mind that I commonly see will be introduction of grape water, and in you know, infant probiotics, and you know, there's another kind of, you know, call it calm, which is essentially like a gripe water, right, those sorts of things. And what I generally tell patients is, you know, those, those things, you know, really aren't going to treat, you know, if it was a food allergy issue, that's not going to help you if your baby swallowing air, and that's what's causing that digestive discomfort. That's definitely not going to clear out that air bubble like what is the goal in offering that? And when you kind of talk about what would be the effect of giving those things? Most parents go, Yeah, I haven't really seen a difference. And I've been giving this for two weeks. So they often kind of know, but they feel beholden to it. Like if I don't give it what if things get worse, and they feel sort of locked into that. So I'm glad that you brought that up.

 

Dr. Dave Stukus  19:18  

Yeah, we're all subject to anecdotes from others of other social media people you know, in real life, but anecdotes aren't evidence. We also don't know everybody's conflict of interest, whether they're making money off of you know, selling you these things by telling you their story. And we're all subject to cognitive biases. My favorite one of my favorites is sunk cost fallacy. If I spend $100 on a treatment, I sure as heck want it to work. And I'm going to believe it works even if it doesn't really show good objective proof that it's working. So once you buy into it, it's really hard to think clearly and evaluate whether it's working or not.

 

Jacqueline Kincer  19:50  

Yes, so true. And I know you had mentioned, you know, infant stool patterns, and I'd love for you to talk about that. So what what are the variations of normal for infants tools in terms of color and texture, and especially if they're breastfed since most people listening to this, we'll be talking about that. And then also, you know, frequency. So one complaint that I often hear is babies that aren't stalling frequently enough. So maybe let's talk about that for a few moments.

 

Dr. Dave Stukus  20:20  

The answer is yes, it's all normal. Well, there's so many variations, you know, it can be yellow, green, yellow, green, your green stool is not a sign of anything bad. That can be perfectly normal. Brown, it can smell awful, it may have no smell to it, they can poop 12 times a day, every time they feed. There's a very strong gastro colic reflex, where when we swallow, it causes our intestines to spasm. And that forces poop out it makes sense, right? If you're putting more into the tank, then you have to empty out so you can make room for it. So there are some people that have a very strong gastric colic reflex, people who in the morning when you drink your coffee, you know, if you have to go the bathroom immediately, you know what I'm talking about. So, you know, frequency doesn't really become too much of a concern, we do get a little worried when babies can get constipated. So you know, if the stool is coming out, and they don't seem like they're struggling, it can be once a day, it can be once every other day, if it's nice and soft, kind of frozen yogurt it if it comes out real hard, or in pellets, or they seem like they're in pain as they're trying to go, that's when we are worried that there may be you know, constipated. And there's some ways that we can try to increase the fiber in their diet to give them some more liquid or things like that. And on the flip side, if there's stooling too much, where they're, you know, having diarrhea and watery stools, we really worry when, then when they're having a lot of pain when they go to the bathroom. So if they're upset and crying, or if they're losing weight or failure to gain weight, those are the red flags and babies otherwise, they're theirs, every baby has their own pattern, and the pattern is going to change. So whatever they did today, they're going to do something different two weeks from now. And as I mentioned before, once they start eating solid foods look out, because that is going to they're going to do some really interesting things, then.

 

Jacqueline Kincer  21:58  

I love that. And that's true for all things, whether it's It's poop, sleep, you know, whatever they're doing developmentally, babies are never doing the same thing, it seems. What about mucus in the stool? You know, this is a big one where all have parents think that it's like some giant red flag to see a clump of mucus in the stool. Is that a problem?

 

Dr. Dave Stukus  22:18  

No, not at all. You know, there's a lot of stuff that doesn't get digested. Again, it goes back to overall, we will always want to in when you talk to your pediatrician about this, please, if you have concerns about your baby, talk to your own pediatrician. Don't Don't go on the internet and ask questions. And don't ask Dr. Google and don't talk to the social media group because you're gonna get all kinds of bad advice. And you know, so pediatricians will tell you, okay, they're gonna go through, how are they sleeping? How are they feeding? are they behaving normally? You know, any, and they'll go through the whole global assessment, if everything else checks out, okay? It's usually nothing of concern. 

 

And you know, what often happens is pediatricians want to help. And sometimes it seems like, Oh, if we make a formula change, you know, we'll offer something to do. Most of these things in babies are benign conditions that are self resolved. So if you make a formula change, it's gonna get better in two weeks. If you don't make a formula change, it'll get better in 14 days. To get there. It's the same amount of time. So I think there's, a lot of times you just have to be comfortable with reassuring parents. And that's what pediatricians love to do read. I do that all the time. Reassure parents. I'm really glad you came to see me today. I want to clarify, I don't believe your child has any food allergy based upon x y&z and then I offer alternate explanations and reassurance. Sometimes that's all it takes,

 

Jacqueline Kincer  23:31  

huh? Yes, absolutely. You know, you had talked about intolerance and tolerance. So there's this labeling of, oh, I have or my baby has a food intolerance? What are people really meaning when they say it out? Or what are the misconceptions around that? Because like you said, if you don't eat something for a long time, you will become Intel her into it, which makes sense when you think about it. So is there a is there another version of something that is not allergy, but is sort of on the spectrum? Or is it allergy or nothing?

 

Dr. Dave Stukus  24:07  

Well, all of these terms are overused and misapplied. Self diagnosis is filled with misdiagnosis. And even you know, well intentioned pediatricians, they just don't understand the important nuances with this. So it's not like you're going to become intolerant if you don't eat it. But you know, so there are food intolerances. Well, let's back up a second, let's talk about food allergy, because I don't think we've defined that yet. A food allergy is when the immune system forms a response against a food and then every single time you eat that food no matter what form your immune system says you don't belong here. The most common type of food allergy is caused by the antibody known as IGE IGE. Food allergies cause rapid onset reproducible symptoms every time you eat it, typically within a few minutes, rarely longer than two hours later. It can be any combination of big red, itchy hives, swelling, vomiting, wheezing, recurrent cough or anaphylaxis. If you have an allergy to cow's milk, you really shouldn't be able to eat cheese or yogurt or drink milk because symptoms should occur. Every time there are delayed allergies as well that don't involve that IGE. So you're not at risk to having anaphylaxis, there's something called food protein induced enterocolitis syndrome is a mouthful called F PIs. And this is typically in young babies less than a year of age, they eat a food, they're fine. 

 

Two to three hours later, exorcism type, vomiting, profuse vomiting, and then sometimes diarrhea, and then they're pretty lethargic afterwards. That's a very different type of allergy, but it's reproducible, because every time they eat it, and then there's something called cow's milk induced prokta colitis, which is the typical definition for cow's milk allergy. And this is an otherwise happy baby, you know, four to eight weeks of age, you change the diaper and say, Oh, my God, they have bright red blood in their stool. And this is typically due to ingestion of cow's milk protein, this is also a benign condition, the babies are acting fine, they're not losing weight, and not vomiting or anything like that, and then transition them off of a cow's milk based formula. And then some others do need to stop eating cow's milk for a period of time that resolves it, and then you can give it again, usually you don't have to wait to a year oftentimes, it resolves by nine months of age. So there's the spectrum of immediate onset allergy risk for anaphylaxis and severe reactions towards delayed allergies. But here's the thing that all allergies have in common. They are reproducible. 

 

If you want to play detective and want to figure out if it's an allergy and things are kind of coming going over time, or it happens one time with this group and another time or you have a long list of 20 foods thinking that is that your child is allergic to those aren't worrisome for allergy allergy is pretty apparent. And it's all based on the history. Food intolerances do not involve the immune system. This is difficulty with digestion. Now this is where it gets tricky, because this may change based upon what you eat, how much you eat, how frequently you're eating, and may also wax and wane over time. Food intolerances are also grossly over diagnosed, the most common of which will be lactose intolerance. Lactose is a simple sugar found in dairy products for people who lack the enzymes to digest it. Those foods pat the lactose passes through their intestines sucks water into the bowels therefore makes you very uncomfortable. bloating, diarrhea gassiness, you pretty unhappy if you avoid eating lactose. So there's lactose free dairy products, you don't have those symptoms. If you really want to figure this out. If you think that you're lactose intolerant, or trying to figure out if you're cow's milk protein intolerant, try a lactose free dairy product symptoms go away, maybe it was the lactose symptoms still occur, maybe it's the cow's milk protein. And then if you starting to have multiple symptoms, or you have no idea what's going on, or there's a long list of foods, then maybe it's not the specific food that's causing all these issues, maybe it's more of an internal issue. And that's where we want to do more of an evaluation. So I covered a lot of ground there. I'll pause sorry about that.

 

Jacqueline Kincer  27:25  

Oh, that's great. I love that you mentioned lactose intolerance. I cannot tell you how many times people have come to me and said My baby is lactose intolerant. And I'm like, so they wouldn't be able to drink breast milk if that was true, because it's full of lactose. So it's it is possible, but it's a rare genetic condition is that that's my understanding, is that correct?

 

Dr. Dave Stukus  27:47  

There's a couple of types. So there's there can be temporary intolerances, anybody who has like a stomach bug or a viral gastroenteritis or they get sick for some reason, you can have temporary inability to digest specific foods. On the lining of our intestines. There's these very fine like hair like structures and all these enzymes that help digest all of our foods. And if you get sick, or there's inflammation or something going on, it can damage our ability to absorb those foods. So that can be temporary. And that gets better after your body heals. And then you can have the genetic kind where you simply just have it in the last lifelong, I would say like you said, that's very rare. And we do want to make sure we establish the diagnosis properly. So you know, I get very picky with the terms I use, I think it's really important to clarify the diagnosis. And the reason why is because the prognosis and risk really matters based upon what we're talking about here. Lifelong avoidance, eat it, I'm at risk for having a life threatening reaction very different than, you know, I'm not really sure what's going on here. Maybe just take a break from it for a few weeks and then try again.

 

Jacqueline Kincer  28:46  

Huh, yeah, I like that. So you've talked so much about different types of foods and things. And I'd love to talk about that. There's a lot of new things on the market when it comes to food allergy and children and a lot of parents are wanting to avoid the dreaded peanut allergy. And so I've seen various suggestions, introduce peanuts early by giving, you know, peanut powder in a, you know, formula or breast milk, or we're somehow mixing some of these things in with solid foods or what have you. Again, I agree with you that there's no one size fits all approach. Some of those things could be dangerous. If your infant does have something that you know, they've never been exposed to this turns out they do have an allergy or something. So maybe you could talk about that, like in terms of, you know, what is the ideal timing for introducing solid foods when we're talking about the infant digestive system and potential allergies? And then is there are there certain foods that we're looking to introduce at certain times or not? That would be really helpful.

 

Dr. Dave Stukus  29:51  

Yeah, thanks for asking. So a culture of fear has been created surrounding feeding babies, their parents driving to the Parking Lot of an emergency room the first time they feed their baby peanut butter because they think they're going to spontaneously combust. And we have to acknowledge that it's just like we're feeding our babies here. It doesn't have to be a medical procedure. Part of this is because we used to recommend avoidance of allergenic foods such as peanuts, tree nuts, seafood, milk, egg wheat, and soy to kids who are a certain age, sometimes one, two or three years of age. That was 20 years ago, the evidence has evolved and changed dramatically. And we have very strong evidence that shows the earlier we introduce especially peanut and egg, but other allergenic foods as well. And most importantly, keep them in the diet consistently. That's the best way to prevent allergy and promote tolerance. Ideally, we'd start around four to six months of age. While but we start with other solid foods, some babies aren't ready to eat solids till the nine months other babies are ready to four months. So start with a typical cereals and oatmeal and purees. And then just start mixing in some of these allergenic foods and keeping it in their diet consistently. We don't want to medicalize that I don't want you to have to measure this, there are guidelines that were put out, I was one of the co authors on them where we actually have measurements, but those were based upon one specific study. So I don't want people losing sleep if they go for days without eating it, or they have to measure certain amounts. But the idea is, you know, keeping in their diet consistently, there are commercial products that are developed that have different allergens in them that you can either mix into cereals, or purees, or their biscuits or, or pasta, things like that, for some families that this is great for them because you know, they're very busy and they're struggling to you know, introduce these foods to their babies, but they are relatively expensive. 

 

For a lot of folks, they are not medically necessary, we will always want to promote real food. When it comes to peanut, we don't want to give holder partial peanuts, because they're choking Restall kids are four or five, but you can use them to peanut butter with water. There's great peanut flour and peanut powder. Now, these peanut puffs snacks called bomba, which kind of started this whole peanut allergy prevention study and research in the first place. But you know, this is really as a paradigm shift in our understanding of food allergy prevention. So we want to get the word out that you know, Feed Our Babies, let them eat, enjoy a bunch of different foods, it is there was never any evidence to suggest one new food every 34567 days, that was all made up by a bunch of very conservative people that was that feeds into the culture of fear, you can absolutely feed your baby 20 new foods today, because odds are nothing is going to happen. And even if something does happen, which would be unexpected, then we can go back and figure it out. Regardless, you know, everybody listening, you can do whatever you want to your baby. And 98% of these babies will never develop a peanut allergy ever. But if 100% of parents out there are treating them like they're a ticking time bomb ready to have a severe reaction when they eat peanut for the first time. 

 

That's a disservice to the vast majority of people. There are babies that are at increased risk. So those who truly have persistent eczema, not that little spot on their cheek that kind of comes and goes over time that gets better with over the counter cortisone. But if they have a significant part of their body surface covered in eczema, and they're using really potent topical steroids and other medications to try to control it, those are the ones raising their hand saying, I'm at risk to develop food allergies, and those are the ones we absolutely want to get them to eat it as soon as possible and keep it in their diet. Because we may alter their life by preventing food allergy development, it's not 100% effective, some kids will still react, but we're going to you know, on a population level help more than we're going to hurt. And then the other aspect I want to address is we know that infants when they have allergic reactions, very rarely do they have you know, there's promote swell shot or respiratory symptoms, more often than not, it's they get some hives and they throw up ones. That's the typical allergic reaction and babies. So even when it does occur, and we don't want this to occur, but even when it does, it's not nearly as scary as most parents think about as a pediatric food allergist. I don't get patients because they they die the first time they eat a food I get patients because parents feed them and they notice a rash or they throw up and then they seek evaluation.

 

Jacqueline Kincer  33:46  

Hmm, that's so so clear. And and I think really just answers so many questions that I think a lot of, you know, parents will have and professionals as well. You know, you mentioned eczema and how that, you know, if it's persistent, like you said, not coming and going that that could potentially put a child in a higher risk category of developing food allergies. Maybe tell us what it is because I do see a lot of misconceptions out there as to what Eczema is or what might potentially cause it.

 

Dr. Dave Stukus  34:18  

Yeah, there's a lot of misconceptions surrounding it. And this goes back for years and years and what some of us were taught even during our training, but I want to be very clear because it is it is well established. What I'm about to say is not controversial at all, despite what people have heard otherwise it is well established that Eczema is not caused by food allergy. Alright, so Eczema is a skin condition. We know that there are genetic human mutations that some people can inherit about 40% of babies with eczema have a mutation in the skin barrier where the skin cells don't join, you know completely so what happens is, the moisture escapes as the moisture escapes, the skin gets very dry, and barriers work both ways. So if the barrier is allowing moisture to Escape. It's also going to allow irritants and other things to enter as well. So that's when you get the inflammation and things like that. Now, Eczema is often the first sign that babies will go on to develop food allergies, or they may develop environmental allergies or asthma. So we call this the allergic march. 

 

So a lot of our most allergic children, they start with really bad eczema in the first year or two of life and then they develop the other allergies. It's not like their allergies are causing the eczema though. So it's not the reverse causation. It's Eczema is the first outward sign of the body saying I have allergic inflammation going on in my immune system. And then as they get older, that's how they develop the other allergies. So Eczema is a skin condition. It is chronic. For most children, it's gone by the first or second birthday. It waxes and wanes over time. There are so many environmental influences on eczema because it's the outward part of the body, it's a skin. So what does the skin interact with, it interacts with the air, anything you put on the skin, and most importantly, lack of moisturizer so as I mentioned, Eczema is dry, dry, dry skin, you can't put enough good moisturizer on the skin, we want to replace the moisture using very thick unscented samolians you know stuff that you have to scoop out of a jar, and then you have to put on the skin several times a day. Super annoying, really hard to do. But that's the best skincare regimen. We want to avoid any fragrance or scented products even if they're all natural or if we think that they're helpful because anything with a scent to it, including essential oils can be very irritating to eczema skin. Viral infections can make eczema flare, heat and humidity and sweat can flare for some children. Cold winter air is very dry so that can be that can flare eczema, indoor heat, when it kicks in, it's very dry as well. Some some babies do develop environmental allergies as they get older. 

 

So if they have cat and dog allergy, and they're exposed to cat and dog dander in the home that may contribute to their eczema flares as well, or seasonal allergies and things along those lines. We really only consider food as a contributing factor for eczema and those infants with truly severe persistent refractory eczema, meaning they have severe eczema, they're bleeding, they're getting super infected, a significant portion of their body is impacted. And they are doing a great daily skincare regimen with all the moisturizers. They're avoiding all the triggers, they're using good, you know anti inflammatory, topical medications and they still have their eczema. That's when we start to think well, maybe there may be some limited foods, let's do a trial avoidance and see if their eczema improves the way you know it. I stopped eating this my eczema was completely better. I ate it again, my eczema came back again. More often than not, people are given the wrong information or they're given these large panel food allergy tests that have false positives, they take a bunch of food out of their baby's diet, their Eczema is going to naturally improve anyways, because it waxes and wanes naturally over time, you happen to catch them on a period where their eczema improved. 

 

And then they take all these foods out of the diet and what happens again, the eczema is gonna flare because it's gonna flare from other reasons. And then they start taking more foods out of the diet. Or lastly, what's really heartbreaking, this is well established. We know that children, infants with eczema, if they're eating a food, and they're not having immediate onset hives, or swelling or vomiting, they're not allergic to that food. If you do a bunch of IGE food allergy tests, they will have false positive test results to that if that baby stops eating that food that they were actually tolerating, and they avoid it for a period of time and go to eat it again, about 15 to 20% may develop food allergy, then that means we are causing food allergy and somebody who is tolerating the food. It's heartbreaking. I see this every day, and it is 100% avoidable.

 

Jacqueline Kincer  38:19  

Hmm. Oh, my gosh, I am so glad you you started to talk about that. Because there's a couple of things that I'd love to have you explain. One is, you know, we kind of just said there, there can be false positives with that. So what kind of testing options are there for infants, especially when it comes to allergy? Are any of those valid? Is it just you know, that okay, we know those symptoms are reproducible based on you know, XY and Z things? Are there other things that we're looking at. And then also to that point that I've seen some various tests come out on the market for moms to test their breast milk. And as far as I understand it, I know there's one where it detects food proteins in the milk? Well, as far as I know, with lactation, we're supposed to have some food proteins and for the milk, because that is a way of exposing our baby to various foods. And I don't think that there's anything that says the breast is not supposed to allow that in there when it produces milk. So is there any accuracy to breast milk tests? And maybe you can speak to that?

 

Dr. Dave Stukus  39:21  

It goes back to the diagnosis, what is the diagnosis? Oh, take a bunch of foods out of your diet just to see why. What's the diagnosis? Why am I avoiding this? What what what is my actual diagnosis? So when it comes to IgE, immediate onset food allergies, we have very valid skin and blood tests that measure they look for the detection of specific IGE antibody to a food. They should only be used when the story suggests when I eat this I have rapid onset hives or swelling or vomiting. These were never designed to be used as screening tests, because they do have false positives. So some people say, Well, they're not very they're not very accurate. They are imprecise, but they are accurate when used properly. They are very nice. accurate as a screening test, you can't just test for a bunch of foods and find out what comes back positive and diagnose allergy that's backwards. That's not how it works. 

 

So you have to take a very detailed clinical history first. So there's at home IGE tests that are marketed. That's not how we diagnose allergy, you start with a history. If I'm eating a food not having rapid onset hives, difficulty breathing, swelling anaphylaxis, I'm not allergic to food from an IGE standpoint. The other important concept is there are delayed onset food allergies I talked about before cow's milk induced practical itis F pies. Ige tests are useless for those conditions, because they're not mediated by the IGE antibody. We don't have good tests for those. So sometimes it is based on the history and a trial avoidance period, sometimes even reintroduction. And then that's it as far as validated tests. I mean, there are some breath hydrogen tests that can be used to look for lactose intolerance. Those are, you know, typically offered in the hospital setting. They're kind of, you know, technically challenging to do in the outpatient setting. But all these other things that are marketed food sensitivity tests, these aren't validated this, these measure IgG antibody, which is not IGE. IgG is a memory antibody, if you eat a food, you will form IgG to that food, all these tests show you are what you've eaten in the past, there are no normal reference ranges. And if you see anybody who does these tests, nobody comes back with a completely negative test result. That's not what these tests show. These tests are just showing what you've been exposed to. But then the people who market it flip around and say, Oh, this must be in the you have a high sensitivity or things like that. muscle testing is offered. There's different types of blood testing called immediate release testing, which is not validated as well. 

 

There's chiropractors that do all sorts of weird manipulation and testing to diagnose, none of this is validated. And here's why validation matters with a test. Validation means this is very simple. The test went through rigorous studies that shows three important things one, everybody with a condition will have a positive result to those without a conditional have a negative result. So that means we can differentiate those with and without a condition based upon the results. And three, the same person takes the same test over and over again, you're going to get a consistent result. So without that validation process, these tests are meaningless because they're all over the place. And we don't know what means what means you have a condition or what means you don't have a condition. So for any mother out there that's going to test their breast milk, I go back to the basics, why am I doing this? Why? What's the diagnosis for my child. And then as far as those tests, I honestly have no idea whether they're valid or not. And my suspicion is, they're probably not going to be of much use. Even when it comes to food allergy I, you know, you can have the most severe food allergy in the world life threatening fatal anaphylaxis if you eat it. But even then everybody has their own threshold meaning you there's different thresholds of how much protein somebody needs to eat to cause a reaction. And you know, there's very few people that are exquisitely sensitive to trace amounts cross contact. So there's a threshold that's involved there. So that's another thing that can be teased out for those people who have legitimate food allergy. But I will go back to what you said about the breast milk, if there's some protein in there, we'll so what is Is it enough to cause a problem? And even so, what's the diagnosis?

 

Jacqueline Kincer  43:00  

Right, and I think my problem with that method of testing is that it has nothing to do with the baby, one baby could consume that breast milk and be perfectly fine, another baby could consume it and have problems. And then even if there are problems, do we know that it's a food allergy? Or is it something else? And so I don't know why we would just in a vacuum, that would be like testing a carrot? And wonder if it's causing a food allergy? Shouldn't we test the baby who's eating the carrot? Like, doesn't it just scientifically, I don't know how that would make sense. So thank you for your clarification on all of the different kinds of testing, muscle testing, I think it's a big one that I see come up in the quote unquote, holistic community as well, and chiropractors and naturopaths. 

 

And, you know, doing all these various tests or protocols and things of that nature that, you know, for the most part really aren't needed, like you said, you know, one of the things I see too is when, you know, like you said, Eczema is not a food allergy issue as its root cause. But when babies do have eczema, I see a lot of parents really hesitant to treat it using steroid creams. I'm making the assumption here that they've already been given that direction, by the pediatrician or whomever, to do that proper skincare, like you said, you know, put that moisture back into the skin, avoid fragrances, all of that, hopefully, that's been done. If your baby needs something, you know, we want to make sure that they're getting what they need. Do you think, you know maybe it's different, you know, how you practice and whatnot. But what you see are steroid creams over prescribed for infants with eczema Are they under prescribed, there's there's kind of a lot of fear. It seems around that like, once you start you can't stop so let's chat about that too. Because I have a lot of parents having questions and I just go this is not my area. Please go back to your pediatrician who prescribed this cream. But I see a big big hesitancy there on on some of those treatments.

 

Dr. Dave Stukus  44:56  

Yeah. Oh you Sterrett phobia is rampant and rightfully so. Because steroids do have side effects and everything we do has side effects. You know, I like to talk about when Eczema is inflamed, meaning you get really read rough, thick areas of the skin, what's the what's the risk and side effect, if we don't treat that inflammation? Well, the side effect is very real, that you're gonna have longtime scarring, you're gonna, you're gonna lose the pigment in the skin, you're gonna have discoloration and put that child at risk for infection as well. So there's, there's real, you know, there's, there's consequences to consider if we don't treat the inflammation adequately. When it comes to the steroids we use on the skin, there are various potencies and the higher potency that you use the the higher risk for side effects. And the side effects typically occur with more long term use. And most often, it's involved in the skin so you can get some thinning of the skin and some discoloration and scarring. So we want to be we want to be thoughtful about when we use this just like we want to be thought about anything that we do. But not everybody needs that those high potency steroids even when we do use them, you know, they can be very safely used for a couple of weeks at a time, and then stop using them. And then this is where we talk about how things have evolved. For any parent out there that doesn't want to put a topical treatment on your child with eczema. 

 

Ask your pediatrician or dermatologist or ologists for non steroid options. We have so many different options now that are really effective. We have calcineurin inhibitors like Protopic and Ella dill that have been around for over a decade, if not longer, that are very effective and they don't have any steroid at all. And they're very safe to use on the face and no custody of the skin and things like that. There's a newer one called Chris aberle, which is a it inhibits prostaglandin D two that's a topical ointment that you can put on the skin as well that treats the inflammation. There are biologics, called de Pilla Mab, which blocks part of the, you know, the pathway, the immuno immunologic pathway involved in eczema where we can give an injection into the body and target that part of the immune system that has no steroid whatsoever. There's other things looking at Jak inhibitors and small molecule. And I mean, this is just in the last nine months, I think there's four or five new treatments all non steroid that have been approved to treat eczema, so don't suffer, you don't have to suffer, there is help available. And if your pediatrician isn't aware of it, talk to a specialist. That's what we do we stay on top of all this stuff. Yeah, you got me on

 

Jacqueline Kincer  47:13  

soapbox? Well, it's funny, I'll link up your podcast. But I just listened to an episode where you talked about some of these biologics. And it was a you brought a doctor on to share a summary of those. And I was just so fascinated, because I've been introduced to the world of biologics through my hobby of listening to podcasts about virology and COVID. And all of that. And there are like you said, there's there are so many more options now for all different things out there. And it's really, really cool. I actually have a former client whose husband is battling a blood cancer right now. And when she sends these, you know, email updates about all of the treatment he's going through, I'm in awe, I am in awe that we have that available, and he is doing so well. Like it's absolutely incredible to me. So I love what you said about there are other options, and you know, think new things are being created and approved all the time. So that gives me a lot of hope for sure. Yeah, I just would love to also ask, you know, we talked a little bit about cow's protein. Can we talk about gluten? Because so many people think that gluten is this massive problem. And if it you know, everyone's just going to become intolerant or allergic to it at some point. Now we have celiac disease. What is going on with that? Is this a problem that we're seeing in infants who are breastfed? Because I'm hearing a lot of ideas that parents have out there.

 

Dr. Dave Stukus  48:36  

Let me start by saying that the gluten free industry is a billion dollar industry, okay, which means they have the money, they have the marketing, they have infiltrated our lives, to try and influence all of us into thinking that gluten is the cause of all that ails humanity. Now, there are people who have a medical reason to avoid gluten, which is basically the same as wheat. If you have celiac disease, about 1% of the population has celiac disease. This is an autoimmune condition where if somebody's eating gluten, their body forms antibodies against their own self. You can have any myriad of symptoms which can be quite severe in many people, it can affect your nervous system, it can wreck your skin, it can affect your GI tract. Once it's diagnosed, and you stop eating gluten, the body generally repairs itself and then you do fine on a gluten free diet. But you have to have proper diagnosis, which often involves a biopsy of the small bowel, but there are some blood tests that may be useful as well. So if you have concerns about talk to your doctor, there's a wheat allergy which goes back to what I said before there are people that when they eat wheat, they have IGE allergy to it so they have rapid onset hives or swelling or could have anaphylaxis. Again we can properly diagnose that through the history and through testing. There is a condition known as non celiac gluten sensitivity, which is somewhat controversial. Of there are people who don't feel well when they eat wheat. You take it out of their diet and their symptoms improve and they eat it again and it comes back again. That's pretty much it for the most part. 

 

Every thing else is, you know, if you go anywhere online, they will attribute any symptom imaginable to the ingestion of gluten. Did you have a poor night's sleep? Did you have, you know, did you forget to sentence the other day when you were talking to somebody? Did you ever lose your keys? Did you blink more than three times in a row? Have you sneeze more than six times this week, you may have a gluten sensitivity. And then they say, some unvalidated test or whatever. So look, even if even if you want to figure this out, if you're truly worried about a specific food completely taken out of your diet, but just do it for like two weeks, you don't have to do it for the rest of your life. Pick one food at a time be as objective as possible. What symptoms Am I having that I attribute to this food? Whether it's frequency of bowel habits, or whatever, be as objective as possible? Did those symptoms completely resolved within a couple of weeks? If not, it probably wasn't that food, if they did eat the food again, and then see if the symptoms come back again. That's the best way to figure this out. But a lot of people don't take the time to do that.

 

Jacqueline Kincer  50:51  

Right? Yeah, no, I think you said there's just this culture of fear that's been created around food in general. And it almost is almost I don't want to, you know, put it in that category. But I think sometimes certain behaviors belong in that category of eating disorder, where we've seen it, you know, especially with people just following very strict diets, right, like, Paleo is a great example. For instance, low fiber diets are generally not healthy for us as human beings, everybody is an individual, maybe that's appropriate for you. But for the vast majority of people, you know, fiber is really important for our digestion, for prevented prevention of certain cancers, all these things, if you're cutting that out, and just, you know, eating certain foods, then, you know, that could be problematic, and potentially creating some issues of tolerating other types of foods should you choose to, you know, change your diet later on. 

 

So there's all these rabbit holes that are available, you know, all these different things that people are being sold, you know, this juice cleanse this protocol, this detox, this supplement, this type of food, and I cannot believe that the gluten free industry is as huge, as you said, for, you know, a very, very small percentage of the population that really, truly needs that. So, we've gotten into all of these ideas, you know, we'll look back at those 20 years from now and go, Oh, what are we thinking, you know, just like kind of the low fat sort of, you know, praise that was going on in the 90s. Everything in my grocery store as a kid was low fat. Meanwhile, as a child, I probably shouldn't have been eating a low fat diet, ya

 

Dr. Dave Stukus  52:24  

know, it's not that far of a stretch for a lot of people to make this connection. And so if you think about a lot of the symptoms attributed to gluten, people's ice, I feel sluggish, I feel tired, I don't I don't move my bowels very well, I just don't feel I don't have a lot of energy. Well, gluten is often present in a lot of, you know, highly processed foods. And if you stop eating, if you're eating a lot of pasta, and bread and other things, you're gonna naturally just feel better. Because these are these are a lot of foods that are pretty heavy, and they have high glycemic indices and things like that, that just make you tired. I saw a console, this is when I was in training. 15 years ago, this this person said, I'm really worried about food allergy, what's going on? Well, every day, I come in my office in the afternoon and I can't stay awake. I'm like, Okay, well, what's going on? What's it? Well, you know, what do you normally eat for lunch? Well, I have, I have a big bowl of pasta, some bread, and a little bit of a salad. And then I'm just so tired. And I said, that is not an allergy at all, like you you are loading, you're crashing and burning with your blood sugars and your glycemic index and like, that's what's going on here. So again, if you have concerns about specific foods, see a board certified allergist, a Board Certified gastroenterologist, we can help separate causation and correlation and really clarify what's going on with you.

 

Jacqueline Kincer  53:40  

Hmm, I love that. And back to babies, specifically, if there's a mom who's breastfeeding, and she has an allergy, let's say she has a nut allergy. Is that something that her baby is likely to inherit from her?

 

Dr. Dave Stukus  53:56  

Yeah, specific allergies are not inherited, there's, you know, we don't need to worry about just because one family member has an allergy that other family knows about the same allergy, there's great evidence looking at sibling dyads. So an older child with peanut tree nut allergy, if you test all the younger siblings, you're gonna see a lot of false positives, but they don't have increased risk of actually having the allergy to that. But I get the concern, because if you witness your five year old have anaphylaxis to peanut, there's no way you're going to feed it to your baby. So that's why we're here I can I can help that I can clarify. Sometimes we do testing, with the knowledge that if it's negative, that's reassuring. If it is elevated, doesn't mean they're allergic, it means Hey, come hang out with me in my office in a very safe environment. We'll feed it to them for the first time here. So for parents out there, if you have concerns about don't assume anything, go talk to a board certified allergist, they can help clarify and help guide your feeding. Now the other question is where I thought you're gonna go with it is I do have parents and mothers specifically that have legitimate food allergies and even anaphylaxis, where they want to introduce these foods to their baby, but then they're gonna latch on to their breast. So that gets a little tricky. Yes, yeah. 

 

So this is really interesting. And this is where we kind of have to work with each person, you know? On a nuanced level, what's going on? Typically having an allergen free meal or snack washes that protein out of the saliva. So say you wanted to feed your baby peanut butter lunch, make sure they have a snack or something else that doesn't have peanut in it before they latch onto your breasts that should do a good job. You could you can consider something like a nipple shields that don't have direct contact with the breast, even like a barrier ointment, or something like that. But that you know that women should talk to her on allergist as well, even then, it'd be unlikely for prote out food protein in the saliva to contact the breast to cause a severe systemic allergic reaction. More often than not, you're gonna have a lot of irritation around the breast. It's gonna be uncomfortable. But, you know, there's, there's a lot of nuance there to discuss.

 

Jacqueline Kincer  55:43  

Huh, that's such an excellent point. I'm glad you you thought to mention that too. I've definitely had that question as well as parents concerned about that. One of the biggest things I see as babies with reflux, and there's a lot of different rabbit holes that people kind of go down once that's happening to their baby. And, you know, there's everything from, you know, the idea that babies should never split up to there's normal babies split up to it's caused by a food allergy or intolerance. What's your perspective on reflux and how that relates to allergy.

 

Dr. Dave Stukus  56:15  

Reflux is rarely a medical problem, it's typically a laundry problem. And what I mean by that is, it's normal for babies to have reflux is completely normal. And here's why. There as we talked about, already, they're undergoing significant maturation, part of that is just the muscle strength and the muscle tone. So the sphincter a little muscle that wraps around the top part of the stomach and the lower part of the esophagus. For some babies, it's not very strong until they're a lot older in life. So contents are going to much easier, they're going to come back and they're going to spit up. The typical story is that, you know, babies that can be pretty severe in regards to frequency and how much comes out, but they're otherwise usually not bothered by it. Sometimes it does make them upset because he can burn a little bit from stomach juice and acid and stuff like that. But this isn't a food allergy. This is not this is not how food allergies present. It's also not a food intolerance. 

 

Reflux is an internal problem, there are certain foods that may make reflux reflux worse. Here's my example. I'm a 46 year old, otherwise healthy male, as far as I know. And if I won buffalo wing, I'm fine. If I eat 12, buffalo wings, I have severe heartburn and reflux. I'm not allergic to Buffalo wings, I'm not intolerant to Buffalo wings, I don't have a buffalo wing sensitivity, I don't need to do it test word, but it makes it spicy food. So spicy foods, greasy foods, you know, tomato based products, citrus, you know, these are all things that can activate more stomach acid and cause reflux to worse. And so there's a lot that goes into it. But if you have concerns about it, talk to your pediatrician, pediatricians are so good at treating reflux, sometimes we do recommend some anti, you know, acid medication you can take every day, there's different forms that you can take. Sometimes you can do it sort of as needed. But we don't want to go down the rabbit hole, you know, specific food elimination or sensitivity testing or allergy testing or some stuff like that based upon reflux.

 

Jacqueline Kincer  58:01  

Oh, I'm so glad you clarified that, you know, just a comment from things that I've learned from, you know, other professionals as well is that there's something that they're calling arrow facia induced reflux. So that's for babies that might be swallowing a lot of and during feeding. And when that air wants to come back up, it can bring milk with it. And so a lot of times babies will be unnecessarily prescribed medications or parents will think it's a food allergy issue, when neither of those issues, you know, shouldn't they shouldn't be treated, because that's not going to fix it. And other times, it's absolutely positional, you know, someone parents aren't thinking, you know, and I'm like, Well, did you put the baby in the car seat right after they ate? Or did they did they go down for a nap right after and then you saw that, you know, they're now they're laying down and you know, the contents of the stomach are freshly in there. And like you said, there's some maturation going on and all of that. So, I would love for parents to worry a lot less about reflux. And like you said, it's mostly a laundry problem. If there's a difference between reflux and vomiting, and I think that's just really important for people to know, vomiting can be, you know, obviously a concerning symptom of an infectious disease or an allergy, but that is not at all the same as reflux. You mentioned, you know, being able to find, you know, board certified allergist. Is there a great way for parents to let's say have a history of this and maybe other children or something or if they do suspect something like a directory you know, from a body of professionals that they could go to to look one up in their area that is specifically for pediatrics or infants.

 

Dr. Dave Stukus  59:34  

Yeah, so both the American College of Allergy Asthma and Immunology and the American Academy of Allergy Asthma immunology, have online search engines where you can you can look for a board certified allergist in your area, but you bring up a key point. You know, I all I do. I run our food allergy Center. I'm a pediatric food allergy specialist. You can't even get an appointment to come see me for a new concert unless you have concerns for food allergy so I still take care of asthma allergic rhinitis and eczema, but that's not my primary area of focus. So my approach and understanding and you know, the research I do, that's very different than somebody who's just in private practice that sees a lot of allergic rhinitis and other things like that, not to say they're not going to do a good job. But there are different levels of sort of understanding and approaches and things like that some of its personality, some of its level of experience, some of its the training received. So, in general, if you know, for more complicated patients, being seen it like an academic medical center, we have trainees and you know, academicians like myself, that's typically where we have more time to spend with some of these more complex patients. Oftentimes, they have multiple sub specialists involved in their care. That's something to consider as well. But no, I mean, starting just with a board certified allergist to see if they can give you you know, the guidance that you need is great place,

 

Jacqueline Kincer  1:00:44  

huh? Yeah, that's really good advice. One of the other things that I would love for us to chat about too, in it's kind of come up in the background here and whatnot, is formulas specifically, you know, most babies who are breastfeeding are also getting formula. And so, you know, formula has, you know, it's FDA approved for very specific ingredients in there and all of that. Now, sometimes babies are prescribed soy or hydrolyzed, formulas and whatnot. What are the indications for that essentially something like the the hives and vomiting? Or are there other use cases for those specialty formulas? Yeah,

 

Dr. Dave Stukus  1:01:23  

it always goes back to what's the diagnosis. So it's pretty easy in my world, with IGE food allergies, every time I eat this, I get hives, swelling, vomiting, anaphylaxis, I'm at risk to have severe reaction, we need to find a substitute that doesn't have that protein. So typically, if they're reacting to cow's milk formula, we can just transition to soy. Soy has no cross reactivity with cow's milk cow's milk is you know, it comes from a mammal, it's from an animal soy is a plant, they're different. Just because they're both in milk doesn't mean they have any relationship. So more, almost always, we can go straight to soy. And then we have more of that cow's milk. And just practical itis, whether you have painless red blood in stores, there's other rare conditions as well, where cow's milk may cause gastrointestinal problems from an allergic standpoint. And then yeah, you need to avoid that food for a period of time, you can almost always go to soy, I typically try not to go straight to like these very expensive elemental, amino acid based formulas, especially the formula shortage we just went through, you know, there's a process and entailed here, we can figure this out. 

 

If you have cow's milk and is practical, it is that the blood in a diaper, it can, it can take three to four days for before that resolves. Because that's to heal. So if you make the formula change, and they still have blood off to the next feeding, it doesn't mean that formula is causing the issues. But there's too many skittish sometimes even pediatricians that say, oh my gosh, okay, we need to make a change, a change, change, and you play this formula roulette, so you have to be thoughtful about it. And then we have, you know, unfortunate cases with with children that have severe gastrointestinal disorders, where they just can't digest foods for whatever reasons. So they're on these elemental formulas. So there's different reasons, but it always goes back to the person recommending it should be able to answer very basic questions. Here's why I recommend you make the change. Here's what will happen. If we don't make the change. Here's how long we need to make the change for it. Here's how we're going to know whether or not we can change back. Right, they can answer those questions for you find another doctor?

 

Jacqueline Kincer  1:03:11  

Yes. Oh, that's such an excellent list of questions to ask. And I would say that more often than not, I see parents initiating these changes, you know, switching to a goat's milk formula, or a soy formula, hoping that that will resolve issues. And I would say that I'm a big fan of, you know, please don't do that without consulting the pediatrician, you could be doing something unnecessarily. And especially in light of the formula shortage, like you said, those formulas are harder to come by. And if you're taking that off the shelf for a family who truly needs it, and you don't need it, or your baby doesn't need it, that's problematic. So we don't ever want to switch the baby's food entirely unless we need to. And I think you brought up some excellent thinking points and questions for people to ask their doctors.

 

Dr. Dave Stukus  1:03:57  

Yeah. And you know, are there people listening right now that said, if I didn't make this change, my baby would have, you know, had severe illnesses? And like that, yes. But it goes back to you know, those are the extreme examples, because for every one of those, there are 1000s of other parents that made the change unnecessarily, because their baby just had some normal variation of what's expected at that age. So yeah, is it necessary times? Absolutely. But it just goes back to can we be thoughtful about why we're doing this every time just take an easy standardized approach every single time and it's really hard to go wrong?

 

Jacqueline Kincer  1:04:28  

Yeah. Well said, Well, you are just a great example of what we are looking for in a well trained clinician, because these are these are the thought patterns that you're going through when you're working with your patients and you're wanting them to think about these things, you know, not to come to you unnecessarily and, and all of that right. And not to be stuck in fear and so much. Sometimes I feel like it's simplicity, right. You know, certainly things can be complex, but let's not make them more complex than they need to be. So I We'd love to hear you know, any wisdom or like the best advice that you would want to share with a parent who's listening to this information right now,

 

Dr. Dave Stukus  1:05:07  

I deal a lot with anxiety. And I acknowledge it. And there's kind of a running joke with the nurses I work with, oh, Dave made another mother cry again. And it's not because I want to be mean, it's because I asked some really basic but important questions like, you know, who do you Who do you have to support you through this? You know, do you feel guilty about harming your baby, because of the food that you're eating or something you did during pregnancy, things nobody's ever asked them. And they're, you know, by the way, if anybody out there, if somebody, a physician or other health care professional, anybody you know, tells you that you caused your child to have food allergy, just glare at them and walk away. They're wrong. There's nothing you could have done to cause your child to have food allergy, even if you want it to not that you would. So I really address the psychosocial aspect of this, because that makes people vulnerable, and really susceptible to some some really bad advice. So I hope people out there can take time to acknowledge, like, what you're going through is hard. And you're not alone, I promise you. And just to be wary of anybody who offers miracle cures, and you know, the anecdotes of oh my gosh, I did this and my baby was cured. Okay, well, how do I know that you're receiving real, you're some stranger on social media, or some influencer or whoever, like, that's your story. And we don't even know if that's true. So take a deep breath. I hope you have a trusted relationship with your child's pediatrician or other healthcare professional and go to them with your specific concerns.

 

Jacqueline Kincer  1:06:31  

Hmm, yes, well said. And I would say, you know, for anybody who's listening this episode, and you haven't listened to the one where I interviewed a pediatrician, Dr. Rebecca diamond. She just gave some great insight and perspective as a pediatrician and I what I loved about her is she's able to acknowledge you know, that there are some gaps in specific training, especially when it comes to breastfeeding as a pediatrician and whatnot. So, you know, if there's ever anything that you feel like your pediatrician can't answer, you know, ask those questions will, where can I get help with this? And if you're feeling shamed by your provider, walk away, that is not okay. I am always appalled when you know, we even see it as lactation consultants where people will say, Well, the other lactation consultants said, you know, you probably just can't do this, you probably can't breastfeed, some people aren't meant to breastfeed. And I'm like, yeah, absolutely. There are people that physically cannot write, but I would never say it like that I would never put you in that position. 

 

So I'm always really sad when I hear that there are good providers out there. And I think that's what you're, we're, you know, you're helping us learn today. So, I think that's excellent advice. And, you know, to that point about anxiety, you know, I think that's something that a lot of new moms are struggling with, because of just our the way we're living, right, there's, there's a massive amount of information coming at us in the United States parental leave is is so lacking. You know, childcare is very unaffordable. There's all of these things that are sort of up against us. And it's easy to kind of snowball ourselves mentally and emotionally into, Oh, my goodness, you know, I have to find a solution quickly, right, we all want a quick fix. But it sounds like nothing we buy at our local drugstore is not really going to make our baby's food allergies go away overnight, if they're truly experiencing something like that.

 

Dr. Dave Stukus  1:08:23  

Yeah. And one last thing, if I may, because I think this feeds into it of there's great support groups out there. And there's oftentimes emotional support that can be helpful. They can offer tips and advice. But be wary of anybody offering individual medical advice, especially through online forums. I don't do that I'm very active on social media, as you know, I never ever give individual medical advice. It's completely inappropriate. I can't do that. I don't know all the details. Even if I did I, you're not my patient. I can't examine you. I can't, you know, take the time to answer your questions. So nobody should ever be doing that. You know, there are rare things. And social media has created a very unique way of looking at the world where louder voices seem to people get confused with expertise. Or people, you can have a condition that affects one in a million people very rare. But if you find a support group where there's 100 of you, it may seem like everybody has that. But that's not true. You just found your people, it's still a very rare condition. So you know, these are complicated things to kind of teach through, but I just want people to be aware of that, you know, social media sort of gives us this false sense of reality at times.

 

Jacqueline Kincer  1:09:29  

That's such a good point. And then of course, the second you engage with a piece of content on a particular topic, social media is going to show you every posts on that topic. So that can certainly seem like a giant echo chamber of oh my goodness, this is so common.

 

Dr. Dave Stukus  1:09:42  

Yeah. Oh, you know, it's funny, we talked before about you know, food, half of the internet is yelling at you that food is harming you through inflammation and hidden dangers and gluten and all these other sensitivities and stuff like that. You know what the other half of the internet is yelling? Food is medicine. Use these super foods. So which is it, so everybody takes their own angle. And if anybody who's offering you medical advice is also selling you products or services, that is a major conflict of interest and a red flag, they don't care about you and your well being, they just want to make money off of you.

 

Jacqueline Kincer  1:10:13  

Hmm, that's such a good point. And I full disclosure, I do sell supplements, too. But I am very careful about the reason I made them was because I, I've looked at the evidence, and I've looked and seen what works for most people. And I've been disappointed at a lot of the products in the market outside of my patients over the years. But I'm not out there saying that everybody should take it. And I'm really trying to say, hey, yeah, if you have low milk supply, I don't think of pill is going to be the magic fix for you. But if you are doing all of the other right things, and you know, you're having trouble getting enough of the right foods into your diet, so maybe there's some deficiencies there or what have you, like, there may be some value in this, but you do need to talk to your health care provider first. So it's funny, because, you know, a lot of times people will ask me, Well, why don't you post this about it? Or why don't you say that more people would buy it? And I'm going Yeah, but maybe not the right people would be buying it. And so it's really hard, because I can't control who buys it either. Right? Like, sometimes I'm like, you, you know, you really didn't need that. I don't know why you're buying this. But you know, people think, right, they think I need this, they think I need that. And, you know, it's it's hard. It's really hard to to navigate that I will say, and it's hard when I see companies out there that aren't as cautious. And we all sort of get lumped in together, right? And I'm not saying you're doing that, but I'm like, Whoa, no, no, no, hold on. That one is actually snake oil. This one is not so much.

 

Dr. Dave Stukus  1:11:40  

Right? No, but And to your point, it's so hard to tell the difference. I mean, I so hard living like it's really hard to tell the difference these days. But what you said really resonates because evidence matters. And the quality of evidence matters. You know, studies done in mice, it didn't really affect doesn't really apply to humans. You know, randomized control trials, or you know, you know, meta analyses, much, much stronger evidence. But to your point, it's nuanced. So if anybody out there is saying everybody should be doing this diet or this supplement or whatever, I mean, come on. That's a huge, that's ridiculous. That's, that's assuming that all humans are exactly the same. And we know that that's not the case.

 

Jacqueline Kincer  1:12:19  

Yes. Oh, it's such a good point. Well, you are just a wealth of information. And I bet for the vast majority of our listeners, you won't be super interested in the podcast, Dr. Sukus host, but it's very good. I'll link it up in the show notes, if anybody is is a clinician and you're wanting to dive in more to the world of allergy and whatnot. He's got some excellent episodes there that are happening. I'll link up your Instagram, you post a lot of really great information out there, busting some myths and addressing some common misconceptions and sharing just really great nuggets of information with your audience. But what you've shared here on to on the podcast today has been really powerful, really informative. I think you've given everybody a lot to think about and cleared up so much. So I appreciate your expertise and insight.

 

Dr. Dave Stukus  1:13:07  

It's my pleasure. Thank you so much for having me.