Preventing and Managing Food Allergies with Confidence

Foreign. Welcome to the Where Parents Talk podcast. We help grow better parents through science, evidence and the lived experience of other parents.

Learn how to better navigate the mental and physical health of your tween teen or young adult through proven expert advice. Here's your host, Lianne Castelino. Welcome to Where Parents Talk. My name is Lianne Castelino. Our guest today is a pediatric registered dietitian.

Malina Malkani is also an entrepreneur, speaker and a best selling author. Her latest book is called Safe and Simple Food Allergy Prevention. Malina is also a mother of three and she joins us today from Westchester, New York.

Thank you so much for making the time.

Oh, it's my pleasure to be here. Thank you for having me.

Huge topic, affects all kinds of people and you know, we're hoping that you're able to distill some of the key pieces that parents really need to keep in mind when we're talking about food allergies. I wonder, Melina, if we could start with just sort of the current state.

If you're able to kind of generally describe what is the current state when it comes to food allergies in children and what is one thing that parents need to keep in mind on this topic?

Yes. So food allergies are tough. They can cause a lot of stress.

Parents who are managing food allergies in children, there's a lot of research, particularly mothers, that shows that stress levels and anxiety are high. One in 13 children has a food allergy and so they are quite prevalent. There's some good news in that area.

The rate and the prevalence of food allergies were rising for many, many years. Recently we've seen a little bit of a turn, turning of the tides in that department, which is such great news. And we can talk more about that.

And that's thanks to new. Well, it's thanks to guidance on early introduction of food allergens during infancy, which we'll talk more about too.

But a new study was just released in October of this year that was showing some of the turning of those tides.

But I think the really important takeaway for parents who are listening to this podcast is that there is a very short window of opportunity during infancy when we can in a very realistic and effective way reduce the risk of food allergies. But it's a very short window and it's easy to miss.

That is why I have been pounding on the table about the importance of early allergen introduction and why I wrote this book to help bring early introduction of allergens into the Conversations about starting solids.

So let's unpack one thing at a time in terms of what you just outlined there, because all of it's important with respect to the last decade or so where guidance on allergen introduction has changed a lot. And recent studies have offered evidence as to why this needs to happen.

So take us through what parents need to know about the latest research on that.

Yeah, and it is. You're so right.

There has been a complete kind of 180 degree turnaround in terms of what the guidance has been on allergen introduction over the last couple of decades.

When my oldest child was born, the guidance from the American Academy of pediatrics and from CDC was to delay the introduction of common allergens until 1, 2 and even 3 years of age, depending on the allergen. And during the decades in which that was the guidance, which, by the way, wasn't based on evidence, it was kind of a hunch.

But we just, we didn't have the research yet that informed us about the importance of early allergen introduction. During those decades, the prevalence of food allergies in children increased by over 50%. So we saw a huge rise in the number of food allergies.

So that was wrong, that guidance was incorrect. But, you know, nutrition is a pretty relatively new science and we learn and we can adapt our guidance to those learnings over time.

And this was a study that found that when we introduce peanut foods in infant safe forms to babies starting between 4 and 6 months of age in high risk babies, that reduces the risk of peanut allergy by 86%. And this was such a complete bomb that went on.

It was just absolutely turned the tides around in terms of how we guide families on the introduction of allergens. But that kind of information takes time to not only reach healthcare providers, but then to trickle down to families as well.

So it's taken a lot of time for people to receive that information and then to put it into practice. But it has changed the guidelines quite a bit now. So now what we recommend for families to do is to introduce top allergenic foods early and often.

So between two and three times a week, depending on the level of risk for the baby, but a couple of times a week starting between four and six months of age, depending on the baby's level of readiness for solids, and then to continue offering those food foods regularly throughout infancy and then even beyond to help maintain tolerance to those allergens.

It makes sense, right?

Because if they're not exposed to it regularly and on a consistent basis, they're not going to be able to develop, you know, the ability to accept it when it's finally introduced. So I see it from, in layman's terms, as a non registered pediatric dietitian, how that makes sense.

So when you talk about these foods, what kind of foods are we talking about that should be introduced early and often?

Well, there are nine allergens that are considered the top allergens, the allergens that people are most likely to be allergic to in the US and these are foods that are responsible for over 90% of all food allergies. So they're kind of the big nine that we want to focus on. The ones we have the most research on are peanut and egg.

So peanut for sure, that is really a high priority for parents between 4 and 6 months of age. Egg, we have some really good research on that. So about two teaspoons of peanut foods two or three times a week. Same goes for egg.

The rest of the foods we have wheat, fish, shellfish, sesame tree nuts, milk, what am I forgetting? And soy. And so those are the top nine.

We don't have as much research on the rest of those allergens, but we can surmise that the same principles hold true for those allergens as they do for peanut and egg. And there's really good data on the importance of diet diversity during infancy as a way to also help reduce the risk of food allergies.

In fact, babies with more diverse diets, so babies that eat a wide variety of different foods have a lower likelihood of developing food allergies later on in life. And it's just healthy to eat a variety of different foods, right?

Because we need all the different nutrients, wide spectrum of nutrients from all the different food groups in order to be able to thrive and grow. So a lot of this is common sense.

You know, when you think about it, eating a wide variety of foods, making sure babies are getting foods from all the different food groups. But for some, I think there's been a lot of fear around introducing new foods. There's a lot of fear about allergen introduction.

And so that holds a lot of families back from just, you know, getting the show on the road and getting those allergens in.

So that's what I'm hoping with my platform and with nutrition education to be able to inspire people to just feed their babies a variety of different foods.

So on that note, we should probably remind our listeners and our viewers that early allergen exposure doesn't guarantee, but it can lower the risk.

So how do you get that message across to, let's say, a parent who themselves may have suffered and continue to suffer with an, you know, food allergies about now, their child with this new guidance.

That is a great, great question and I'm so glad you flagged and brought up the importance of it, it not being a guarantee, because it isn't.

I have many babies in my private practice and families who have come to me who have said, I did, I followed all your advice, I did everything, quote unquote right, and I still ended up with a food allergic baby. And the reality is that can happen for sure. When we don't exactly know why food allergies develop, we're learning more every day.

The hypothesis that seems to make the most sense, and that researchers feel is the hypothesis that is probably the most likely in many cases is that the babies that are at the highest risk for food allergies are babies with severe eczema.

So when that skin barrier is broken and you have an eczema flare up and the skin is exposed, it seems that when allergens from the environment enter that baby through broken skin, through the skin, that sort of kicks off the mechanism of action that can lead to food allergy development. Unlike when we can get it in through an oral route and the first exposure for the baby is through the gut.

So that's sort of part of the rationale behind early allergen introduction.

And I think one of the biggest misconceptions around early allergen introduction that causes some of the fear that you mentioned is that people are afraid that there will be a big reaction from the baby when they do introduce those allergens.

And what the research tells us, the leap study in particular, is that when we introduce allergens orally, so through the gut during infancy, the likelihood of a severe reaction is extremely, extremely low. Early allergen introduction is safe. The most common reactions that we see are hives or vomiting in infants. Anaphylaxis is very rare.

And in other countries they don't even have a screening step.

In the United States, we're the only country that has a screening step where if you have a high risk baby, you go to your allergist and then they may or may not decide to do testing before allergen introduction. That's how safe it is considered in other countries.

So the other thing to consider too is that if we wait and don't introduce allergens and Just sort of hold off and wait until toddlerhood. A lot of people think, you know, from a sort of, what's the word?

It just makes sense to them that the immune system is more developed and more able to handle those allergens when they reach toddlerhood. But it's actually the reverse. There's a much higher likelihood of a severe reaction in toddlerhood than there is during infancy.

So we want to know that child's allergy status early, when the risk of a severe reaction is low, so that if there is an allergy, we can then get that child into an allergist's patient care, develop an allergy action plan and then keep that child safe going forward.

So on that note, Melina, it's such an interesting point. What would you then say that science has taught us about how babies immune systems learn to tolerate these types of foods?

That is an area that we are still learning so much about. And the area that I can tell you, where I think the most interesting research is happening with regard to that question is around the microbiome.

We know that the microbiome is connected to this, the process of allergy development, but we don't know enough yet about it to be able to manipulate the gut microbiome in such a way that it helps. There's a really interesting emerging research and we could go super deep into the science around that.

There are some really interesting probiotics that are being developed.

There's interesting research about in developed countries like ours, there are missing key gut bacteria from the infant gut microbiome that for example, in Amish communities or farming communities, these gut microbiota are present and the risk of allergy development is much lower in those populations. So there's something about our environment, our current developed environment that is encouraging allergy development.

We just need to figure out how to manipulate that. And there's great research happening in that area.

But what we, what we know now, what we can say now with confidence in terms of a, of an evidence based method of reducing the risk of food allergy, is that getting those allergens in to the baby orally early helps reduce the risk that the allergy will develop.

That's the actionable thing that we can do now and we can give as much support and funding and whatever we could do to the, to the researchers who are doing really excellent work studying the infant microbiome and allergy development and hoping that they will continue their great work and unlock more information. You.

And I was just going to say building on that point, that you just made you focus on feeding being simple and safe. So what does that actually look like in practice to the tired, sleep deprived parent of a newborn who's just trying to get through the next minute.

Right, Totally.

And it needs to be simple. It needs to be simple. We could talk about the science.

I mean, I would love to sit down with you a cup of coffee and talk about the science till the cows come home. But that's not helping the mom with a newborn who's a exhausted. Really.

The first thing I would love for parents of babies to know is that it's a great idea to start educating yourself about the process of starting solids when you're in your third trimester, when you're getting ready for baby, because when the baby comes and you are tired, the last thing you want to do is sit down and start, you know, doing all the reading. But if you can just sort of immerse yourself in some of that info so that you're ready for it.

And start having the conversation with your healthcare provider when the baby's around 2 to 3 months old. So you can understand your baby's level of risk for food allergies. If your baby has severe eczema.

If you have, if your, if your baby has a diagnosed food allergy, that increases the risk of food allergies to other foods. If you have a family history of food allergy, that's less of a risk factor than we once thought, but it's.

There is, there is some risk, elevated risk. Start those conversations early with your healthcare provider.

What's really wonderful about it is that when you do put it into action, it is quite simple. Peanuts are actually quite a nutritious early food for babies.

They've got iron, they've got zinc, they've got wonderful protein, fiber, so many nutrients. Babies need to thrive and grow.

We do need to modify them before we feed them to an infant, because a whole peanut and even a glob of peanut butter is a choking hazard for a young infant.

So really simple ways to do it, just thin out 2 teaspoons of peanut butter, smooth peanut butter with a little breast milk or a little formula or even water. You can feed it on the tip of a spoon.

You could mix it with some mashed banana, you could spread a thin layer of it on a teething cracker and feed it that way. Lots of really safe ways to do it.

Two teaspoons is the goal because that contains 2 grams of peanut protein, which is considered the threshold dose that helps prevent food allergy to peanuts. But it's really easy to build into the diet. And egg, same thing. I mean it could be just a little bit of scrambled egg.

You could take hard boiled egg and mix it with some breast milk or formula and puree it. If you're going the puree route, you could feed strips of omelet or strips of frittata and babies tend to really like it.

It's a nice little kind of squishy texture that works well for infants.

You know, you've covered so much there that I don't think the average new mother, new father gets in advance of them introducing solids to their children. One of the things you talked about is the diversity of the diet, what's possible.

But for many parents, you know, the idea of there's only one right way to feed my baby is quite prevalent in their minds.

So what can you say to those parents to kind of help them do a shift where that's concerned, that there isn't just one right way potentially to feed your baby?

I love that question because as much as I'm a huge fan of baby led weaning, my, my first book is called simple and Safe Baby led Weaning. It's, it's a wonderful way to feed babies, has many potential benefits, but it's not right for every baby.

And I think the baby led weaning kind of movement has created a lot of maybe shame amongst some parents who feel more comfortable spoon feeding their baby and wanting to use purees. And there's no evidence that a combined approach, so doing some spoon feeding, some purees, some finger foods, some self feeding is detrimental.

There are so many ways to feed a baby really well, just so many ways to do it and no one right way. And often the baby will tell you which way is right for them.

But I think considering what's going to be easiest for you and your family, what your baby's needs are, if there's an oral motor delay, if your baby's premature, if there's some sort of a medical indicator that makes spoon feeding a better choice for your baby, that is fine.

If you want to use an iron fortified infant cereal, that's a great vehicle for, you know, mixing in some peanut butter or even mixing in some egg, that's a great way to get allergens in. There are so many ways to do it.

That's one of the reasons why when I, when I was naming this book and the title, I called it a baby lid feeding guide. So there are options in this book that allow you to use purees that allow you to let your baby self feed using finger foods. Whatever works for you.

I will say there is some good research showing that, you know, no matter how you choose to start solids, we do want to get around nine or 10 months for babies to start to experience some texture and to experience more chewing and to experience, you know, to move on from a pureed texture.

Because there is a slightly higher risk of feeding issues down the road if we miss that window of time when they start to be able to really use their jaws and experience and know what to do with different textures in their mouths. But that's a good amount of time between six and nine months to do what works best for you and your family.

So on that note, if a parent misses that short window that you talked about off the top with respect to introducing allergen foods to their infant, is there a way to make up for that or is that something now that is going to be a potential red flag that that baby could suffer food allergies down the road. Is there any way to recover from that missed window?

You know, the reality is only about 3% of babies will develop a food allergy. That means 97% won't. So the likelihood is that the vast majority of babies will not develop food allergies.

So I'll just put that out there to start because I think that's it's a nice mindset shift for parents. Instead of thinking, oh, you know, that's going to be, I missed the window, I failed. No, the likelihood is that your child will not be food allergic.

Yes, the window, technically the window of opportunity to reduce the risk, closes at 12 months. That does not mean that you will end up with a food allergic child. And we do want to know the child's allergy status.

So if you've missed the window to introduce those allergens, I wouldn't avoid those allergens. If you're concerned, talk to your pediatrician.

They can determine if your baby is high risk and if there's need for, let's say an in office food challenge for some of those foods.

If it's easier for you to do that in office, most of the time it won't be necessary and you can just feed those foods and, and most of the time it will be fine. As far as I know, to my knowledge, there isn't some sort like a makeup, a way to, to make up the loss of that window.

And the truth is a food allergy can develop at any point in life, I mean, into a, you know, teenagehood, adulthood, Even long into adulthood. So there's just, there's still a lot we don't know about food allergies and why and when they develop.

You alluded earlier to the fact that essentially, you know, knowledge is power, especially for the expectant parent, when we talk about learning how to feed your child in advance of that happening.

So from your perspective, what should the standard or the baseline be of when a parent who's expecting should start really diving deep into what does starting solids look, what does what we're talking about here look like, at what point in that pregnancy and where should they go to for that information?

In a perfect world, in my perfect world, most parents will be really developing a plan and educating themselves when the baby is around two months of age, even three months of age. And I'll tell you why. The strongest window of protection for peanut allergy prevention in particular is between four and six months of age.

The longer that we wait. So for every month, past six months that we wait to introduce peanut in high risk babies, the protective effect is reduced by 30% per month.

So the stakes are high when it comes to peanut in particular. We don't want to miss that for peanut.

But what happens often is that by the time you kind of wrap your mind around starting solids and you've introduced some banana and some sweet potato and some avocado and kind of, you're getting into a routine with that, the baby is seven months old and peanut hasn't even come into the picture.

And so if we can get parents educating themselves, wrapping their minds around the milestone that's coming up, starting to understand what the signs of readiness for solid foods are, because we want to, we want to see those before we start introducing any foods.

And those are things like being able to sit upright with minimal, minimal support, the baby having good head and neck control, showing an interest in food.

If they're not interested in solid foods, it's going to be a little, it's going to be a little rockier to get started, being able to grab larger objects and bringing them up to the mouth. If parents know that they're looking out for these signs, it goes smoother.

And if I could put this in the hands of everyone as a, as a go to guide, it not only has the information about starting solids or introducing allergens, it also has everything you need to know about starting solids in general.

So how to create a balanced baby meal, what the key nutrients are that we want to be really considering, like iron and zinc, how to balance the baby's milk intake, Breast take breast milk and or formula with solid foods when that starts.

Because you can't really have a conversation about introducing allergens without considering all these other things because they really are inextricably linked.

But what concerns me is that, and the reason why I wrote this book was that I really felt that there are so many resources about starting solids, there's resources about baby led weaning, about purees, but they don't put food allergy prevention front and center as a part of those conversations. And that's, I think one of the reasons why many parents miss the window.

The other reason why I really, I would love to get this into as many hands as possible is because it does simplify it and make it easy. It has not only a nine day allergen introduction plan, so it walks you through how to introduce each allergen safely and in a baby safe form.

But then it gives you meal plans, so eight weeks of meal plans that help you keep every single one of those allergens in the diet at least twice a week. So instead of trying to hold in your mind, did I check off peanut, did I check off egg? It's all laid out for you.

And then there's 80 recipes that are infant safe, but also you can feed them to your toddlers and your teenagers and your partner and everyone else so that whoever's cooking doesn't have to prepare something different and you know, sort of deal with the mental load of trying to feed everybody else in the family. Hit all of those allergen introductions and make sure the baby is getting the nutrients needed to thrive and grow.

It's so interesting because I've heard from many other guests over the years that they've written the book book that they wish that they had access to. Is that the case for you?

That is so the case.

And it was really funny because as I was developing all the recipes, my three girls who we, by the way, the reason why I do what I do is because we experienced the gamut of feeding related issues when they were babies and they were born all within about three and a half years of each other. So I was really struggling when they were babies and I wanted a roadmap.

I wanted someone to sit down, hold my hand and say, this is what you should do. This is just do this and don't, I will do the thinking for you. And so that's, that is what I created.

And then as I was developing the recipes, they're the most brutally honest recipe tasters you'll ever meet in your Life. And they were very clear with, there were many recipes that they were like, mom, this can't go in the book.

So they had a real, they had a real hand in the development of the book as well, which was very sweet.

The other thing that you've kind of alluded to, but I think it's a really important point to kind of dive into a bit, is the confidence of a caregiver, of a parent in and around that baby's feeding experience. How can simpler meals actually help boost a parent's confidence about feeding their baby and thereby actually help build connection with that baby?

Oh, I love that you ask wonderful questions. They really are wonderful.

And the reason why I love that question is because one of if there's one other thing that I can impart to your listeners, it's that eating with your baby, preferably the same foods whenever possible, is one of the hallmarks of raising a responsive, adventurous, intuitive eater. One who connects with you over meals, one who can self regulate their intake, one who makes healthy choices on their own, one who mimics you.

And so if you if there's be, if there are behaviors that you want to see around meal times, the way that they're going to learn that in the most powerful way is by eating with you.

And one of the biggest mistakes I see in families, and I see it all the time in my private practice, is families that are feeding their babies separately from the rest of the family.

And the baby doesn't learn or understand even that solid foods are nourishing, let alone how to eat them on their own and how to develop those feeding skills. And meal time is one of the most precious, connecting, sort of important times in the life of a baby.

And then if you look at the statistics on the benefits of family meals over the lifespan of it child, it's mind blowing. And that's from all ages and stages.

Now with three teenagers, I can tell you right now, the families who have meals together three times a week or more, their children have less risk, less of a risk of risky behaviors like drugs and alcohol. They do better in school, their grades are better, they make healthier choices on their own, they have better relationships with their parents.

The statistics are, it's kind of all the, all the things that we hope for in terms of parenting and that can start in infancy.

So that's one piece, but also when you're just when you're making one meal at a time as opposed to one separate meal for this picky eater and then something else for someone else, and then something for you. First of all, it's a fast road to burnout because it's exhausting.

And second of all, it creates an opportunity where different members of the family are missing out on some of these amazing potential benefits. So the simpler, the better. The fewer meals that you're creating for everybody, the better. One meal everybody eats. Lots of benefits.

It is such an important point because I have seen families, I've seen mothers, you know, make three, four separate meals cater to each individual in terms of I want boiled broccoli, I want steamed broccoli. The third one wants something else. So it's a really, really important point.

For parents of tweens and teens, adolescents, anything that you think they should really know about whether they have a child that has food allergies or not?

Yes, I think two things. First of all, once you reach the teen years, we are no longer their strongest role models.

When it comes to the food choices that the children are making. During infancy, during toddlerhood, even in the younger child, early childhood years, we are their most important role models.

But then it shifts and in those teen years, their peers really become so much more of an influence. But one thing that can really, really help is if you can empower your teen or your tween with the skills to prepare food on their own at home.

That is such an incredible confidence booster for them and it gives them such a sense of ownership and control over what they're eating and it boosts their self esteem so much and then gives them tools that they can, as they go and fly and do whatever it is they're going to do, they can build on those.

I've seen that happen so many times that just even something as simple as teaching them how to make their own Mac and cheese and then, you know, adapt it to in the ways that they want, that can be very empowering for a teen and those are important skills for them as they, as they go on and do whatever it is they're going to do in life. So as much as you can foster that, it's not easy, but it's definitely worth the time and effort.

As somebody who's been on the front lines of this topic of food allergies for a long time in your professional life as well as a mom, what gives you hope as you look out at, you know, whether it's the science or the fact that we have more access to more resources on this topic, because it is one that affects so many people, it, it does cause trust, it does, you know, impart fear and it, and that can last a lifetime. So when you look at that sort of landscape, what gives you hope?

Two things.

The first is that I do see a very significant shift in the number of healthcare providers who are interested in this topic, willing to learn about it and implementing what they're learning. And there's research to back that up. Back.

I don't, I can't remember the year, but there was a year in jama a study came out on the number of healthcare providers who were implementing the new guidelines with regard to early allergen introduction, and it was low. It was only about a third. They were aware of the changes, but they weren't implementing them in their daily practice.

I've seen a seismic shift in that and a lot of resources being poured into things like I speak a lot at WIC conferences, Women Infants and Children, the special Supplemental Nutrition Program for Women Infants and Children. And the providers are really interested in learning about this and the organization is putting resources toward educating them about it.

And then they go out and educate the many, many, many parents. I mean, it's. Half of all babies in the United States are eligible for wic.

And so that information is being made more available to more families than ever about the importance of early allergen introduction.

The other thing that gives me hope is that what I mentioned before about the microbiome, we are learning more about how to reduce the risk of allergy development.

And there's really interesting, interesting emerging research about ways that we can hopefully give babies a better chance of not developing allergy in the way that we not only feed them, but maybe it's a probiotic, maybe it's a, a change in the way that we. I don't know yet. I don't, I can't speak to that yet.

But there's, there's a lot of really amazing emerging research in that area that I think is very helpful.

Well, you've certainly shared so much information, important information for parents to consider. Melina Malkani, entrepreneur, author and registered pediatric, registered dietitian. Really appreciate your time and your perspective. Thank you.

Thank you so, so much.

To learn more about today's podcast, guest and topic, as well as other parenting themes, visit whereparentstalk. Com.