Oral Immunotherapy (OIT) For Food Allergies

There has been press recently on a “new” food allergy treatment by a company which plans to bring standardized doses of peanut flour to market so that individuals with peanut allergy can be desensitized. This has generated a lot of discussion and excitement in the food allergy community over the past month.

However, it is important to note that this is not really a “new” treatment. Recent studies on this type of treatment using peanut flour go back more than a decade, and this form of treatment has been offered for food allergies by practicing, board certified physicians in allergy and immunology (allergists) for at least 10 years. Our practice, Allergy, Asthma & Food Allergy Centers of St. Louis, has been offering this treatment since the summer of 2016, when our first patient (the daughter of one of our providers) was desensitized to peanut when she was 9 years-old. Since then, our practice has desensitized 35 children to peanut with smaller numbers for other food allergens. In addition, we have 58 children currently going through the OIT process as well.

So let’s back up a bit and review a few basic questions.

What is oral immunotherapy or “OIT”?
This is a process of desensitizing someone to a food to which they are allergic by giving very tiny doses of that food and slowly increasing the amount of the dose over time. It is a way to get a person who has life-threatening food allergy to be able to consume the food without having a reaction. This is not necessarily a “cure” for food allergies, and people need to consume the food on a daily basis to prevent reactions in most cases. They should also continue to have access to their epinephrine autoinjectors. However, promising studies suggest that some children (especially younger children) may not have to consume the food daily to be protected.

What is the primary goal of OIT? The primary goal of OIT is to prevent an episode of anaphylaxis with an accidental exposure. In other words, the single most important goal of OIT is to make it so a person who accidentally consumes a food allergen to which they are allergic does not have a life-threatening reaction.

Why did Allergy, Asthma & Sinus Care Center of St. Louis start offering OIT?
First, as mentioned earlier, one of our provider’s has a child who has had food allergies since infancy (as a side note, that provider still gets a little blame at home and has a certain amount of guilt for not having done more to prevent or treat food allergies sooner), so there was clearly a significant amount of self-interest in investigating food allergy treatment options in our practice. Therefore, our practice believes there is an urgent need in our community to offer options for the treatment of food allergies in all patients but especially in very young children. Let’s briefly talk about why we believe this using peanut allergy as an example.

The general consensus is that peanut allergy is only outgrown in about 20% of people who develop it. This means that the vast majority of children who are diagnosed with peanut allergy will not outgrow the allergy compared to the much greater chances of outgrowing milk and egg allergy for example. However, an excellent study from 2017 published in the Journal of Allergy and Clinical Immunology (“Early oral immunotherapy in peanut-allergic preschool children is safe and highly effective”) showed that 91% of children 9-36 months of age who were treated with OIT for peanut were able to successfully introduce peanut into their diet and did not have reactions when challenged even after stopping daily peanut treatment for 4 weeks! Let’s repeat that- basically 91% of kids who successfully went through OIT at a young age and then stopped consuming peanut daily, still did not have reactions 4 weeks later when challenged with peanut. That is incredibly exciting news, and this led us in 2017 to expand our OIT offering to infants who are diagnosed with peanut allergy. If only 20% of kids generally outgrow peanut allergy, and we can turn that number upside down and make it so that nearly every infant/toddler initially diagnosed with peanut allergy can start eating peanut without the risk for a life-threatening allergic reaction…..well, we feel strongly that the potential impact of this treatment in our local community is a game changer for food allergy, especially in our youngest patients. In fact, the authors of the study mentioned above concluded “E-OIT [early-OIT] had an acceptable safety profile and was highly successful in rapidly suppressing allergic immune responses and achieving safe dietary reintroduction.” One of our provider’s only regret is not being able to offer this sooner, especially for their own family.

While the focus of the previous paragraph was on younger children, this treatment clearly works for a majority of older children as well. While OIT is not necessarily the right option for everyone, and by no means do we intend to imply that everyone with food allergies should go through OIT (this is a very personal decision for individual families), we feel that families should have choices beyond just strict avoidance for the treatment of food allergies. We understand that a teenager who has avoided peanuts their entire life and is doing fine may have no interest in going through OIT, but we still feel that having the option for treatment available is important for our community.

Why don’t more allergy practices offer this?
While we cannot speak for everyone, there are likely several reasons for this.

First, we are the community experts when it comes to food allergy (in addition to being leaders in treatment of asthma, environmental allergies, hives, and immunodeficiency). In addition to offering OIT, we offer comprehensive management of food allergies. We do numerous food challenges (well over 200/year), often to rule out food allergy or to determine if someone is still (or ever was) truly allergic to that food, so that people do not need to avoid foods unnecessarily. We have been using advanced component testing for food allergies for about 10 years (initially for egg and milk and more recently for peanuts and tree nuts). This has helped us determine over the years who may be good candidates for food challenges. The wait list for food challenges at both Cardinal Glennon Children’s Medical Center and Saint Louis Children’s Hospitals is often more than 6-12 months. We had been able to get people in for food challenges within 1-2 weeks, but as more patients have found us, this wait time has started to creep up, and as we write this, the wait time can be up to a couple of months.

Second, the practice of OIT is not standardized. Most people in academic medicine feel that since we do not know the exact, best protocol and doses that should be given for OIT, it should not be offered outside of research studies. The problem with that response is that a generation of children do not necessarily have time to wait until everyone agrees on the (single) absolute best approach. Children’s immune systems are constantly developing, but the older they get, the more likely their immune systems will become “locked into” their food allergy. We know from studies not only in food allergy but also from studies with allergy shots that the earlier people get treated, the better the long-term outcomes.

Third, the broader academic allergy community feels that the risks outweigh the benefits. We have heard at allergy meetings from some key thought leaders, statements (to paraphrase) such as “people with food allergies can simply avoid the food, and they don’t have reactions. Why treat them with OIT that has the associated risk of life-threatening allergic reactions?” “Avoidance is still the best option.” “Until we have all the necessary studies, people outside of research settings should not do OIT.” Respectfully and vehemently, we disagree. Again, we recognize that OIT is not right for everyone, but it is a valid treatment option. Most (not all) people doing this research do not have children with food allergies. Some of them seem not to recognize that terror that some of us may feel when our children may be in an environment where eating something as innocuous as a small cookie can lead to an emergency department visit or even death. They don’t understand the fear that may prevent us from eating out or going to baseball games to cheer on the Cardinals. They may not know that it is not always “fun” to be one of the only or the only child sitting at an “allergy free” table at school. There are many more examples too numerous to list here of the day to day experiences families dealing with food allergies have to go through. With all of that being said, there are significant risks in OIT, including anaphylaxis and the possible development of an inflammatory condition of the esophagus called eosinophilic esophagitis (EoE; about 3-5% in published studies), and the risks may outweigh the benefits for some people.

Finally, OIT is very labor intensive, not just for families, but for allergy practices. This is not an endeavor to be entered into lightly, which is why our practice considered this for over 3-4 years, taking the time to develop the infrastructure and excellent staffing (our front desk staff, medical assistants, nurses, office management, administrative/billing, and providers are all awesome!) required to at least start offering OIT on a smaller scale. We have grown since 2016, and we hope to continue to do so in the years to come so we can serve more of the community in a safe and efficient manner. We are proud to report that some local allergy practices in the greater St. Louis area have started referring some of their own patients to us specifically for OIT, but those practices will continue to manage the other allergy/asthma health conditions of their patients.

We welcome new patients and appreciate how much we ourselves have learned from our established patients. We are not looking to dictate one treatment for everyone. We know every individual/family is different and what works for one person may not be the best option for another. We honestly feel that medicine should be a partnership between patients and providers. Our mission is to use our expertise to improve the quality of life for adults and children through the diagnosis and management of asthma, food allergies, and other allergic conditions. We look forward to working with you and your family to improve everyone’s health outcomes. As we often say to our patients during OIT treatment, remember, this is a marathon, not a sprint.

Is There Any Reason Not To Get A Flu Vaccine?


It’s that time of the year to get a flu vaccine again. Routine vaccination against influenza A and B viruses is recommended for everyone 6 months of age and older unless there is a specific reason not to. (More on that later.)

In spite of the recommendations, fewer than 50% of Americans got a flu vaccine last year. In order to minimize the risk of an epidemic of influenza, officials would like for at least 70% of Americans to get vaccinated. There are many choices of vaccine. Unfortunately, for those who hate needles, the nasal spray vaccine is no longer available. It was found to be less effective than inactivated vaccines (flu shots) in preventing influenza illness in children. Due to that, the ACIP (Advisory Committee on Immunization Practices–a part of the Centers for Disease Control) advises against using the live intranasal flu vaccine for anyone this year.

As health care providers, we hear a lot of reasons (excuses) for not getting the flu vaccine. Here are a few…

I’m tough. I have never had the flu.

We hope that all of our patients have an immune system to be proud of. But the fact is that 5 to 20 percent of the US population gets influenza each year. The influenza virus doesn’t care if you have had it before or not. As our friends in advertisement would say, “Past performance is no guarantee of future returns.” So if you don’t get a flu vaccine, you are gambling that you will be lucky. There is a very good chance that one of these years your luck will run out. And if you lose, you can expect at best to feel crummy and miss a week of school or work. At its worst, you can die from influenza (even if you are healthy before you get it). The rate of death for influenza is 1.4 people for every 100,000 persons. In the greater St. Louis area of about 3 million people, that is 42 people. Ask someone who works in a hospital. People die of influenza each year. It is best to protect yourself and your friends and family that you are exposed to.

Can’t I get the flu from the vaccine?

Nope. Other than the nasal vaccine (which is no longer available), NONE of the influenza vaccines contain any live virus, and cannot cause influenza. They are either inactivated virus vaccines or a recombinant vaccine that is produced without the use of influenza virus or chicken eggs.

But people say that the flu vaccine made them sick.

An influenza vaccine can cause soreness at the injection site, and rarely it can cause aches or fever. But it cannot cause an infection. Influenza vaccine is commonly given in the late fall and early winter when people get a lot of viral infections that are not influenza. When millions of people get a vaccine, it is likely that some of them will get a cold shortly after which is not caused by the flu vaccine.

How do I know the flu vaccine will really work?

You really don’t; however it does significantly increase your odds of staying healthy. The decision of what strains of virus go in the vaccine is made months before the influenza season. Some years the educated guess of what should be in the vaccine is better than others. If the match between the vaccine and the viruses in the community is good then you reduce your risk of getting sick by 40 to 60%   Even when it is a poor match, vaccination has been shown to reduce the risk of hospitalization and death from influenza.

How do I know which influenza vaccine I should get?

Your healthcare provider can advise which vaccine is best for you.
In our practice (because we see a lot of people with allergies) we use only preservative free vaccines. If you are 65 or older, a high dose vaccine is recommended. It has four times the amount of antigen (inactivated virus) as the standard dose vaccines. It has been shown to be more effective than the standard dose vaccine for those 65 and older.

What about the vaccine during pregnancy?

Vaccination of pregnant women not only protects them against influenza-associated illness, but also protects their infants for up to the first 6 months of life.

What about egg allergy and the vaccine? Doesn’t it contain egg?

Studies have shown that even people with severe allergy to egg and tolerate the influenza vaccine, but they should be vaccinated in a healthcare setting, like our office.

So who should NOT get the vaccine?

Influenza vaccination has been associated with Guillain-Barre syndrome (a disorder in which the body’s immune system attacks the peripheral nerves resulting in weakness and tingling), but the risk is very low and the influenza infection itself has also caused this syndrome. If someone has had Guillain-Barre syndrome, then they should not get the influenza vaccine.

We hope for your sake (and ours too) that you and your family get the influenza vaccine this season.

In addition, this article by Dr. Aaron Carroll explains why getting vaccinated is important for the whole community.

Loving Your Pets



Yes, pets can cause allergies but they are adorable and make their way into your hearts and families. We get it! It is true that the gold-standard treatment for pet allergy (or allergy in general) is avoidance or to remove the trigger – i.e. remove the pet from the home. In some settings, this is the best option for the patient and/or family. However, most families are attached to their pets and would rather get rid of their allergist than get rid of their pet. Often it is not (or even a consideration for that matter).

If the pet remains in the home, the most effective intervention is to remove the pet from the bedroom. Washing the pet frequently, twice a week, may be helpful but understandably, this can be burdensome and not always practical. The use of HEPA filters may provide some benefit. The most effective option for treating pet allergy, aside from avoidance, is allergen immunotherapy or allergy shots. All dogs and cats have the potential to cause allergy.  Contrary to popular belief, there is actually no such thing as a “hypoallergenic dog” or hypoallergenic dog breeds. The particles responsible for allergy in cats are much smaller than those in dog and remain airborne for significant lengths of time. Pet allergy has the potential to cause severe allergy and asthma symptoms and should be taken seriously. We are here to help as best we can!

Battling Recurrent Sinus Infections?



Sinus disease is a major health problem.  Americans spend more than $1 billion each year on over-the-counter medications to treat it.  People who have allergies, asthma, or structural blockage in their nose or sinuses and people with a weak immune system are at greater risk.  People who smoke or who are exposed to tobacco smoke get sinus infections more frequently than non-smokers, and smokers respond less well to treatment than non-smokers.

A bad cold is often mistaken for a sinus infection.  Many symptoms are the same, including headache, facial pain, runny nose and nasal congestion.  Sinus infection is often caused by bacterial infection, but sometimes it can be caused by viruses and molds.  Acute sinus disease by definition can last up to eight weeks.  Anything that lasts longer than eight weeks is considered chronic.

A healthy child or adult can get up to four colds a year.  If you are a smoker, a day care worker, or a teacher, you might get more than this.  Most colds resolve just with symptomatic treatment, but some can progress to sinus infection.  One clue is that a cold will resolve in 7-10 days.  A sinus infection typically lasts longer than ten days.

Sinus disease is often confused with rhinitis, which is simply inflammation of the nasal passages.  Rhinitis could be caused by a cold or by allergies, and it should not be treated with antibiotics.  The diagnosis of sinusitis depends on symptoms and requires an examination of the nose and throat.  Your doctor will look for redness, swelling of the nasal tissues, colored secretions and bad breath.  An exam might involve the use of a rhinoscope, a long flexible fiberoptic tube that allows for a more thorough exam of the nose and the opening of the sinus cavities.  If the diagnosis is uncertain, or if you do not seem to get better with an antibiotic, then a CT scan of the sinuses will be done.  This is the best way to see all of the anatomy of the sinus cavities, and to be certain whether or not a blockage is present.

Antibiotics are the standard treatment for bacterial sinusitis.  Antibiotics can be taken from between five days and six weeks, depending on the duration and the severity of the sinus infection.  Overuse of antibiotics is a concern, so treatment is not given unless there is clear evidence of infection either on exam or by CT imaging of the sinuses.

If underlying allergies are a contributing factor, then using allergy medications, such as nasal sprays, oral antihistamines, and even allergy shots can help to treat or prevent recurrent infections.

Nasal saline washes such as the Neti Pot or Sinus Rinse can also be helpful in flushing away thick secretions.   Used at the onset of a cold, nasal saline washes can often prevent a cold from progressing to a sinus infection.

Remember that the diagnosis of a sinus infection is not easily made over the phone.  If you have treated your symptoms for at least seven days and have not improved, then you should see your doctor to see if further evaluation or treatment is needed.  If you get more than four sinus infections a year, or if your sinus infection does not improve with standard antibiotic treatment,  then testing for underlying allergy, immune deficiency or other risk factors should be done.

Keeping Asthma In Check


The best way to keep your asthma in check is to avoid what triggers your asthma. Common asthma triggers include:
• Allergens such as pollen, mold, dust mites, and pet danders
• Irritants in the air such as tobacco smoke and air pollution
• Extreme weather conditions of heat, humidity and cold air.
• Exercise
• Emotions–not only sadness and stress, but also sometimes laughter.
• Respiratory infections

Some other health problems can make asthma symptoms worse, such as obesity, acid reflux, sleep apnea, stress and depression.  If you have one of these other problems, let your allergist know so that they can be addressed as a part of your overall treatment.

Treating your asthma includes identifying and avoiding asthma triggers when possible.  Nearly everyone needs some medication in addition to avoidance measures.  In addition, some people benefit from monitoring their lung function with a portable device like Wing or a peak flow meter.  This type of device allows you to measure your airflow, and then to follow the Asthma Action Plan that you and your allergist create.

There are many effective medicines to treat asthma.  In simple terms there are two kinds:  quick relief medicines (short acting bronchodilators like albuterol) and long-term control medications (like inhaled corticosteroids, long-acting bronchodilators, and other oral and inhaled medications) that control airway inflammation.  The right medications depend on your triggers, asthma severity and your your control.  The goal is to make you feel your best with the least amount of medication.

There are health risk concerns with corticosteroids.  They are powerful medications that can be dangerous if taken in excessive amounts.  Medical research over the past 30 years shows that when taken as directed, inhaled corticosteroids are safe and well tolerated, and one of the most effective treatments for asthma.

In recent years new medications for severe asthma have become available that fall into the category of biologic medications.  These typically block a specific antibody or other chemical that the body makes in excess that has made the asthma worse.  Currently these biologic medications for asthma are given in the form of an injection or intravenous treatment in the office.  If you have severe asthma that is not controlled with other medications, your allergist will discuss these medications with you.

When allergies play a role in asthma, then you should consider allergy shots.  These are very effective in relieving allergy symptoms and in some cases cure your allergy.  The treatment typically occurs over several years involving injecting small amounts of the allergen in gradually increasing amounts over time.  Allergy shots are generally given for three to five years, and sometimes longer.

Most of all, remember that your allergist is an asthma specialist.  You allergist can help you learn more about your asthma and develop a treatment plan that works for you.   You should see an allergist if:
• Your asthma symptoms interfere with your daily activities or your sleep.
• You’ve had a life-threatening asthma attack.
• Your doctor believes that you are not responding to your current treatment.
• Your symptoms are not usual.
• You’ve taken oral corticosteroids for asthma more than twice in one year.
• You have been hospitalized for your asthma.
• You need help to identify your asthma triggers.

Although asthma can be treated and symptoms can be controlled, there is not yet a cure for asthma.  Preventive treatment should allow you to lead a normal, active lifestyle.

If you would like to see if your asthma and allergies are not under control, take the asthma and allergy symptom test from the American College of Allergy, Asthma & Immunology.

Managing Eczema




Atopic dermatitis or eczema is a chronic inflammatory disorder of the skin that can range in severity from scattered, mild patches to very severe itchy, red, rash that can affect all of the skin. In people with eczema, even normal looking skin can be very itchy. Eczema is sometimes called the “itch that rashes” because itching leads to scratching that can worsen eczema and lead to more itching. It is important to identify environmental allergens that may be contributing to eczema. Food allergies can contribute to severe eczema, but in general, before broad food allergy testing is done, the skin care regimen should be optimized.

The skin of people with eczema has a dysfunctional barrier that makes it hard to retain moisture. Good regimens for eczema generally involve daily baths (soaking for 15-20 minutes) using a non-soap cleanser such as Cetaphil followed by patting the skin dry and then applying topical steroids to active, eczema lesions. The rest of the skin should undergo very aggressive moisturizing. Moisturizers can be applied several times per day. Plain, unscented petroleum jelly is often the best option to use on the skin for most individuals. The better the basic skin care regimen, especially using petroleum jelly or simple moisturizers (avoid scented lotions and those with too many ingredients), the easier it is to prevent flares of eczema and itching. In severe cases, bleach baths (2-3 days/week) and wet wraps may also be considered.

Living With Food Allergies



A diagnosis of a life threatening food allergy is a life-changing experience for individuals and their families. While living with food allergies requires always being vigilant, having a game plan helps make it manageable. There are many excellent national and in some cases local resources to guide families living with food allergies. FARE (Food Allergy Research & Education) is one of the most prominent national groups. They have a very useful “Food Allergy Field Guide” that is geared to families newly diagnosed with food allergy and can be downloaded in PDF format. Their website ( has a lot of resources.  Locally, the Asthma and Allergy Foundation of America- St. Louis Chapter (AAFA-STL) is a fantastic organization. While they are geared a little more toward asthma, AAFA-STL holds Food Allergy 101 meetings throughout the year and has other resources.

How families deal with food allergies varies from family to family, in part because everyone has a different risk tolerance. For example, some families avoid all foods labeled with “may contain”, “processed in the same facility”, “processed on shared equipment”, and etc., while other families may allow consumption of foods with such labels in certain circumstances. Good rules to live by are:

ALWAYS have access to epinephrine. Lack of access or delayed administration when having a serious reaction are more likely to lead to poor outcomes.

ALWAYS read labels. If a food is not labeled, and you do not know who made it, then it is best to avoid it.
Communicate effectively with friends, family, schools, and caregivers regarding the food allergy. Advocating for yourself or your family member is essential.

Traveling and eating out can present their own challenges. A recent New York Times article discussed the difficulties individuals with food allergies may have when traveling by plane. Allergy Eats is a good resource to check out when it comes to dining options.

It is important to remember that some food allergies may be outgrown, especially those to cow’s milk (dairy), eggs, wheat, and soy. Peanut, tree nut, finned fish, and shellfish allergies are less likely to be outgrown, but some individuals can still outgrow these. Therefore, regular follow up with your allergist is important. There are also new exciting treatment options currently available or on the horizon. Studies with the peanut and milk patches have been very promising. Oral immunotherapy (OIT) for foods is also an option for some individuals – but not for everyone. Our practice offers OIT with the first goal being risk reduction or significantly decreasing the risk that an accidental exposure will lead to a life threatening reaction or anaphylaxis.