Eating shouldn’t cause fear, but for kids with allergies, food can feel like a minefield, making even simple pleasures like parties and picnics dangerous. Instead of resigning ourselves to a lifetime of avoidance, allergy sufferers can take action and embrace desensitization therapy.
In this episode, Dr. Sakina Bajowala, author of The Food Allergy Fix and a board certified allergist and immunologist, is going to demonstrate how allergies can be managed through oral immunotherapy. Dr. Bajowala has a huge success rate, which proves that it’s possible to live in a world without allergies.
By the end of this episode, you’ll have taken the first step toward reclaiming food freedom.
Dr. Sakina Bajowala: I would go back to 2008. I had recently graduated from my allergy-immuno fellowship, and I had started working in private practice. At the time, I had two very young children. One who had a peanut and tree nut allergy and another one who was a newborn and was randomly breaking out in hives without any clear reason.
Here I was being the mother of allergic children on one end and going to work during the week and taking care of other people’s allergic children on the other.
One of the things that was incredibly frustrating to me as a physician with a number of years in specialty training under my belt is that, for these particular patients, these very young patients with potentially life threatening food allergies, I had very little to offer them.
It was, “Okay, I’m going identify what you’re allergic to. Okay, well that’s done,” and then the next thing was, “Okay, don’t eat this. Here’s some emergency medication because at some point, you may accidentally ingest this allergen and then it might be a life-threatening situation so let me show you how to use auto injectable epinephrine. Allergy action plan.”
It’s always like worst case scenario, right? I was not offering anyone any hope at all.
“It was peddling fear.”
You’re sitting there talking to people, everybody’s tearing up in front of you because you’re giving them the worst possible news. They come to you for help and for solutions, but you really didn’t have any.
I had solutions for runny noses, I had solutions for asthma. I had solutions for immune deficiency. I had solutions for drug allergies, but I didn’t really have any concrete solutions for a food allergy—which, arguably, is much more impactful to your day to day quality of life than many of these other conditions.
I just hated this feeling.
Growing Out of It
Charlie Hoehn: How long did this go on for?
Dr. Sakina Bajowala: Well, I didn’t let it go on for all that long, because what happened is my elder son actually outgrew his allergies.
We had spent the life of an allergic family for four years, just avoiding, having our emergency medication with us at all times. I was following the same instructions that I was giving my patients.
But he had an accidental peanut exposure, and there was no reaction.
I just looked at him, like okay—now what? Now let’s retest him and see if he has outgrown the allergy, because his first test was just unequivocally positive. Markedly positive. There was no question, right?
“The repeat test was unequivocally negative.”
The next step was to actually perform peanut food challenge. Which we did, and he passed, eating the equivalent of approximately twenty peanuts worth of peanut butter, and once again, no reaction. He had outgrown his food allergy.
And it is an awesome feeling, right? Our lives changed substantially in terms of all the limits that had been put on us and him and all the fear that I was harboring internally as a mother.
Always that worst case scenario that I had been preaching to my patients that I had to be prepared for all the time. I’m sure that sometimes I was a real pill to be around, because all I can ask is, “What’s in that? Are you sure it hasn’t touched any peanuts?” Did you read the labels?”
It was limiting.
Suddenly, all of that was lifted and I was more motivated than ever to bring that same kind of freedom to the rest of my patients.
Now, I knew that all of my patients weren’t going to spontaneously outgrow their peanut allergies. That’s just not the natural course or the natural history of peanut allergy. In fact, most children with peanut allergy actually have that hypersensitivity for life.
“I had to come up with something else.”
I started researching and looking into the possibility of translating what we already knew about allergen desensitization therapies that we were already performing for environmental allergies and drugs.
Charlie Hoehn: What kind of treatments do those look like? Are you talking about the shots or the pill or the droplets that you put under your tongue?
Dr. Sakina Bajowala: All of these methods are different ways to desensitize or perform immunotherapy for allergens. They’re just different ways of delivering the allergen into the body. But the whole concept of desensitization is retraining the immune system to tolerate something that it is currently over-reacting to.
The way this occurs is by gradually and incrementally over time increasing the amount of allergen that is introduced to the immune system and going up and up and up. During that process, you create tolerance and reduce the sensitivity.
How Allergies Develop
Charlie Hoehn: I’m curious in the first place, how do allergies to foods develop?
Dr. Sakina Bajowala: That’s a million-dollar question. If we knew the exact answer, we might be in a position where we don’t even need to consider desensitization therapy because we would prevent the allergies in the first place.
There are a number of theories there in terms of hygiene hypothesis or that we’re simply not exposed to enough microbes in our early life to properly stimulate our immune systems. Then the lack of anything to do, for a lack of a better term, the immune system gets bored and starts reacting to stuff that it should be ignoring. That’s one theory.
Then, of course there are others. One is that of gastrointestinal dysbiosis. That we may be born with a certain genetic susceptibility to allergy. But it is our environmental exposures that determine whether that’s susceptibility is expressed or not expressed. That’s a concept known as epigenetics.
What is happening here is that there may be certain environmental exposures—in terms of illnesses or environmental pollution, antibiotics exposure, certain types of delivery, vaginal versus C section, timing of exposure to certain potential allergens—that all play a role in the epigenetics expression of food allergy.
And so all of these different factors interplay with your genetic susceptibility, turning that little genetic switch on and off.
A History of Allergies
Charlie Hoehn: I’d imagine that the exposure to all the different chemicals and the fact that we’re eating so many processed foods, that has to play a major role, but do we know how far back food allergies as a thing have been on record?
Dr. Sakina Bajowala: Well, what we know is you can look all the way back to the ancient text of Ayurveda in the Indian sub-continent and there is a concept of something that is unwholesome for your body.
Now, this concept is not necessarily the same for each person. Something that may be unwholesome for me might be wholesome for you, so it has a parallel with the concept of food allergy. Something that most people are okay with, some people are not okay with.
“You can see the idea of intolerance to foods going back, way back in history.”
That said, what we do know is that the prevalence of food allergy seems to be increasing over time. If we look at the factors in terms of what has changed, once again, it’s multifactorial.
You mentioned diet, right? You mentioned the nutrition in our diet and how processed foods may not be as wholesome for the body as a whole food based diet or a plant based diet. This is definitely something that is being explored.
Other factors are that we have a definite rise in C section deliveries, we have decrease in the amount of babies who are being breastfed for an extended period of time.
Charlie Hoehn: I just learned this recently because we’re still breastfeeding our one year old daughter. The average, historically for breastfeeding was like three to four years, and it’s still that way in some parts of the world. Whereas in the United States, it’s what, now it’s like, for a lot of moms, it’s three to six months, correct?
Dr. Sakina Bajowala: Right. But you know, even those three to six months can be helpful because it’s a really critical input window. You know, as much we can do to get skin to skin nursing, vaginal delivery whenever safe for mom and baby, avoidance of unnecessary antibiotics, right?
And doing the wholesome whole foods, unprocessed diet as much as possible. Getting some fermented foods into the diet. Taking care of the skin and really safeguarding that immunologic barrier against the outside world that intact skin provides.
“All of these are things that we can do to try to mitigate risk.”
There’s a huge push for antibiotic stewardship and making sure that we’re only prescribing antibiotics when it’s really indicated, and that when it is indicated, we choose the narrowest spectrum antibiotics that will get the job done and target the infection at end.
Because indiscriminately, using very broad spectrum antibiotics affects a lot more than the organ you’re targeting. Some of the data out there now is suggesting that even a single course of antibiotics can disrupt your gut bacteria balance for a whole year.
Charlie Hoehn: What kind of results have you seen since you started to implement desensitization into your practice?
Dr. Sakina Bajowala: We’ve been incredibly fortunate in that our success rate is hovering right around 94, 95%.
Charlie Hoehn: Holy cow, when you say success rate, do you mean completely – no more sensitivity to that allergy?
Dr. Sakina Bajowala: No, that’s not what I mean. The food allergen desensitization is not a cure. I can’t stress that enough. It’s a management strategy, and the goals of therapy are to reduce risk and to improve quality of life.
The way we define success is that our patient is able to continue dosing with their food allergen on a regular basis without experiencing any distressing side effects.
The ability to continue doing that is what gives the patient protection against a severe allergic reaction from accidental exposure in the future.
“Out of the hundreds of patients that we treat, well over 50% are from peanuts.”
What’s so interesting is that wheat was the very first food that I desensitized to in my practice. But it’s actually not that common that patients come to us to be desensitized to wheat.
That’s not to say that it doesn’t happen at other practices. In my own personal experience, the vast majority of my patients are requesting desensitization for peanut, tree nuts, milk, egg, and seeds.
The First Allergist Appointment
Charlie Hoehn: Let’s pretend I am your patient and I am coming in for my first appointment. What should I expect?
Dr. Sakina Bajowala: Well, there is a lot to prepare before you come in, but the way your appointment will typically go, we’ll start by taking a really detailed history.
I always say that allergists are the detectives of the medical world. We sit there and have to tease out all these little factors that may have contributed to the big event.
The history actually may take more than half of the visit. We’ll be going through your history from the very beginning. For example, I usually start all my visits by asking mom how their pregnancy was. And I’m taking it even before the patient was born and going through events surrounding delivery.
For example, like we discussed earlier, was it a vaginal delivery, was it a C section, were there any antibiotics given around that time, did the baby have reflux, was there any significant eczema, were we nursing or did we do formula? At what age did we start solids, were solids well tolerated?
All of these things are really important to the background history, and then we move on into, well when did you first come to suspect that a food allergy might be in play and why?
What we need to tease out from those reactions is what was consumed, how much of it, how long did it take until the reaction started, what were the symptoms during the reaction, how was the reaction managed, how long did it take for the reaction to subside, what were the results of any testing that were performed in the aftermath of the reaction and what did they show us?
“We do that for each and every reaction that has occurred.”
And in doing so, we build up this kind of rich history of the allergy in the patient. So we can really paint a really vivid picture of the time course of how the allergy has progressed and also place it on a timeline with other important life events.
For example, somebody might tell me, “I got Charlie here in the office and his mom is here too.” You brought your mom, Charlie.
She tells me that, “You know what’s so funny is that Charlie was always doing really well with milk, but then he got a really bad case of the flu and was sick for three weeks and didn’t really eat a lot during that time, but when he started drinking milk afterwards, he didn’t seem to tolerate it anymore.”
Those are the types of things that we want to put into context. Have multiple timelines going in at a time so we can make connections between different life events.
More to the Exam
Charlie Hoehn: I’d venture that’s pretty difficult for some people, especially in regard to the last comment about, right after the flu. That’s a hard thing to pin down typically, right?
Dr. Sakina Bajowala: It is hard to pin down, but you’d be amazed at what parents remember.
Charlie Hoehn: Definitely believe you there. Is that the entire first appointment is focused just on that is pinning down the history?
Dr. Sakina Bajowala: It is not the whole first appointment, but it is a very essential part of it. So we have to get that whole history down, and that all has to happen in the first appointment.
In addition to getting that history, we’re also reviewing any previous labs or skin testing that have been done. Because food allergies do not occur in isolation it is essential to pay attention to other allergic or what we call atopic conditions that might be occurring simultaneously along with the food allergy.
This could include eczema, environmental allergies—so allergic rhinoconjunctivitis, asthma, allergic gastrointestinal conditions. All of these things need to be taken into account, because if one of them is not under excellent control, it affects the whole body.
Charlie Hoehn: Got it, okay. So are we done with the first appointment?
Dr. Sakina Bajowala: No, now we have to do a physical exam. So we’ve done our history, we’ve done our review of the labs, but now it is time for the actual checkup.
So we are doing a detailed full head to toe physical, and during this time, we often uncover little secrets that the patient has not mentioned. This is not to blame the patient, because many times they just don’t realize that they are not well.
Imagine, if you have lived your whole life with a stuffy nose, how do you know what it feels like to be able to breathe easily?
“This is your new normal.”
You felt bad for so long that you don’t know what it feels like to feel good.
So when I asked you how you feel, you’re like, “I feel fine,” and then I look in your nose and I say, “I have no idea how you just tell me that you feel fine because there is no air moving here.”
And that happens all the time. Or I will look in a back of a patient’s throat and it will be what we call cobblestoned, where it’s an inflammation of the mucosal tissue in the back of the throat from constant irritation from post nasal drainage.
Do You Have Allergies?
Charlie Hoehn: What is an at home kind of quick check in with themselves that they can do that might indicate, “Hey, maybe it is not so normal?”
Dr. Sakina Bajowala: You want to keep a diary, and you can just like the detective work that we do during that visit. Do it over in an extended period of time and see if your symptoms are correlating with certain environmental exposures, animals or pollen, mold, dust exposure.
Also pay attention to if your symptoms improve when you take allergy medication. So if you take an antihistamine or a nasal spray consistently and your symptoms actually improve, and then you stopped the medication and your symptoms get worse, well guess what? It is not a cold, it’s about the allergies.
So it makes sense to then visit your friendly local allergist and have them help you identify what your allergic triggers are.
If you have a chronic dog exposure but you didn’t realize that you were allergic to dogs—not only are you congested and your sinuses are inflamed, but your lower airwaves are also inflamed. And then you come to me to treat your milk allergy, and I introduce milk into your system, you might have a reaction because you’re already skating on thin ice from the perspective of airway control and allergy control.
In order to perform food allergen desensitization safely where we actually take something that you could potentially have a life threatening allergic reaction to and deliberately put it back into your body, I need to make sure that your body is as healthy as possible and everything is tuned up and rearing to go. That your airways are clear and your sinuses are clear and you are breathing well and your skin is in good shape and your stomach isn’t hurting.
Because that is the only way I can optimize your chances of success.
Testing for Allergies
Charlie Hoehn: So first appointment, we are covering a lot of ground here, is there anything else?
Dr. Sakina Bajowala: Now we have to do some testing. So certainly, many of my patients walk in the door with a binder full of previous test results, and allergy testing results can fluctuate over time. So it’s important to track that and be consistent and see what we are dealing with.
An allergy that you may have had when you are two years old doesn’t mean you’re going to still have that allergy when you are eight years old.
It might resolve, and there are certain allergies, food allergies in particular, that the natural history is for them to resolve over time. That includes milk, eggs, soy, wheat for example.
And then there are other allergies that tend to stick around long term like seafood, nuts and seeds.
We do want to track things over time, because the most recent information is going to help me craft an accurate plan. So in addition to looking at historical results, I am going to take that and we’re going to do some new testing.
“Testing for foods can be done via skin testing or blood testing.”
Both are accurate and helpful, and sometimes I do both.
There is a little bit more granular information that you can get by doing some blood-based testing for food allergies, but it requires a great deal of interpretation. So generally it’s best to wait and let your allergist order that blood work, because they know exactly what they’re looking for and they won’t over test you.
Because it is really easy to just order a full panel for a blood test for food allergies and test things that are in your diet and get a lot of false positive results.
Clinical context is really important here, which is why we spend so much time getting the history. We are doing testing, we are identifying what our current food allergy triggers are. We can do similar testing via skin testing for the environmental allergens so we can identify those.
In blood work, I also look at a few other parameters. I look at the complete blood count and look for a few things there.
Number one, we know that children with very limited diets and especially with multiple food allergies are at an increased risk for some nutritional deficiencies including iron deficiency anemia. So we want to make sure that children aren’t anemic, because if they are that can lead to fatigue and issues with focus and overall malaise and a feeling of not feeling well.
“We definitely want to correct something like that before we get started with an intensive treatment regimen.”
I look at the white blood cell counts, specifically particular white blood cell called the eosinophil. The eosinophil is involved in protecting the body against parasites, but it is also an important player in mediating allergic reactions. And the eosinophil count can be a proxy marker of internal allergic inflammation. So I like to get a baseline so that I can track that over time. If the baseline eosinophil count is significantly elevated, it is going to prompt me to do a little bit more investigation to figure out why that might be the case.
Is this because of chronic environmental exposures? Is there a drug allergy? Is the skin very inflamed, or is there some allergic gastrointestinal inflammation kind of burning under the surface that we haven’t recognize yet that we need to look into and correct?
Occasionally, I will choose some herbal supplements to help mitigate that eosinophilia or that inflammation depending on the count. I also look at a vitamin D level.
Vitamin D is an immunomodulatory hormone that has been demonstrated to play an important role in the modulation of the immune system when it comes to autoimmune disease and atopic disease.
There are some studies that show that optimizing the vitamin D level can actually improve the body’s production of anti-inflammatory molecules or cytokines. So it’s to our patient’s benefit to have an optimized vitamin D level.
And my personal practice is to really boost that above the bare minimum of normal. Generally in the level of 30 is considered sufficient, but I really like my patients to be quite a bit higher than that. I am aiming for levels around 50 with the vitamin D3 or 25 hydroxyl vitamin D hovering there still high enough to be optimized but low enough to not have any concerns about toxicity.
Options for Desensitization
Charlie Hoehn: In other words, all of this to say the first appointment is amazingly comprehensive and let’s touch upon what follow up in treatment, making the most of treatment really looks like.
Dr. Sakina Bajowala: Right, so like I mentioned before I would say 50 to 60% of successful treatment involves tuning up the body and getting the patient at baseline to be as healthy as possible.
Once that is done, we can move onto dietary expansion. What that means is taking a look at our blood work and our skin testing results and categorizing the foods that a patient is currently avoiding into three different columns.
One is sensitized and likely allergic. Which means, okay well you are certainly sensitized to this food, and the levels are high enough and the clinical history is such or the particular proteins that you are sensitized are high risk enough that we believe that this is a true allergy and that you should continue avoiding it. Although you will be potentially a candidate for treatment down the road.
Category two is sensitized but likely tolerant. What this means is that we think it might be a false positive result. That on paper it looks like your body is producing IGE or an allergic antibody against this food. Your skin test may even be positive. However, due to the level of IGE that you are producing, maybe it is relatively low or that you may only be sensitized to certain low risk proteins. We think it’s worth the chance of trying to introduce that allergen back into your body under medical supervision to see if you can handle it, and the way we do that is within an in-office oral food challenge.
What this involves is taking the food that we are testing and reintroducing it into the body in very small doses that increase every fifteen minutes or so until you have eaten a whole serving of that food within around an hour, an hour and a half. And then we watch you for another hour after you’ve done eating to make sure that you are tolerating it well.
In between each dose, we keep checking on you to make sure you’re doing well, and of course, if there were any signs of an allergic reaction, we would halt the challenge, treat the reaction, then you would go back to avoidance.
But if you can pass the challenge and not experience a reaction, then there is no reason to not introduce this food into your diet on a regular basis, because you are not allergic.
A Dramatic Turnaround
Charlie Hoehn: Tell me your personal favorite success story of a patient you’ve treated?
Dr. Sakina Bajowala I would say I really, really loved treating a patient who had a very severe milk allergy to the point where she had experienced anaphylactic reactions to trace amounts of milk from walking into a room where somebody was boiling milk on the stove or from walking into a coffee shop where milk was steaming, and needing epinephrine injections multiple times before she came to see me.
Her level of allergy was high enough that we went through our full or long protocol for treatment, which starts with taking diluted extracts of the food allergen in question and introducing it to the immune system by giving drops under the surface of the tongue once daily. Those doses of the drops increase gradually over the course of around six months. Once that is complete, you transition into what we call oral immunotherapy where you are taking actual food and ingesting it on a daily basis and building that up over time.
This patient was so allergic to milk that it actually took far longer than we anticipated to get to our goal dose of drinking 240 milliliters or a whole eight ounces of milk in a single sitting.
But she did it, and the greatest feeling was when her mom pulled out of the chocolates out of her bag because it was her very first time eating chocolate.
“So the three of us sat there and ate a bunch of chocolate together.”
It was just such a nice bonding moment.
Afterwards, I got text messages from both of them sharing pictures of a family event where, for the very first time she was able to eat this traditional dish that her family had been making for generations for the holidays. She had never been able to taste it because it had milk in it. And there she was sitting in the center of this photograph with a big plate of this dish in front of her and whole family beaming surrounding her, and it was just a lovely feeling of everything is right in the world.
A Challenge from Dr. Sakina Bajowala
Charlie Hoehn: I’d like for you to give our listeners a challenge, maybe something they can do this week that can have a positive impact on their life if they think or they know they have a food allergy.
Dr. Sakina Bajowala: So first of all Charlie thank you so much for inviting me to come and talk to you about this topic which is so near and dear to my heart. I am proud of my patients, and I am just grateful to be able to help them in whatever way I can.
My challenge to anyone listening is, if you do have an allergy and you’ve been living life in a cage where you feel limited in any way, I challenge you to get out of that box and just educate yourself.
There is a lot of information out there, and it can be really difficult to separate the wheat from the chaff here when it comes to medical things online. But there are some really great resources.
So obviously read the book. I’d love for you all to read the book and take that information with you to a local board certified allergist.
“Sit down and have a real conversation about your options.”
If you read the book and you talk to your allergist and afterwards you decide that, no, treatment isn’t right for you, you just want to continue on with avoidance, that’s fine. More power to you.
At least you knew all the options that were out there and you made an educated decision.
What I hate is when I hear from people who say, “If only I had known about this five years ago, I would have done it and I would have avoided a stay in the ICU.” Or people who say, “If only I had known about this before my son went off to college, I could have protected him before he left my house.”
Because this information has been out there, but it just hasn’t been publicized. So that’s my challenge. Just read as much as you can, educate yourself as much as possible, and then go armed with that information and knowledge and talk it out with somebody who is an expert in the field who can help you really make sense of it all so you can make an informed decision on how to move forward.
Charlie Hoehn: Now you have a long list of patients, but how can our listeners maybe connect with you, follow you on your journey, potentially get on that list?
Dr. Sakina Bajowala: Sure, so my private practice in North Aurora, Illinois, is Kaneland Allergy and Asthma Center and our website is www.kanelandallergy.com and patients are welcome to call us there, schedule a consultation appointment. We would be happy to meet with anyone who is interested.
If you are not local to us and you’re still interested, I would certainly encourage you to utilize the resources in the back of the book where I list a number of support groups, Facebook pages, and websites.
Where you can go to find allergists in your community who are also skilled in the practice of food allergen desensitization therapy and who can serve as resources for you locally.
If you just want people to talk to, I encourage you to go online and join a lot of those Facebook groups that are available specifically for education about sublingual immunotherapy, oral immunotherapy, and any other of the food allergy treatment options that are coming up the pipeline.