Episode 57: Baby Eczema, Food Allergies and Oral Immunotherapy (OIT)
If your baby has eczema, they face a much higher risk of developing a food allergy, but could early action help lower that risk? In this episode of the Eczema Breakthroughs Podcast, Dr Brian Vickery, Chief of Allergy and Immunology and Director of the Food Allergy Program at Children’s Healthcare of Atlanta, and Professor of Pediatrics at Emory University School of Medicine, explains the research connecting baby eczema, food allergy and the skin barrier, plus the evidence behind early allergen introduction.
For parents of children already diagnosed with a food allergy, Dr Vickery explains oral immunotherapy (OIT) and discusses emerging approaches including sublingual immunotherapy (SLIT), and the investigational peanut patch (EPIT).
In this episode you’ll learn:
✅ Why eczema and an inflamed, leaky skin barrier may lead to food sensitization
✅ How early introduction of peanut and egg may reduce food-allergy risk
✅ Practical skincare habits when managing eczema around food
✅ How OIT may protect against accidental exposure plus emerging gut microbiome research
Important: This episode is for education and does not replace individual medical advice. Families of babies with eczema, an existing food allergy or a previous reaction should seek personalized guidance before introducing an allergen.
Listen now on Spotify, Apple Podcasts, or gper.org/podcast
Support GPER’s research with a tax-deductible donation
-
[00:00:28] Lynita: Hello, and welcome to the podcast. Today we're exploring a topic that affects many families in the eczema community, food allergies Food allergies affect around one in 10 children, but the risk is much higher for babies with eczema. In fact, around one in three babies with moderate to severe eczema will go on to develop food allergy. My son is one of them.
Over the past decade, we've learnt a lot about food allergy prevention . Early introduction of allergenic foods can reduce the risk, but for many children with eczema, sensitization may have already begun before those foods are introduced.
Fortunately , There has also been remarkable progress in food allergy treatment. New therapies are helping children increase their tolerance to allergens, offering a level of freedom that wasn't possible just a few years ago. To explain these exciting advances and what they mean for families, we're joined today by pediatric allergist immunologist Dr. Brian Vickery. He is the chief of allergy and immunology and the director of the food allergy program at Children's Healthcare of Atlanta and associate professor of Emory University School of Medicine, Dr. Vickery is devoted to improving the long-term health and wellbeing of children and families who suffer from allergies. Dr. Vickery, welcome
[00:01:48] Dr. Vickery: Thanks so much for having me. it's a pleasure to be with you
[00:01:51] Lynita: We are talking about food allergies today, and as I mentioned, eczema kids often have food allergies. Why is it that eczema kids are such high risk
[00:01:58] Dr. Vickery: Well, we've known for a long time that most patients with food allergy also have eczema, more than ninety percent of them do. but I think we've started to understand that, eczema may actually be causal.
[00:02:11] Lynita: So eczema might be causing food allergies?
[00:02:14] Dr. Vickery: That's right. So, , um, we've become t- better acquainted withwhat is happening in the skin and how that might ultimately lead to sensitization, and that's starting to kind of put together the different pieces of the puzzle, that help explain things that we previously couldn't quite understand. For example, why the first time you try a food, there's a reaction.
And that has always confounded us a little bit, like how could that happen? Usually you have to have an exposure, then you have an immune response, and then the allergy comes on subsequent exposures. And it turns out that it actually may be that that's because the immune response is coming from exposure through the inflamed, leaky skin barrier that is part of eczema.
[00:02:58] Lynita: So Because children with eczema have a skin barrier that's not functioning the way it should be, it's giving allergens an extra opportunity to get into the immune system and say, "Hey, this is something that we need to overreact to."
[00:03:13] Dr. Vickery: That's right. so we know that the skin barrier function of patients with eczema or atopic is impaired, and we know that mutations in a gene called filaggrin are extremely common. Filaggrin's helps form a,a nice tight layer, of barrier that kinda keeps the outside world out And in fact a mutation in filaggrin is a very strong genetic risk factor for the development of food allergy, even though filaggrin is only expressed in the skin. So , eczema is the single strongest risk factor for the development of food allergy. The earlier it starts and the worse it is, the higher your risk of going on to develop food allergy. And that really tells us that the mechanism to how food allergy originates in the first place may come through the skin.
[00:04:01] Lynita: So We Need to get on top of eczema as soon as possible if we want to try and prevent future food allergy.
[00:04:07] Dr. Vickery: That's absolutely it. I think as your own experience suggests, oftentimes, over time, the eczema tends to get better but then you're left with food allergy. And eczema is often the very first sign early in life that, your child m-may be destined for, other allergic diseases to come. And so when we think about, , how do we, intervene to prevent the consequences of all that allergic disease down the line, our focus should be the development of eczema in early life because that seems to be where it's all starting.
[00:04:41] Lynita: Yep. So don't let the eczema go. Do everything, you can right at the beginning, Is food allergy for life?
[00:04:49] Dr. Vickery: some cases it might be, but in others not. So what's interesting is that, different food allergies tend to have, different natural histories even within the same patient.oftentimes milk and egg and wheat allergies tend to go away naturally, whereas nut allergies do not. And this is really interesting because this can happen in the same individual, right? So somebody that's allergic to egg and peanut early in life can progressively outgrow their egg allergy, while the peanut allergy sticks around. And to me, this is a fascinatingobservation. This suggests that the body has a program to deal with food allergens, and that program works to kind of correct some allergens but not others even in the same individual. So, , boy, I'd really love to understand this program because to me, the cure for food allergy is somewhere in there.
[00:05:43] Lynita: And we will talk a little bit more about what we can do for people that are living with a, nut allergy. but what are the most common ages for food allergies to appear?
[00:05:52] Dr. Vickery: So usually, allergy appears in the first or second year of life. And historically the guidance had been to wait to introduce allergenic foods. And so, those first, second, third exposures weren't happening until the child was a little bit older. But then when that happened, that's when the food allergy would become apparent .
as We have now understood the importance of early allergen feeding for preventing food allergy, that has sort of shifted the age atpresentation a bit younger, 'cause now worldwide our guidelines, want us to be introducing these common food allergens early in life, five, six months of age. We still see lots of kids presenting with food allergy but ,, we're starting to see some evidence that it's making a difference for the most common pediatric food allergies that we see the milk, egg, wheat, nuts, and so on. It tracks very much with exposure.
[00:06:46] Lynita: interesting. So just thinking as a parent with a tiny baby that hasn't even started on their first foods yet, and they've got this impaired skin barrier, as a mother, you're going to be putting cream on them to try and moisturize it
Should, in that situation, peanuts be banned from the house? I want to protect my child from a food allergy, but they're not eating yet, so this is a bit of a,tricky situation.
What do you recommend?
[00:07:14] Dr. Vickery: Yeah, it is a tricky situation and, it can be even trickier if there are other kids in the house. Let's say there's a non-allergic sibling we want that sibling to continue to expose themselves to allergens, how do you manage that? But you raise an important point, which is how to manage inadvertent skin exposure in a baby who already has eczema. And so the first point I'd make is that soap and water, removes allergens from surfaces and hands. Good old soap and water, okay? Alcohol-based sanitizers do not. And so anytime anyone is eating and there's a baby in the house where they might have to change a diaper or apply some cream after they eat and before they touch the baby, they should wash their hands thoroughly with soap and water. There are some that advocate when it comes to applying medications or emollients to a baby that has eczema that the parent should use gloves, so that their own skin is not touching the baby's skin. And the only thing that goes into the jar of emollient is a spoon or a wooden tongue blade So that you're not dipping your hand into the pot, because this can also get Food proteins or bacteria into the pot.
[00:08:23] Lynita: So with a eczema baby in the house, we wanna try and minimize the allergens on their skin.
So If we do have a toddler who we're wanting to expose to milk and eggs and wheat. maybe Try and keep that process separate from putting cream on the baby so that we are protecting that baby's skin as much as possible before that baby has a chance to eat the allergen themselves.
[00:08:46] Dr. Vickery: Yeah, so if there's another child in the house, there can be allergen in the house and still protect the baby, but there has to be, procedures that are followed, right? We've all been there before ex-exhausted, stressed parents trying to manage multiple kids. And sometimes the baby's crying and you're holding the baby while you're trying to deal with the older one right? But there are basic things , that can be done like, trying to separate mealtimes. Always just, again washing hands with lots of soap and water and really setting aside those times where , the skin care is intensive.Um, Those should be separate times where there's a lot of care taken.
[00:09:23] Lynita: Absolutely. So now let's move on, our, eczema baby's being introduced to foods, is the recommendation now, as soon as baby's introduced to foods, we bring these allergens in?
[00:09:34] Dr. Vickery: That's right. this has been a, major change in our recommendations in the last few years. when I was trained as a pediatrician, the theory was that , we should wait until the immune system matures and develops and gets stronger, and then we should feed babies, allergens. And that was a well-intentioned but completely unscientific idea. Then there were a series of very important studies that demonstrated that babies introduced to allergens, especially those with, moderate or worse eczema starting in the first year of life. those, children, when exposed to allergens starting at about five months of age have substantially reduced likelihood of developing food allergies compared to those who practice the avoidance that we were recommending at the time.
Since then,we have globally, completely revised our feeding guidelines. Like a hundred and eighty degree turn. Now the new science suggests, no, no, no, we were completely wrong. You need to do the opposite. You need to feed the babies these things like peanut at age five months."
[00:10:35] Lynita: For sure.
[00:10:37] Dr. Vickery: there's a lot that still needs to happen , to enhance the public health uptake of this new messaging.
[00:10:44] Lynita: We are Making Progress, though. I think There has been research that's come out saying that peanut allergies are decreasing with these new guidelines.
yeah, there, been a couple of studies, that are, starting to show changes. Um, I think it's still... a little bit of an open questionabout how big the effect is gonna be. in the real world where folks , are trying to manage this in the midst of their busy life that is the thing we're really trying to study now. But it raises all these questions about how much and how often. What's the minimal amount? , are you doing it right? some of these questions remain a little bit unanswered, which might explain why we're not seeing dramatic shifts at the population level, Sure
[00:11:25] Dr. Vickery: Feeding babies potentially allergenic foods it's probably good for babies, right? So we wannaincrease diet diversity and feed the baby like we feed the family.You don't need special products. You start early and do it often and just try to normalize this behavior.
[00:11:41] Lynita: as a parent That was being given advice on how to manage my child's eczema, nothing was ever clear. So been told, "Introduce your baby to peanut," I'm gonna say, "Exactly at what age? And exactly how much? And exactly how often should I be doing it?" What would you say to a parent who's asking these questions of you?
[00:12:00] Dr. Vickery: And we have these conversations all the time. So when it comes to, what is the best evidence,the things I recommend are as follows. Number one Where possible, um, breastfeed your baby as long as you can. it's the best source of nutrition for baby, and the longer you can do it, the better. There is no evidence that restricting allergens from the diet of a pregnant or lactating mother is helpful in terms of allergy prevention. And we want mothers to consume a healthy diet, get plenty of rest, lots of liquids, but that includes potentially allergenic foods if that's part of your diet. Don't restrict them. And frankly, we know that ingested foods, wind up in the breast milk and that probably historically for eons is how babies were introduced to allergens for the first time is through mother's milk, right? , So keep a normal diet, breastfeed as long as you can. No grainsbefore age four months, so that's the second thing. In the old days, providers would often recommend putting some rice or, oats in a bottle for baby with reflux, We really don't wanna do that. Um, Introduce a grain between four to six months. Follow that with some fruit and veg a nice ripe banana or a sweet potato, something like that. And once the baby's done that and had a few purees and couple of grains, the baby has a little bit of oral motor function, knows what to do with, , some soft foods, that's the time to start introducing allergen, right? , Four or five months of age.right? And puree becomes a very nice vehicle to mix in a little bit of peanut butter or an egg paste. So when it comes to egg my recommendation is hard boil, an egg, cook it ten to twelve minutes so it's really firm, let it cool, and then just mash it up into a paste. All of the allergens are in the egg white. And mix that with your vehicle your, sweet potatoes, your banana, the thing that babies already know and like. And then,continue to do it. Incorporate it in the diet, give it regularly. The amount that we're targeting , for peanut it's roughly, , a teaspoon at least three times a week, you
know, , if you can do more than that, great. we wanna move away from this idea, like you just do a little bit, and you do it once, or you do it infrequently because that might not be enough to teach the body that this allergen is normal
[00:14:18] Lynita: Okay. That's really helpful advice for parents . Let's say now our child has eaten something and they've had a reaction.
Maybe it's a red rash around their mouth. Maybe it's more severe, and you've had a quick trip to the, ER. Now we have a food allergy. We've been given an EpiPen, or maybe some of the newer technology. You suddenly realize that you are going to be managing parties, play dates. You're gonna be that parent that says, "Can this thing not be at a party?" it's not nice, and how do you travel with a child with a food allergy?
the research has really advanced in how to help children with food allergies oral immunotherapy is what we're talking about.
sometimes it's referred to as OIT. Can you explain what is oral immunotherapy and what's involved?
[00:15:05] Dr. Vickery: Oral immunotherapy is treating the allergy by exposing the patient to small amounts of the thing they're allergic to
the body develops a tolerance to the allergen over time, it actually changes the immune response, and addresses the root cause of the problem. So you follows this microdosing type strategy where you start with a tiny fraction of allergen under supervision. If that's tolerated in the office, you go home and take that small amount every day at home, and then return to the clinic,after some period of time to test the next slightly higher dose. If that's tolerated, you take that every day at home, and so on. You kind of go through this ladder conceptuntil you achieve what we call maintenance dose and that is the dose you stay on.
And, if somebody can get through that up-dosing ladder to their maintenance dose, approximately a peanut's worth of protein, the studies show that a very high percentage of them are protected to large exposures.
[00:16:01] Lynita: okay.
[00:16:02] Dr. Vickery: Now, it's important
to remember that OIT is not a cure. . But it's highly effective in creating what we call desensitization. which would be enough to protect them from accidental exposures.
[00:16:12] Lynita: The reality is it's never gonna be something you can forget about. But you may be able to say, I've got my EpiPen if something does really go wrong. My life isn't at risk.
[00:16:24] Dr. Vickery: right. So while they're still reading labels and still carrying epinephrine and still, , largely acting like,, somebody who has food allergy,we know that despite all those precautions, accidents are inevitable, and OIT is designed to protect people from those accidents, okay? And that's a reasonable expectation for the people who are able to achieve that maintenance dose.
[00:16:45] Lynita: it's never gonna go away.
[00:16:47] Dr. Vickery: right?
Now, there is a an additional advantage of starting OIT in early life that adds the possibilityof not just desensitization, but something we call remission. And remission is more likely when you start, oral immunotherapy, soon after diagnosis in the first year or two of life. the odds of remission can be as high as, fifty to eighty percent. Remission is still not a cure, it's still there, you're not cured, but it's not as active anymore. And that's the reason that, this conversationabout starting oIT in early life in this newly diagnosed case that you just described. Increasingly, those patients are being offered OIT right out of the gate, shortly after the diagnosis. Because compared to when we use it in an eight or 10 or 15-year-old the odds of remission are much, much higher
[00:17:39] Lynita: That's interesting.
So we're gonna have more success if we start younger with OIT, . So it's really something worth thinking about if you've got this newly diagnosed child.
[00:17:51] Dr. Vickery: that's right. I mean, , We have not yet been able to take somebody who is allergic and flip them to the point where they become tolerant., , Like we make it go away completely. But these interventions early in life get us as close to that as we, have been, , with anything else so far and the search is still on to try to figure out how to switch it off entirely.
But increasingly, there's this intense interest in, intervening with these young kids..not to say that older patients can't be treated. They can be. and we have some interventions for them beyond even the ones we've already talked about. Uh, so there's a lot coming down the pipeline, for food allergy treatments.but ultimately the holy grail, right, is to intervene and modify the course of the disease, like switch it off. and we're still trying to figure out how to do that.
[00:18:35] Lynita: But it does make a difference to have a higher tolerance if you know that you can have a little bit more freedom in your life.
However, it is a big burden, it's not a short program. It's not like you're gonna visit your doctor and in a few months' time, voila, you're done.
[00:18:50] Dr. Vickery: right
[00:18:51] Lynita: How many years are we talking about in this, process of oral immunotherapy,
[00:18:55] Dr. Vickery: Well, because like I mentioned, it's not a cure that means that we can't stop it and expect a prolonged effect, you know, I have conversations with families who are considering it, and prepare them for what it takes. that, yes, this becomes a daily thing that you have to do at home most of the time. It's gonna create some mild allergic reactions that you're gonna have to manage because, we're exposing you to the thing you're allergic to. That's gonna be a little bumpy at times
because, part of having a child with food allergy is,, as a caregiver, you have to become a bit of an expert in managing reactions, and when you take OIT, you have to be the one to deliver the treatment at home and then figure out what to do. And so it it can be something that feels a little overwhelming at first. But, I think with the right amount of support it, can be a verymeaningful treatment experience.
Great. , I do wanna go through some terms, that are often thrown around when you're looking into, OIT, and these are SLIT, and EPIT. They're all different forms of immunotherapy. We've been talking about oIT, oral immunotherapy, so the route of administration, you're giving small doses that are swallowed,right? And that gradually builds up to a target dose of, like I said, about a good-sized peanut kernel. , Three hundred milligrams of protein. sublingual immunotherapy or sLIT instead of swallowing it, involves putting a dose underneath the tongue, so one to two to maybe four milligrams of protein underneath the tongue to be held there.
And then ePIT is epicutaneous immunotherapy. This is the peanut patch. So the dose is applied to the outside of the skin underneath essentially a sticker about the size of a coin,and left there. the patch is designed to be worn ultimately twenty-four/seven. You start with a few hours a day and build up as you tolerate it, and ultimately it's, worn all the time. And there the dose is two hundred and fifty micrograms. It's a tiny little dose but it interacts with the immune system in the skin and can be done by patients who have eczema. Almost all the patients in these trials have eczema. the key differences between these different therapies is the route of administration and the amount in the dose. um, OIT is probably most widely available. There is one company that's developing a sublingual tablet That is in clinical trials and not yet approved. And then the peanut patch is also not yet approved.
[00:21:26] Lynita: I didn't realize it wasn't out yet. .. , Let's hope it comes soon, though. it, with the FDA for approval ,
[00:21:33] Dr. Vickery: um, there has been a study completedin older children aged four to seven with the peanut patch which, had a positive result. And so if it does get approved, it is likely to get approved in the four to seven-year-old population first. there is an ongoing study in patientsaged one to four, which my site is participating in as others are around the world, . So I think we're relatively close. I, I'm hopeful that we'll end up with an approval first in four to seven-year-olds, in the next,year, two years, three years, .
[00:22:08] Lynita: Well, this does give hope for families that are trying to live with food allergies and . What do you think the future looks like for managing and preventing food allergies , particularly for high-risk kids
[00:22:22] Dr. Vickery: I'm excited, about a number of prevention studies that are increasingly looking at ways to modify the skin itself, right? We think that the skin inflammation of eczema is where the allergic, journey first starts and we know we need to feed these kids when they're able to take foods. Still, there are plenty that react even on the first exposure, and, we are not really addressing the underlying problem of the skin and how it all starts.
So there are some studies that are starting to look athow can we intervene even earlier to actually repair the skin barrier? with the skin microbiome? Speaking of microbiome, there've also been studies about the gut microbiome,which we know is really important in the development of both eczema and food allergy. And was a recent phase two trial which showed that introducing three live bacteria into the gI tract of newborns less than 14 days of age was, superior to placebo in actually preventing eczema at one year of life, and also reduced food allergy by about 60%. And this was really one of the first studies to show that affecting the GImicrobiome affects later development of both eczema and food allergy.
[00:23:50] Lynita: I'd be actually really interested to read that study Do you know who the author is,
[00:23:54] Dr. Vickery: The study is not yet published, and It's based on a lot of work that was done, in Susan Lynch's lab at UCSF but , they identified these three bacteria, that were always absent in the kids that grew up with allergies and
so we'll see. It's likely that that will soon be tested in a phase three study. and if it replicates in phase three, then we might have our first like truly preventative intervention, to alter the course of not only food allergy, but also eczema.
[00:24:25] Lynita: We have been in contact with Nicole Kimes and Susan Lynch, and we are following their studies, And we're looking forward to this paper being published.
[00:24:32] Dr. Vickery: So What I hear is that, people should be doing things early for their baby to, avoid exposure to allergens before eating it, and then definitely exposing them to allergens after they've started consuming foods. and we should keep an eye on the research.
[00:24:49] Lynita: Dr. Vickery, thank you so much for sharing with us how parents can try and mitigate the risks of food allergy, and if they do get a food allergy, what they should do to, improve the tolerance of food allergies. Well, thank you very much, and have a great day. Thank
[00:25:06] Dr. Vickery: It's been a pleasure. I've really enjoyed the conversation, and very much.
