How Sublingual Immunotherapy Can Increase Safety and Freedom, With Dr. Allison Freeman

Transcript Disclaimer:
This transcript was generated using AI software from the original podcast audio and may contain errors, omissions, or minor inaccuracies. It has been lightly edited for readability. Please refer to the full podcast episode for the most accurate representation of the conversation.

Allison Freeman, MD 0:00

All of these tools have a place, but I think as allergists I really wish every child with a diagnosis of a food allergy, at least got to hear this once and thankfully your podcast and others, I think that's the service as allergists we need to do is make sure everybody knows food therapy is possible.

Speaker 0:20

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence.

Amanda Whitehouse, PhD 0:40

Today's episode is one that I've been so excited to share with you because Dr. Allison Freeman is here to talk to us about slit or sublingual immunotherapy, which is an immunotherapy treatment option that is to me, surprisingly underused in the allergy world. I'm going to say this upfront. I am not going to pretend to be neutral about it. Slit is my favorite immunotherapy option that we have tried. My son agrees, and it's one of multiple treatments that we've done in our house. So we do have a little bit of experience under our belt to compare. But that's not the only reason that I'm excited for this episode.

It's also especially meaningful because Dr. Freeman is one of the physicians who helped us get there. She specializes in immunotherapy and innovative treatment approaches for both environmental and food allergies. I know her as a physician who not only helps her patients find practical, personalized solutions that make treatment more accessible and sustainable for them, I also know and appreciate that she is so open to the mental health impact of living with food allergies and undergoing food allergy treatment. I had the honor of working with her with shared patients when she was here in Buffalo, and then s sadly, she left us and moved to the Richmond, Virginia area where she practices now I'll say a little bit more about it in the episode, but when my son transitioned into Dr. Freeman's care, he was already on maintenance dose for OIT and Slit, but Dr. Freeman looked at his plan and translated his protocol into a food-based recipe for his slit drops instead of extracts. That saved us a fortune already. That's one of many reasons that I love slit, that she'll explain to us today and forgive us because being old friends, we jumped right into the conversation without much of a formal intro. So I hope you enjoy this conversation as much as I did.
Dr. Freeman, let's start by you talking in terms of the use and the role of SLIT and the big picture of allergy treatments.

Allison Freeman, MD 2:25

So about 17 years ago when the research was first coming out, there was a couple of published studies from Johns Hopkins on the use of oral therapy for egg and allergy. And then we started the consortium of food allergy researchers work on peanut oral therapy. And so we were seeing that in our medical journals, seeing that they had some very nice success. You know, up to 80% of kids treated with oral immunotherapy could successfully be brought to a very high level of desensitization to the product and some of them truly became fully tolerant. So that was very reassuring. And that's when I first got involved with the other allergist physicians that are part of the food allergy support team. And we started sharing things back and forth. Have you tried this? Have you tried that? What food have you tried?

And I really, I think I'm a late comer to SLIT, so I was doing almost exclusively oral immunotherapy until two and a half, three years ago. And that's when I was hearing a strong tendency at the food allergy support team annual conference towards more and more people trying sublingual, and I decided to give it a go. I am really glad I did. I have found that a very helpful additional tool. I still firmly believe that young toddlers should try oral first and can be very successful at reaching full desensitization and even future tolerance with oral therapy if possible. But if a family doesn't have the time commitment for oral and wants to do something much quicker process with just somewhere between four and seven visits to get to maintenance dose. It's also a much easier process on the family in that you only have that half hour post dose preclusion of exercise and we're not even sure that that needs to stay in the long term.

Dr. Wyndham has done some studies in his office to show that kids could be exercised after a maintenance dose successfully, and we'll have more data on that in the future. I'm sure that maybe we don't need that much time after SLIT dosing, so it's an easier lifestyle with far fewer stomach side effects, far fewer risk of anaphylaxis and a much simpler schedule for families. And so I think they need to hear about both options. However, I do encourage people that if your child is really young and you are really wanting to maybe one day have a child that doesn't seem to have any food allergies, that oral is the tool that will get you to that level and that we don't yet have the data that sublingual can reach that. And when we use those words, we refer to being basically able to be exposed to a certain amount with no reaction. And then when we talk about tolerance. We talk about a child that they freely eat large amounts and may be able even to have gaps in the eating. And this is where we're still figuring this out, that the gaps can certainly be several days, but may even be possibly several weeks in some children I've had times where I used oral therapy and later were able to show that they could even go two to three months without dosing it, successfully still be able to tolerate it. So that's what we mean when we say tolerance is that there can be some gaps in treatment and that is not at the beginning, that's all after years of ingestion.

In that same group of physicians, I learned that many of the maintenance oral kids don't need to dose every day. That daily buildup of the induction phase can be modified gradually over time down to a frequency of dosing of every other day or even just a couple of days a week. So that, that was a another thing that would speak to the long-term for oral, being much easier on families. So I always present that to them, that oral is gonna be really hard at the start. A lot of time invested. You're gonna watch your child much more carefully and have a lot more rules, but at the five-year mark it may become fairly easy. In sublingual you're going to have a faster induction, get to maintenance really quickly. It's not gonna get in the way of your family life all that much. It's something you can do before school. Something that you can take with you on travel really easily, that you can do multiple foods simultaneously without the risk of stomach symptoms increasing for every additional food treated.

Your chance of an anaphylactic reaction is very, very low with sublingual. And then of course, we get those parents that wanna start with one and then move to the other, or vice versa. It's a great time to be doing food therapy because having these tools and being able to go back and forth between these tools is making it possible for me. To treat a lot more people. I was mentioning to you earlier that I have now been doing a lot of my OIT and sublingual starts using these Mission Mighty Me nut puffs. And that's allowed a cost free oral solution. So the family provides the puffs, I just do the office visits. And so up until the introduction of those puffs to my practice, the only. Thing I could treat that was covered by insurance for families was peanut. And now I can treat five nuts using these puffs at a very inexpensive total bill for the family and be able to keep the kids on a maintenance that's kind of kid friendly so that's working well for me. And you know, I welcome being able to do that with other foods down the road using real food SLIT. Successfully with low doses of tahini and low doses of egg white and things like this to try to maintain SLIT with low cost to families.

Amanda Whitehouse, PhD 8:19

Yeah. Well, and even for my family, you touched on the difference, but we had been doing SLIT. With another doctor and then switched from extract to real food, which originally was created in the office, but then you taught me how to mix it at home and gave me a recipe. Mm-hmm. And even that transition was so much easier and, and then less expensive from what we were doing prior to switching over to you. That just makes it so much more accessible.

Allison Freeman, MD 8:40

Yeah. And I, I'm always amazed how many people come to the office and I'm the first allergist to tell them that these exist. Mm-hmm. And also, I, I do use omalizumab injections in some patients, especially for young adults going on travel adventures and parents who are nervous about sending a child to college and they just want that additional safety for the college age or the high school age child.

So all of these tools have a place, but I think as allergists. I really wish every child with a diagnosis of a food allergy, at least got to hear this once and thankfully your podcast and others, I think that's the service as allergists we need to do is make sure everybody knows food therapy is possible. I will tell you a little, an aside that kind of brings this home. I had a youngster I was working with in a previous office who does not eat orally. Well, we were able to use gastrostomy tube food challenges to clarify which were real allergies and which were not, and then begin sublingual therapy in that child even though they do not eat orally. So now that that youngster is a whole lot safer, and even though they may never actually wish to eat these trigger foods, that parent can now relax to know that their child is treated to the point of bite safety.

Amanda Whitehouse, PhD 10:02

Wow, that's amazing. We talk about food allergies, like they're this isolated thing, but obviously have so many comorbidities and different issues in conjunction that people are dealing with. It's amazing that that could help in that way. Do you have other colleagues who've approached that issue as well?

Allison Freeman, MD 10:16

Well, I'm sure I do. I, I haven't had a heart to heart with very many of them about it, but at the children's hospital at Oshei Children's at Buffalo, I was able to be working hand in hand with the feeding therapy clinic. A lot of food allergy kids are also picky eaters, and have very narrow diet range, which puts them at risk for developing more food allergies. And so if we could intervene with those kids that are super picky, or the kids that just got a slow start on solids and things like that, we still need to do early intervention for those kids, but sometimes we have to be creative and do it using g-tubes or I had lots of kids that I put a little nut milk into their bottles when they were still bottle feeding at a later age and things like this.

Amanda Whitehouse, PhD 11:00

Yeah. I would argue that kids with a wide range of different needs would need that protection even more. If they're not eating food, people would assume then there's no risk, but maybe there's more.

Allison Freeman, MD 11:09

Exactly. Yeah. And that's how I felt about it, that this child who's graduated our NICU is still on the bottle at 10 to 12 months of age and later is going to go to daycare or have brothers and sisters walking around with food on their fingers. And we need to try to mediate that risk as well.

Amanda Whitehouse, PhD 11:26

Absolutely. Wow. We're talking about just holding something under the tongue and spitting it out. I think people don't understand how you can hold something under your tongue and spit it out and your body's developing any tolerance to it.

Allison Freeman, MD 11:37

Well, there's some key immune cells in the body, and, and one is underneath the tongue. And so that oral mucosa is a nice entryway straight into the lymph nodes that we'll then talk to the rest of the immune system and try to produce these antibody shifts that result in later tolerance. In Europe now they do a large amount of their environmental therapy as sublingual and even in the United States, we have sublingual therapy for grass, ragweed and dust mite that's been tested and shown to be effective over the last decade. And so we've known that that set of cells exists, but we really weren't thinking of it as a food treatment area. I think more of us have been persuaded that that is an effective way to present antigens to the body.

And the question about swallowing versus spitting out, there are more studies coming up of low dose oral immunotherapy and low dose might be somewhere in the 30 milligram protein range. And, and our sublingual is more like five milligrams or seven, but whether they're actually getting some oral exposure, even the kids who spit out the extract probably still have some in their saliva and get some oral exposure. The whole idea about spitting out the extract was mostly to prevent the development of any gastrointestinal irritation symptoms. So sublingual can be practiced by swallowing or spitting out.

Right now we believe that both are effective, but again, we'll know more when we've got these bigger scale studies like the one Dr. Kim is doing at at Chapel Hill. Edwin Kim's peanut study at Chapel Hill that's now enrolling. He's got a very large placebo controlled peanut SLIT trial and he is done a lot of the background research anyway on peanut SLIT. From this trial, we hope to see the exact numbers in terms of how many kids get how much protection at one year, two years, three years, four years, and some of the ins and outs as to is there any long-term GI side effects, which people always ask me and I just, I don't have much to go on there. And what if we convert them to food? I don't know if he'll be doing that or not. But if we stop doing drops and convert to actual food, does that change the outcomes in any way?

Amanda Whitehouse, PhD 13:57

Okay, and so to clarify, then does that make SLIT more possible for kids who might have a history of EOE or other, you know, eosinophilic issues or, yes. Okay.

Allison Freeman, MD 14:08

We, we believe that kids who have a history of acid reflux kids with other eating disorders, I've sometimes interacted with children who are still working through an oral motor problem with our speech and feeding therapy team. That having that sublingual exposure can certainly still be effective in those kids if they're not yet re ready to swallow these foods. I think the thing we don't yet know is how many years of exposure does it take to reach high levels of tolerance? However, bite safety doesn't take a very high level of exposure. And so we, we know that most may contains and shared equipment warned foods, if they have anything in them, it's, you know, in that 10 milligram or less range. And certainly sublingual can get you some protection for May Contains and, and shared equipment, which is liberating as you know, for a lot of families to reach that threshold that you don't have to worry about every may contain anymore. And then. The more time you spend on sublingual, we think it's gonna get you that one bite to two bite safety range within a year or two years.

Amanda Whitehouse, PhD 15:17

Yeah, and I can attest to that. You know this from our interactions, but that freedom that, that brings of what life used to be versus just reading the ingredients label now. For us, it was a combination of OIT and SLIT, but that just opens up a whole new world of freedom and safety to a child. I can't even express how life changing that is to, to not have to be concerned with that anymore. It's amazing.

Allison Freeman, MD 15:40

Yeah, I've heard that from lots of other families, that threshold they keep asking me every week as we're seeing each other, are we may contain safe yet, are we may contain it safe yet? And I know it's a really critical threshold for families.

Amanda Whitehouse, PhD 15:52

What do you tell your patients about the difference between may contain a shared equipment on packaged food versus potential cross contact in like a bakery or, or a restaurant situation?

Allison Freeman, MD 16:03

So, so, um, you know, again, those, uh, proprietary labelings don't specifically tell you, I, I know you know this exactly what the risk is. It could be the first box that went down, the conveyor belt is contaminated, or it could be many boxes. Or that it's the whole other side of the factory and there's really no risk. But they just had to be a little careful on the labeling. So we, we really, it doesn't matter which statement, and I always tell parents, this may contain processed in, made on shared equipment made in a shared facility. You really have no idea until you call that factory and find out what else they're making, how close is it and what are your cleaning practices between batches? So we also don't know that a lot of the younger children whose allergies have not really reached a a maximum level don't seem to have problems with may contains and processed ins. And that may be about and a lot of parents don't understand this when you, when your child avoids a food for years and years, that allergy's actually growing in the background. A child could have been perfectly fine with may contain at four and not be fine at 18. And we need to make sure parents are more clear about those natural histories also. However, donut stores and also ice cream stores, which is a real setting for cross-contamination events, those I would would say are, are likely to be at a higher level. If you're talking the peanut donut sat next to my donut. The ice cream scoop was rinsed, but the, the last person had butter pecan with their vanilla, and now my vanilla is contaminated with pecan dust. Those are, are probably more like 10 to 30 milligrams. However, we strongly believe that staying on sublingual over the course of six to 12 months is gonna give you that coverage.

Amanda Whitehouse, PhD 17:56

Thank you for that answer. I think that helps to clarify. I I wanted you to talk about, you mentioned accommodating people with different medical needs, and I know about you that you are very receptive and aware of different psychological needs too. Especially, we've had many conversations about kids managing anxiety, and I think SLIT fills a hole in that area too.

Allison Freeman, MD 18:15

That's a great point. Yeah, it absolutely does. And, and so I have had a few youngsters who converted to SLIT. Some of them chose to, because the schedule was easier after trying oral, some of them after their first reaction to oral and who converted to SLIT. And I had the chance to ask them a couple months in, how is this working for you now? And they are very much more relaxed. Especially after they've had a single anaphylactic reaction. I still see that on day one, regardless of SLIT versus oral, those kids that have been trained by all of us to completely avoid this food and stay away from it need a lot of coaxing, and they are still very nervous day one of either protocol and one of the most powerful things I've found is introducing them to a youngster halfway up the protocol. So I group visit my kids so that they can go and where two families are willing to meet each other, talk to somebody who's three or four weeks ahead of them and get a chance to see that that person was also nervous on day one, however, has now learned that this very carefully dosed, sublingual is something they can tolerate. So getting their faith, especially if I've just done three food challenges and one didn't go so well, getting their faith in the process of sublingual sometimes requires talking to somebody other than me.

Amanda Whitehouse, PhD 19:39

Yeah. I have found in my work that is one of the toughest spots to be in. Obviously before you start a long and expensive treatment, you want to food challenge anything that might be able to be eliminated, but when kids have those reactions to a food challenge in the preparatory phase, that's where I see them get stuck and not want to then try anything.

Allison Freeman, MD 19:56

Or do anything else? Yeah, I totally agree. Almond turns out to be one of the highest pass rates of all food challenges done in our offices. Baked egg, baked milk can be fairly high pass rates also, and I'll do those first to give the child some confidence in the food challenge process. Again, another reason why the puffs are so attractive to me now is that I'm co-treating. So if I have a youngster who's got a borderline hazelnut and needs cashew and walnut. If I'm using a puff that contains 4.5 milligrams of everything, then we may be taking care of things and at some later date I'll show them what their specific level of protection is. I know some, some allergists may be more purists and want the challenges done first, but since the puff is the same price. To treat all five nuts. I think that represents a way to work with a child who's phobic of food challenge and then later broaden the number of foods with that minor allergen.

Amanda Whitehouse, PhD 20:57

I love that. I see you incorporating the mental health side of it because that is such a hurdle to get over, like many mental hurdles. We have to incorporate the anxiety we're gonna have about that.

Allison Freeman, MD 21:07

Yeah, I think the biggest thing I would encourage parents with OIT or with SLIT is that if you're following a, a structure and it's working well, talk to your doctor, see where we can start to make this more livable for you. But at the same time, if you take a gap and, and you and I both know that teenagers sometimes do things, especially teens and preteens, I would say, do things in terms of their dosing. I can recall the first time as a physician, I got confronted by a child who did not dose at all at camp. Came back from camp and just stood there in the kitchen taking the dose, knowing full well she had not had a dose in her mouth for a month. And parents, of course had to treat an anaphylactic reaction and we pieced the story together later. But I think it's so important that parents in OIT and SLIT understand that if you have an inkling that your child did not have the dose. If you missed a couple of days or if you had an illness and are just coming back, that's when you need to go back to those two hour no exercise rules and the always eat first rules and all of those sort of things. You need to tighten it up when there's been any kind of gaps,

Amanda Whitehouse, PhD 22:19

work back into it.

Allison Freeman, MD 22:21

Yeah,

Amanda Whitehouse, PhD 22:21

thank you for sharing that because yeah, those stories, oh my gosh. And it's multiple kids I know that the parents have found a stash of the peanut m and ms that were being used for the dose hidden in a spot in the kids' room. And I think, oh my gosh, all that time and that hard work, but it's not a lost cause. You just have to be more cautious for a while, you're saying.

Allison Freeman, MD 22:36

Yeah. And, if your youngster is really fussing about the two hour no exercise rule, chances are they're finding ways around it. Of the anaphylactic reactions to OIT that I had in my practice, the vast majority were teenagers and many of them were evening, they dosed too late, they were tired, they dosed and went to a party. And even though they said they were not doing anything exercise wise at that party, we know that's probably not realistic. They didn't eat properly first because they were in a big hurry to get out the door. When OIT starts to get in the way of your teenager's lifestyle, I think this is where I'd encourage you to at least think about sublingual, right? OIT is a great tool if somebody's trying to get to the point they can enter the US military. Although, thankfully lately, the air Force is now starting to accept food allergy patients. But for most older kids and teenagers, I think sublingual is a tool. It fits better with where they're mentally and emotionally at.

Amanda Whitehouse, PhD 23:37

Yeah. So why are more doctors not offering this?

Allison Freeman, MD 23:41

Um, I think part of the issue is that you have to learn from each other. And if you come to these food allergy support team conferences every June, you will get all kinds of free protocols and so on. I think another part of it is the cost side of things. OIT and Sublingual require a lot of time invested from the physician handling the calls at night, talking people through things. I personally don't mind that. I like knowing my families, but I know that there are physicians out there who don't run their practice that way and, and wanna do whatever they can to minimize the night and weekend phone calls. And then I think a third part is figuring out ways to treat people creatively that they can afford. The point of OIT and SLIT isn't to, make your doctor rich. It's for us to cover the costs of providing the items you can't get on your insurance. But I think a lot of my colleagues haven't yet heard these other ways around that, and I've been sharing with a lot of people about, Hey, just start with peanut and tree nut and just start with the puffs. I think a lot of the newcomers to OIT and SLIT are finding that a useful way to begin. Then they don't need to train their nursing staff how to mix and create binders or protocols and things like that.

Amanda Whitehouse, PhD 24:56

That's a great point. Yeah. I understand there are a lot of challenges to the doctors offering this and a lot of demands on them. More are offering OIT though than the SLIT. It seems like it would be easier, there's less reactivity, there's probably less need for emergency calls and things like that. It just seems like it should be So much easier is more widely available.

Allison Freeman, MD 25:15

I agree with you on that. I think that's changing gradually at the meetings. I'm finding more and more people interested in doing SLIT. But I, I believe it's important that we have these food-based protocols. The extract based SLIT is very expensive and not many families can afford that extract based SLIT. I think that's another area is that a lot of allergists aren't seeing research on SLIT nearly as often as research on OIT. And so they're waiting for there to be solid data before they leap on board with it. And I do understand that. I've, most of my career being an early adopter and occasionally wondered if I was too early of an early adopter. However, I believe each physician needs to decide what levels of safety and risk they're willing to take. And I, I would agree with you that SLIT is a minimal risk intervention and knowing how to do that with food-based therapy can make it doable by more people. Absolutely.

Amanda Whitehouse, PhD 26:12

We dove into this conversation so quickly here as we started chatting. I should have had you clarify earlier about the extract versus the food-based dosing for SLIT. Can you tell us about that and the effectiveness as far as we know.

Allison Freeman, MD 26:25

There's two ways to do SLIT. One is food based and the other is extract based. The one year data comes from a study by Leanne Soller, et al in BC and, and they looked at what. Amount of not a child could challenge successfully to at one year. And they used multiple different foods out there, and I think theirs was food based. What they showed is that the vast majority of kids at one year could successfully tolerate a hundred milligrams of their trigger food in a food challenge, a single event, single food challenge event, and that the ones who did not successfully get to a hundred were coming close, and I'd have to pull that paper to know what those numbers were, but it was more than 70% could get up to a hundred milligrams. We still, again, do not know at year two. At year three, we believe that goes higher every year you stay on it.

And Dr. Wyndham, Hugh Wyndham from Sarasota, Florida is the one who's been sort of helping us decide what to challenge when. Generally the kids that are one year in, we do those challenges for 10 30 and 50 milligrams. Year two, we do a hundred, 150. Year three, we do 200, 250 or 300. And that way we can show people along the way, your child is protected to this much versus another child that might be in it and give them a very specific cutoff. Then the transition to eating, so in the Soller study they did transition some kids to eating. There's, there's two things we always remind parents when you transition from SLIT to eating and one of those is that the rules change completely. You instead of 30 minutes to exercise, or less or less, you're back into that two hour no exercise window. And your anaphylaxis rates are certainly higher by far with oral. We know that if you start OIT without previous SLIT, you get about 15% of children who have some esophagitis in the buildup phase of their OIT. Most of those can be managed by slowing down the intervals and increasing them much more gradually so that ultimately only three to 5% actually have to stop it because of GI symptoms. However, when a child has been on SLIT for a year, we're not sure if that's lower than three to 5%.

Amanda Whitehouse, PhD 28:45

Right?

Allison Freeman, MD 28:46

But that's definitely something I would be watching for as I transition a child from SLIT to OIT is are they now having new GI symptoms and do I need to revert? The children will either come in with a, some of them have a strong infant history for acid reflux. I see. That's a child that I will try to leave alone for oral and maybe start with sublingual and see how they do. And then at some point, if parents are asking for oral, we'll just watch their symptoms, the frequency, the severity, and if necessary, either revert back or get a scope, because I've had a couple of kids over the years that I felt like I was seeing esophagitis who scoped and we're okay. That's just our best estimate when we get the symptoms. If they're coughing at night or they're having chest pain or chest tightness or something and we think it's esophagitis, we're not always right.

Amanda Whitehouse, PhD 29:37

Okay.

Allison Freeman, MD 29:38

We sometimes need to scope to know.

Amanda Whitehouse, PhD 29:40

Okay, well, and of course, you know, from my perspective, I always think. You know, and kids like that, do you think there's some anxiety symptoms sometimes, like that chest tightness and that discomfort?

Allison Freeman, MD 29:49

I definitely think there are kids and it's more in the abdominal pain crowd. I've had several of the kids I've treated over the years that have had complaints of abdominal pain. And usually I, I say first to the parents, don't ask them because the parents can actually make this more of a thing by surveillance. Every dose do you have abdominal pain? Is your tongue swollen? The kids will start saying yes to those things, even if they don't quite understand the question. So I, I do ask the parents to kind of back away and just write down on your diary what your child spontaneously told you, or if you see a behavior change that concerns you, write that down. But I also have had some kids do that for secondary reasons, like, they don't wanna be on this anymore. And especially with oral, complaints of abdominal pain will get you off oral faster than almost anything. Yep. And so they will do that because they don't like the two hour rule. And I will later ask them, if I could convert you to something that only gave you a 30 minute no exercise rule, would you wanna do it? Oh, yeah. That's okay. Right. So I, I now know there's some secondary reasons why abdominal pain is being complained about. I wanna hear what the child has to say, but I also don't wanna get blindsided by other things that may present as abdominal pain and sometimes the only way for me to know what's really going on is to let my GI colleagues do the appropriate testing

Amanda Whitehouse, PhD 31:13

right. And rule out a medical cause for it. You have been more receptive to the psychological piece of this than any other allergist that I have worked with, either personally with my own son or just, or professionally. And so I would love you to share your perspective on that, how we can better incorporate that and meet people's needs, mental health wise too.

Allison Freeman, MD 31:32

That might start from being a female, a mother, and a grandmother myself. Mm-hmm. And understanding it from my pediatric training, child development and the things that kind of are unique to each child in their development. I also think that it's so important in OIT or SLIT to have buy-in from the youngster and I am always looking for what it is they want out of it. And I think that's an important thing that many of my colleagues are now trying to focus on. But it, it was also a luxury, I will say, Amanda, to have you so nearby, I had heard about you for years before we ever started treating patients together. And once I learned that there was a psychologist interested in working with food kids that, that became a great relief for me. And now in Virginia I do not have that contact. So I'm still, there are places in the United States where an informed food allergy therapist doesn't exist. So you getting the word out with your colleagues is also part of us improving how many kids can work through their food allergy anxiety. Even those that don't do therapy, work through their therapy questions and even after therapy questions because I know that there's young adults out there that have a lot of questions about dating and about how about when we move in together and he still eats peanut and I don't, and all those sort of things. It is been one of the reassurances about doing sublingual is that you can work with young adults and even middle-aged adults successfully and safely, and if they are, uh, nervous about relationships and social eating and business eating sublingual is a tool they should definitely look at to get them to that level of safety.

Amanda Whitehouse, PhD 33:21

Yeah, that's a great point. People who might have felt one way or not interested or unable to access it younger in life, it's still accessible and maybe even more so an option to consider when they get to that phase of life where things change and it starts to get trickier.

Allison Freeman, MD 33:33

Absolutely.

Amanda Whitehouse, PhD 33:34

Thank you again while I have you for all of the help that you gave to my family and my son because that was the next phase that we needed for sure at that time. And we were lucky. For those who are listening who don't know, we drove to Pittsburgh to get OIT because it wasn't in Buffalo. Dr. Freeman was there, but she wasn't the doctor that we saw. But then she came back to Buffalo and we got to see her when she was here. So came full circle.

Allison Freeman, MD 33:55

Thank you. Yes, I'm traipsing about the Northeast and now down, down in Richmond. But, anyway, the resources at Buffalo are still there for your listeners in Buffalo. That food allergy support team meeting is the third weekend in June in Dallas, every year. An excellent meeting for physicians wanting to learn more about SLIT and OIT. Other health providers in nursing, dieticians, et cetera, that are present to learn more about the treatments.

Amanda Whitehouse, PhD 34:21

Well, thank you for taking the time to talk.

Allison Freeman, MD 34:23

Thanks.

Amanda Whitehouse, PhD 34:24

As we wrap up, I wanna leave you as always, with a few action steps if this conversation sparked your curiosity or motivated you to look into immunotherapy.

First, if you are in the Richmond, Virginia area or anywhere in Virginia and willing to drive, I highly recommend looking up Dr. Allison Freeman. She is an incredible physician and I will put the details in the show notes for how to find her.

Second if you are not in her area, but you do want to explore immunotherapy options with a provider who has experience. You can visit fast oit.org where you'll find a directory of providers who offer different forms of immunotherapy, including slit, which we talked about today.

And third, if you are trying to navigate treatment decisions and want to framework for thinking through your options. I wrote a workbook just for you. It's called Fear to Freedom and it focuses on the social and emotional preparatory decision making and coping skills that will help patients and families who are considering or navigating immunotherapy. I'm so grateful for all the amazing guests who've been on the podcast, who helped me shape that workbook through these interviews and episodes. But I'm the most grateful to Dr. Freeman, who so generously took the time to be my medical advisor on the workbook, reviewing the medical information, and making sure that I had everything correct so that you could have the best information at hand.

You can find links to all of those resources in the show notes. Thank you so much to Dr. Freeman for being here and to all of you for listening. If this episode helped you to understand slit or opened up new possibilities for your family, please consider sharing it with someone else who might benefit from hearing it too. Would you also consider leaving a rating or a review for the show to help other people find it? It would mean so much to me. Thank you, and I will talk to you next week.

The content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember don't feed the fear.