The Allergist

ENCORE—Epinephrine Essentials: Balancing Confidence, Safety, and Misconceptions

“If that medicine is associated with fear of an injection, then we are giving the impression that a diagnosis of food allergy is worse than a life sentence.” — Dr. Paul Turner When it comes to managing anaphylaxis, epinephrine is the gold standard. But even with its life-saving potential, misconceptions abound, and newer delivery methods like nasal and sublingual formulations are raising questions for allergists and patients alike. In this episode, Dr. Mariam Hanna sits down with Dr. Paul Turner, pediatric allergist, clinical immunologist, and global expert on anaphylaxis, to explore the science, controversies, and clinical realities surrounding epinephrine use. On this episode: Anaphylaxis demystified: Why the "ABC" symptoms (airway, breathing, circulation) are crucial for timely diagnosis. Epinephrine explained: How it works, why timing matters, and when it’s not enough. Alternative delivery methods: Intranasal and sublingual epinephrine—why Dr. Turner is skeptical about their use in clinical practice without robust evidence of efficacy. When epi fails: Understanding the limitations of autoinjectors in severe reactions and the role of IV infusions. Improving patient confidence: Strategies for addressing fears and teaching appropriate use to improve outcomes. Whether you're an allergist navigating these evolving treatment landscapes or a clinician seeking clear guidance for patient care, this episode provides critical insights and practical advice. Tune in to strengthen your understanding of epinephrine’s role in anaphylaxis management and gain clarity on when—and how—it should be used. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Milk and egg: different ladders, different outcomes

"Food, milk and egg ladders look the same, but they're not the same." — Dr. Juan Trujillo Ladders are close to standard in some clinics now. The evidence that they change the course of anything is still thin. So families are climbing, clinicians are advising, and nobody has settled the question underneath: is a ladder modifying the disease, or is it keeping everyone busy while a child outgrows it on schedule? On this episode, Dr. Mariam Hanna puts that to someone who has lived with the question longer than most. Dr. Juan Trujillo is a consultant paediatric allergist at Cork University Hospital and a senior lecturer at University College Cork. He is careful not to oversell. There isn't much literature to go on, he says, so ladder practice ends up tracking something else: how many appointments a clinic can offer. In a stretched service, a ladder can mean fewer visits rather than more. When it comes to egg and milk allergies, different ladders, different timelines, different success rates. Clinics tend to treat them as one thing. Trujillo doesn't. Key points The evidence base is incomplete. Practice moved ahead anyway, largely because indefinite avoidance is not a neutral default. In resource-limited systems, ladders can reduce appointments rather than generate them. Milk and egg are not interchangeable and should not be presented to families as though they are. Skin testing, specific IgE and components will diagnose the allergy. They will not give you the threshold, and they will not tell you who is going to climb. Counting milligrams of protein overcomplicates what is, for most young children, dietary advancement. Age matters. The younger the child, the better the prospects. Older than five, Trujillo approaches with caution. Patient selection is doing more of the work than any step-by-step protocol. In young children, selected carefully and supported properly, ladders are worth doing on practical grounds, whether or not they turn out to be disease modifying. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

Managing the child-to-adult transition

"...these are chronic conditions that are not going to magically go away when a patient turns 18 or 21." — Dr. William Anderson Adolescence and early adulthood tend to be a rough stretch for patients with allergic disease. Asthma that used to be well controlled can start to drift. Teenagers take more chances with foods they are meant to avoid, and they show up for fewer of their appointments. Meanwhile the daily management is sliding off the parent and onto a patient who often is not ready to carry it, from refills to the action plan to knowing what to do in an emergency. On this episode, Dr. Mariam Hanna welcomes back Dr. William Anderson, a pediatric allergist and director of the transition program at Children's Hospital Colorado. Their conversation is about why the shift from pediatric to adult care should begin years before a patient turns 18, how a clinic can actually build a young person's independence, and why he treats transition as a core piece of managing the disease itself. Key Points Transition is something you plan for over years, not something that happens on a birthday. Teenagers and young adults are more likely to lose disease control, miss follow-up, and land in the emergency department. Starting at 12 to 14 leaves runway to build skills before adult care becomes urgent. Parents stay in the picture, but the patient has to start talking in appointments and handling refills. A tool like TRAQ helps, but confirm the answers with the patient. The work does not have to fall on the physician alone. Nurses, staff, and care coordinators can carry a lot of it. The real obstacle is usually cultural. Handing over control feels like a loss. The goal is not to push patients out early. It is to keep a young person from vanishing into the gap between pediatric and adult care. Someone who knows their own medications and can handle a refill or a scare without a parent is far safer than someone who just ages out and hopes. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

New Epinephrine Options. Fewer Fears?

“If you are willing to use it and use it quickly, that's what I want you to have.” — Dr. Jay Lieberman Epinephrine is everywhere in allergy practice. Prescribed, refilled, demonstrated, repeated. And still, it carries a strange kind of fear. Patients hesitate. Clinicians sometimes hesitate too. Is it dangerous? Is it a last resort? How bad does the reaction have to be before it counts? On this episode, Dr. Mariam Hanna is joined by Dr. Jay Lieberman, professor of pediatrics at the University of Tennessee and interim division chief of allergy and immunology at Le Bonheur Children's Hospital. He talks through what epinephrine does in the body, where the evidence is still messier than many assume, and how new needle-free options may change whether patients actually use it when it matters. Key Points Epinephrine remains first-line because it targets the major physiologic problems in anaphylaxis. Fear of epinephrine still gets in the way of early use. Anaphylaxis definitions are useful, but hard to translate for patients. Nasal and sublingual routes may reduce the barrier of the needle. The best device is still the one the patient will actually use. Needle-free epinephrine won't answer every question in anaphylaxis care. But it may change the most practical one: not whether patients know they should treat, but whether they actually will. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

CVID? No. SAD? Maybe.

“You can have a patient that has normal immunoglobulins and abnormal responses to protein antigens as well. Historically, I’ve seen these patients. They do happen. They are out there.” — Dr. Benjamin Prince Specific antibody deficiency (SAD) has never been a clean diagnosis. Some patients carry normal immunoglobulins and still land in clinic with recurrent infections and poor vaccine responses. The newer pneumococcal vaccines have scrambled the old testing pathways. This episode covers which parts of the workup still hold up, and where a titre should actually change what you do next. Dr. Mariam Hanna is joined by Dr. Benjamin Prince, Associate Professor of Pediatrics and Associate Division Chief of Research in Allergy and Immunology at Nationwide Children's Hospital in Columbus, Ohio. He walks through the shifting definition of SAD, what pneumococcal titres can and can't tell you, and how to read testing in the Prevnar 20 era. Key Points Clinical history as the gatekeeper for who gets worked up What Prevnar 20 did to polysaccharide response testing Reading the patient ahead of the titre Recommendation 4.7 and impaired protein-antigen responses Pneumococcal titre thresholds: useful, imperfect, lab-dependent The management range, from watchful waiting through immunoglobulin replacement A useful listen for any clinician who has stared at a borderline pneumococcal panel and wondered whether to keep pulling the thread. The lab pathway exists, but the history is still what tells you whether the result will mean anything. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

When It’s Not Asthma, Think Larynx

“If the asthma is under good control but they are still having these episodes, then I do think that maybe they have a PVFMD component to their breathing issue.” Dr. R. Jun Lin Patients come into clinic short of breath. It hits during exercise, it looks dramatic, and they may even describe noisy breathing or the feeling that they “can’t get air in.” So we do what clinicians do: we think asthma. We try inhalers. But sometimes, no matter how many puffers are thrown at the problem, nothing changes. That’s when it may be time to look higher, to the larynx. On this episode of The Allergist, Dr. Mariam Hanna is joined by Dr. R. Jun Lin, a fellowship-trained laryngologist and chief of the Division of Laryngology at the University of Toronto, for a practical discussion of vocal cord dysfunction, inducible laryngeal obstruction, and paradoxical vocal fold motion disorder. Dr. Lin walks through how these patients present, how to distinguish laryngeal obstruction from asthma, when both may be present, and why respiratory retraining therapy is often the cornerstone of care. Key Points VCD, ILO, EILO, and PVFMD describe the same basic problem through different specialty lenses. The key clue: trouble breathing in, not out. In teens, it often shows up during warm-up or early competition. In adults, common triggers include perfume, bleach, gasoline, cooking fumes, cold air, humidity, speaking, or laughing. Asthma and PVFMD can coexist. If asthma is controlled but symptoms persist, think larynx. Laryngoscopy is often normal in PVFMD, but helps rule out structural causes. Respiratory retraining therapy is the cornerstone of treatment. Pursed-lip breathing can reduce the severity and duration of episodes, but patients need to practise it before symptoms peak. Food triggers, urticaria, tongue swelling, or rash point away from PVFMD. Botox is a last resort, not first-line treatment. For clinicians, this episode is a reminder that not every dramatic breathing episode starts in the lower airway. When the history points to trouble getting air in, especially with poor response to inhalers, PVFMD deserves a place on the differential. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

When AI meets the allergy clinic

“AI might feel like magic at times, but mostly it's just powerful technology, and with any technology, it's a tool.” —Merlijn van Breugel AI is no longer a future-tense possibility for allergists. It is already shaping diagnosis, prediction, documentation, patient communication, and the way clinicians think through complex decisions. But if AI can process more than we can, what still belongs to the clinician? On this episode of The Allergist, Dr. Mariam Hanna is joined by Merlijn van Breugel, a data scientist and philosopher whose work focuses on AI in allergy and immunology. Together, they get into where AI may be most useful now and in the near future, including phenotyping asthma and eczema, supporting diagnosis in young children, combining genetic, environmental, wearable, and clinical data, and reducing the administrative work that pulls clinicians away from patient care. But the episode does not dodge the hard stuff: hallucinations, bias, validation, liability, overtrust, and the very human problem of changing behaviour in real clinics. Key Points Allergy and immunology are not early adopters of AI, partly because the field relies on complex, heterogeneous data. AI is most promising when it helps reveal patterns clinicians struggle to synthesize on their own, such as asthma or eczema subtypes. Large language models can hallucinate, so clinicians need to stay critical even when an answer sounds polished and convincing. Decision-support tools should augment clinical judgment, not replace it. Bias in training data can create real harm if AI tools work better for some patient populations than others. The best use cases are significant, underserved problems where AI can do something that older tools could not. AI literacy will become a core skill for clinicians who want to use these tools safely and effectively. For allergists, the message is not to fear the machine or blindly follow it. AI may help identify patterns, reduce administrative work, and open new research possibilities, but the clinician still brings the judgment, context, accountability, and critical eye. The future is not AI instead of allergists. It is allergists who understand how to use AI well. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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The Expanding Toolbox for Food Allergy

“It’s a fun time to be a food allergist”—Dr. David Fleischer Food allergy treatment is no longer just about avoidance, epinephrine, and hoping for the best. With high-dose OIT, low-dose OIT, SLIT, EPIT, Xolair, and other biologics entering the conversation, allergists now face a more practical question: what are we trying to achieve, and what approach best fits this patient and family? On this episode, Dr. Mariam Hanna is joined by Dr. David Fleischer, section head of allergy and immunology and director of the Allergy and Immunology Center at Children’s Hospital Colorado, and professor of pediatrics at the University of Colorado School of Medicine. He walks through how dose, route, safety, family goals, practicality, and flexibility all shape the choice of therapy. Key Points Low-dose OIT may offer similar protection to higher-dose protocols in some patients, making the dose question more about goals, risk, and fit. Protection is the first goal; clinical remission remains the harder, longer-term hope. Lower-dose approaches may offer practical advantages, including fewer up-doses, fewer clinic visits, and potentially fewer side effects. SLIT and EPIT may be useful options for families looking for more forgiving, lower-burden approaches. Xolair can provide protection for selected patients, but Dr. Fleischer emphasizes that it is not disease-modifying. Food allergy treatment is becoming a shared decision about efficacy, safety, practicality, and what the family actually wants from therapy. With more tools in the food allergy toolbox, the future may not be one perfect protocol for everyone. It may be choosing the right therapy for the right patient, then having the flexibility to change course when life, goals, or tolerance change. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

Evidence-Based or Autopilot? A review of systematic reviews

“We need more than just random care. We need randomized care.” — Dr. Derek Chu For years, the allergy world has been drowning in a sea of data—risk factors, prevention strategies, and enough diagnostic tools to fill a warehouse. But how do you translate 340 different risk factors into a cohesive plan when an anxious parent is sitting in your clinic demanding a skin test for their four-month-old?. On this episode, Dr. Mariam Hanna is joined by "systematic review genius" Dr. Derek Chu to unpack the evidence-based roadmap for food allergy and atopic dermatitis. It’s time to move past the "noise" and start reading between the lines of what our patients actually need. Key Points: Major vs. Minor Signals: Eczema severity and family history are the big players, while being first-born or male are merely minor notes in the risk profile. The Diagnostic Trap: Testing only works if it changes practice; otherwise, you’re just putting a baby through the trauma of an itchy back for a 20% certainty bump. De-escalating Momentum: Be skeptical of previous "avoid all nuts" labels; if the patient is already eating the food, do not skin test them to it. The TITAN Initiative: We need national, high-quality food challenge capacity to provide the clarity that families are actually looking for. Beyond Narrative Synthesis: The new eczema guidelines involve patients as partners and weigh everything from JAK inhibitors to the humble (but low-certainty) bleach bath. Clean Hands, Frequent Moisture: Prevention of atopic dermatitis may be gray, but moisturizing with every diaper change—using clean hands—is a low-stakes win Dr. Chu walks us through the "diagnostic momentum" that often leads clinicians to over-test and over-restrict, and why your Royal College exam cutoffs might not be as definitive as you remember. From the major and minor predictors of food allergy to the "multimorbid" patient with eczema, this conversation is a masterclass in being sensible and judicious at the bedside. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Microbiome in IEI, Much More Than Probiotics

“We came up with the idea of testing a ketogenic diet… which in mice, it’s basically a lot of Crisco… giving a keto diet to mice with CGD… led to a decreased susceptibility to colitis.” —Dr. Emilia Liana Falcone The microbiome isn’t something sitting on the sidelines. It’s part of the immune system, interacting with the barrier, shaping responses, and, in IEI, reflecting the underlying defect. On this episode, Dr. Mariam Hanna is joined by Dr. Emilia Liana Falcone, physician-scientist and director of the Microbiome and Mucosal Defense Research Unit at the Montreal Clinical Research Institute, to walk through how these host–microbe interactions drive disease. From early-life immune programming to microbial signals that activate inflammatory pathways, this is a shift from association to mechanism. And a step toward therapies that target both sides of the equation. Key Points: The microbiome reflects the underlying immune defect in IEI Focus on what microbes are doing, not just which ones are present Microbiome changes both result from—and contribute to—disease Early life is a critical window where these interactions are set Loss of protective microbial functions matters more than specific bacteria Microbial signals can directly drive inflammation (including inflammasome activation) Future treatments will likely combine immune therapy with microbiome-targeted approaches This is not about adding a probiotic. It’s about understanding how immune defects reshape the microbial environment, and how that environment feeds back into disease. Get that interaction right, and you’re not just managing symptoms. You’re changing the system driving them. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

Small Risks Big Rewards with SCIT

“This is a safe and very effective therapy, which is probably underutilized within our own community.” —Dr. Susan Wasserman Subcutaneous immunotherapy (SCIT) sits in that uncomfortable space between routine and risk. It’s one of the few interventions in allergy that can actually modify disease. But it also carries a small, very real risk of severe reactions. On this episode, Dr. Susan Wasserman, professor at McMaster University and a national leader in immunotherapy, walks through what safety really looks like in practice. And where things still go wrong. Key Points: Systemic reactions are uncommon but not rare Safety has improved through better patient selection, standardized extracts, and clinic preparedness Uncontrolled asthma is the most important risk factor for severe reactions Prior systemic reactions require reassessment, especially if the cause is correctable Build-up dosing carries higher risk than maintenance Rush and cluster protocols increase risk and need clear justification The 30-minute observation period captures most but not all reactions Beta blockers and ACE inhibitors may worsen reaction severity without increasing incidence SCIT is one of the few tools we have that can actually change the trajectory of allergic disease. But it demands discipline. Careful screening. Reliable processes. And a team that’s ready to act when things go sideways. Because most of the time, it’s safe. And the rare times it isn’t—that’s where preparation matters most. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Rewriting the Immune Code

"So the future is one IV infusion, likely no chemotherapy, and that'll cure our IEIs." — Dr. Nicola Wright For children born with inborn errors of immunity, bone marrow transplant has long been the closest thing medicine had to a cure. It works — but it comes with chemotherapy, graft-versus-host disease, and a donor search that doesn't always end well. Gene therapy is changing that calculus. Dr. Mariam Hanna speaks with Dr. Nicola Wright, a pediatric hematologist and clinical immunologist at the Alberta Children's Hospital and holder of the Barb Ibbotson Chair of Pediatric Hematology, whose research focuses on developing gene editing platforms for blood and immune disorders. On this episode, they discuss: Why bone marrow transplant is, in Dr. Wright's words, "almost a poor man's gene therapy" and what gene therapy offers instead The spectrum of technologies: lentiviral insertion, CRISPR, base editing, and prime editing. What each does, and where each falls short Immune reconstitution outcomes across diseases, including over 90% good immune reconstitution in ADA-deficient SCID treated with lentiviral therapy How to counsel a family when gene therapy might be an option and why most patients still can't access it The "valley of death": why therapies that work in trials are failing to reach patients, and what it will take to cross it CAR T-cell therapy in IEI, including a Canadian trial underway for refractory autoimmune disease What long-term follow-up looks like and why 15-year post-trial monitoring is now an FDA requirement The science is outpacing the infrastructure. Dr. Wright's vision of shipping cells instead of patients, in vivo delivery via lipid nanoparticle, no chemotherapy required isn't speculative. The runway is being built. The plane is already flying. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

Consent is a Conversation

"That wholesome conversation that you take a minute or two to go through really creates a physician-patient relationship, expands that communication. Probably will not only improve patient outcomes, but reduce medical-legal risk for physicians in the consent process." — Dr. Lisa Thurgur A signed form isn't consent. It's paperwork. On this episode, Dr. Mariam Hanna is joined by Dr. Lisa Thurgur — emergency physician, award-winning educator, and a physician advisor with the Canadian Medical Protective Association — to unpack what meaningful consent looks like in daily practice. Inadequate consent is one of the most common allegations in CMPA cases, across every specialty. On this episode: The three elements of valid consent — and what capacity actually means Why a signed consent form is not the same as an informed patient Implied versus expressed consent: when each applies, and when to re-consent Why serious risks like anaphylaxis — and death — must be disclosed, and how to frame that conversation Consent in minors: why maturity — not age — determines capacity (with one exception in Quebec) What to do when parents disagree — or a minor refuses Patients recording their visits: what physicians need to know PARQ: a four-point mnemonic for structuring both the conversation and the chart note The say-back technique: asking patients what they understood, and why it matters Done well, consent isn't something you do in addition to practicing good medicine. It improves outcomes, strengthens adherence, and reduces medical-legal risk. In other words, it is good medicine. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Infant anaphylaxis: What it looks like when they can't tell you

"I have come across allergists in different countries who often don't even prescribe epinephrine for very young children that have only had a history of mild reactions." — Dr. Katherine Anagnostou An inconsolable cry. A baby who's just not acting right. Tongue thrusting. Lip licking. Scratching at their own tongue. These aren't the symptoms that make it into standard diagnostic criteria — but they might be the clearest signal a non-verbal child can give. On this episode, Dr. Mariam Hanna is joined by pediatric allergist and immunologist Dr. Katherine Anagnostou to explore how anaphylaxis presents in infants and toddlers, why the standard criteria don't always apply, and how allergists can help caregivers recognize — and treat — serious reactions in children who can't yet put words to what they're feeling. On this episode: Why modified criteria for infant and toddler anaphylaxis matter Behavioral signs like irritability, clinginess, lethargy, or withdrawal as red flags The role of context and timing in recognizing reactions Surrogate symptoms — tongue thrusting and lip licking for oral itching, drooling, horse cry Why urticaria shows up in 90% of infant anaphylaxis cases Epinephrine dosing: the 0.1 mg option for infants 7.5-15 kg and safety of 0.15 mg in smaller babies Why not every infant who receives epinephrine needs the ED Second-dose timing: five minutes, not ten Novel delivery routes on the horizon — intranasal and sublingual epinephrine Dr. Anagnostou returns to one principle throughout: parents generally know their children pretty well. The job of the allergist isn't to create fear or overcomplicate recognition — it's to help families spot what's different, understand the context, and feel equipped to act when it matters. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

The many faces of milk problems

“There is nothing magical that happens in your gut that says, ‘oh, now you’re ready for cow’s milk.’ — Dr. Farah Khan Milk has a special talent for creating chaos in clinic. One day it’s mucousy stools and a terrifying diaper photo, the next it’s hives after yogurt, delayed vomiting with lethargy, or a family that’s been dairy-free for years with no improvement in eczema. On this episode, Dr. Mariam Hanna is joined by pediatric allergist and clinical immunologist Dr. Farah Khan to walk through the many ways “milk problems” show up — and how allergists can avoid overdiagnosis, unnecessary testing, and prolonged elimination diets that may do more harm than good. On this episode: Why allergic proctocolitis (cow’s milk protein intolerance) is often overdiagnosed When skin testing and IgE testing are useful Understanding the difference in lactose intolerance How baked milk can be used to improve quality of life in IgE-mediated milk allergy What makes FPIES to milk tricky, including earlier-than-expected reactions Why dairy elimination for eczema or EOE needs caution and frequent reassessment Across each of these scenarios, Dr. Khan returns to the same principle: eliminating dairy should never be a one-and-done decision. Revisiting the diagnosis, retrying thoughtfully, and weighing quality of life alongside risk are essential — especially when prolonged avoidance can set the stage for the very allergy clinicians are trying to prevent. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Developing that immunology spidey sense

“It’s not about knowing each one. It’s about knowing the patterns, the warning signs, the general pathways, and knowing when to ask a friend when you’re a little bit lost.” —Dr. Tamar Rubin On this episode of The Allergist, Dr. Mariam Hanna turns the focus to how allergists LEARN to recognize when common presentations may signal a deeper immune problem — and how that diagnostic instinct is built, taught, and sustained. She’s joined by Tamar Rubin, pediatric allergist and clinical immunologist, Assistant Professor at the University of Manitoba, and a national leader in immunology education. Dr. Rubin makes the case that inborn errors of immunity are not a fringe interest, but central to understanding immunology across allergy, asthma, infection, and biologic therapies — and that allergist-immunologists are the specialists uniquely trained to recognize and teach this. On this episode, they discuss: Why allergist-immunologists “own” inborn errors of immunity, and why teaching these conditions is part of the specialty’s responsibility Moving trainees away from memorizing rare syndromes and toward recognizing immune pathways, patterns, and warning signs How patient-based teaching, case discussions, OSCEs, and national academic half-day curricula help trainees develop diagnostic “spidey sense” What happens when you build dedicated immunology clinics, and how volume and exposure increase once you start looking The importance of national collaboration and collegial networks when managing ultra-rare immune conditions Practical ways allergists in community practice can stay engaged with inborn errors of immunity, even with limited volume or access to specialized testing Knowing when — and how — to ask for help matters as much as knowing the diagnosis. Because in the end, inborn errors of immunity aren’t just about rare diseases. They sharpen how allergists think, teach, and listen when the immune story doesn’t quite fit. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Highlights from the 2025 allergy literature

Keeping up with the allergy literature can feel like a second job layered onto an already full clinic day. Between evolving guidelines, expanding biologic options, and long-held assumptions quietly being challenged, it’s hard to know which papers are worth slowing down for. This episode takes a deliberately selective approach. Dr. David Khan — chair of the American College of Allergy, Asthma, and Immunology literature review — walks through five papers from 2025 that stood out not because they were flashy, but because they asked practical questions allergists actually wrestle with in clinic. Timing of repeat epinephrine to inform pediatric anaphylaxis observation periods: a retrospective cohort study For most children treated with epinephrine, prolonged emergency department observation may be unnecessary, with two hours appearing sufficient unless cardiovascular features are involved. Two-year data of tapered dupilumab shows high effectiveness in chronic rhinosinusitis with nasal polyps with NSAID-exacerbated respiratory disease In real-world practice, most patients with CRSwNP maintained excellent control while spacing dupilumab doses far beyond every two weeks, challenging long-term fixed dosing assumptions. Remibrutinib and chronic spontaneous urticaria This trial marks a major shift for CSU, introducing an oral, targeted option that delivers rapid symptom control and meaningful rates of complete remission. A randomized trial comparing direct challenges to penicillin skin testing for outpatient low-risk penicillin allergy evaluations in pregnancy For pregnant patients with low-risk penicillin allergy histories, direct oral challenge proved safe, efficient, and more streamlined than traditional skin testing. Age differences in inducible laryngeal obstruction in adult populations Inducible laryngeal obstruction appears common in older adults, often presents more subtly, and frequently masquerades as asthma or anaphylaxis. Taken together, these papers reflect a broader shift in allergy care: less reflexive caution, more precision, and a growing willingness to question long-standing habits when better data emerge. Whether it’s shortening observation times, tapering biologics, simplifying drug allergy evaluations, or recognizing long-ignored mimics of allergic disease, the 2025 literature nudges allergists toward care that is more precise, less reflexive, and still clinically vigilant. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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ENCORE: New Rules for Old Hives

== Happy holidays to our audience around the world! As a gift, and a break for The Allergist team, we are replaying our most popular episode from 2025. We hope you enjoy it as much this time around. See you in the New Year! == “We have to keep in mind that urticaria has to be treated until it's completely gone. So, absolute control of the disease.” — Dr. Hermenio Lima Chronic spontaneous urticaria has long been managed with the goal of complete symptom control. But for many patients, that goal remains elusive. In this episode of The Allergist, Dr. Mariam Hanna talks with dermatologist and clinical immunologist Dr. Hermenio Lima about the updated urticaria guidelines—and how new treatment options are giving clinicians more ways to act, and more hope for getting patients all the way to control. On this episode: What’s new in the 2025 guideline—including additional second-line options beyond antihistamines Why nearly 40% of patients may need to escalate to biologics How remibrutinib compares to omalizumab and what its trials revealed What the CUPID studies say about dupilumab, especially in biologic-naive patients Key safety signals and clinical considerations for the new treatment options How to move toward full disease control—and why suboptimal outcomes are no longer acceptable Complete control is still the destination, but the path to get there is about to get a lot more flexible. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

Nutrition and food allergy with Dr. Carina Venter

“We should stop being scared of food, and we really should just let babies eat.” — Dr. Carina Venter Dr. Mariam Hanna sits down with Dr. Carina Venter, a leading dietitian and researcher in food allergy prevention and management. They get into the everyday realities of feeding infants and children in allergy practice, from early introduction to texture challenges, growth concerns, and the rise of allergen-free processed foods. On this episode How nutrition supports the microbiome and immune system, and helps clinicians navigate the anxiety common in food-allergy clinics. Practical early-feeding strategies: pairing low-allergen foods with allergens, starting early, and keeping allergens in the diet once introduced. How to approach families whose infants reject certain textures or flavours, and realistic ways to incorporate allergens like egg and peanut. Why baby-led weaning may not work well for allergenic foods, especially in babies with eczema. Nutritional red flags: milk allergy, multiple food allergies, and texture delays that warrant dietitian referral. Concerns about ultra-processed allergen-free products and how emulsifiers may affect gut health. This episode brings nutrition back to the centre of allergy practice. Dr Venter’s guidance keeps things practical — diverse diets, consistent allergen exposure, and attention to growth and texture — so families can feel confident and kids can learn to enjoy food safely. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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Managing the Confident but Incorrect

“It's kind of like we opened a Pandora's box and trying to close it up again is going to be very hard.” —Dr. Zachary Rubin Dr. Zachary Rubin joins Dr. Mariam Hanna for a candid look at the “difficult and misinformed” patient — the growing phenotype every allergist now manages weekly. A double board-certified pediatrician and allergist-immunologist with a massive social media footprint, Dr. Rubin breaks down how misinformation spreads, why it resonates, and how clinicians can approach these encounters without burning out or burning bridges. From TikTok-fuelled certainty to patients demanding full panels, he offers a practical, clinician-first playbook for navigating the mess. On this episode: Why today’s misinformation is stickier, faster, and more emotionally charged than a decade ago, and how parasocial trust amplifies it. How the “nugget of truth” inside misinformation gives it power and how to dismantle it without escalating conflict. A clinic-ready strategy to approach resistant patients: open-ended questions, triaging what must be corrected now, and focusing on one actionable change at a time. Why continuity, follow-up, and small pieces of information over time often outperform a single “big correction.” How to use shared decision-making to reframe testing and treatment choices, especially when patients arrive convinced they need “the full panel.” Practical tools to support patient understanding, including targeted education resources, structured discharge summaries, and multimodal materials for different learning styles. How teams can protect each other through debriefs, preparation, and collaborative communication during high-stress encounters. A grounded, real-world conversation for clinicians who balance patient frustration, digital misinformation, and the realities of modern allergy practice. Have an idea for the show or a comment, send us a text! Visit the Canadian Society of Allergy and Clinical Immunology Find an allergist using our helpful tool Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca The Allergist is produced for CSACI by PodCraft Productions

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