The Allergist

“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.

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

"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

"...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

“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

“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