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If you have a dairy allergy, it probably doesn’t surprise you that it’s one of the more complex common food allergies.
While there are 25 proteins in milk (yes, you read that right!), only a handful have been shown to trigger antibody production against them.
Now, remember that a dairy allergy is different from being lactose intolerant. Lactose intolerance is considered a non-allergic reaction to milk products that can lead to uncomfortable GI symptoms like bloating, gas, and diarrhea.
Anaphylactic dairy allergy symptoms include hives, swelling, coughing, wheezing, nausea, and vomiting, and these usually manifest shortly after you eat the food containing dairy.
BUT this is where it gets confusing.
There are several non-IgE-mediated milk allergy symptoms that affect the gastrointestinal tract. These reactions are immune-mediated…which can make it really difficult to differentiate between lactose intolerance and a true milk products allergy.
Dr. Stacy Silvers returns to the podcast to clear up some confusion surrounding the complexity of dairy allergy. He’s a board-certified allergist specializing in environmental and food allergy diagnosis, treatment, and prevention. And he oversees the allergy program and protocols, and also leads the food allergy and oral immunotherapy (OIT) program at Aspire Allergy & Sinus.
Dr. Silvers is considered an expert in the field of food allergy diagnosis and treatment and I’m THRILLED to share this interview with you!
Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android
In This Episode:
- Are there specific milk proteins that cause dairy allergy symptoms?
- A1 casein vs A2 casein in dairy (which is better tolerated?)
- Can you have a dairy allergy to whey protein?
- Testing options to figure out a dairy allergy
- If you have a milk products allergy, are you only allergic to cow’s milk?
- Can you stop dairy allergies? (OH BOY!)
- Dairy in topical products IF you have a dairy allergy
Quotes
“When you're looking at anaphylactic reactions to milk, there is a very, very high likelihood of there being cross-reactivity between cow's milk, goat, and sheep's milk. 90%, 95% of the time, if you react to cow's milk, you’ll react to those other milks.”
“What we find is the majority of infants or toddlers who have a milk allergy do have it resolved as they get older…It's roughly 50% will have it resolved by age six, according to one study. And it can oftentimes get better as the years go on after that.”
Links
Follow Aspire Allergy on Instagram
Healthy Skin Show ep. 269: Allergy Testing: Everything You Need To Know w/ Dr. Stacy Silvers
Healthy Skin Show ep. 327: Demystifying Food Allergy Signs, Symptoms + Skin Rash w/ Dr. Ruchi Gupta
Additional Research:
Modulation of Milk Allergenicity by Baking Milk in Foods: A Proteomic Investigation
Food Allergies and Cross-Reactivity
330: Everything You Need To Know About Dairy Allergy (In Food + Skincare Products) {FULL TRANSCRIPT}
Jennifer Fugo (00:13.57)
Thank you so much for coming back, Dr. Silvers, to talk about dairy allergies. I really appreciate it. Welcome back to the show.
Dr. Stacy Silvers (00:19.078)
Of course, it's a pleasure to be here.
Jennifer Fugo (00:20.906)
So today we're gonna dive into all of the questions I have about dairy allergy. I don't know why, but it seems like milk products allergy tend to, I don't know, I think that it's more complicated than some of the other top nine allergies. So I thought you were the perfect person to discuss this.
They tend to be more complex, at least I think so, because what I came to discover is there's over 20 proteins, different proteins in dairy, and some you can react more so than to others. Could you explain why there are some more specific proteins, specifically, that one could react to or even be allergic to, and what those are and why?
Dr. Stacy Silvers (01:10.182)
Yeah, I mean, I think what makes milk difficult from my perspective as an allergist is the myriad of different types of reactions you can have to them. You know, for me as an allergist, the number one thing we typically are thinking about is IgE-mediated reactions. So these are the anaphylactic type of reactions. But there are a whole host of different types of reactions that these proteins you're referring to can trigger.
From an allergic standpoint specifically, while there are 25 plus proteins in milk, there's really just a handful that I'm most interested in. These are proteins that are the ones that have been shown to cause antibody production against them. And there's different classes of these proteins that help predict what kind of reactions, how bad milk allergy symptoms may be. A lot of little details go into which specific protein you're allergic to.
Jennifer Fugo (02:13.346)
And there's an interesting thing I always saw in the grocery store, A2 milk. And it wasn't until I did my whole dairy series that I was like, oh, that's an actual protein that that's referring to. Can you describe to us the difference between A1 versus A2 casein in dairy?
Dr. Stacy Silvers (02:32.55)
Yeah, so first it's important to know that the milk proteins kind of fall into one or two categories. As you said, one of the predominant categories is casein levels, and whey tends to be the other group of proteins. Within casein, there's a few different types. There's the alpha, beta casein, the kappa casein, and within the alpha casein there's an A1 and A2. So those are kind of the four big ones we're talking about. But for the beta casein specifically there are two different types of proteins, these beta casein proteins, that are produced by cows. Some breeds tend to produce more A1 beta casein, some tend to produce more A2, some tend to produce a mixture of those.
So what these differences are is a single amino acid change in the protein structure of them. I'm getting kind of technical here, but the big point is there's not a whole lot of difference here. A single change. The difference between the A1 and the A2 is how those proteins can be broken down by the enzymes in your gut. So that one single amino acid change makes the broken down products of different links, and how that is absorbed and interacted with your gut can vary.
I will say the data on this and how it impacts humans, it's not very good. A lot of the data is coming from animal models, there's less that I can reliably look at in humans. There are some case series that suggest that A2 protein is a bit easier to digest, and that way for some patients it's tolerated better. So this really isn't from an immune allergic response, it's just how that protein is broken down.
Jennifer Fugo (04:43.206)
Interesting. So is it almost similar to like a lactose enzyme or like the lactase enzyme perspective?
Dr. Stacy Silvers (04:49.626)
It's, yes, somewhat similar to that. Lactose intolerance is the classic example we give for non-allergic reactions to milk, right? So lactose intolerance, you don't break down some of the sugars, and that's caused some of the symptoms you can get with milk ingestion. This is somewhat similar, except we're talking about proteins and not the sugar.
Jennifer Fugo (05:13.266)
And with whey protein, you can also, you can have a dairy allergy specifically to whey? Or to casein and/or whey?
Dr. Stacy Silvers (05:23.582)
That's correct, absolutely. And which of those proteins you're allergic to, and again, I'm talking about that IgE anaphylactic reactions, can really impact the course of the disease and also likely impacts whether you can tolerate heated versions of the milk as well.
Jennifer Fugo (05:43.998)
Really? Could you say a little bit more about that?
Dr. Stacy Silvers (05:46.218)
Yeah, absolutely. So, the casein dairy proteins, they tend to be what we refer to as heat stable. So you heat them up, particularly in baked goods is the classic example of that. Those proteins don't change shape. They stay the same regardless of whether they're heated or not. The whey proteins, they are heat labile, meaning they do change shape. They unfold. And in many cases when they unfold, your antibodies don't recognize those proteins anymore. They're not allergenic anymore.
So in many cases, patients who have a true milk products allergy can then tolerate baked products. It's a nice way, it's a thing that we can measure now to kind of give us a little bit better idea of whether our patients can tolerate those baked products or not.
Jennifer Fugo (06:35.338)
Wow, that is really neat. And we'll talk about testing options in a moment, but since we're talking about these different types of reactions, and we mentioned, we touched on lactose intolerance, does lactose intolerance make it more difficult to suss out whether you’re dealing with a food allergy or a non-IgE-mediated issue? Does that add a layer of complexity to try to figure out exactly what type of reaction one of your patients is having to dairy?
Dr. Stacy Silvers (07:10.818)
Absolutely, it can make it very, very difficult. Now, for those anaphylactic type of food allergy reactions, that's usually fairly easy to pick up, right? Those milk allergy symptoms occur very soon after you eat the food and hives, swelling, cough, wheeze, nausea, vomiting. But there are a whole host of non-IgE-mediated reactions that are immune-mediated that can make it difficult to determine whether this is a non-allergic response to milk versus an allergic response to milk. Again, some of those would be things like EOE, eosinophilic esophagitis, food protein-induced enterocolitis syndrome, FPIES. They can have these primarily GI symptoms that many people can think are related to lactose intolerance.
Jennifer Fugo (08:00.638)
And if it is lactose intolerance that is causing this, obviously that's not a dairy allergy. That is an actual intolerance where perhaps you don't produce enough of the enzyme lactase to break down the sugar. Is basically the best solution for that just supplementing with the enzymes before a meal where you potentially could be exposed to that sugar?
Dr. Stacy Silvers (08:25.926)
Yes, that's correct, that or avoidance. There are no ideal dairy allergy treatment option other than supplementing that enzyme, as you said. And that works for some people, it doesn't work so well for others, and it may depend on how much of the milk you consume, those kinds of things.
Jennifer Fugo (08:44.222)
Okay, so in terms of testing, like if we're actually going to talk about testing, one thing that I think I've learned over the last year is that testing can sometimes be a little tricky with allergies. And sometimes you have to dig a little deeper, you've got to try sometimes oral food challenges and different things. So for dairy specifically, what do you think is the best way to ascertain a true dairy allergy? And what happens when somebody has eliminated dairy for who knows, six months, a year on their own? Does that interfere potentially with the results?
Dr. Stacy Silvers (09:25.202)
Okay, so again if we're talking about the anaphylactic type reactions to milk the best allergy tests we currently have available are either the skin prick test that we can do in an allergist’s office or we can measure the amount of IgE, that allergic antibody, through a blood test. And both are helpful in different ways. I use both in my clinical practice all the time. But what they're measuring is whether you are making allergic antibody to milk proteins or not. So that's usually where we start. However, the gold standard for diagnosing anaphylactic reactions to milk is a food challenge as you alluded to. And that is basically where we bring you into the office under supervision and incrementally give you larger amounts of milk over the course of a few hours, and basically just see if there's any dairy allergy symptoms that develop. Sounds scary, right?
Jennifer Fugo (10:22.086)
It can, I would imagine for somebody who's had a scary dairy allergy reaction in the past that might evoke a lot of concern or fear or maybe worry that something could go wrong. But you are with a professional who can step in, I would assume, which is nice to have somebody by their side.
Dr. Stacy Silvers (10:39.178)
Correct, that's why we typically do these in the office, so we're there to help out if there are any symptoms. But we also utilize those other testing modalities to give us an idea of the risk of reacting and whether it's a good idea to do a food challenge or not.
Jennifer Fugo (10:53.83)
So with that being said, what if someone does remove dairy for a long period of time, is it possible that the testing could look clear, but in reality, they do have a reaction to things? I just know a lot of people are, you know, unfortunately, we have this whole world now where people are taking foods out of their diet to test things out to see if that's a problem or a trigger. And then I have just noticed, as I shared with you, there can be some issues where all of a sudden we develop allergies to something. So would taking dairy out potentially interfere with the accuracy of, say, the prick test or the blood test results?
Dr. Stacy Silvers (11:34.502)
It likely wouldn't interfere with those test results. The labs or skin prick testing for foods tend to have a much bigger problem with false positives than false negatives, okay? So if the lab tests, the prick tests are negative, we've got a pretty good idea that there's a low, low risk of having an anaphylactic reaction to the food. Not zero, nothing in medicine is 100%, but probably less than 10% chance of there being an anaphylactic type reaction to the food.
Jennifer Fugo (12:06.722)
Wow, okay, that's good to know.
Dr. Stacy Silvers (12:14.034)
So the avoidance doesn't necessarily change that test result. But to your point, long-term avoidance of foods could be a potential reason you develop food allergies as an adult. We know that's the case for kids and likely is the same for adults. There's a growing idea that more regular consumption of the food helps minimize your risk of developing an anaphylactic reaction to the food.
Jennifer Fugo (12:36.558)
So when we say “dairy,” a lot of times most people think cow dairy, right? In the United States, I think most dairy is cow, but you can also get some goat milk, goat butter, lots of goat cheese. There's some sheep's cheese. I don't know how much of sheep's milk is actually sold here. Do you feel like it's still predominantly cow's milk allergy that is the most prevalent, or are you also seeing reactions to some of these other types of animals that we can derive milk from?
Dr. Stacy Silvers (13:13.65)
Yeah, I get this question a lot. When you're looking at anaphylactic reactions to milk, there is a very, very high likelihood of there being cross-reactivity between cow's milk, goat, and sheep's milk. 90%, 95% of the time, if you react to cow's milk, you’ll react to those other milks.
Jennifer Fugo (13:32.852)
Really?
Dr. Stacy Silvers (13:35.378)
Yes. That being said, there may be these other non-IgE-mediated reactions where these milks might be better tolerated, so I do see that on occasion. But if you're dealing with anaphylaxis, please do not try these other types of milks, because there's a pretty high chance it would cause a reaction.
Jennifer Fugo (13:54.022)
Just for somebody who's not familiar with the term cross-reactivity, could you just define that for us? I want to make sure, because that seems like a really important point. What would that mean in terms of the immune system?
Dr. Stacy Silvers (14:06.586)
It means the protein structure in the milk is very similar between cows, sheep, and goat, which means the IgE, the allergic antibody you're creating, binds to all of them. And if it binds to all of them, then you're likely going to have symptoms because of that.
Jennifer Fugo (14:26.538)
Okay, so we've got to be careful. So you're saying if there's a true food allergy, this is where it's probably not a good idea unless you discuss with your doctor first to try goat or sheep. And I would assume like, you know, we have bison, isn't it? Buffalo, buffalo milk is big in Italy. I know, because they make the mozzarella. I think we get a little bit of buffalo milk here. Would that also be in the same category?
Dr. Stacy Silvers (14:53.862)
So, less so probably, and particularly there are a few milks that people may be able to tolerate. Mare milk (from a female horse), for example, or camel milk. Those have a higher chance of being able to be tolerated by these individuals because there's less cross-reactivity between the milks. Again, I wouldn't go on and do that on your own. The risk is not zero by any means. So, have that conversation with your allergist.
Jennifer Fugo (15:20.042)
Yeah, I think that's always important. And that's a lot of times a question I'll ask clients. I'll say, can you discuss that with your allergist? Because really when it comes to an allergy, like a true allergy, folks, we're not talking about a food sensitivity here, like a true allergy, that can become a medical emergency. So I feel like that's where it's really important to get the guidance from a medical professional who A, knows your case and B, knows how to best guide you as to whether the food or some alternative is safe to introduce. Because I would never want to see somebody have, you know, I realize that not every allergy can result in anaphylaxis, but I would assume, I have a client right now, I believe she requires an EpiPen for a dairy allergy. We have another client that now needs an EpiPen for an egg allergy. I guess dairy is a sizable, can that be a sizable anaphylactic response, like the group of people that react at a level of anaphylaxis, is that pretty substantial for dairy?
Dr. Stacy Silvers (16:28.454)
So, I mean, dairy is one of the more common causes of anaphylactic-type reactions, primarily in kids, though. What we find is the majority of infants or toddlers who have a milk allergy do have it resolved as they get older.
Jennifer Fugo (16:45.826)
Thank goodness for that.
Dr. Stacy Silvers (16:45.97)
It's roughly 50% will have it resolved by age six, according to one study. And it can oftentimes get better as the years go on after that.
Jennifer Fugo (16:53.96)
So the milk products allergy is self-resolving. Is that what I'm hearing? As in for children.
Dr. Stacy Silvers (16:45.652)
Yes, in many cases, you just start producing less of the allergic antibody for whatever reason, and many kids are able to tolerate milk as they get older.
Jennifer Fugo (17:10.642)
Wow. So does that work the same as an adult? Or is there less flexibility perhaps?
Dr. Stacy Silvers (17:17.258)
There's probably less flexibility. There's an idea that your immune system kind of gets set as you get older and there's gonna be less change in your food allergies as things progress.
Jennifer Fugo (17:33.022)
So it sounds like you might be a little more stuck with it if you develop it as an adult, but with something like, maybe, the oral immunotherapy for food allergies, would that be a potential option to an adult or a child? What are your thoughts on that?
Dr. Stacy Silvers (17:51.178)
Sure, absolutely. Yeah, we do milk oral immunotherapy (OIT), quite regularly. Because it's so prevalent in Western societies, it's a major stressor for families when you have to avoid milk in all forms. So we do do it. It is one of the more difficult foods to desensitize patients to because some of these are the GI symptoms that can be attributed to milk. And we can do it in adults. Again, it tends to be more difficult in adults than it is in younger kids, but we have done that on a few occasions, yes.
Jennifer Fugo (18:30.715)
I guess the worst case scenario would be obviously like you don't see any improvement with this, but is it possible, if maybe there's not 100% clearance for an adult, is it possible with the OIT to maybe lessen the reaction so that you have more runway in terms of like the amount of cross-contamination, let's say, in a food product or something, you know, like getting on the plane and eating a snack and then flipping it over and going, oh no, this was made in a facility that uses milk, you know? Can it give us more flexibility for an adult who's allergic, possibly?
Dr. Stacy Silvers (19:09.354)
Sure, sure. I think those are a lot of conversations to have with your OIT provider because how we proceed with OIT can oftentimes be impacted by what your goals are, what your expectations are. So some people want full incorporation of food into the diet. They want to be able to go eat an ice cream cone, for example. Others, as you point out, just want to be protected from these accidental ingestions, have a little safety measure built in there. And if that's the case, yeah, we don't have to quite push as far. We can stop at a lower dose. It all depends on the dialogue between the provider and patient.
Jennifer Fugo (19:51.414)
That is so neat. It's so great that we're having these options. And when I attended, as many of my listeners know, I went to the Food Allergy Research Expo event in 2023. And I learned so much. And it's just fascinating how much science is going into this area to help at least reduce and lessen the risk of these types of reactions, better testing, hopefully some improved options for desensitization of different types of allergies. So I do think it's an exciting time because it felt like there are more things coming, which is, I'm sure, a relief to people who are dealing with true food allergies.
I did find one interesting note in one of the papers I was looking at where it talked about breast milk-fed children, that breast milk-fed children seem to have a lower risk of dairy allergy or lower rate, excuse me, of dairy allergies. From your experience and the data that you've looked at, do you think that for parents or soon-to-be parents, do you feel like there is some accuracy to that or do you feel like the jury is still out?
Dr. Stacy Silvers (21:10.11)
It's probably the case of the jury still out. We know a lot more about peanut allergy and egg allergy, for example. Early introduction of those foods, without a doubt, is one of the better ways to help prevent those allergies from developing. Introducing peanut by four to six months of age and then keeping it in the diet consistently is the best thing you can do to help minimize the risk of allergy. Whether that's true for milk or not it's harder to know. Certainly, breastfeeding is, I'm a proponent of it, we need to do it, but there is some data out of Japan that early and again consistent exposure to cow’s milk-based formula is also one of the better ways to help prevent IgE and maybe even non-IgE-mediated food allergy reactions to milk as well.
Jennifer Fugo (22:07.543)
Wow.
Dr. Stacy Silvers (22:09.19)
So in this study, they were only giving infants 10 milliliters, two teaspoons of milk, cow’s milk mix formula a day. And those who started very early and continued for months, that cohort of patients had the lower incidence of milk allergy. Fascinating, right?
Jennifer Fugo (22:30.338)
It is, it also feels like, and obviously you've been on the show before and I've talked to some other allergists more recently who said like, we got it wrong. We told people years ago, stop giving kids these allergens. And now it's like we're having to rethink this entire framework of how we introduce these little ones to foods.
Dr. Stacy Silvers (22:57.002)
Absolutely. It's becoming clearer and clearer that the sooner the better. But I want to emphasize this yet again, it's not just you give them peanut one time and that's it. That may be actually the worst thing to do. What you need to do is give peanut and then keep giving it week after week after week until the kids are older.
Jennifer Fugo (23:21.942)
So it sounds like what you're saying is, for parents that are introducing foods, number one, we want to keep it in. Once you get it in, you want to keep it in consistently. But I would assume you would say if you notice concerning dairy allergy symptoms in your child, that's where you want to speak with the pediatrician and maybe then ask for a referral to an allergist.
Dr. Stacy Silvers (23:43.514)
Absolutely, that changes anything if there are any symptoms that you're concerned about. But I'll also say I see a lot of patients who come in who said, well I think there was a rash after I gave peanut to this infant, I'm not quite sure, I was told to avoid peanut no matter what. So if it's not a very convincing history, I'm going to see that patient because my goal is to try to get those foods into the kid's diet as soon as possible.
Jennifer Fugo (24:11.978)
Okay, and so we've talked a lot about diet, but as you know, there has been this whole explosion of adding food-type ingredients to topical agents and products and body care, and obviously there's goat milk soap products and all sorts of things. So, for someone who has a true allergy, because lactose, I just have to say this as a nutritionist, lactose intolerance is a gut-only problem. You're not going to have a problem if it's on the skin. But for somebody who has a true dairy allergy, if a topical product contains, I don't know, whey or cow's milk or goat's milk or something like that, is it safe to use a topical product because you're not ingesting it, or is it possible that you would react to that product that you're using on the outside of the body?
Dr. Stacy Silvers (25:10.47)
Yeah, in general I'm not a fan of any food products going onto the skin or food-containing products. So there is this hypothesis that many food allergies are also developing because of skin contact. And this is typically those patients who have eczema, right? The skin is already broken down. The barrier of the skin is not functioning like it's supposed to. In addition, you've already got this red inflammation right under the skin going on, all these allergic cells are just right there. So when you're introducing foods through the skin, you're putting them right into these immune cells that are going to recognize them as foreign and try to get rid of them. So the thought now is that by putting these food proteins on the skin, you're actually producing an allergic response. You're not going to calm down the inflammation you've got in your skin, you're going to cause an IgE-mediated food allergy reaction.
Jennifer Fugo (26:15.078)
Even though you didn't consume the food…
Dr. Stacy Silvers (26:17.09)
Even though you didn't consume the food. Because of that skin, the breakdown of skin barrier, those proteins are making their way inside. Alternative to that though is consumption tends to produce tolerance. The cells in your gut are used to being exposed to these foreign protein, so you tend to get more of a tolerant response to these foods when you eat it.
Jennifer Fugo (26:45.778)
So it sounds like we've got to hit the pause button. If you've got a really broken skin barrier, especially a child, you have to be careful. I know a lot of parents are like, I want natural, I want these ingredients that I know what they are. And it might even be something that you could eat. I've heard people say that, that they want ingredients in their skincare that they can eat. But there is a risk, especially in kids, introducing or triggering, I guess is what you're saying, triggering an IgE reaction, not because they ate it, but because it was applied to the skin.
Dr. Stacy Silvers (27:23.41)
Absolutely, absolutely. And a lot of this work is coming out of London. There are some really well-done studies that are looking at this hypothesis. And it really seems like it's what's triggering a lot of immune IgE-mediated reactions to foods.
Jennifer Fugo (27:40.874)
And so if somebody doesn't have broken skin, but even still, let's just say, like you were saying, there's a lot of cross-reactivity between cow and goat milk and maybe they can't tolerate goat milk at all in the diet due to a milk products allergy. It sounds like what you're saying is, if you have a dairy allergy, unless your allergist has other thoughts about your specific case, potentially avoid it both in the diet and a topical use product as well, if that contains that particular dairy protein or substance.
Dr. Stacy Silvers (28:11.494)
Yeah, so if you have a cow's milk allergy, you're obviously not gonna be adjusting it, right? Unless you're doing treatment like OIT. I'd probably recommend avoiding it on the skin as well. Not that you're necessarily gonna go into anaphylaxis, but it can be irritating and itchy. You may get a few localized hives where it's touching your skin.
Jennifer Fugo (28:34.526)
Okay, that's really helpful. That was something that I've been asked so many times and I assumed that was the case. I always try to err on the side of caution, but, you know, it's a good question. And I think it helps give people better guidance around when they pick their skincare products and whatnot to avoid things that contain actual allergies, like IgE allergies, right? I think we're in this place where we intermix some terms like food sensitivities and food intolerances and whatnot so much and call them food allergies, which, guys, you know, it's thoroughly inappropriate. All of my listeners, you know now, we've talked about this. We're really talking about true food allergies here. And that can be something that can become life-threatening for some individuals. So this is obviously a bigger deal than something that you're like, oh, I did an IgG food sensitivity test and I have this allergy too. And I'm like, that's not an allergy. That's not an allergy, it's a whole other problem.
Dr. Stacy Silvers (29:32.102)
Yeah, I tend to be as clear about the language that I'm using because it matters. It really matters. And how you approach people and the recommendations you give really depends on what that type of response is or not. If you've got lactose intolerance, you can go bathe in milk, I don't care, right? So those things need to be set up from the very beginning.
Jennifer Fugo (29:59.419)
Yeah, I love it. Well, thank you so much for clarifying all of this. I will definitely link up our other episode that we did together. And we've had two of your colleagues as well on the show. You guys are at Aspire Allergy, which I know you have several different locations in the southern part of the US. Is that correct? And you're taking patients?
Dr. Stacy Silvers (30:22.718)
We are. We're in five states now. We're in Arizona, New Mexico, Texas, Colorado, and Florida.
Jennifer Fugo (30:29.442)
Perfect. And we'll make sure to connect everybody with your website and whatnot so they can reach out to your practice if they're looking for some help and guidance around this. I really appreciate your time and thank you so much for sharing this.
Dr. Stacy Silvers (30:43.21)
Absolutely. I appreciate it. Thanks for having me.
