Oral Immunotherapy for Peanut Allergy in Children 1 to Less Than 4 Years of Age

Oral Immunotherapy Should Play a Key Role in Preschool Food Allergy Management

Food allergies pose significant challenges including the risk for severe allergic reactions. This review article highlights the advantages and disadvantages of the historic standard management approach-avoidance and carrying epinephrine in case of accidental ingestion-and argues, based on accumulating evidence, that oral immunotherapy (OIT) should play a key role in preschool food allergy management. Firstly, our review will highlight pitfalls with the 'wait-and-see' approach to natural resolution of food allergies, with recent data pointing to lower resolution than previously thought. For those who do not outgrow their allergies, waiting until school age to offer OIT means missing the window of opportunity where OIT is safest, and prolongs unnecessary dietary restrictions. For those who do outgrow their allergies, research indicates they may not reintroduce the food due to fear and aversion and can become re-sensitised, putting them at risk of severe reactions. Secondly, the risks associated with allergen avoidance are higher than previously believed. Allergen avoidance is imperfect and carries an increased risk of severe reactions when compared with the risk of severe reactions while on OIT, particularly in preschoolers. Although an allergic reaction can be stressful, it is preferable to have this occur during OIT where caregivers are vigilant following a scheduled dose, rather than having this occur at a potentially unexpected time following an accidental exposure. Lastly, there is a growing body of evidence supporting favourable safety and effectiveness of OIT in preschoolers, and preliminary data suggesting higher likelihood of remission in infants. OIT has the potential to significantly improve quality of life, and future research is needed to answer this important question in preschoolers. In summary, while ongoing research will further clarify cost-effectiveness, long-term adherence and psychosocial impacts of OIT, this review suggests that OIT should play a key role in preschool food allergy management.

Infant and Toddler Peanut Oral Immunotherapy: Initiation Before Age 2 Increases Ad Libitum Peanut Consumption

BACKGROUND

Peanut oral immunotherapy (POIT) has promising potential of disease modification, but there are no studies to date evaluating high-dose POIT, leading to ad libitum (ad lib) consumption of peanut products, especially in children 6 months to 4 years of age.

OBJECTIVE

To report real-world outcomes of high-dose POIT in children 6 months to 4 years of age, including adverse events, achievement of ad lib consumption, and the impact of age on these outcome measures.

METHODS

Patients 6 months to 4 years of age with a diagnosis of peanut allergy were enrolled in a POIT protocol with a goal dose of 3000 mg. Demographics along with POIT and clinical outcomes 6 months after POIT are reported.

RESULTS

Sixty children, with a median age of 16 months, started POIT. Three (5%) were lost to follow-up, and 6 (10%) discontinued POIT because of recurrent adverse events or the inability to consume daily peanut protein. Fifty-one (85%) children completed POIT in a median of 7 months and were consuming ad lib peanut products for a duration of 6 months after completion of the POIT protocol. Sixteen (26.7%) children experienced a total of 22 adverse reactions during POIT. Initiating POIT before 24 months of age increased the likelihood of ad lib peanut consumption by an odds ratio of 11.69 (1.19-114.31, P = .035).

CONCLUSIONS

Our study demonstrates that high-dose POIT in infants and toddlers is well tolerated and can lead to ad lib introduction of dietary peanut products into the diet, especially if initiated before 2 years of age.

Food allergy yardstick: Where does omalizumab fit?

Food allergy management has greatly evolved in the last several years, moving from passive approaches, such as strict food allergen avoidance, to more active treatments, including regulatory approval of the first specifically indicated immunotherapy product (for peanut) in 2020. In 2024, a second therapy, omalizumab, received regulatory approval for the treatment of 1 or more IgE-mediated food allergies, providing clinicians with multiple treatment options to offer patients and families. With this expanded armamentarium of food allergy treatment options, the practicing clinician requires detailed knowledge of benefits and risks of omalizumab, how omalizumab fits into the management landscape, and how to use shared decision-making to optimize therapy. This yardstick aims to provide the clinician with a review of data leading to omalizumab's food allergy indication and an evidence-based expert opinion approach regarding on how best to use this and other therapies available to optimize patient management.

EAACI guidelines on the management of IgE-mediated food allergy

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

Comparing Two Peanut Desensitization Protocols in Preschool Children: A Real-World Clinical Practice

INTRODUCTION

Peanut allergy is the main food allergy in childhood and poses significant health concerns. This study aimed to critically evaluate the effectiveness and safety of oral immune therapy (OIT) using crushed peanuts versus peanut puffs.

METHODS

Children with an allergist diagnosed peanut allergy based on a history of an IgE-mediated reaction and a positive skin prick test for peanuts were recruited at the Montreal Children's Hospital and the Children's Clinic located in Montreal. Based on age and personal preference, initial doses of peanut were given in either puff (Bamba) or crushed peanut form. Patients continued the same dose for 2-5 weeks at home, filled out a symptom diary, and returned to the clinic for up-dosing until maintenance was reached (2 teaspoons of peanut butter). A continuation ratio regression model was used to evaluate the effect of the allergen type on the severity of anaphylactic and allergic reactions (ARs) during OIT while adjusting for potential confounders.

RESULTS

Between October 2020 and June 2023, 191 children (59.6% male; median age 1.95 years) were recruited. Most patients (75.1%) had eczema, and 12.7% had asthma. Oral desensitization was performed using one of two strategies according to the allergist: crushed peanut (n = 60 [31.4%]) and peanut puff (n = 131 [68.6%]). Of the participants, the consumption of puff lowered reaction severity by a factor of 3.94 (95% CI, 1.6-9.6), in comparison to crushed peanuts. Older age markedly elevates the adjusted odds of reacting to a particular severity level as compared to a lower level by 1.20 (95% CI, 1-1.4).

CONCLUSION

Modified peanut desensitization using peanut puffs has shown potential in reducing the severity of ARs in younger children. Older children may experience a higher risk of severe reactions, indicating the need for age-specific approaches to desensitization protocols.

Doing More with Less

Peanut allergy affects 1 to 3% of children in Western countries and is increasing in prevalence in Africa and Asia. In most patients, peanut allergy develops early in life and continues into adulthood. Peanut allergy is the most common cause of food-related anaphylaxis and death and creates significant medical, financial, and psychosocial burdens on patients and their families.1-3 Until recently, the mainstay of treatment for peanut and other food allergies was strict avoidance of peanut and carrying injectable epinephrine in case of accidental exposure.