While there is still no cure for food allergies, oral immunotherapy is a popular treatment to reduce children’s risk for reaction upon accidental exposure.

Specific risk factors appear to affect how strongly preschool children react to peanut oral immunotherapy (P-OIT), researchers state in a report appearing in The Journal of Allergy and Clinical Immunology Global.

“Our study identified several clinically important risk factors for grade 2 and higher reactions during P-OIT: pre-OIT grade 2+ initial reaction, allergic rhinitis, older age, and higher baseline peanut-specific IgE,” senior study author Lianne Soller, PhD, MSc, and colleagues write.

“These results highlight the need for individualized risk stratification for OIT—for example, consideration of slower buildup for patients with these risk factors,” Dr. Soller says. Grade 2 reactions to OIT peanut desensitization commonly include: mild to moderate limitation in activity, persistent hives, vomiting, and wheezing, notes Jodi Shroba, MSN, APRN, CPNP, who was not involved in the study.

To explore the links between baseline traits and reactions during preschool P-OIT, Dr. Soller and her colleagues analyzed Food Allergy Immunotherapy (FAIT) registry data from various allergy clinics.

Participants Showed a History of Objective Reaction to Peanut

The study included 653 patients aged between 9 and 70 months who initiated P-OIT between April 2017 and June 2021. Participants also had a history of objective reaction to peanut and positive skin-prick test wheal at least 3 mm in diameter or peanut-specific IgE at least 0.35 kilounits per liter. For children without a history of peanut ingestion, peanut-specific IgE was at least 5 kilounits per liter. The study excluded patients who initiated more than 12 mg of peanut protein and those who were still updosing at the time of analysis.

Participants began receiving 1 to 12 mg of peanut protein, based on their age, clinical history, and whether they ingested P-OIT as peanut snacks only, as capsules only, or in hybrid form. Doses increased every 2 to 4 weeks until they reached a maintenance dose of 300 mg protein. After continuing the maintenance dose for around 1 year, the children were given an exit oral food challenge targeting 4 g of peanut protein.  

After adjustments for potential risk factors. pre-OIT grade 2+ initial reaction (ORs, 1.33; 95% CI, 1.10-1.61), allergic rhinitis (OR, 1.60; 95% CI, 1.08-2.38), higher baseline peanut-specific IgE (OR, 1.02; 95% CI, 1.02-1.03), and older age (OR, 1.01; 95% CI, 1.00-1.02) were linked with grade 2+ reaction during P-OIT (Table).

Shared Decision-Making Is Critical

These findings do not surprise Shroba, who notes that previous history, comorbid conditions, higher peanut-specific IgE, and older age are known risk factors for P-OIT.

“While there is still no cure for food allergies, OIT has become a popular treatment option to reduce children’s risk for reaction upon accidental exposure, and we are seeing more patients beginning OIT in preschool years,” Shroba says. “Previous publications have discussed the success of OIT in young children, who may have ‘more impressionable’ immune systems.”

“OIT is not for everyone,” she advises. “It is important that the allergy care team discuss all options with the family and use shared decision-making to consider what is best for the child. Avoidance is still a treatment option if the child is not a good candidate for OIT.”

Risk Factors May Require Personalized Treatment

Current dietary guidelines recommend introducing peanuts to children at around 6 months of age, and preschool OIT may be a good option for those who do not tolerate early introduction, Shroba says. “As the authors mention, these risk factors are not exclusion criteria to OIT, but if the patient does proceed, personalization of treatment with up-dosing at a slower rate may be required.”

The authors plan to collect more data to refine the model and create “an algorithm to predict the safety of OIT for each patient on the basis of their unique profile, which could reduce the risk of moderate or severe allergic reactions and ultimately transform clinical practice.”