“Microdosing” Kids with Peanut Allergies May End Risk of Serious Reactions

Going through everyday life can feel like a minefield when you have a child with a peanut allergy. Does that birthday cake have peanut butter frosting? Are there traces of peanut in that granola bar? Did you remember to ask the restaurant server if there are peanuts in the brownie your kid ordered for dessert? 

While avoidance has long been the go-to strategy doctors and parents have used to manage a child’s peanut allergy, a new study has found that “microdosing” toddlers and preschoolers with small amounts of peanut can significantly reduce the risk of a life-threatening reaction. 

The treatment, known as oral immunotherapy, can reduce the impact that managing a peanut allergy can have on a child’s quality of life—but it may not be right for everyone. Here’s what to know about oral immunotherapy for a peanut allergy and how to determine if it’s appropriate for your child.

Microdosing Against a Peanut Allergy

In a study published on November 19 in The Journal of Allergy and Clinical Immunology: In Practice, researchers from Canada set out to investigate how well oral immunotherapy works in young children with peanut allergies who receive the treatment in a “real-world setting” rather than a clinical trial.

The study involved 117 children between the ages of 9 months and about 5 1/2 years old who either had a history of a reaction to peanuts or were believed to have a peanut allergy based on bloodwork. The participants attended between eight and 11 in-person appointments at a health clinic, where they would receive small but increasing “doses” of peanut protein of up to 300 mg, the equivalent of about a single peanut or quarter teaspoon of peanut butter.

The children would continue to consume that same amount of peanut in between appointments as a form of “maintenance” for their desensitization to the allergy over the course of a year. Participants were then given an oral food challenge, where they consumed 4,000 milligrams of peanut protein, or almost 17 peanuts. 

The findings showed that more than 98% of young children who received oral immunotherapy for a year were able to consume 1000 mg of peanut protein, or four peanuts, without having an allergic reaction. Researchers say that’s enough to protect them from almost all accidental ingestion of peanuts in everyday life.

Nearly 80% of the participants could eat the equivalent of 17 peanuts with no reaction. Those who did have an allergic reaction generally experienced mild or moderate symptoms, but one participant did require treatment at the emergency department.

While not the first study on microdosing for peanut allergy, this research offers a deeper understanding of the safety and efficacy of oral immunotherapy outside of a lab and the potential for it to be used as a treatment for very young kids. 

Pros and Cons of Oral Immunotherapy

Oral immunotherapy has been gaining increased attention as a potential way to reduce the risk of severe reactions in children with peanut allergies. The findings of this latest research come less than a year after the U.S. Food & Drug Administration approved Palforzia, the first oral immunotherapy drug for peanut allergy in children age 4 to 17 years old.

“The current mainstay of treatment for peanut allergy is avoidance, avoidance, avoidance,” says Dr. Tamar Weinberger, allergist and immunologist at the Center for Allergy, Asthma, and Immune Disorders at Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and assistant professor at Hackensack Meridian School of Medicine. “You avoid food, you carry emergency medicine, and you have the possibility of an accidental reaction if you didn’t read the label or the ingredient was inadvertently in there.”

That can lead to extra stress on a daily basis and even cause social implications for children who may not be able to go to birthday parties, eat at restaurants, and participate in other activities.

Oral immunotherapy shows promise as a way to alleviate some of those quality-of-life concerns and potentially eliminate the risk of a serious allergic reaction from accidental peanut ingestion in some children.

Despite its benefits, the treatment does come with downsides. It requires a significant time commitment, involving regular in-person appointments with a physician and a willingness to take a “dose” of peanut every day.

“There are potential side effects from oral immunotherapy, as well,” adds Dr. Catherine Monteleone, professor of infectious diseases, allergies, and immunology at Rutgers Robert Wood Johnson Medical School. “Patients can get gastrointestinal symptoms during the build-up, like mild abdominal pain or an itchy mouth, and some can get worse symptoms.”

Oral immunotherapy isn’t considered a cure for a peanut allergy, but rather a way to desensitize a person’s immune system so it is less reactive to that allergen. It usually takes at least several months to work. However, patients will need to continue eating small amounts of peanut every day, potentially for the rest of their lives, in order to remain desensitized. 

“Maybe researchers find that after a decade, a person can stop the maintenance therapy and tolerate peanuts, but they don’t have that information yet,” says Dr. Monteleone, adding that kids may need to restart the entire therapy if they forget to take their peanut dose a few days in a row.

Is Oral Immunotherapy Right for Your Child?

Given the potential for adverse reactions during treatment and the requirement for a long-term commitment, oral immunotherapy may not be right for every child with a peanut allergy, experts say.

“Oral immunotherapy is highly effective, but whether it’s appropriate depends on what the goal is and what the shared risk is,” explains Dr. Weinberger. “It’s not a one-size-fits-all approach.” 

Parents and their children should have a conversation with an allergist to understand the risks and commitment involved with oral immunotherapy before starting treatment. 

“A lot of parents have watched their children have such severe reactions that they would rather do oral immunotherapy than risk having to use an EpiPen or go to the hospital,” says Dr. Monteleone. “Some are comfortable with avoidance of peanuts, and they’d rather stick with that."