After 100 years, new guidelines propose rules for common food allergy treatment

shelled and unshelled peanuts on a table

Oral immunotherapy attempts to desensitize patients to common allergens, including eggs, milk, and peanuts. Deposit Photos

Food allergies are a growing health and safety risk, with the Centers for Disease Control and Prevention (CDC) estimating that about 1 in 3 children in the United States are affected. To help combat this, physicians use a technique called oral immunotherapy to try to build a child’s tolerance to some common food allergens. Now, a study published April 8 in the Journal of Allergy and Clinical Immunology aims to create the first set of international guidelines for clinicians to use to help families and clinicians succeed in this sometimes life saving process. These guidelines are not currently mandatory and aim to help standardize care to improve patient outcomes. 

“These families must provide the therapy every single day. That’s why these guidelines are so important,” Douglas Mack, study co-author and a clinical professor at McMaster University in Canada, said in a statement. “Safety can be optimized to make sure that they understand what they’re taking on, while ensuring that they are aware of the kinds of side-effects that can be dangerous.”

What is oral immunotherapy?

Oral immunotherapy involves giving very small amounts of a food allergen like peanuts, walnuts, milk, or egg to a child with a documented allergy. The amount is then gradually increased in an attempt to build up the body’s tolerance and the process has been used for over a century. In 1908, oral immunotherapy helped desensitize a 13-year-old patient with an egg allergy. In that study, the starting dose was 1/10,000th of an egg every day. After six months, the patient could safely eat eggs. More recent analysis found that it can induce desensitization in most patients who are allergic to peanuts, milk, and egg by 76.9 percent

This process is not without risks, as it is administered every day at home to children by their caregivers, which requires caregivers to act like “amateur medical professionals” by observing a child’s reactions and deciding if medical treatment is necessary. These new guidelines are intended to help prepare families and standardize the approach to the process. 

[Related: Babies who grow up around pets may be less likely to develop food allergies.]

“Families need to learn about food allergies, anaphylaxis, immunotherapy, how to safely dose the food, which things to look out for, when to treat, and when to contact the medical team,” Julia Upton, a clinical immunologist at the Hospital for Sick Children in Toronto, Canada, told DW. Upton is not a co-author of the new study. 

What’s in the new guidelines?

A panel of 36 international oral immunotherapy experts worked together to craft a detailed standardized consent form and topics to discuss with families. This includes mentioning that oral immunotherapy is not a cure, that asthma should be controlled before starting the therapy, and stress all caregivers must understand how the process works. This should ensure that all parents and caregivers know the risks and benefits, and alternative treatments if they are unwilling to take on oral immunotherapy. 

“If they decide they want to do it after following these guidelines, they’re prepared for what they’re getting into,” said Mack. “They understand the risks and most importantly, it makes it safer because they can anticipate the challenges. This protocol sets the standard moving forward.”

The guidelines also stresses adequate adult supervision of dosing before treatment begins and that potential risk factors to the patient should be identified before the therapy begins. Some of these risk factors include uncontrolled asthma in the patient and an unwillingness for the caregiver to use epinephrine in case of a reaction. Failure to administer epinephrine in the event of a severe allergic reaction can result in death. 

[Related: A peanut allergy patch is making headway in trials with toddlers.]

The team estimates that as many as one-third of patients were not getting any degree of counseling or preparation before starting the treatment. It took about 30 to 60 minutes for a clinicing to provide adequate counseling about all of the risks and benefits of oral immunotherapy, according to the study.