Oral Immunotherapy for Multiple Foods in a Pediatric Allergy Clinic Setting

To summarize the clinical experience with multiple-food oral immunotherapy (OIT) in a pediatric allergy clinic.

Selected patients had a low likelihood of spontaneous resolution of food allergies and strong family motivation to adhere to the protocol. Those with a history of, or symptoms suggestive of, eosinophilic esophagitis were excluded. Food allergies were diagnosed by a combination of clinical history, positive skin prick test (SPT) and/or sIgE test results and/or reactions to oral food challenges (OFC). Large SPTs, high sIgE levels, and severe initial allergic reactions were included in the study.

Patients undergoing OIT were identified via the electronic medical record. OIT was initiated at the highest tolerated dose at OFC or a graded series of doubling doses. Initial administration and updosing sessions were in clinic. The remainder of the OIT was instructed to be given at home daily, with an understanding of how to manage reactions. SPTs and sIgE tests were followed every 6 months.

Of the forty-five patients who underwent OIT, 76% received OIT for 4 or fewer foods; the most common being peanuts, tree nuts, and seeds. Mean time to reach maintenance was 24 weeks. No correlation between baseline allergy test results and threshold for reacting to OFC was seen. Reactions occurred in 22 patients (49%) during up-dosing or in the first 3 months of maintenance dosing. 91% were mild (ie mouth and throat pruritus), 9% were moderate, and there were no severe reactions. After 6 and 12 months of maintenance dosing, there was a decrease in SPT size and sIgE levels respectively.

A similar approach to that used for peanut OIT can be undertaken for multiple foods simultaneously regardless of baseline allergy test results.

This study illustrates, in a highly selected population, how multiple-food OIT is reasonably safe and efficient compared with multiple-food avoidance and/or single OIT. This study was limited in its self-selected patient population, lack of ethnic diversity, lack of blinding, and lack of control group. Doses were also adjusted more freely than in a clinical trial. The allergic profiles (ie severity of asthma, allergic rhinitis, and atopic dermatitis) of its patients were variable, which could have affected the results in this study. Further controlled studies are needed.