New study explores peanut allergy treatment for children with higher tolerance levels

A recent study led by researchers at the Icahn School of Medicine at Mount Sinai, New York, has provided encouraging evidence that a supervised, gradual peanut ingestion protocol may help children with a high-threshold peanut allergy increase their tolerance to peanut protein.

It is important to note that this trial was carried out under strict medical supervision and should not be attempted at home without guidance from an allergy specialist.

This trial explored peanut oral immunotherapy (OIT) in children aged 4 to 14 years who already had a ‘high-threshold’ peanut allergy – meaning, they could tolerate at least the equivalent of half a peanut. Research suggests, this ‘high-threshold’ subgroup represents about half of all people with peanut allergies.

In the past, many treatments have only been tested on children with “low-threshold” allergies—those who react to even the tiniest amounts of peanut. By including children with higher tolerance levels, this study addresses an important need by exploring a treatment plan specifically for children who have a higher baseline tolerance yet remain at risk of severe reactions.

What is peanut oral immunotherapy?    

Peanut OIT is a treatment approach designed to help people with peanut allergies become less sensitive to peanuts. The idea is to build tolerance by gradually introducing small, controlled amounts of peanut protein over time. This helps the immune system learn to tolerate peanuts better, so that if a person accidentally eats some, they may not have a severe reaction. OIT is not a ‘cure’ for allergies, however, it can increase the amount of peanut a person can safely consume, adding an extra layer of safety.

How did the study work?

In this trial, 73 children were randomly divided into two groups. One group followed a supervised peanut-ingestion programme, while the other group continued to avoid peanuts.

• Those in the peanut-ingestion group started with a daily dose of 1/8 teaspoon of store-bought peanut butter. The dose was then gradually increased every eight weeks. Throughout the process, all dose increases were performed in a controlled medical setting to ensure the safety of every child.
• Those in the avoidance group continued to avoid peanut as usual.

The goal was to see if slowly increasing small amounts of peanut under medical supervision could help children with a high-threshold peanut allergy safely tolerate more peanut protein.

What did the study find?

After about 18 months on the treatment plan, the children took part in a supervised oral food challenge to see how much peanut they could tolerate. The main findings were:

• All 32 children in the ingestion group were able to eat 9 grams of peanut protein—roughly the same as three tablespoons of peanut butter.
• In the avoidance group, only 3 of the 30 children reached the same level of tolerance. These children were considered to have developed a natural tolerance to peanut.
• Further statistical analysis, which took into account some missing data due to COVID-19, found that 100% of the ingestion group, compared to only 21% in the avoidance group, could tolerate at least two doses more than what they started with.
• After 16 weeks of regular peanut dosing, the children stopped eating peanut for 8 weeks. Then, a final food challenge was done. Out of the 30 children who took part, 26 were still able to safely eat the maximum dose after an 8-week break, showing they had achieved what is known as sustained unresponsiveness to peanut.
• The study reported that none of the children in the peanut-ingestion group needed adrenaline to treat severe allergic reactions during the home dosing, and only one child required adrenaline during a supervised dosing visit at the study site. 
• All other recorded reactions were considered mild.

What’s next?

These results mark an important step in allergy treatment research. However, more research is needed to understand whether the tolerance to peanuts gained during treatment lasts over the long term, beyond the 8-week trial period.

The researchers at Mount Sinai plan to carry out further studies to see if this treatment approach could be used for other food allergies. They are also looking for a safer way to identify people with ‘high-threshold allergies’, as the current method—an oral food challenge—can trigger an allergic reaction.

In summary, this study adds to the growing evidence that supervised peanut OIT could be a safe and effective option for children with high-threshold peanut allergy. It contributes to the research needed for this treatment to potentially become available on the NHS in the future.

Any treatment involving OIT should always be discussed with a qualified allergy specialist and carried out under their supervision.

The research was funded by the National Centre for Advancing Translational Sciences and the National Institute of Allergy and Infectious Diseases. You can find more information here: https://evidence.nejm.org/doi/full/10.1056/EVIDoa2400306