Hazelnut oral immunotherapy appears effective for children

Oral immunotherapy appeared effective and well-tolerated by children with hazelnut allergy, according to a retrospective study published in Annals of Allergy, Asthma & Immunology.

However, aversion to hazelnut led to a high treatment discontinuation rate, Marie Sabouraud, MD, of University of Lyon and the department of pediatric pulmonology and allergology at Hospices Civils de Lyon in Lyon, France, and colleagues found.

The analysis included 70 patients aged 18 years and younger (60% male; median age 10 years; interquartile range [IQR], 6-13.8), 66 of whom (94.3%) had a confirmed IgE-mediated hazelnut allergy, and four (5.7%) of whom had IgE sensitization to hazelnut. All the children had multiple sensitizations, with 69 (98.6%) co-sensitized to another food allergen.

Patients ingested daily doses of cooked hazelnut corresponding to 10% of their individualized target dose, a rate that was progressively increased to reach the intermediate target dose at 6 months. They took these doses at home after their evening meal while in a calm state and without lying down.

Also, patients took part in oral food challenges with increased doses of raw hazelnut powder in capsule form, from 1 mg of hazelnut (0.15 mg of proteins) to the target dose or until objective or persistent subjective symptoms occurred.

At the 6-month consultation, 69 patients (98.6%) still followed the protocol. The median cumulative ingested dose (68.3 mg of hazelnut proteins; IQR, 31.2-175.1) was significantly greater than it was at the initial consultation (21.4 mg; IQR, 12.8-36.8; P < .0001).

At the 1-year consultation, 55 patients (78.6%) still followed the protocol. The cumulative ingested dose (220.9 mg of hazelnut proteins; IQR, 86.1-492) was significantly greater than the dose at the first consultation.

Overall, 36 patients (51.4%) reached a tolerated dose of greater than 120 mg of hazelnut proteins, or approximately one hazelnut, at the 1-year consultation.

At home, 40 patients (57.1%) experienced at least one side effect, including 36 (51.4%) experiencing a mild allergic reaction such as local pruritus or edema, 17 (24.3%) developing aversion to hazelnut and 14 (20%) experiencing recurrent abdominal pain after ingesting the daily dose.

Two patients (2.9%) experienced severe systemic allergic reactions, including one who needed to use an epinephrine auto-injector.

Between the initial and the 6-month consultations, one patient discontinued the therapy due to recurrent abdominal pain. Between the 6-month and 1-year consultations, eight patients discontinued therapy for various reasons.

After the 1-year consultation, five more patients discontinued the therapy. However, one of these patients discontinued therapy due to the COVID-19 pandemic and then appeared motivated to restart treatment months later.

Further, 42 of 63 children (66.7%) and 42 of 63 legal representatives (66.7%) completed questionnaires about how well they accepted the oral immunotherapy. With a numerical score of 1 to 7, responses equal to or greater than 4 were considered positive.

The median scores were 5 (IQR, 4-6.8) for satisfaction and 6 (IQR, 5-7) for effectiveness among the children.

The children also said they would recommend the therapy to other allergic children, with a median score of 7 (IQR, 5.3-7). However, they did not enjoy eating hazelnut every day (median score, 3; IQR, 1-4) and considered the therapy a strain (median score, 5; IQR, 3-6).

Considering the numbers of dropouts during the therapy, the researchers wrote, it is important to advise patients of all possible adverse reactions, particularly the risk for developing an aversion to hazelnut.

Further, the researchers wrote, there is a need to maintain motivation during the up-dosing phase because many children did not enjoy eating hazelnuts daily, and long-term studies are necessary to evaluate the impact of such long treatment.