Caregivers open to low-dose oral challenges for children during peanut allergy workups

LOUISVILLE, Ky. — Most parents would be interested in low-dose oral challenges during diagnostic workups for peanut allergy, according to a study presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

Single, low-dose oral food challenges for determining eliciting doses usually are not performed as part of diagnostic workups for children with peanut allergy, Lisa Biswas, MD, a second-year allergy and immunology fellow at the University of Tennessee, told Healio.

“There is a lot of research out there on eliciting doses, which is the actual protein content that is going to cause a reaction in your child,” Biswas said. “But we have never asked parents, ‘Do you want to know what threshold your kid is at?’”

Even though 90% of children with peanut allergy can tolerate up to 10 mg of peanut, Biswas continued, many parents are terrified of accidental ingestion and avoid foods with labels indicating that they may include peanut or that they were produced in facilities with peanut.

“Yet research has shown that those products probably have less than 1 mg of peanut,” Biswas continued.

Survey results

The researchers created and administered a prospective and anonymous survey to 60 caregivers of children aged 1 to 18 years (60% male; 58.3% Black; 45% aged 0-5 years; 35% aged 6-12 years; 20% aged 13-18 years) with physician-diagnosed peanut allergy during their child’s scheduled clinic visit. Overall, 68.3% of the cohort was covered by Medicaid.

Participants answered questions about demographics, other food allergies, history of ED visits and epinephrine use for allergic reactions to food as well as perceived risk for life-threatening allergic reactions to accidental ingestions.

The survey found that 73.3% of these caregivers avoided foods with labels that said they may include peanuts or that they were produced in facilities with peanuts.

“The most important questions I asked were, ‘Are you interested in knowing whether your child can pass a low-dose challenge to peanut?’ and ‘Are you actually willing to do the challenge to low doses of peanut?’” Biswas said.

According to the survey, 75% of caregivers said it would be helpful to know if their child could tolerate 10 mg of peanut, and 71.7% said they would be willing to have their child undergo a challenge to 10 mg of peanut.

Specifically, most of the caregivers expressed interest in a single-dose oral challenge whether they were men (72%), women (71%), Black (71%) or white (89%), or had Medicaid (68%) or commercial insurance (78%).

Additional interest was registered whether they had or had not visited the ED (64%; 78%), used epinephrine (81%; 68%) or avoided foods with allergy labels (68%; 81%).

“Across the board, everyone is pretty interested in actually knowing if their child can tolerate a low dose of peanut and are actually interested in doing the challenge,” Biswas said. “There was no characteristic or variable associated with who said yes and who said no.”

Biswas noted that generally, caregivers of children with eosinophilic esophagitis, severe asthma or developmental delays were more likely to say no, but the survey did not ask questions about comorbidities or illnesses, so she has no specific data about these associations.

Creating options

Also, Biswas noted that caregivers overwhelmingly indicated that these challenges would be helpful and decrease their anxiety. For example, these tests may encourage caregivers to try immunotherapy and other treatment beyond avoidance, Biswas said.

These challenges also may reduce the fear of foods with labels indicating possible peanut inclusion that these caregivers and patients may have, Biswas said.

“This could really open up a lot more options for these patients if they weren’t avoiding those foods. They may be able to go to more social events as well,” Biswas said. “This would decrease the anxiety that builds for years and years over accidental ingestion, which may not create the severe reaction that they’re all fearing.”

These results could help clinicians provide guidance to their patients, Biswas said, but challenges may remain.

“We learn new things about food allergy every day. With the younger patients, we are able to give them the guidance of everything that we have learned,” Biswas said.

“But when I see adolescents and 16- to 18-year-olds, they have zero interest whatsoever in eating peanut and adding it to their diet. They automatically assume that they will die if they are in the same room as peanut,” she continued.

Biswas called this a takeaway for primary care providers and allergists alike.

“Try to incorporate some of that mental health aspect of anticipatory guidance that we give for peanut allergies, and try to prevent that from happening,” she said.

Now that Biswas knows that parents are interested in these low-dose challenges, she plans on offering them starting in January.

“We have such a huge population of peanut-allergic patients,” she said. “Should this be part of the workup? The parents say yes.”

For more information:

Lisa Biswas, MD, can be reached at lbiswas@uthsc.edu.