Is Food Oral Immunotherapy Right For My Child?
Severe allergies to common foods (e.g., milk, egg, wheat, peanut, tree nuts) carry substantial psychosocial and nutritional burdens for children and their families. Oral immunotherapy (OIT) offers protection from allergic reactions with accidental ingestion of the offending food(s), and in sufficiently high “doses” may permit children to freely consume full servings of the allergenic food. Improvements in quality of life have been demonstrated for children and their parents who have successfully completed food OIT. However, OIT is not without its own risks and burdens, including the need for daily regimented dosing and the possibility of allergic reactions.
Even with more than 10 years of experience and thousands of children across the globe successfully desensitized to common allergenic foods, there remains an essential question for every family considering food OIT to ponder: Is this treatment the best approach for my child? There are many factors to consider when weighing the pros and cons of OIT versus strict avoidance of an allergenic food, and each child and family presents a unique set of circumstances that influence these decisions. One of the tenets of medical decision-making is never to make the treatment of a problem worse than the problem itself. What follows is a suggested framework to help guide parents in deciding if OIT is the best treatment for their child with severe food allergies.
FOOD RELATED ISSUES:
How difficult is it to avoid the allergenic food? For example, in the U.S. peanut is much more commonly encountered compared to macadamia nut. Considering that OIT involves daily consumption of the allergenic food indefinitely, in this country the “return on investment” for this treatment would be much greater for peanut than for macadamia nut.
Is the food in question a staple of your child’s diet? In addition to safety issues, allergies to common food staples may present significant nutritional and social challenges for children. Prime examples in the Western diet include milk, egg and wheat, while lentils and chickpea are more important in South Asian diets.
Is the food allergy likely to resolve spontaneously over time? Peanut and tree nut allergies are usually lifelong problems. For these foods, early OIT makes good sense to prevent allergic reactions with accidental ingestions in both the short and long run. By contrast, allergic sensitivities to milk and egg often resolve spontaneously in 5-10 years. If levels of IgE antibodies to these foods are trending downward in a way that suggests a high likelihood of outgrowing the food allergy in a few years’ time, then OIT would generally not be advised. On the other hand, avoiding these foods for 5-10 years carry nutritional and social burdens that some parents would prefer to avoid. In such cases, OIT would be a reasonable approach to make the food allergy go away sooner than later.
Are you prepared to undertake a treatment that involves daily supervised ingestion of an allergenic food for an indefinite number of years? Because OIT carries a risk of allergic reactions, it is crucially important that parents understand the commitment of time and effort required to administer this treatment safely. In addition to regular visits to the allergist’s office for OIT updosing under observation, there are a number of safety precautions involved in daily dosing of the allergenic food(s) at home. These safety precautions include daily attention to the timing of dosing (i.e., soon after a meal and avoiding physical activities or heat exposure for at least 2 hours afterwards) as well as vigilance for conditions that might lead to allergic reactions (i.e., illness, fever, mouth sores). Without any setbacks due to illness, adverse reactions or travel, OIT escalation generally takes around 6 months to complete. Because only a small minority of children (approximately 10%) are able to discontinue maintenance OIT after 3 years without losing protection, the maintenance phase should be assumed to be forever, or at least until the child is old enough to make adult decisions.
How worried are you about accidental ingestions of allergenic foods? For some parents, the daily tasks involved in protecting their children from accidental ingestions of an allergenic food feels like a full-time job, and loss of sleep caused by anxiety adds to these burdens. Early adoption of OIT for peanut or tree nuts can be especially helpful in alleviating parental anxieties about accidental nut ingestions in their young children. For other parents, the avoidance management strategy is “second nature” and does not feel especially burdensome. In these cases, the burdens of a treatment involving daily supervised ingestion of an allergenic food for an indefinite number of years exceeds the burdens of the avoidance management strategy.
CHILD / DEVELOPMENTAL CONCERNS:
How has the food allergy impacted your child’s daily life? In addition to safety concerns, food allergies carry substantial social burdens for children and teenagers. Has your child expressed unhappiness about “being different” from other kids, including the constant need to check ingredients, the inability to eat certain foods, or having to sit at the “nut-free table” at school? Has your child ever been excluded or bullied by other children because of their food allergies? If your child is too young to have experienced such problems, you may make a substituted judgment regarding how you might feel in their shoes.
Is your child willing to participate in OIT? For toddlers and young children, the decision to undergo an elective treatment is entirely the choice of their parents. However, it is important that older children and teenagers understand the reasons for choosing OIT and indicate their willingness to participate in the process. Without the older child’s “buy-in”, daily OIT dosing can become an unpleasant parent-child struggle. As teenagers make the transition to leaving home, the decision to continue maintenance OIT versus stopping treatment and resuming strict avoidance of the allergenic food should be theirs to make and live by. Your allergist should have frank discussions with your teenage child to explain the pros and cons of these decisions.
It is hoped that the foregoing information is helpful in guiding your decisions about the appropriateness of food OIT for your child. For additional advice regarding these issues, please consult with an allergist who is experienced with OIT.
Robert W. Sugerman, MD