About 1 in 13 children in the United States suffers from a food allergy. Current recommended treatment is to avoid eating the allergen and to always carry epinephrine in case of an accidental ingestion. A scary reality for families is that this isn’t always effective in protecting kids from accidental exposure and potentially life-threatening reactions.
There are more than 200,000 visits to the emergency room each year for allergic reactions to food. Severe food allergies and required dietary restrictions are associated with increased reports of being bullied, family anxiety over potential accidental exposures, feelings of social isolation and self-imposed travel restrictions, among other things. All can contribute to feelings of sadness and to the disruption of daily activities, decreasing quality of life for some families.
New treatments are becoming available for kids with a food-allergy diagnosis. One emerging option is oral immunotherapy (OIT). What you should know to make an informed treatment decision for your child follows.
OIT involves consulting a qualified medical professional and creating a specific plan of treatment to be carried out only under medical supervision. During a series of appointments your child will eat the allergenic food in small, slowly increasing doses until able to tolerate a pre-determined target amount of the food.
OIT generally occurs in three phases, the first of which is an initial dose escalation day. During a long appointment day, your child will be fed very small, but increasing, amounts of the allergen while trained medical professionals watch carefully for signs of an allergic reaction. With OIT, it often takes months for a child to be able to eat a single peanut, for example.
The second phase of OIT is several months to more than a year long and involves eating the allergen daily at home with clinic visits for supervised dose increases, usually weekly or bi-weekly. During this phase, your child progresses from very small amounts of the allergen to larger portions. Some OIT protocols aim for a goal of being “bite proof,” meaning that a child who accidentally eats something cross-contaminated with the allergen or bites into a food containing the allergen would ideally be protected from a severe reaction. Other protocols aim for a child to be able to ingest a full serving of the allergen. The third phase begins once your child has reached the target dose for her allergen specified by the specialized healthcare provider. In this phase, your child ingests a maintenance dose of the allergen daily for the foreseeable future.
Is OIT Right for Your Child?
Multiple studies have suggested that OIT is a promising treatment option for food allergies. Researchers have studied OIT for many years, finding that between 75 and 84 percent of children reach the target dose of their allergen, often being able to eat a full serving of it without incident. Due to the increased risk of a reaction requiring emergency epinephrine treatment during therapy, however, it is important to maintain constant contact with your healthcare team during the OIT process.
Certain situations put kids at increased risk of reaction during OIT treatment, including illness and exercising after a dose, which may require a change in the treatment plan. OIT providers also ask that kids refrain from exercise for two hours after dosing, even once they reach the maintenance phase, a significant lifestyle consideration. Children with uncontrolled asthma or a pre-existing condition called Eosinophilic Esophagitis (EoE) should be excluded from OIT therapy.
OIT only works on those with traditional IgE mediated food allergies, not those with intolerances to foods. So, OIT might be indicated for a child with a milk or wheat allergy, but it would not work on a child with lactose intolerance or celiac disease. Younger children and those with lower allergen specific IgE (a type of blood test that your provider may run) may have an easier time during OIT, but older kids and those with high allergen specific IgE have also been successful in treatment.
Insurance coverage for OIT varies widely, depending on the allergist providing the treatment and individual insurance plans. The best way to determine coverage is to check whether an OIT provider’s office accepts your insurance. OIT is generally one long appointment, followed by 20 to 25 shorter appointments for a period of several months or longer. Some or all of these visits may be covered by medical insurance. If you do not have insurance, or the OIT allergist near you does not accept your insurance, most OIT providers can quote you an out-of-pocket cost for treatment. There may not be an OIT provider in your community, so consider travel and associated expenses for appointments.
Researchers are currently studying several forms of immunotherapy for food allergies. Although OIT is the most widely studied and effective form to date, Sublingual Immunotherapy (SLIT) and Epicutaneous Immunotherapy (EPIT) are also being studied. SLIT involves placing drops of an allergen extract under the tongue each day. This therapy is available from qualified providers, and may desensitize children to a small amount of their allergens, much less than OIT, but still an amount of the food that might protect kids from cross-contamination with their allergens. SLIT is generally safer than OIT, with few to no systemic reactions involving epinephrine treatment recorded in SLIT studies.
EPIT, an immunotherapy patch worn similar to an adhesive strip on the skin, is also safer than OIT, but failed to meet a key endpoint in a recent clinical trial, with less than 40 percent of patients responding to treatment. EPIT is not yet available to the general public.
Why OIT Isn’t More Widely Available
Some allergists believe it is too early to widely offer OIT because clinical trials are still ongoing. Others are waiting for an OIT product to be FDA-approved. The FDA cannot approve the process of OIT, as it only approves products such as medications. There is an OIT biologic product, a peanut pill, currently in phase-three clinical trails and slated for approval by 2019.
As OIT becomes more popular among patients, the number of providers offering OIT is growing steadily. Only you and your healthcare team can decide whether OIT is right for your child. Several studies show it increases quality of life for both food-allergic children and their caregivers, but the treatment is not without risks.
In addition to the increased risk of severe reaction during treatment, some kids do not like the taste of their allergen, and daily dosing can become difficult. It is also possible to develop symptoms of EoE during treatment. Carefully weighing the risks and benefits, discussing this treatment option with your provider and scheduling a consult with an OIT provider can help you make the best decision for your child. All food-allergy families want their children to be healthy and happy, joining the fight against childhood allergies.
Jessica L. Peck, DNP, RN, MSN, CPNP-PC, CNE, CNL, is an Associate Professor at the University of Texas and has been practicing in pediatrics for more than 20 years. She is currently the secretary for NAPNAP.
E. Katherine Larson, MAT, holds a master’s degree in teaching and is studying to become a Physician Assistant. As the mother of a food-allergic child, she was inspired to direct a parent/caregiver support group, to help provide optimal care for children with food allergies.