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Background Anaphylaxis is defined as a serious, generalized or systemic allergic reaction that is rapid in onset and may cause death. It is unpredictable and can be the result of various allergic triggers including food, insect venom and medication. The European Anaphylaxis Registry confirmed food as the major elicitor of anaphylaxis in children, specifically hen's egg, cow's milk and nuts. Objectives It has been reported that the incidence of anaphylaxis is on the rise. In the US, there is a continued trend of increasing food-induced anaphylaxis hospitalizations among children, which is supported by nationally representative data. Methods Anaphylaxis can occur both in the home and outdoors and can be life-threatening, however, fatalities are a rare occurrence. A recent systematic review and meta-analysis reported that fatal food anaphylaxis is rarer than accidental death in the general population. Studies of fatal and near-fatal allergic reactions have identified potential risk factors for fatalities and have provided important information that may help minimize future risk. Following confirmation of the relevant allergen trigger, prevention of anaphylaxis is through strict avoidance of the allergen and optimal management of existing co-morbidities. The cornerstone in the successful management of anaphylaxis is early recognition of signs and symptoms and the prompt administration of intramuscular adrenaline. Result and conclusion Patients and their families need to be well educated on how to manage potential anaphylactic reactions with training in the use of adrenaline auto-injectors and personalized emergency management plans. Healthcare professionals must be familiar with this clinical emergency and able to respond to anaphylaxis in a timely and appropriate manner.

Anaphylaxis is a serious systemic allergic reaction that is rapid in onset and may cause death. Despite numerous national and international guidelines and consensus statements, common misconceptions still persist in terms of diagnosis and appropriate management, both among healthcare professionals and patient/carers. We address some of these misconceptions and highlight the optimal approach for patients who experience potentially life-threatening allergic reactions.

Background Eliciting doses (EDs) (eg, ED01 or ED05 values, which are the amounts of allergen expected to cause objective symptoms in 1% and 5% of the population with an allergy, respectively) are increasingly being used to inform allergen labeling and clinical management. These values are generated from food challenge, but the frequency of anaphylaxis in response to these low levels of allergen exposure and their reproducibility are unknown. Objective Our aim was to determine (1) the rate of anaphylaxis in response to low-level peanut exposure and (2) the reproducibility of reaction thresholds (and anaphylaxis) at food challenge. Methods We conducted a systematic review and individual participant data meta-analysis of studies that reported at least 50 individuals with peanut allergy reacting to peanut at double-blind, placebo-controlled food challenge (DBPCFC) and were published between January 2010 and September 2020. Risk of bias was assessed by using National Institute for Clinical Excellence methodologic checklists. Results A total of 19 studies were included (covering a total of 3151 participants, 534 of whom subsequently underwent further peanut challenge). At individual participant data meta-analysis, 4.5% (95% CI, 1.9% to 10.1%) of individuals reacted to 5 mg or less of peanut protein with anaphylaxis (moderate heterogeneity [I2 = 57%]). Intraindividual thresholds varied by up to 3 logs, although this variation was limited to a half-log change in 71.2% (95% CI, 56.2% to 82.6%) of individuals. In all, 2.4% (95% CI, 1.1% to 5.0%) of patients initially tolerated 5 mg of peanut protein but then reacted to this dose at subsequent challenge (low heterogeneity [I2 = 16%]); none developed anaphylaxis. Conclusion Around 5% of individuals reacting to an ED01 or ED05 level of exposure to peanut might develop anaphylaxis in response to that dose. This equates to 1 and 6 anaphylaxis events per 2500 patients exposed to an ED01 or ED05 dose, respectively, in the broader population of individuals with peanut allergy., Graphical abstract

Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. The incidence of anaphylaxis is increasing. Clinicians are highly likely to encounter a case during their career, hence they need to be equipped to make a diagnosis through taking a thorough history, mast cell tryptase levels and allergy testing. After confirming the allergen trigger, prevention of anaphylaxis is through avoidance of the allergen, optimal management of co-morbidities such as asthma, desensitization and adjuncts such as anti-IgE therapies. The management of anaphylaxis is different in hospital and community settings, but in both the key emphasis is the prompt administration of adrenaline. Patients therefore need to be empowered to manage potential anaphylactic reactions with training in the use of adrenaline auto-injectors and personalized emergency management plans.

Antihistamines are commonly used in paediatric medicine mainly for the treatment of allergic conditions. First generation antihistamines have been in use for many years, despite limited research studies supporting their use. Second generation antihistamines have been investigated for both efficacy and safety in paediatrics. An optimal understanding of their effects and pharmacology are required for optimal use in each patient. In this review we discuss the indications for use, as well as efficacy and safety of both old and newer antihistamines for the paediatric population.

The prevalence of allergic disorders has been increasing worldwide and significantly impacts the quality of life of the atopic individual. There has been an increased interest in the role of probiotics for the prevention and treatment of allergic disorders, given the recent evidence that atopy risk may be associated with a dysbiosis of the gut microbiome. Research in this area is ongoing with some studies showing possible benefits of probiotics, with seemingly little to no risk. While these studies suggest that there may be a promise in probiotic use for the prevention or treatment of allergy, further evidence is needed to determine its efficacy, optimal dosing, and strains needed for treatment. In this review, we discuss recently published studies examining the benefits, risks, and role of probiotics in preventing atopic dermatitis, asthma, allergic rhinitis, and food allergy.

Background Anaphylaxis is a rapid-onset, multisystem, and potentially fatal hypersensitivity reaction with varied reports of prevalence, incidence, and mortality. There are limited cases reported of severe and/or fatal pediatric anaphylaxis. Objective This study describes the largest cohort of intensive care unit pediatric anaphylaxis admissions with a comprehensive analysis of identified triggers, clinical and demographic information, and probability of death. Methods We describe the epidemiology of pediatric anaphylaxis admissions to North American pediatric intensive care units (PICUs) that were prospectively enrolled in the Virtual Pediatric Systems database from 2010 to 2015. One hundred thirty-one PICUs in North America (United States and Canada) were queried for anaphylaxis International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes from the Virtual Pediatric Systems database from 2010 to 2015 in the United States and Canada. One thousand nine hundred eighty-nine patients younger than 18 years were identified out of 604,279 total number of patients admitted to a PICU in the database during this time frame. Results The primary outcome was mortality, which was compared with patient and admission data using Fisher exact test. Secondary outcomes (intubation, length of stay, mortality risk scores, systolic blood pressure, and pupillary reflex) were analyzed using the Kruskal-Wallis test or Wilcoxon rank-sum test, as appropriate. One thousand nine hundred eighty-nine patients with an anaphylaxis International Classification of Diseases code were identified in the database. One percent of patients died because of critical anaphylaxis. Identified triggers for fatal cases were peanuts, milk, and blood products. Peanuts were the most common trigger. Children were mostly male when younger than 13 years, and mostly female when 13 years and older. Average length of stay was 2 days. There was a higher proportion of Asian patients younger than 2 years or when the trigger was food. Conclusions This is the largest study to describe pediatric critical anaphylaxis cases in North America and identifies food as the most common trigger. Death occurs in 1% of cases, with intubation occurring most commonly in the first hour. The risk for intensive care unit admission in children underscores the serious nature of anaphylaxis in this population.

This review examines the current literature and provides insight into the role of food immunotherapy in the management of food-allergic children. Key food immunotherapy trials, benefits, and risks of the intervention, as well as areas requiring further study are all discussed.Research studies have reported encouraging results regarding the efficacy of food immunotherapy in desensitizing food-allergic patients with an acceptable safety profile and a documented improvement in quality of life. The role of biologics and long-term effects of food immunotherapy are still under investigation.The burden of food allergy is significant, multifaceted, and well documented. Food immunotherapy is a novel treatment option and an exciting area of research that has seen tremendous progress over the last decade, presenting encouraging results for the treatment of children with food allergies.

Peanut allergy is a common disease and the cause of severe, life-threatening allergic reactions and death. It is rarely outgrown; most pediatric patients carry the disease into adulthood. Peanut allergy poses a significant burden on the quality of life of sufferers and their families, which results mainly from the fear of accidental peanut ingestion but is also due to dietary and social restrictions. Current standard management involves avoidance advice, patient education, and provision of emergency rescue medication. Immunotherapy, commonly used to treat other allergic diseases, has shown promise as a disease-modifying therapy for peanut allergy. Results from studies of oral immunotherapy show high efficacy rates, improvement in quality of life, and a good safety profile. Treatment may result in sustained unresponsiveness in a proportion of patients, whereas others require ongoing treatment.

Many children now suffer with a food allergy, immunoglobulin E (IgE) and/or non-IgE mediated. Food allergies have a significant impact on the child’s quality of life, as well as that of their family, due to the resultant dietary restrictions and the constant threat of a potentially life-threatening reaction. At present, there is no cure for food allergies, but there are exciting advances occurring in the management of IgE mediated allergies, including a more active approach to management with anticipatory screening testing, early introduction of common food allergens, active tolerance induction, use of biologics and active risk management. These areas will be discussed in this review.

Peanut allergy is a common problem and can be the cause of severe, life-threatening allergic reactions. It rarely resolves, with the majority of patients carrying the disease onto adulthood. Peanut allergy poses a significant burden on the quality of life of sufferers and their families, which results mainly from the fear of accidental peanut ingestion, but is also due to dietary and social restrictions. Current standard management involves avoidance, patient education and provision of emergency medication, for use in allergic reactions, when they occur. Efforts have been made to develop a vaccine for peanut allergy. Recent developments have also highlighted the use of immunotherapy, which has shown promise as an active form of treatment and may present a disease-modifying therapy for peanut allergy. So far, results, especially from oral immunotherapy studies, have shown good efficacy in achieving desensitization to peanut with a good safety profile. However, the capacity to induce long-term tolerance has not been demonstrated conclusively yet and larger, phase III studies are required to further investigate safety and efficacy of this intervention. Peanut immunotherapy is not currently recommended for routine clinical use or outside specialist allergy units.

Food allergies are common in children and they can be severe. They result in dietary restrictions and significantly affect quality of life. There is currently no cure for food allergies and the mainstream approach to management consists of food avoidance and provision of emergency medication. Recently, a more active approach to management is being adopted, which includes anticipatory testing, early introduction of potential food allergens, active tolerance induction and active risk management, all of which are discussed at length in this review.

IgE-mediated food allergies are common and currently there is no cure. Traditionally, management has relied upon patient education, food avoidance and the provision of an emergency medication plan. Despite this, food allergy can significantly impact on quality of life. Therefore, in recent years, evolving research has explored alternative management strategies. A more active approach to management is being adopted, which includes early introduction of potentially allergenic foods, anticipatory testing, active monitoring, desensitisation to food allergens and active risk management. This review will discuss these areas in turn.

SummaryBackgroundSmall studies suggest peanut oral immunotherapy (OIT) might be effective in the treatment of peanut allergy. We aimed to establish the efficacy of OIT for the desensitisation of children with allergy to peanuts.MethodsWe did a randomised controlled crossover trial to compare the efficacy of active OIT (using characterised peanut flour; protein doses of 2–800 mg/day) with control (peanut avoidance, the present standard of care) at the NIHR/Wellcome Trust Cambridge Clinical Research Facility (Cambridge, UK). Randomisation (1:1) was by use of an audited online system; group allocation was not masked. Eligible participants were aged 7–16 years with an immediate hypersensitivity reaction after peanut ingestion, positive skin prick test to peanuts, and positive by double-blind placebo-controlled food challenge (DBPCFC). We excluded participants if they had a major chronic illness, if the care provider or a present household member had suspected or diagnosed allergy to peanuts, or if there was an unwillingness or inability to comply with study procedures. Our primary outcome was desensitisation, defined as negative peanut challenge (1400 mg protein in DBPCFC) at 6 months (first phase). Control participants underwent OIT during the second phase, with subsequent DBPCFC. Immunological parameters and disease-specific quality-of-life scores were measured. Analysis was by intention to treat. Fisher's exact test was used to compare the proportion of those with desensitisation to peanut after 6 months between the active and control group at the end of the first phase. This trial is registered with Current Controlled Trials, number ISRCTN62416244.FindingsThe primary outcome, desensitisation, was recorded for 62% (24 of 39 participants; 95% CI 45–78) in the active group and none of the control group after the first phase (0 of 46; 95% CI 0–9; p

Objective To determine the outcome of neonates with a suspected antenatal diagnosis of congenital heart disease (CHD) who were delivered away from a paediatric cardiothoracic centre and were initially managed in a level 3 Neonatal Intensive Care Unit. Methods An 18-year ongoing study conducted in a single institution. Results Between 1992 and 2009, 143 fetuses with suspected CHD were identified, and 124 babies were delivered locally. 13 babies with a normal postnatal echocardiogram and six with isolated arrhythmias were excluded from the study. Structural CHD was confirmed in 105 infants; of these, 94 (90%) survived the neonatal period. Of the 11 neonatal deaths, only four of these infants underwent surgery; most had additional risk factors including: prematurity, very low birth weight, and genetic and other structural congenital anomalies. Conclusions This study demonstrates that appropriately selected infants with antenatally diagnosed CHD can be safely delivered and initially managed in a non-cardiac centre during their neonatal period. Deliveries need to be carefully planned with close collaboration among neonatologists, obstetricians, paediatric cardiologists, mid-wives and parents.

Summary Background Egg allergy is common and although resolution to uncooked egg has been demonstrated, there is lack of evidence to guide reintroduction of well-cooked egg. Objectives To examine the rate of resolution to well-cooked, compared with uncooked egg in children, and safety of egg challenges. Method A longitudinal study of egg-allergic children from 2004 to 2010, who underwent challenge with well-cooked and if negative, uncooked egg. Participants underwent repeat annual challenges and egg-specific IgE measurement. Results One hundred and eighty-one open egg challenges were performed in 95 children whose median age of allergy onset was 12 months. Fifty-three of 95 (56%) had at least one annual repeat challenge. Pre-study historical reactions occurred to baked egg in five (5%), lightly cooked in 58 (61%) and uncooked in nine (9%); respiratory reactions occurred in 11 (12%) and seven (7%) had anaphylaxis; adrenaline was used during five reactions. There were 77 well-cooked and 104 uncooked egg challenges. Tolerance was gained twice as rapidly to well-cooked than uncooked egg (median 5.6 vs. 10.3 years; P

Summary Background Peanut allergy is severe and rarely resolves. Objective To test the efficacy and safety of a new oral immunotherapy (OIT) protocol for peanut allergy. Method Twenty-two peanut-allergic children underwent oral challenge. OIT was administered by gradual updosing with 2-weekly increments (8–38 weeks) to 800 mg of protein (5 peanuts/day) followed by 30-week maintenance. Oral challenge was repeated after 6 and 30 weeks maintenance. Results Twenty-two children (median 11 years) had positive challenges (threshold 1–110 mg). Nineteen of 22 (86%) tolerated updosing and maintenance at 800 mg protein/day. One of 22 dropped out; 2/22 tolerated updosing and maintenance at 200–400 mg protein. Reactions, mostly mild, occurred in 86% during immunotherapy, adrenaline was not required. Eight of 8 with pre-immunotherapy peanut IgE

Cow’s milk protein allergy (CMPA) is the most common food allergy in infants and can affect a family’s quality of life. The purpose of this paper is to evaluate the knowledge and experience of general practitioners (GPs) in terms of CMPA diagnosis and management and to explore the views of parents on the current diagnostic process. Two surveys were conducted in June 2014, which collected data from GPs and parents of infants diagnosed with CMPA in the United Kingdom. The questionnaires included quantitative and qualitative questions, which measured self-reported knowledge, management and perceived treatment progression, and the educational needs of GPs. We also explored parents’ experiences of local healthcare support in relation to CMPA. A total of 403 GPs and 300 parents completed the surveys. The main symptoms of CMPA and diagnosis period differed between GPs and parents. Other key points include different perceptions on symptom presentation and improvement, lack of awareness from GPs about current guidelines, and the significant burden on both families and GPs. This is the first study attempting to establish GP and parental experience in diagnosing CMPA. It is notable that the difference can be improved through training, appropriate diagnostic tools and improved communication between physicians and parents.

Food allergy is a common problem in childhood. The term is used to include both immunoglobulin E (IgE)-mediated and non-IgE-mediated food allergies, which have a significant effect on the quality of life of patients and their families. In this report, we aim to discuss recent advances in the diagnosis, management, and treatment modalities of food allergy in children.

BackgroundPeanut allergy is a common disease that causes severe and fatal food allergic reactions. Currently, the best treatment is avoidance as repeated reactions can occur. Quality of life (QoL) is reduced by fear of severe reactions and social limitations. Oral immunotherapy (OIT) is a novel treatment that may be an effective treatment for peanut allergy.ObjectivesTo determine the efficacy of peanut OIT in children.DesignA phase 2 randomised, controlled, crossover trial (open label).SettingSingle UK centre study.ParticipantsChildren aged 7–15 years with peanut allergy diagnosed by double-blind, placebo-controlled food challenge (DBPCFC). No children were excluded because of anaphylaxis or asthma.InterventionsDaily immunotherapy (2 mg, 5 mg, 12.5 mg, 25 mg, 50 mg, 100 mg, 200 mg, 400 mg and 800 mg of peanut protein) was administered as peanut flour (containing 50% peanut protein). Doses were increased at 2-weekly intervals to a maintenance dose of 800 mg of protein. The control group underwent peanut avoidance for 6 months during phase 1.Main outcome measureA peanut DBPCFC up to 1400 mg of peanut protein was performed in both groups at 6 months. The highest amount of peanut tolerated was the main outcome measure.RandomisationRandomised by online audited system to active or control group (1 : 1).BlindingThe intervention arm allocation was not blinded.MethodsWe assigned 99 participants aged 7–16 years with peanut allergy of all severities to active OIT or control (peanut avoidance/current standard of care). The primary outcome was desensitisation, defined as negative peanut challenge (1400 mg of protein DBPCFC) at 6 months (phase 1). Control participants underwent OIT during phase 2, followed by DBPCFC. Immunological parameters and disease-specific QoL scores were measured.ResultsThe primary outcome, desensitisation, was observed in 62% (24/39) of the active group and none (0/46) of the control group after phase 1 [95% confidence interval (CI) 45% to 78% vs. 0% to 9%;p p p p ConclusionIn children with peanut allergy of any severity, OIT successfully induced desensitisation in the majority, with a clinically meaningful increase in peanut threshold. QoL improved after intervention and there was a good safety profile. Immunological changes reflected clinical desensitisation. Peanut OIT should not be undertaken in non-specialist settings. Future work will include a phase 3 confirmatory study and studies of long-term tolerance; similar studies of other allergens are also required.Trial registrationCurrent Controlled Trials ISRCTN62416244.FundingThis project was awarded by the Efficacy and Mechanism Evaluation programme and is funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership, and jointly sponsored by the University of Cambridge and Addenbrooke’s Hospital [Cambridge University Hospital Foundation Trust (RD authorisation A091686)]. The project will be published in full inEfficacy and Mechanism Evaluation; Vol. 1, No. 4. See the NIHR Journals Library website for further project information.

Peanut allergy is common and can be a cause of severe, life-threatening reactions. It is rarely outgrown like other food allergies such as egg and milk. Measures aiming to reduce its prevalence via maternal avoidance during pregnancy and lactation, or delayed introduction into the diet, have failed to show any benefit. Peanut allergy has a significant effect on the quality of life of sufferers and their families due to dietary and social restrictions, but mainly stemming from fear of accidental peanut ingestion. The current management consists of strict avoidance, education and provision of emergency medication. Families find avoidance challenging as peanut is hidden in various food products. Despite the fact that food labelling has improved, with a legal obligation to declare certain food allergens (including nuts) in prepacked products, it still causes confusion and does not extend to cross-contamination. In an effort to address issues of safety at school, a lot of work has been undertaken to better care for peanut-allergic children in that environment. This includes training of school staff on how to recognise and treat allergic reactions promptly. Recent developments in the management of peanut allergy, such as immunotherapy, have shown some promise as an active form of treatment, but larger studies are required to further investigate safety and efficacy.

Acute and chronic symptoms of allergic rhinitis (AR) can disrupt school and leisure activities, significantly reducing quality of life. Symptoms often impair sleep, resulting in tiredness and poor concentration. Children with seasonal AR perform significantly worse in summer exams, relative to their mock exam results, when compared with their peers. Those individuals showing most symptoms are also likely to be affected by other allergic diseases, magnifying the detrimental impact on quality of life. Nasal blockage is the most common complaint associated with chronic AR, with acute exacerbations causing sneezing, clear nasal discharge and itchy eyes following exposure to the relevant airborne triggers. Allergen avoidance measures should be instituted according to seasonal or perennial symptomatology guided by allergy testing, alongside nonsedating antihistamines such as cetirizine or loratadine. Continued symptoms should be treated with regular intranasal steroid spray. Anti-leukotrienes should be considered early in children presenting with multi-trigger wheeze. Temporal patterns of exacerbation give clues as to the most important aeroallergens implicated. In the UK, tree pollen allergy predominates throughout the spring, whereas those affected by grass pollen allergy may find their symptoms increasing over the summer months. Perennial AR symptoms are the result of exposure to house dust mites, animals and moulds. Children who are allergic to these often find the winter more troublesome as they spend more time indoors and the central heating disperses these household allergens. Where continuing deterioration presents a challenge and allergic symptoms remain uncontrolled, patients should be referred to a specialist allergy service to be considered for immunotherapy.

Confidential enquiries into asthma deaths can identify inadequacies in medical management and factors which contribute to patients' death. To identify risk factors for paediatric asthma deaths over a 6-year period. Observational case-series study of paediatric asthma deaths between 2001–2006 in the UK Eastern Region. Hospital, primary care and post-mortem data were obtained for every child (≤17 yrs) with asthma recorded on the death certificate, and a detailed questionnaire was completed. Information was obtained on asthma severity, medications, hospital admissions, GP and hospital follow-up, adherence, psychosocial / behavioural factors, allergies, details of the terminal attack and precipitating factors. 20 children (10 male; 8–17yrs; median: 11.5yrs) died of asthma between 2001–2006. 9/20 had mild to moderate asthma (BTS/ SIGN criteria), 10/20 had severe asthma and 1 child was not known to have asthma. 13/20 were clinically atopic. Only 3 had undergone allergy assessment. 10/20 died between June and August. 12/20 children had adverse psychosocial and behavioural factors. 7/20 children were on non-combination long-acting β2-agonist (LABA) treatment without inhaled corticosteroids (ICS). Almost half the deaths occurred in children with mild/moderate asthma. We recommend that allergic factors and seasonal allergy should be identified early, non-combination LABAs avoided, and speculate that overuse of short-acting β2-agonists (SABAs) may indicate non-adherence with ICS. Asthma deaths in children can be avoided if risk factors are identified early.

Background Double-blinded challenges are widely used for diagnosing food allergy but are time-consuming and cause severe reactions. Outcome relies on subjective interpretation of symptoms, which leads to variations in outcome between observers. Facial thermography combined with nasal peanut challenge was evaluated as a novel objective indicator of clinical allergy. Methods Sixteen children with positive blinded peanut challenge underwent nasal challenge with 10 μg peanut protein or placebo. Mean skin temperatures were recorded from the mouth and nose using infrared thermography over 18 min. Results The area under curve of nasal skin temperature was significantly elevated after peanut vs placebo (18.2 vs 4.8°Cmin). The maximum increase in temperature was also significantly greater after peanut: mean difference +0.9°C. Conclusion This feasibility study shows thermography can detect inflammation caused by nasal challenges whilst employing one thousand-fold less peanut than an oral challenge. This novel technique could be developed to provide a rapid, safe and objective clinical allergy test.

Background: Peanut allergy is common, potentially severe and rarely resolves causing impaired quality of life. No disease-modifying treatment exists and there is therefore a need to develop a therapeutic intervention. Aims of the study: The aim of this study was to investigate whether peanut oral immunotherapy (OIT) can induce clinical tolerance to peanut protein. Methods: Four peanut-allergic children underwent OIT. Preintervention oral challenges were performed to confirm clinical allergy and define the amount of protein required to cause a reaction (dose thresholds). OIT was then administered as daily doses of peanut flour increasing from 5 to 800 mg of protein with 2-weekly dose increases. After 6 further weeks of treatment, the oral challenge was repeated to define change in dose threshold and subjects continued daily treatment. Results: Preintervention challenges confirmed peanut allergy and revealed dose thresholds of 5–50 mg (1/40–1/4 of a whole peanut); one subject had anaphylaxis during challenge and required adrenaline injection. All subjects tolerated immunotherapy updosing to 800 mg protein and i.m. adrenaline was not required. Each subject tolerated at least 10 whole peanuts (approximately 2.38 g protein) in postintervention challenges, an increase in dose threshold of at least 48-, 49-, 55- and 478-fold for the four subjects. Conclusions: We demonstrated a substantial increase in dose threshold after OIT in all subjects, including the subject with proven anaphylaxis. OIT was well tolerated and conferred protection against at least 10 peanuts, more than is likely to be encountered during accidental ingestion.

Peanut allergy is common and can be a cause of severe, life-threatening reactions. It is rarely outgrown like other food allergies, such as egg and milk. Peanut allergy has a significant effect on the quality of life of sufferers and their families, due to dietary and social restrictions, but mainly stemming from fear of accidental peanut ingestion. The current management consists of strict avoidance, education and provision of emergency medication, but a disease- modifying therapy is needed for peanut allergy. Recent developments involve the use of immunotherapy, which has shown promise as an active form of treatment. Various routes of administration are being investigated, including subcutaneous, oral, sublingual and epicutaneous routes. Other forms of treatment, such as the use of vaccines and anti-IgE molecules, are also under investigation. So far, results from immunotherapy studies have shown good efficacy in achieving desensitisation to peanut with a good safety profile. However, the issue of long-term tolerance has not been fully addressed yet and larger, phase III studies are required to further investigate safety and efficacy. An assessment of cost/benefit ratio is also required prior to implementing this form of treatment. The use of immunotherapy for peanut allergy is not currently recommended for routine clinical use and should not be attempted outside specialist allergy units.