Oral Immunotherapy for Food-Allergic Children: A Pro-Con Debate

Abstract

The prevalence of food allergy has increased in recent years, especially in children. Allergen avoidance, and drugs in case of an allergic reaction, remains the standard of care in food allergy. Nevertheless, increasing attention has been given to the possibility to treat food allergy, through immunotherapy, particularly oral immunotherapy (OIT). Several OIT protocols and clinical trials have been published. Most of them focus on children allergic to milk, egg, or peanut, although recent studies developed protocols for other foods, such as wheat and different nuts. OIT efficacy in randomized controlled trials is usually evaluated as the possibility for patients to achieve desensitization through the consumption of an increasing amount of a food allergen, while the issue of a possible long-term sustained unresponsiveness has not been completely addressed. Here, we evaluated current pediatric OIT knowledge, focusing on the results of clinical trials and current guidelines. Specifically, we wanted to highlight what is known in terms of OIT efficacy and effectiveness, safety, and impact on quality of life. For each aspect, we reported the pros and the cons, inferable from published literature. In conclusion, even though many protocols, reviews and meta-analysis have been published on this topic, pediatric OIT remains a controversial therapy and no definitive generalized conclusion may be drawn so far. It should be an option provided by specialized teams, when both patients and their families are prone to adhere to the proposed protocol. Efficacy, long-term effectiveness, possible role of adjuvant therapies, risk of severe reactions including anaphylaxis or eosinophilic esophagitis, and impact on the quality of life of both children and caregivers are all aspects that should be discussed before starting OIT. Future studies are needed to provide firm clinical and scientific evidence, which should also consider patient reported outcomes.

Oral Immunotherapy in Food Allergy: A Critical Pediatric Perspective

“…The main treatment option of FA is dietary restriction, using rescue medications in case of severe allergic reactions ( 130 ). Moreover, novel therapies for FA treatment including microbiome, biologic agents, oral/sublingual/subcutaneous/epicutaneous immunotherapy (IT) were reported in the last decades ( 29 , 50 , 131 , 132 ). While results of recent OIT studies are encouraging, the major issue of OIT is the heterogeneity of study protocols including the duration of maintenance doses, primary end points, definition of desensitization, OFC protocols to evaluate desensitization, SU and safety profiles ( 35 ).…”

“…The major OIT contraindications include: non-IgE mediated allergy; uncontrolled asthma; treatments contraindicating adrenaline, low family compliance ( 33 , 48 ). Further criticisms in OIT come from the lack of standardized protocols, the spontaneous development of tolerance especially for cow's milk and egg, the need for patients' compliance and the possibilities of side effects as well as the requirement of the availability of trained health care professionals, appropriate clinical facilities to provide OIT and deal with adverse effects ( 35 , 49 , 50 ). Decision aids might help individuals (and their parents) make decisions consistent with their values and preferences.…”

Prevalence of parent-reported food allergy among children in China: A population-based cross-sectional survey

“…The prevention and treatment of FA are becoming a challenge for doctors, scientists, politicians, and the public ( 2 ). Allergen avoidance and drugs in case of an allergic reaction currently remain the standard of care for FA ( 14 ). Therefore, a clear understanding of the characteristics and patterns of FA prevalence will help to improve public health services and the prevention and management of FAs.…”

“…Based on numerous epidemiological studies, FA has become a common chronic disease in children (3) and affects approximately 8% of children (4)(5)(6)(7)(8), and even up to 10% in developed countries (9). The prevalence of FA is increasing globally (10)(11)(12)(13)(14) and the types of foods causing allergies and serious allergic reactions are growing (2,15). Therefore, FA is described as the "second wave" of allergic disease after asthma and allergic rhinitis (16).…”

Mast Cell Desensitization in Allergen Immunotherapy

“…AIT with aeroallergens is usually administered subcutaneously and is less likely to induce anaphylactic reactions (36,37). On the other hand, adverse allergic reactions including anaphylaxis are more common in AIT with food allergens (38). In terms of the route, subcutaneous AIT in peanut allergy is highly associated with anaphylaxis (39), but oral and sublingual AIT for peanut (and other food allergens) are clearly safer (40)(41)(42)(43)(44).…”