The Case for Prompt Salvage Infant Peanut Oral Immunotherapy Following Failed Primary Prevention

Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy

Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.

Optimising the management of peanut allergy by targeting immune plasticity

Randomised controlled trials investigating the efficacy of oral tolerance induction to peanut have enabled detailed comparison of their clinical and immunological success. They have demonstrated that the regular consumption of peanut for at least 2 years by babies who are not allergic enables protection from developing peanut allergy. The LEAP study intervention tested the impact of regular peanut consumption for 4 years and demonstrated a sustained protection against the development of peanut allergy even after 12 months of peanut avoidance from 5 to 6 years of age. The PreventADALL trial introduced multiple allergens into babies' diets from early infancy and reduced the prevalence of food allergy at 3 years, especially by protecting against peanut allergy. Immunological studies from the LEAP cohort demonstrated that regular peanut consumption was associated with a prompt induction of peanut-specific IgG4 and reduced manufacture of peanut and Ara h 2-specific IgE. Even after stopping peanut consumption for 5 years, there continued to be a significant fall in peanut-specific Ara h 2 IgE in the consumption group from 5 to 6 years of age (p < .01). Children who developed peanut allergy by 5 years started to develop increasing sensitisation to linear sequential peanut epitopes from 2.5 years of age, suggesting that putative disease-modifying interventions should commence before 3 years. Data comparing clinical outcomes between children undergoing peanut immunotherapy from infancy suggest that younger children can consume higher portions of peanut without reaction on challenge whilst taking immunotherapy, have fewer side effects and are more likely to enjoy remission of PA. Peanut oral immunotherapy modulates T-cell populations in order to bring about hypo-responsiveness of allergy effector cells. Studies are now needed to characterise and compare different states of immunological tolerance. This will accelerate the design of interventions which can promote primary, secondary and tertiary levels of PA prevention across a range of age groups.

Risk subgroups and intervention effects among infants at high risk for peanut allergy: A model for clinical decision making

BACKGROUND

The Learning Early About Peanut Allergy (LEAP) trial showed that early dietary introduction of peanut reduced the risk of developing peanut allergy by age 60 months in infants at high risk for peanut allergy. In this secondary analysis of LEAP data, we aimed to determine risk subgroups within these infants and estimate their respective intervention effects of early peanut introduction.

METHODS

LEAP raw data were retrieved from ITNTrialShare.org. Conditional random forest was applied to participants in the peanut avoidance arm to select statistically important features for the classification and regression tree (CART) analysis to group infants based on their risk of peanut allergy at 60 months of age. Intervention effects were estimated for each derived risk subgroup using data from both arms. Our main model was generated based on baseline data when the participants were 4-11 months old. Specific IgE measurements were truncated to account for the limit of detection commonly used by laboratories in clinical practice.

RESULTS

The model found infants with higher predicted probability of peanut allergy at 60 months of age had a similar relative risk reduction, but a greater absolute risk reduction in peanut allergy with early introduction of peanut, than those with lower probability. The intervention effects were significant across all risk subgroups. Participants with baseline peanut sIgE ≥0.22 kU/L (n = 78) had an absolute risk reduction of 40.4% (95% CI 27.3, 51.9) whereas participants with baseline peanut sIgE<0.22 kU/L and baseline Ara h 2 sIgE <0.10 kU/L (n = 226) had an absolute risk reduction of 6.5% (95% CI 2.6, 11.0). These findings were consistent in sensitivity analyses using alternative models.

CONCLUSION

In this study, risk subgroups were determined among infants from the LEAP trial based on the probability of developing peanut allergy and the intervention effects of early peanut introduction were estimated. This may be relevant for further risk assessment and personalized clinical decision-making.

Viewing Pediatric Food Oral Immunotherapy Through an Ethical Lens-A Narrative Systematic Review

BACKGROUND

Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits.

OBJECTIVE

To explore implementation of OIT in children through an ethical lens.

METHODS

To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area.

RESULTS

Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients.

CONCLUSIONS

Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.

Shared decision-making, communicating risk, and food allergy in 2023

Background

Across the practice of allergy and clinical immunology, disruptive innovations have accelerated the adoption of shared decision-making (SDM) to improve the health of patients and populations, particularly with regard to food allergy prevention and management of food allergy and anaphylaxis.

Methods

A narrative review was performed to describe recent innovations in shared decision-making, risk communication, and food allergy.

Results

Several challenges, primarily related to the coronavirus disease 2019 (COVID-19) pandemic and misinformation campaigns, have catalyzed adaptations to evolve clinical care. Recent pressures have facilitated the rapid adoption of telemedicine. In 2023, many allergist/immunologists routinely incorporate both in-person and virtual visits to contextually deliver value-based care to each patient. SDM may occur in a hybrid model that incorporates both in-person and virtual encounters, with many patients experiencing benefit from a combination approach. This may be facilitated by leveraging previsit web-based SDM tools. Whether in person or by telemedicine, effective risk communication to avoid cognitive overload while appreciating population variation in numeracy is key to competent implementation of SDM. Misinformation continues to disproportionately harm patients who belong to groups that encourage denial of evidence-based medical recommendations and COVID-19 vaccination intent correlating with sociopolitical factors. Still, strategies to address misinformation that leverage empathy, respect, and expertise can help to mitigate these effects. Physician wellness is a key component to realization of the Quadruple Aim of health care, and the use of positive framing and appreciative inquiry can help to optimize outcomes and improve value in health care.

Conclusion

SDM is an important component to consider when incorporating recent innovations in allergy and clinical immunology care, particularly in the setting of contextual and conditional medical recommendations. Effective risk communication is critical to SDM that is truly reflective of patient goals and preferences, and can be facilitated through in-person encounters, telemedicine, and hybrid models. It is important to foster physician wellness as a component of the Quadruple Aim, particularly in the recent pandemic climate of misinformation and denial of evidence-based medicine within large groups of society.

Food Allergen Immunotherapy in Preschool Children: Do We Have the Evidence?

Standard care for the management of food allergies previously centered on allergen avoidance and the treatment of adverse reactions after allergen exposure. An increase in the development of immunotherapy treatments for food allergy has occurred over the past 2 decades, with many centers now offering immunotherapy. Previous studies mainly focused on school-age children in whom food allergies are likely to be persistent. However, there is increasing evidence that delivering immunotherapy for food allergy to preschool-age children may deliver higher rates of success, and that peanut allergen immunotherapy leads the way. Conversely, the natural resolution of food allergies occurs primarily in these younger age groups, resulting in challenges to selecting patients who will ultimately benefit from these treatments. Both immunotherapy and natural history studies reveal the inherent plasticity of the immune system in early life, which may be more amenable to intervention, but this raises a delicate yet unknown balance between the optimal timing of intervention versus waiting for natural resolution of the food allergy. Here we review the evidence for early food allergen immunotherapy in preschoolers, and present the pros and cons of this approach while acknowledging important research gaps in this age group.

Early peanut introduction: To test or not to test?

OBJECTIVE

To review recent evidence and international guidelines on early peanut introduction for preventing peanut allergy and provide an update on the status of the debate around testing before early peanut introduction.

DATA SOURCES

Review of published literature documenting: infant feeding guidelines; impact of early peanut introduction on peanut allergy; risk factors for peanut allergy; and impact of early peanut introduction guidelines on infant feeding practices and allergy.

STUDY SELECTION

We used a narrative approach and present both pro and con arguments for testing before peanut introduction. Data from randomized controlled trials and post-hoc analyses of these trials and observational studies were included.

RESULTS

Allergy prevention guidelines around the world now consistently recommend introducing peanut into an infant's diet before 12 months of age for countries with high peanut allergy prevalence. In the US, guidelines recently shifted away from recommending allergy testing before introduction for those at risk of peanut allergy. There is evidence primarily from Australia that recommending early introduction without prior testing is safe and effective in increasing early peanut introduction for both high and low-risk infants, although the subsequent reduction in peanut allergy prevalence at the population level was less than expected.

CONCLUSION

Current evidence supports recommending early peanut introduction without routinely testing for peanut allergy. If testing is offered, this should be based on shared decision making between families and practitioners and only be undertaken where there is provision for rapid access to definitive diagnosis including oral food challenges.

Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist

Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.