Two of my three children are allergic to tree and peanuts. I assume OIT isn't really feasible when allergic to a variety of nuts? Unfortunately our 5 year old is an unknown because we have been afraid to give him any nuts...need to have him tested.

We haven't tested the two allergic children in 3-4 years, so we should do that again.

My peanut-allergic son is not doing OIT because his allergist said it might well kill him. He has to have prednisone when tested because the scratch test begins anaphylaxis…thank you for the info about these meds, PPs. I will inquire about them.

Anonymous wrote:

Anonymous wrote:Hi OP, I work in food allergy. I can tell you we are all eager for the announcement of Xolair, which could before the end of the year, with a Q1/Q2 FDA approval.

It's important to differentiate Xolair is not being considered a cure for food allergy, but a medicine that takes away the risk of anaphylaxis on accidental exposure. Still lots of questions to be answered- monotherapy vs with OIT, can it help get to sustained unresponsiveness with the right pt (either bite proof or "free eating"), will it be needed for life or a period of time? Lots to consider, and pt age and acuity will factor in, but a potent new tool.

Dupixent trials have been less promising for food allergy, though a wonderful biologic for eczema, asthma and may still have use. I share the reservations about OIT. In application, there are many hurdles of which families often aren't aware. A pt and family will want to be fully informed and make a shared decision with an allergist.

And since I'm here, please help get this message out, EARLY INTRODUCTION IS ESSENTIAL. All the top allergens into the diet in age-appropriate forms when your child is ready for solids at 4-6 MONTHS OF AGE. Yes, that early. If there is any hesitation (bc of eczema, sibling/family history, etc), get to an allergist for support, but don't unilaterally take it out of your child's diet. We now know this has the possibility to potentiate an allergy and there is for many a window on immune plasticity.

Thanks for indulging the PSA, best of luck OP.

I'm so curious if you have input/theories on causes of food allergies and the rise of food allergies in children. Our first is allergic to tree nuts, initially also dairy and egg, but passed oral challenges to both of those by age 2. With his sister, we followed ALL of the guidelines for early introduction with a mix-in formula starting at 4 months and continued to offer bamba, lara bars, dairy, egg, everything. She never liked straight peanut products so we didn't force it, but we didn't remove them or restrict her from eating peanut-containing cookies, candy or anything. So it was pretty shocking when at age 7 she had an anaphylactic reaction to ice cream and was formally diagnosed with a peanut allergy. I know this is atypical and we feel like we did everything "right" to avoid. No history of allergies in the family other than her brother, but they both had eczema as infants and toddlers.

I've read about the theory that specific gut bacteria may be responsible for allergies. Hopefully this line of research will be pursued.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Hi OP, I work in food allergy.

And since I'm here, please help get this message out, EARLY INTRODUCTION IS ESSENTIAL. All the top allergens into the diet in age-appropriate forms when your child is ready for solids at 4-6 MONTHS OF AGE. Yes, that early. If there is any hesitation (bc of eczema, sibling/family history, etc), get to an allergist for support, but don't unilaterally take it out of your child's diet. We now know this has the possibility to potentiate an allergy and there is for many a window on immune plasticity.

Thanks for indulging the PSA, best of luck OP.

UGH this is SUCH BS. Look, early introduction works for kids who don’t have food allergies because they DON’T HAVE FOOD ALLERGIES. Statistically speaking very few kids have food allergies but those who do, it is NOT because their parents didn’t introduce the food early enough. It is simply luck of the genetic draw.

While we are at it, let us set aside the myth that farm kids are hardier when it comes to asthma. Every farming community has kids with severe asthma. Yes, in a family of farmers there can be a few family members who get severe respiratory troubles with the harvest season. There is nothing inherently alllergy protective about being raised on a farm, again—it is just genetics.

This is a really harsh response. There was a well known study that came out in 2015 that showed scientific evidence that introduction of peanuts at 4-6 months reduced the risk of kids developing peanut allergies. I get it - my daughter was born in 2014 and I wish I would have known this before she developed her own peanut she developed her peanut allergy. Allergies aren’t the fault of any parent doing the best they can with available evidence, and there’s absolutely a major genetic component to it. But when my younger DS was born, I spent a lot of time with my DD’s allergist going over the evidence, and I was absolutely convinced that it made sense to introduce common allergens to him at 4 months.

https://www.foodallergy.org/resources/learning-early-about-peanut-allergy-leap

I have a peanut allergic kid born 2008, and I gave peanuts to her at 15 months (per the ped) and I have a kid with no allergies born 2011 that didn’t get nuts until age 3 (per our allergist.) So, I’m skeptical.

NP. I don’t think it is an absolute, by any means. I developed a peanut and tree nut allergy as a teenager, after having practically lived off of PB&J sandwiches in my childhood. I followed the recommendations for early introduction when my older child was born, but she ended up developing a peanut allergy when she was 3. Younger DD went anaphylactic to her very first intro to eggs. I feel like there’s certainly a genetic component and, while early introduction may help, parents shouldn’t be made to feel like their child’s food allergies are somehow their fault because they didn’t introduce everything early enough.

Dos xolair work for tree nut allergies? We also see Scarupa, and he did not mention this at our last visit, which was more than a year ago. But there's no peanut allergy, so Maine that's why? Just trying to decide whether to check back with him sooner rather than later....

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Hi OP, I work in food allergy.

And since I'm here, please help get this message out, EARLY INTRODUCTION IS ESSENTIAL. All the top allergens into the diet in age-appropriate forms when your child is ready for solids at 4-6 MONTHS OF AGE. Yes, that early. If there is any hesitation (bc of eczema, sibling/family history, etc), get to an allergist for support, but don't unilaterally take it out of your child's diet. We now know this has the possibility to potentiate an allergy and there is for many a window on immune plasticity.

Thanks for indulging the PSA, best of luck OP.

UGH this is SUCH BS. Look, early introduction works for kids who don’t have food allergies because they DON’T HAVE FOOD ALLERGIES. Statistically speaking very few kids have food allergies but those who do, it is NOT because their parents didn’t introduce the food early enough. It is simply luck of the genetic draw.

While we are at it, let us set aside the myth that farm kids are hardier when it comes to asthma. Every farming community has kids with severe asthma. Yes, in a family of farmers there can be a few family members who get severe respiratory troubles with the harvest season. There is nothing inherently alllergy protective about being raised on a farm, again—it is just genetics.

This is a really harsh response. There was a well known study that came out in 2015 that showed scientific evidence that introduction of peanuts at 4-6 months reduced the risk of kids developing peanut allergies. I get it - my daughter was born in 2014 and I wish I would have known this before she developed her own peanut she developed her peanut allergy. Allergies aren’t the fault of any parent doing the best they can with available evidence, and there’s absolutely a major genetic component to it. But when my younger DS was born, I spent a lot of time with my DD’s allergist going over the evidence, and I was absolutely convinced that it made sense to introduce common allergens to him at 4 months.

https://www.foodallergy.org/resources/learning-early-about-peanut-allergy-leap

I have a peanut allergic kid born 2008, and I gave peanuts to her at 15 months (per the ped) and I have a kid with no allergies born 2011 that didn’t get nuts until age 3 (per our allergist.) So, I’m skeptical.

4-6m is the recommendation. We also were told to touch our infants with hands after touching peanuts earlier than 4-6m because the skin can increase exposure.

Not everyone is going to develop your allergy. Your 2011 kid probably was never going to develop one. But in kids who might develop an allergy, early exposure has shown a reduction in allergies.

one other caution on OIT is that it may induce EoE in some patients as well as being difficult to manage continuing the maintenance doses

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Yes!! Xolair - our allergist said we can expect FDA approval in Q1 or Q2 of 2024. It’s a once-monthly injection that substantially reduces risk of a severe reaction. There’s another one in clinical trials now that has an even more dramatic effect. And what’s really cool is that a PN-allergic kid could take it during risky times, e.g., high school, college, but wouldn’t need to as a responsible adult with their own kitchen.

This allergist (Mark Scarupa at Institute for Asthma and Allergy) is also not high on OIT, for various reasons. But he was positively giddy about these options. It felt like a bit of relief for my 10yo PN-allergic DS.

Interesting. DS sees Dr Scarupa for peanut allergies and at his last visit in August, right before he left for college, Dr Scarupa didn’t even mention this.

That's too bad. He always discusses the latest research at our appointments. I work at NIH and so we've talked shop a bit before, but that shouldn't matter. He told us this info in June, maybe he changed tactics in discussing it in between then and August?

With respect to early introduction, allergies are NOT solely determined by genetics, but rather by gene-environment interaction. As a PP said, it reduces the risk for development of allergy, but it's not a guarantee. Interestingly, my PN-allergic son was just a tad too old to benefit from findings/updated clinical guidance from the LEAP study. Scarupa was very candid with us after the fact, "we gave you the wrong advice." He was also adamant that our youngest (2.5 years younger than the PN allergic kid) be exposed early, which we did.

Last but not least, his hesitations around OIT were mostly logistical, but he also said that many kids who do it feel sick from the allergen (even if they don't have a true reaction) and also that many develop a strong aversion to the food in question. DS doesn't want to come anywhere near peanuts, so I can imagine it would be a struggle to get him to try a bit, especially since he would have to have it regularly, indefinitely, to prevent loss of tolerance.

Still excited for Xolair. I know it's not a cure, but reducing risk of anaphylaxis is huge.

My daughter used bamba crushed up and mixed into applesauce. She initially hated peanut butter - but now (after passing her food challenge) she eats it almost daily - by choice!

OIT - it was a LOT of time commitment but my daughter officially passed her oral peanut challenge a couple months ago (after being diagnosed with a severe peanut allergy 2 years ago).

1.5 years of frequent allergist appointments is totally worth a lifetime of no longer worrying about accidental exposures.

I urge any parent who has a child with an allergy - try OIT. It could save your child's life one day.

I'm on Xolair for severe allergic asthma. It's absolutely a miracle drug!

Anonymous wrote:Hi OP, I work in food allergy. I can tell you we are all eager for the announcement of Xolair, which could before the end of the year, with a Q1/Q2 FDA approval.

It's important to differentiate Xolair is not being considered a cure for food allergy, but a medicine that takes away the risk of anaphylaxis on accidental exposure. Still lots of questions to be answered- monotherapy vs with OIT, can it help get to sustained unresponsiveness with the right pt (either bite proof or "free eating"), will it be needed for life or a period of time? Lots to consider, and pt age and acuity will factor in, but a potent new tool.

Dupixent trials have been less promising for food allergy, though a wonderful biologic for eczema, asthma and may still have use. I share the reservations about OIT. In application, there are many hurdles of which families often aren't aware. A pt and family will want to be fully informed and make a shared decision with an allergist.

And since I'm here, please help get this message out, EARLY INTRODUCTION IS ESSENTIAL. All the top allergens into the diet in age-appropriate forms when your child is ready for solids at 4-6 MONTHS OF AGE. Yes, that early. If there is any hesitation (bc of eczema, sibling/family history, etc), get to an allergist for support, but don't unilaterally take it out of your child's diet. We now know this has the possibility to potentiate an allergy and there is for many a window on immune plasticity.

Thanks for indulging the PSA, best of luck OP.

I'm so curious if you have input/theories on causes of food allergies and the rise of food allergies in children. Our first is allergic to tree nuts, initially also dairy and egg, but passed oral challenges to both of those by age 2. With his sister, we followed ALL of the guidelines for early introduction with a mix-in formula starting at 4 months and continued to offer bamba, lara bars, dairy, egg, everything. She never liked straight peanut products so we didn't force it, but we didn't remove them or restrict her from eating peanut-containing cookies, candy or anything. So it was pretty shocking when at age 7 she had an anaphylactic reaction to ice cream and was formally diagnosed with a peanut allergy. I know this is atypical and we feel like we did everything "right" to avoid. No history of allergies in the family other than her brother, but they both had eczema as infants and toddlers.

My twins with severe nut allergies were told at age 8 that their allergies were too severe to try peanut challenge. Fast forward to age 14, we redid skin tests and both of them have passed peanut food challenge. If it’s been awhile since your kid was last tested, it’s worth another test.

I'm the PP above with the comments of Xolair and early introduction.

I want to be clear, food allergy parents deserve so much empathy around the stress, fear, changing information and unique presentations of this challenging disease.

Those unique presentations are part of what make unilateral recommendations difficult. Hypothetically, let's say OIT works for 70% of patients. That's a terrific therapy right? But the downside risk is your child has an anaphylactic reaction. Another is a portion for whom the therapy will be miserable. This is not a one size fits all, or even most, therapy, which is why it requires thoughtful consideration.

By continuing to get the word out on changed recommendations, no blame at all is attributed to a parent about what they "could have done." The same is true for whether mothers included certain foods in a prenatal diet or not, or had a vaginal vs caesarean delivery. Families are informed by their clinicians, and the 2000 AAP recommendations were delayed introduction. That has changed: https://www.contemporarypediatrics.com/view/new-evidence-changes-guidelines-food-allergies

We now know that delayed introduction does not provide protection. And, level of correlation unknown, incidence significantly increased.


The 2015 LEAP and follow-on studies showed us early introduction of peanut provided protective benefit to high-risk groups, prompting a change to the AAP recommendation in 2019, which we are still working every day to communicate.

OP and similar parents are doing just the right thing by checking in, because this is far from a static field.

Anonymous wrote:

Anonymous wrote:Yes!! Xolair - our allergist said we can expect FDA approval in Q1 or Q2 of 2024. It’s a once-monthly injection that substantially reduces risk of a severe reaction. There’s another one in clinical trials now that has an even more dramatic effect. And what’s really cool is that a PN-allergic kid could take it during risky times, e.g., high school, college, but wouldn’t need to as a responsible adult with their own kitchen.

This allergist (Mark Scarupa at Institute for Asthma and Allergy) is also not high on OIT, for various reasons. But he was positively giddy about these options. It felt like a bit of relief for my 10yo PN-allergic DS.

Interesting. DS sees Dr Scarupa for peanut allergies and at his last visit in August, right before he left for college, Dr Scarupa didn’t even mention this.

That's too bad. He always discusses the latest research at our appointments. I work at NIH and so we've talked shop a bit before, but that shouldn't matter. He told us this info in June, maybe he changed tactics in discussing it in between then and August?

With respect to early introduction, allergies are NOT solely determined by genetics, but rather by gene-environment interaction. As a PP said, it reduces the risk for development of allergy, but it's not a guarantee. Interestingly, my PN-allergic son was just a tad too old to benefit from findings/updated clinical guidance from the LEAP study. Scarupa was very candid with us after the fact, "we gave you the wrong advice." He was also adamant that our youngest (2.5 years younger than the PN allergic kid) be exposed early, which we did.

Last but not least, his hesitations around OIT were mostly logistical, but he also said that many kids who do it feel sick from the allergen (even if they don't have a true reaction) and also that many develop a strong aversion to the food in question. DS doesn't want to come anywhere near peanuts, so I can imagine it would be a struggle to get him to try a bit, especially since he would have to have it regularly, indefinitely, to prevent loss of tolerance.

Still excited for Xolair. I know it's not a cure, but reducing risk of anaphylaxis is huge.

Anonymous wrote:We did OIT and once we got to the maintenance phase my daughter completely loathed eating the maintenance dose (one peanut m&m a day). It was a constant battle. I didn’t see that coming but it makes sense. Her body hates peanuts and the taste as a defense mechanism. She could tolerate eating it with no allergic reaction she just hated the taste and begged not to do it. It was pretty hard to picture keeping it up for the rest of her life.

I think it’s worth trying though. The OIT is a massive commitment. Not an easy path.

I could have written this post. DD hates her daily peanut m&m. We did the peanut patch to get to this point. She had awful eczema so the patched work great on her.