Low-dose peanut challenges can facilitate infant peanut introduction regardless of skin prick test size

Abstract

The Learning Early About Peanut Allergy (LEAP) trial and other studies recommend early peanut introduction to prevent peanut allergy in at-risk infants. 1 Du Toit G. Roberts G. Sayre P.H. et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015; 372: 803-813 Crossref PubMed Scopus (1239) Google Scholar ,2 Perkin M.R. Logan K. Tseng A. et al. Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016; 374: 1733-1743 Crossref PubMed Scopus (497) Google Scholar In addition, peanut oral immunotherapy (OIT) shows increased rates of sustained unresponsiveness in children younger than 5 years with known peanut allergy, 3 Vickery B.P. Berglund J.P. Burk C.M. et al. Early oral immunotherapy in peanut-allergic preschool children is safe and highly effective. J Allergy Clin Immunol. 2017; 139: 173-181.e8 Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar suggesting better outcomes with early exposure. The LEAP trial excluded infants with skin prick tests (SPTs) greater than 4 mm. 1 Du Toit G. Roberts G. Sayre P.H. et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015; 372: 803-813 Crossref PubMed Scopus (1239) Google Scholar The guidelines recommend peanut introduction or oral food challenge (OFC) only in infants who have SPTs less than or equal to 7 mm and do not specifically address management of infants with SPTs greater than 7 mm (or high peanut IgE levels). 4 Togias A. Cooper S.F. Acebal M.L. et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017; 139: 29-44 Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar Data suggest that patients with peanut SPT greater than 7 mm are likely to react, 4 Togias A. Cooper S.F. Acebal M.L. et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017; 139: 29-44 Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar ,5 Roberts G. Lack G. Diagnosing peanut allergy with skin prick and specific IgE testing. J Allergy Clin Immunol. 2005; 115: 1291-1296 Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar but most reference values for SPT and peanut IgE levels are not standardized for infants. 5 Roberts G. Lack G. Diagnosing peanut allergy with skin prick and specific IgE testing. J Allergy Clin Immunol. 2005; 115: 1291-1296 Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar ,6 Hill D.J. Heine R.G. Hosking C.S. The diagnostic value of skin prick testing in children with food allergy. Pediatr Allergy Immunol. 2004; 15: 435-441 Crossref PubMed Scopus (201) Google Scholar It is unknown whether infants with SPT greater than 7 mm may tolerate and benefit from early peanut exposure. Given the potential long-term benefits of tolerating peanut, we sought to offer peanut OFCs to a wider population of sensitized infants.