When Porter Hall of Raymore, Missouri, was a year old, he broke out in hives after eating a spoonful of peanut butter. It led to a scary night in the emergency room and a diagnosis of peanut allergy.
But today, Porter, who’s now five, is giving peanuts another shot with the help of Kansas City doctors, who have been giving him tiny doses of peanuts over the course of months.
This oral immunotherapy treatment isn’t a cure, but doctors say these tiny exposures may help to reduce or prevent severe reactions – although some critics are warning families to consider the risks.
At Children’s Mercy Hospital in Overland Park, nurse practitioner Jodi Shroba gives Porter a quick once-over in preparation for administering a tiny dose of what’s essentially peanut dust.
Like many parents dealing with a child’s allergy, Porter’s mother, Amy Hall, says she was initially “freaked out,” and took dramatic steps to keep peanuts away, including purging the contents of her kitchen cabinets.
Shroba says this fear can make the exposure sessions terrifying for parents and children alike.
“You see the anxiety,” Shroba says. “They gotta kind of psych themselves up for it, and they’re like, ‘I can do this. I can do this.’”
Children’s Mercy doctor Jay Portnoy explains that gradually increasing exposures are meant to reduce severe reactions by exhausting the immune system’s of chemicals like histamine that lead to those reactions.
“We’re creating like little mini-reactions that are so small that the patient doesn’t notice it. Occasionally, they’ll get itchy mouth, they might get a little bit of stomach ache, but for the most part, these reactions are definitely tolerable, and then as we increase it, they become more and more tolerant of the peanut allergen,” Portnoy says.
After six months, Portnoy says patients may be able to tolerate a few peanuts at a time, if they keep the exposures going.
Right now, the treatment is only offered at a limited number of hospitals and clinics around the country. But it may be on the verge of taking off.
The Food and Drug Administration is now reviewing AR101, a kind of medical-grade peanut flour produced by drug maker Aimunne Therapeutics that was tested at Children’s Mercy and other hospitals.
And a research review recently published in The Lancet shows that oral immunotherapy appears to work. At least it does in clinics, where patients have been able to overcome food allergy challenges.
But one of the study’s authors, allergy researcher Dr. Derek Chu of McMaster University in Hamilton, Ontario, notes that things can change after they leave.
“Outside of the clinic setting, they actually have a much higher rate of reaction,” Chu says. “That’s two to three times more likely to react to peanut or the dose that they are exposed to during this desensitization procedure compared to avoiding it or receiving a placebo instead.”
Jury is out
Chu says that, outside of clinics, factors like exercise, hot weather and illness can affect allergic reactions, making it more likely that patients will react to peanuts.
The vast majority of these reactions are mild. But children doing the therapy had about a 20% chance of anaphylaxis, compared to about 7% doing placebo or avoiding peanuts, according to the review.
Chu says that, given oral immunotherapy’s costs, risks and complications, the jury is still out on who might experience an improved quality of life from it.
“What we do need to ask is, is this really ready for prime time?” Chu says. “I think there’s significant gaps in knowing the values and preference of patients, as well as knowing if are we fully there for en masse use. I’m not saying no, I’m not saying yes, but we need to have a very robust assessment to know where we’re at.”
Children’s Mercy’s Portnoy says they have not seen any reactions more serious than an upset stomach. But Portnoy acknowledges that families will need to weigh risks and benefits for themselves.
After Porter’s checkup, the nurse stirs some peanut flour into apple juice. Now that a few months of oral immunotherapy are behind him, the 5-year-old seems to take it in stride. With plenty of epinephrine nearby, he casually sips it down and goes back to skimming a book.
At this point, it’s unclear how much he’ll benefit from the treatment, but Amy Hall says just seeing her son get this far has been reassuring.
“It’s made me be a little bit more at ease with him being able to eat at other peoples’ houses,” Hall says. “Or when Halloween rolls around, you never know what kind of candy they’re going to get. It makes me feel a little bit more at ease, but not 100%.”
Alex Smith is a health reporter for KCUR. You can reach him by email at firstname.lastname@example.org