Analysis of data from the multi-center FORWARD (Food Allergy Management and Outcomes Related to Racial/Ethnic Differences) study, which tracks more than 1,000 children with peanut allergy, has identified the most common age of onset and shown that elevated peanut-specific IgE levels can predict which patients face a higher risk of anaphylaxis. The findings were presented at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting by Janssen Fang, an MD candidate at Texas A&M College of Medicine.
Study Design and Population
The FORWARD study enrolled 1,496 children ages 0-12 years from four U.S. academic centers to examine demographic, clinical and immunologic features of peanut allergy. Researchers followed participants for more than seven years. Of the enrolled participants, 1,014 children (68%) had peanut allergy. Nearly half of these patients (46.3%) first presented between ages 1 and 3 years, while 19.5% presented at ages 3-5 years and 23.7% at ages 5-14 years.
Overlap Between Peanut Allergy and Other Conditions
The data showed a considerable overlap between peanut allergy and atopic dermatitis, with 82.8% of peanut-allergic children also having atopic dermatitis. Other common comorbidities included allergic rhinitis (47.7%), asthma (44.1%) and oral allergy syndrome (38.4%).
When asked what screening strategies pediatricians should implement given the high rate of atopic dermatitis in children with peanut allergy, Fang stressed that food allergy screening should focus on careful history taking.
“This is especially important in high-risk children like those with atopic dermatitis,” Fang said. “Our results suggest that peanut allergy can start early on, and it is important to ask parents if this food was introduced during infancy and whether there was a reaction to it, in which case the child needs to be tested for proper diagnosis to be made on time.”
Beyond peanuts, children enrolled in the study showed susceptibility to other food allergens; 13.2% were allergic to unbaked egg, 7.6% to unbaked milk, 5.2% to wheat, 4.3% to shellfish and 3.5% to finfish.
Incidence of Anaphylaxis in Children with Peanut Allergy
Anaphylaxis occurred in 3.6% of participants over a mean follow-up of 4.6 years. Children who experienced anaphylaxis had a median peanut-specific IgE level of 36.8 ng/uL, compared with 9.2 ng/uL in those without anaphylaxis.
Fang noted that they are working to establish a specific peanut-specific IgE threshold that could help clinicians identify high-risk patients who need closer monitoring or earlier intervention.
“We are trying to apply more advanced modeling to our data to introduce a threshold or a cutoff that can predict anaphylaxis,” Fang said. “We hope to report on that soon.”
Oral Immunotherapy Outcomes
The analysis also examined outcomes of oral immunotherapy (OIT). Among participants undergoing peanut OIT, 82.5% experienced a reaction, compared with 61.8% in the non-OIT group.
Fang cautioned against drawing conclusions about OIT safety from these numbers, explaining that the higher reaction rate likely reflects the fact that OIT is typically offered only to children with a confirmed history of reactions to peanuts.
“It might be that parents have chosen to go on OIT to reduce the chance of severe reactions in the future, or providers have offered it to reduce that chance,” Fang said. “Hence, our data cannot answer the question of which patient groups would benefit more; however, we hope we can get to that answer soon with our future studies.”
The researchers concluded that among peanut-allergic children in this large cohort, presentation most commonly occurs between the ages of 1 and 3 years and shows a strong association with atopic dermatitis. Although peanut anaphylaxis remains uncommon, higher peanut-specific IgE levels may help identify children at elevated risk.
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