Severity and threshold of peanut reactivity during hospital‐based open oral food challenges: an international multi‐center survey

Peter Arkwright, Jayne MacMahon, Jennifer J Koplin, Shelly Rajput, Stephanie Cross, Roisin Fitzsimons, Neil Davidson, Veena Deshpande, Naveen Rao, Colin Lumsden, David Lacy, Katrina Allen, Gill Vance, James Mwenechanya, Adam T. Fox, Michel Erlewyn-Lajeunesse, Hitesh Mistry, Jonathan O'B Hourihane

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Peanut allergy is classically managed by food avoidance. Immunotherapy programmes are available at some academic centers for selected patients reacting to small amounts of peanut during food challenge. We aimed to determine and compare reaction thresholds and prevalence of anaphylaxis during peanut oral challenges at multiple specialist allergy centers.

A retrospective, international survey of anonymized case records from seven specialist paediatric allergy centers from the UK and Ireland, as well as the Australian HealthNuts study. Demographic information, allergy test results, reaction severity and threshold during open oral peanut challenges were collated and analysed.

Of the 1,634 children aged 1 to 18 years old included, 525 (32%) failed their peanut challenge. 28% reacted to 25mg, while 38% only reacted after consuming 1g or more of whole peanut. Anaphylaxis (55 (11%)) was 3‐times more common in teenagers than younger children and the likelihood increased at all ages as children consuming more peanut at the challenge. Children who developed anaphylaxis to smaller 25–200mg whole peanut were significantly older. Previous history of reaction did not predict reaction threshold or severity.

More than a third of the children in this large international cohort tolerated the equivalent of one peanut in an oral challenge. Anaphylaxis, particularly to small amounts of peanut was more common in older children. Tailored immunotherapy programmes might be considered not only for children with low, but also higher reaction thresholds. Whether these programmes could prevent heightened sensitivity and anaphylaxis to peanut with age also deserves further study.
Original languageEnglish
Pages (from-to)754-761
Number of pages8
JournalPediatric Allergy and Immunology
Issue number7
Early online date19 Jul 2018
Publication statusPublished - 1 Nov 2018


  • anaphylaxis
  • children
  • food allergy
  • oral food challenge
  • peanut
  • threshold


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