Below are extracts from a letter to the Annals of Allergy, Asthma and Immunology from Dr Lyndon Mansfield in Texas - and Dr Harry Morrow-Brown?s response.

Dr Lyndon Mansfield

Dr Mansfield described the case of a six-year-old girl who was so allergic to peanuts that she had had two life-threatening anaphylactic attacks pre-school.

In school just touching the hand of another child who had eaten a peanut butter sandwich caused another severe reaction.

By the time the epinephrine (adrenaline) had been located she had collapsed. The emergency services administered intravenous epinephrine and she did recover.

However, her parents, who believed that they had done everything that they could to protect her, were so distressed that the mother considered giving up her job to teach her at home.

Dr Mansfield suggested that oral desensitisation might protect the child against unintentional exposure to peanuts although it would be unlikely to enable her to eat peanuts as a normal food. The starting dose was administered in Dr Mansfield’s office with a full emergency team in attendance in case of anaphylaxis; her only reaction was a slight rash and wheeze. During the subsequent eight-week period the daily dose was increased to four whole peanut kernels three times daily.

The girl has now been on maintenance dose of two peanuts a day for a year and has had two accidental contacts with peanut without a reaction. Tests showed that the peanut specific IgE antibody in her blood had reduced by more than a half in the year.

Dr Harry Morrow-Brown

I write to support the letter from Dr Mansfield on how oral desensitisation can be a practical alternative to avoidance.

This is far from a new idea, as it was in 1908 that a Dr Schofield reported in the Lancet (2) how he successfully desensitised a boy who was dangerously allergic to egg by giving him pills containing gradually increasing amounts of egg, while avoiding egg completely. The starting dose was 1/10,000 of an egg, a challenge was negative after six months, and thereafter he could eat an egg every day. This treatment was carried out in 1906, the very year that Von Pirquet coined the word allergy!

In 1985 John W Gerrard reported to the AAAAI meeting in New York (3) on six cases of peanut allergy desensitised via the oral route. I was present and recall how severely he was criticised for giving such dangerous treatment. In 2004 Meglio et al (4) successfully desensitised 15 out of 21 children proven by double-blind-placebo-controlled challenge to be severely allergic to milk. After the initial stages this treatment was carried out at home without problems. Three children could not be completely desensitised but because they could tolerate small amounts of milk they were no longer in danger.

John Freeman, who was the first to use subcutaneous immunotherapy in 1911 (5), taught many thousands of patients how to give themselves grass pollen injections safely every day for 54 days with excellent results. Every spring up till 1959 up to 6,000 patients attended St Mary’s Hospital in Paddington to receive their vaccine kits and meticulous instruction in self-inoculation. Although the top dose of 1.0ml of 10% w/v aqueous grass pollen extract was very high, and the final objective a negative skin test to grass pollen, the daily increase was very gradual and no serious incidents were reported.

Complete avoidance of the causative food is the standard medical advice today, but this policy places the main responsibility for avoidance on the parents and on the child, who is left vulnerable to accidental ingestion and anaphylaxis.

Must we condemn more and more unfortunate children and adults to live in constant fear of a dangerous reaction and required to carry epinephrine auto-injectors, with inevitable disruption of the quality of life of the whole family? Surely the better alternative would be inducing tolerance by very gradual reintroduction of the causative food, as reviewed by Niggeman (6)?

I suggest that the uncontrollable danger presented by accidental ingestion of an unknown amount of peanut should be compared with the controllable risk of oral/sublingual desensitisation, using appropriate dilutions of standardised peanut extracts.

A trial of this method must take great care to establish a starting dose below the threshold of reaction, thereafter increasing the daily dose very gradually to avoid reactions and allow ample time for tolerance to be acquired. Meticulous instruction and collaboration with carefully selected families would be essential. I feel sure that many would prefer to take an active part in treatment rather than live in constant fear of anaphylaxis.

A clinical trial of oral/sublingual induction of specific tolerance to peanut or other foods would demonstrate a practical answer to an increasingly common problem.

1. Mansfield l, Successful oral desensitisation for systemic peanut allergy Annals Allergy Clin. Immunol. 1006; 97: 266
2. Schofield AT A case of egg poisoning Lancet 1908; 1:716
3. Shenassa MM, Perelmutter L, Gerrard JW. Desensitisation to peanut J Allergy Clin Immunol. 1985: 75: No 1 pt 2, p177 Abstract 291
4. Meglio P, Bartone E Plantamura M, Arabito W, Giampietro PG. A protocol for oral desensitisation in children with cow’s milk allergy Allergy 2004; 59:980-987
5. Freeman J, Noon L Further observations on the treatment of hay fever Lancet 1911; 2:814-816
6. Niggeman B, Staden U, Rolinck-Werninghaus C, Beyer C Specific oral tolerance induction in food allergy Allergy 2006; 61: 808-811

First published in 2005

If you found this article interesting, you will find many more articles on anaphylaxis here, and reports of research into anaphylaxis here.
You can also find articles on peanut and tree-nut allergy here, cow's milk allergies here, egg allergy here, histamine intolerance hereand articles on a wide range of other allergic and intolerance reactions to a wide range of other foods here.

Back to top