Oral Immunotherapy Fundamentals for Families

If your child has been referred to the Oral Immunotherapy Program at CHOP and you would like your child to participate, you must agree to the following:

1. An intake visit, to evaluate your child’s food allergy history and determine a care plan.
2. Food challenges, based on your child’s allergy history if not completed during the past year.
3. Initial OIT dosing at CHOP’s Philadelphia Campus, so the full OIT team of clinicians can monitor your child’s reaction.
4. Updosing at CHOP’s Philadelphia Campus or select CHOP Specialty Care sites as your child ingests increasingly larger controlled portions of their allergen. Specialty Care sites are an option based on your child’s progress in OIT.
5. Home dosing of oral immunotherapy every day between updosing appointments.
6. Maintenance dose visits to the Oral Immunotherapy Program every three months for a year after your child has reached maintenance dosing.
7. Contact us if your child has a severe adverse reaction at any point during OIT, maintenance dosing or after.

Oral immunotherapy (OIT), helps desensitize children to the foods they are allergic to — such as eggs, nuts and milk — by giving them small quantities of the allergen every day at home, and then gradually increasing the amount under medical supervision at the hospital.

Prior to receiving OIT, your child must be healthy. Patients with other chronic illnesses, like asthma or allergic rhinitis, can participate in oral immunotherapy if their symptoms are under good control.

During OIT, you will work with allergists, nurses and nurse practitioners during clinic visits, and with the OIT program coordinator to schedule visits.

Dosing at the clinic

Before each new dosage of oral immunotherapy, you will meet with OIT Program staff who will:

• Evaluate your child's vital signs
• Review any medical events your child has experienced since their last visit
• Perform a full physical exam of your child

In addition, spirometry or peak flow measurements may be taken to assess lung function.

If your child is healthy and free from illness — including fever, wheezing, coughing or gastrointestinal (GI) illness — they will receive the new allergen dosage. Some children can increase the dosage of their allergen every two weeks, commonly called "up-dosing." Others may need more time to build up their body's resistance to the allergen.

Before up-dosing, patients must eat a meal. Complex carbohydrates are preferred; not snacks alone. If the OIT dosage is in powder form, it can be mixed into your child's choice of food, such as applesauce, pudding or yogurt. You should avoid mixing oral immunotherapy with extremely hot foods.

After the dose is taken, your child will remain under medical supervision for at least one hour, and possibly longer if the team deems necessary. Before your child can go home, clinicians will again assess them for any adverse reactions. If your child is tolerating the new dosage and not showing any allergic reactions, OIT team members will give you allergen dosage supplies for the next few weeks, along with instructions about how best to administer the dosage daily to your child at home. A follow-up appointment will be scheduled to reassess your child in a few weeks.

If, at any time, your child experiences a significant reaction to OIT, you should follow your child’s anaphylaxis plan, which is reviewed regularly with OIT families.

Dosing at home

Your child must take the allergen dose daily as directed. If your child misses a dose of OIT — for any reason — they risk decreasing their tolerance of the allergen, putting them at risk for an allergic reaction. Please call the OIT team BEFORE your child’s next scheduled dose. Your child’s doctor will advise you about the best course of action.

Allergen doses should be taken with a meal or a snack high in carbohydrates, such as rice, pasta, bread, cereal or oatmeal.

Patients must:

• Avoid hot showers or exercise for 30 minutes before dosing, and for two hours after dosing.
• Maintain two hours of calm activities after dosing. Anything that elevates the heart rate can introduce the protein too quickly and trigger symptoms.
• Medications should be avoided during the two-hour window if not prescribed by the CHOP team. Ibuprofen must be avoided for two hours before or after the dose.

• Continue to avoid all foods the patient is allergic to until directed by the OIT team.
• Avoid any alcohol consumption during the study. Alcohol can increase the rate at which foods and nutrients are absorbed by the body and can cause a more severe allergic reaction.

Examples of activities your child should avoid within two hours of dosing include:

• Significant exercise (running around, climbing, going to the gym, playing sports)
• Baths, showers, hot tubs, saunas or swimming
• Going outside on extremely hot days

Concerns when dosing at home

• If your child is vomiting or has diarrhea, their daily allergen dose should not be given. You should contact CHOP'S Oral Immunotherapy Program team at 267-426-4888 for advice and direction.
• If your child develops a cold, fever (≥ 100.4o F) or other illness, you should contact the OIT team to discuss if dose adjustments are needed. 

Allergic reactions

If your child has an allergic reaction — whether during up-dosing at the hospital or during daily dosing at home — patients must follow the anaphylaxis management plan and proceed safely to the nearest emergency department (ED).

When your child arrives in the ED, staff will notify the coordinator of the Oral Immunotherapy Program (if during business hours) or page an on-call physician. The following business day, OIT program staff will determine your child's next steps for dosing.

Visits

Patients must come to all visits with the Oral Immunotherapy Program with a family member or approved visitors.

Program duration

Depending on the number of allergens OIT is treating in your child, the active phase of the program can last from six months to three years. Currently, CHOP's Food Allergy Center offers oral immunotherapy for up to five foods at once. Once your child has reached a “maintenance dose” — a low dose that has proven to protect individuals against exposure to larger quantities of the allergen — your child will remain at this dose for a period of time, and in some cases, indefinitely.

During this time, your child will return for an OIT Program visit every three months for a year. After a year of maintenance dosing, your child will be offered an exit food challenge to determine how much of the allergen your child can safely consume without adverse reactions. Your child will continue to follow up with their primary allergist long term to monitor for reactions.

Families can withdraw their child from the Oral Immunotherapy Program at any time. Oral immunotherapy can also be stopped because of:

• A patient's response to therapy,
• For safety reasons, or
• At the discretion of the OIT clinic healthcare provider.

OIT costs

Costs to participate in the Oral Immunotherapy Program vary depending on the type of visit. The OIT intake visit will be billed similarly to any follow-up appointment for your child's allergies. Food challenges will be billed to your insurance, and increasing dosing visits will be based on a fee-for-service model.