Oral Immunotherapy Fundamentals for Families

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

  1. An intake visit to evaluate your child’s food allergy history and care plan
  2. Food challenges based on your child’s history, if not completed during the past year
  3. "Up-dosing" at the hospital so clinicians can monitor your child's reaction after the child ingests a larger controlled portion of the allergen
  4. Maintenance dose visits to the Oral Immunotherapy Program at least every three months for a year

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
  • Perform a spirometry (a test to evaluate how your child's lungs are working) if your child has a history of asthma
  • Review any medical events your child has experienced since their last visit
  • Perform a full physical exam of your child

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.

Dosing at home

Your child must take the allergen dose daily as directed. If more than two doses are missed in a row, you must inform the Oral Immunotherapy Program staff as your child may need to return to the hospital to be monitored during repeat dosing. 

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 [please provide phone number] 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.