Children with peanut allergies may not need large, hard-to-tolerate doses of peanut to build protection against accidental exposure, according to new research from The Hospital for Sick Children and Montreal Children’s Hospital.
The study, published in Journal of Allergy and Clinical Immunology – In Practice, examined whether very small daily doses of peanut oral immunotherapy could raise children’s reaction thresholds while causing fewer side effects than standard treatment. The research was funded by the SickKids Food Allergy and Anaphylaxis Program, the Canadian Institutes of Health Research, the Montreal Children’s Hospital Foundation and the U.S. Peanut Advisory Board.
Peanut allergy affects nearly 2% of children and adults in Canada and is a leading cause of food-related emergency care. Oral immunotherapy, or OIT, is a clinician-supervised approach that involves eating gradually increasing amounts of peanut to raise the level a child can tolerate before reacting. The goal is not to cure the allergy, but to reduce the risk of severe reactions from accidental exposure.
Current peanut OIT protocols typically rely on relatively large maintenance doses that must be consumed regularly to maintain protection. While effective for some families, these regimens often involve lengthy treatment, close medical supervision and frequent side effects, including allergic reactions. Taste aversion and fear of symptoms can also lead some children to stop treatment altogether.
To test whether lower doses could offer similar protection with fewer drawbacks, researchers randomly assigned 51 children with peanut allergy to one of three groups: a low-dose OIT group with a 30-milligram daily maintenance dose, a standard-dose OIT group with a 300-milligram maintenance dose, or a control group that avoided peanut entirely. The study followed children over time to assess changes in their reaction thresholds and treatment tolerability.
Both OIT groups experienced significant and similar increases in the amount of peanut they could tolerate before reacting, indicating that even small daily exposures can help train the immune system to better manage accidental peanut contact. Children in the low-dose group experienced fewer adverse reactions than those receiving the standard dose, and none withdrew from treatment.
“We were excited to find that peanut OIT maintenance doses can be much lower than previously thought and still contribute to positive outcomes,” said Dr. Julia Upton, co-first author of the study and head of the Division of Immunology and Allergy at SickKids. “The more options we have, the more we can support patients’ experience and provide meaningful, tailored care.”
The lower-dose approach also appeared easier for children to tolerate.
“This is a small enough dose that even children who do not like the taste can continue treatment,” said co-senior author Dr. Thomas Eiwegger.
He added that future research may determine whether the minimum effective dose could be even lower than 30 milligrams.
The researchers emphasized that peanut OIT is always conducted under medical supervision and is not appropriate for unsupervised use. Some families may prefer to remain on very low doses to reduce side effects, while others may choose to increase over time depending on their goals and tolerance.
“The study found that very small amounts of peanuts, that are associated with less reactions, could be used as effectively as large amounts for oral immunotherapy, making it safer and accessible to more Canadians, even those who are very sensitive to the allergen,” said Dr. Moshe Ben-Shoshan, a co-senior author of the study and pediatric allergy specialist at Montreal Children’s Hospital.
Taken together, the findings suggest that lowering maintenance doses could make peanut OIT more accessible to families who previously found standard protocols too burdensome or risky. Rather than changing the goal of therapy, the approach may offer a safer, more flexible way to reduce the risk of severe reactions from accidental exposure, especially in everyday settings such as schools and shared food environments.