Low-Dose Peanut Oral Immunotherapy May Protect Children With Peanut Allergies Just as Effectively as Higher Doses

Children living with peanut allergies may soon have access to a safer, simpler, and more tolerable treatment option, according to new research led by The Hospital for Sick Children (SickKids) in Toronto and Montreal Children’s Hospital. The study suggests that very small daily doses of peanut protein can provide meaningful protection against allergic reactions, without the higher risks and challenges associated with traditional peanut oral immunotherapy (OIT).

Peanut allergy is one of the most common and potentially severe food allergies worldwide. In Canada alone, nearly 2% of children and adults are affected, and peanut exposure remains a leading cause of emergency hospital visits related to food allergies. Even trace amounts can trigger reactions ranging from hives and vomiting to life-threatening anaphylaxis, making daily life stressful for families.

For years, peanut OIT has offered hope by gradually training the immune system to tolerate peanut protein. However, standard protocols typically involve relatively large maintenance doses, long treatment periods, frequent medical supervision, and a significant risk of side effects. This new study challenges the long-held assumption that higher doses are necessary for protection.

What Peanut Oral Immunotherapy Is and Why Dose Matters

Peanut oral immunotherapy works by introducing peanut protein in carefully controlled amounts, starting with extremely small doses and slowly increasing over time. Once a child reaches a target “maintenance” dose, they continue eating that amount daily to maintain protection.

The goal is not to cure peanut allergy but to raise the threshold at which a reaction occurs, so accidental exposure is less likely to cause severe symptoms. This can make everyday situations like school lunches, restaurants, or shared kitchens much safer.

Until now, most protocols aimed for maintenance doses around 300 milligrams of peanut protein, roughly equivalent to one whole peanut. While effective, these higher doses often cause frequent allergic reactions, gastrointestinal discomfort, and anxiety. Many children stop treatment early because they dislike the taste or experience repeated side effects.

Inside the Study: Comparing Low-Dose and Standard-Dose Therapy

The research team designed a randomized controlled trial, the first of its kind to directly compare standard peanut OIT with a significantly lower maintenance dose.

A total of 51 children with confirmed peanut allergy participated. They were randomly assigned to one of three groups:

Low-dose OIT group: 30 milligrams of peanut protein as a daily maintenance dose
Standard-dose OIT group: 300 milligrams of peanut protein daily
Avoidance group: no peanut exposure at all

The children in both OIT groups gradually increased their intake under medical supervision until they reached their assigned maintenance dose. The avoidance group continued strict peanut avoidance, which remains the current standard recommendation for many patients.

Key Results: Small Doses, Big Protection

After approximately one year of treatment, the results were clear and surprising.

Both the 30 mg low-dose group and the 300 mg standard-dose group showed significant and nearly identical improvements in how much peanut protein they could tolerate during food challenge tests. Many children were able to handle amounts well above what they might encounter through accidental exposure.

In contrast, children in the avoidance group showed no improvement, reinforcing the idea that complete avoidance does not train the immune system to become more tolerant over time.

In simple terms, eating even tiny amounts of peanut regularly was far more beneficial than avoiding it entirely, and doing so at a very low dose worked just as well as a much higher one.

Fewer Side Effects and Better Tolerability

One of the most important findings involved safety and side effects.

Children receiving the 30 mg maintenance dose experienced fewer allergic reactions overall compared to those on the 300 mg dose. These reactions included common OIT-related issues such as abdominal pain, nausea, hives, and mild systemic symptoms.

Notably, no children in the low-dose group withdrew from the study, while higher-dose OIT has historically been associated with significant dropout rates. The lower dose was also described as easier to consume, particularly for children who struggle with the taste or texture of peanut products.

Thirty milligrams of peanut protein is roughly one-eighth of a peanut, making it far less intimidating for young patients and their families.

What This Means for Families and Clinicians

These findings suggest that peanut OIT could become more accessible and flexible, especially for children who are highly sensitive or hesitant to begin treatment. A low-dose approach may:

Reduce the risk of severe reactions
Lower the burden of frequent clinic visits
Improve long-term adherence
Make treatment possible for children previously considered unsuitable for OIT

The researchers also noted that treatment goals can vary. Some families may choose to remain on a very low dose indefinitely for safety against accidental exposure, while others may gradually increase their dose over time based on comfort and medical advice.

Understanding the Immune System Response

Beyond clinical tolerance, the study also measured immune markers associated with peanut allergy. Both OIT groups showed favorable changes in immune responses, including shifts in peanut-specific antibodies that are known to play a role in allergic reactions.

These biological changes further support the idea that low-dose exposure actively retrains the immune system, rather than simply masking symptoms.

How This Fits Into the Bigger Picture of Food Allergy Care

Food allergies, especially peanut allergy, have been increasing steadily over the past few decades. While avoidance remains important, it does not reduce sensitivity and may even increase anxiety around food.

Newer approaches like oral immunotherapy, epicutaneous patches, and biologic medications are reshaping how clinicians think about allergy management. This study adds strong evidence that less aggressive strategies may still deliver meaningful protection, potentially shifting clinical guidelines in the future.

However, experts caution that peanut OIT, even at low doses, is not something to try at home. It requires careful diagnosis, supervision, and follow-up by trained allergy specialists.

What Still Needs to Be Studied

While the results are promising, the researchers emphasize that larger and longer-term studies are needed. Key questions remain, including:

How long protection lasts if treatment stops
Whether even lower doses could be effective
How low-dose OIT performs in broader, real-world settings

Still, this study represents an important step toward safer, more personalized allergy care.

Final Thoughts

The idea that very small amounts of peanut protein can provide meaningful protection challenges long-standing assumptions in allergy treatment. For families navigating the daily risks of peanut allergy, low-dose oral immunotherapy could eventually offer a more manageable and less stressful option.

As research continues, this approach may help more children live with greater confidence and fewer emergency visits, without the heavy burden of high-dose treatments.

Research Reference:
https://doi.org/10.1016/j.jaip.2025.10.007