The Daily
Dose

When Avoidance Isn’t Enough

Shaker, who is also a professor of pediatrics and of medicine at the Geisel School of Medicine at Dartmouth, remembers how different allergy care used to be. “When I was in training, the dogma was that you should not give kids peanuts until they’re four if they were at risk,” he says. But “that’s not the way the body works. That’s not the way any of it works.”  

Results from the international LEAP trial (Learning Early About Peanut Allergy) changed that thinking around 2015, revealing that early introduction of peanut products to high-risk infants significantly reduced allergy development. This evidence informed national guidance Shaker co-authored in 2020, recommending peanut and egg introduction around four to six months, with ongoing ingestion thereafter.  

But for some families, changes in guidance came too late.  

Jackie Leopold D ’98 discovered her son Luke’s peanut allergy in the most frightening way possible. Following her pediatrician’s advice to introduce peanut butter around his first birthday, she gave Luke his first taste while washing dishes. “I just heard him kind of start moaning,” she recalls. “I turned around, and his face was just swelling up before my eyes.”  

That first anaphylactic reaction led to Luke’s diagnosis: severe allergies to all nuts and sesame. For years, the Leopold family lived under the standard protocol of strict avoidance and hypervigilance. “It sounds so easy to avoid nuts, but it’s way harder than you think when you consider cross-contamination,” Jackie says. Luke couldn’t go to Chinese restaurants, certain bakeries, even Starbucks. At school, he had to sit at the ‘no nuts’ table at lunchtime. The family’s world revolved around risk management, with Luke’s parents and two siblings also avoiding any foods that might contain nuts and sesame in solidarity and out of an abundance of caution.  

“Every time you go out to eat, if your child is allergic to trace amounts like Luke, you’re taking a chance,” Jackie explains. “It’s constantly [making] judgment calls.”

For infants, severe allergic reactions can be particularly difficult to handle. Drew Stull and Dijana Poljak, who live in Colchester, Vermont, and who both work in medicine, discovered this the hard way when their son Benji developed severe allergies at just six months old. “Just imagine, a six-month-old infant, going into anaphylactic shock,” Drew says. “We were absolutely terrified.” 

Worse, Benji was too small for a pediatric epinephrine auto-injector (sometimes referred to by one brand name, EpiPen). After their baby son was stippled in hives, Drew and Dijana scrambled to find anyone who had an auto-injector small enough for his size. “We called everywhere,” Drew recalls. There were only two auto-injectors small enough for Benji in all of Vermont, and the last one was going to expire in a couple months. “It was an absolute nightmare.”  

Start Low, Go Slow

When the Leopolds moved to Vermont in 2020, finding treatment for Luke’s allergies topped their priority list. Serendipitously, just after the family had begun settling in, they discovered Shaker and Hughes were in the midst of launching a home-based OIT program. Luke became one of the program’s first patients in 2021.  

Allergy desensitization works best by avoiding fast buildups or static dosing, Shaker explains. So families are instructed to increase the daily dose slowly, following the clinic’s “Dartmouth Spoon Sheets,” a microdosing protocol designed for routine kitchen practice.  

Families start with a thousandth of a peanut (or other allergen), mixing a pinpoint of peanut flour into applesauce. Children take “one bite. And that’s it,” Shaker says. The next day, two bites, gradually building until “within a year and a half they’re eating the whole peanut’s worth—300 milligrams.”  

“It’s not a race,” he advises. “It’s OK if you get there in two years instead of nine months.” 

Both Luke and Benji’s families were surprised at how user-friendly the program was. The bulk of care takes place via telehealth. “We thought we were signing up to drive [to the hospital] all the time, and we’re not,” says Jackie, Luke’s mother. “We were pleasantly surprised.”  

Benji’s parents, Drew and Dijana, also found the program’s accessibility remarkable. “Initially, we were terrified of doing this at home. But very quickly, we saw it as a privilege and advantage,” Dijana says.  

The program is orders of magnitude more affordable, too. Drew tracked his family’s total program costs at $1,708—a fraction of commercial alternatives, which can reach $10,000 and have mixed results. The lion’s share of expenses: $385 for applesauce and peanut and walnut flour.  

So far, the Dartmouth Health program has enrolled more than 300 people in home-based peanut OIT, with fewer than 5% needing epinephrine at any point and 85% of toddlers eventually eating full servings of peanut. While some care remains clinic-based—periodic food challenges are conducted on-site at Dartmouth Health’s Dartmouth Hitchcock Medical Center (DHMC) over six-hour sessions to check results—the vast majority of treatment happens at home.  

A World of Bagels and Hummus

After five years of daily treatment, Luke now eats at least one peanut and one cashew daily to maintain his desensitization. He passed his sesame food challenge completely, opening “a whole new world of bagels and hummus,” his mother says.  

The program’s real-world test came when Luke accidentally ate a peanut butter ice cream cone at Ben & Jerry’s. His mother gave him an oral antihistamine and watched carefully, but no epinephrine was needed. “It already saved his life,” Jackie attests. “Besides the fact that he’s a normal kid who doesn’t have to have special food when he’s with friends.”  

Now, Luke feels free to eat almost anything. He can go to birthday parties and eat cake, he can enjoy Halloween candy, and he doesn’t have to read snack food labels carefully anymore. He can eat fast food when out with friends, and he tried sushi for the first time this year.  

“It’s like getting another sense,” Luke says. “It’s really eye opening to have a taste I’ve never had before.”  

Four-year-old Benji now treats his daily routine so naturally that he reminds his parents about his “special applesauce.” The family that once scoured Vermont for expiring epinephrine auto-injectors now travels freely. “I’ve stopped asking at restaurants. I never thought it would be like that,” Dijana says.