Home multifood oral immunotherapy microdosing with Dartmouth Spoon Sheets

We are incredibly grateful Julia will be doing an immunotherapy program called “Dartmouth Spoon Sheets” starting on August 6 (barring more allergy complications over the summer which could delay the start). It is similar to Oral Immunotherapy (OIT) which is more widely offered, but is not exactly the same as OIT in terms of process. The hoped for outcome of this micro-dosing protocol is to get to the point where Julia can tolerate eating the equivalent of one cashew a day and one walnut a day (which per this protocol is 1/2 teaspoon of cashew powder and a 1/2 teaspoon of walnut powder). By treating for cashew you are also treating for pistachio since they have such similar proteins, and likewise for walnut with pecan. This “medicinal cashew and walnut” serves as a buffer against catastrophe: ie she won’t go into a severe allergic reaction if she is accidentally exposed to cashew/pistachio/walnut/pecan. It would also allow us to give her foods that are “processed with in facilities that also process tree nuts,” which would vastly expand what foods we are able to offer her.

There is a possibility that as she works her way through the micro-dosing program she’ll have a major allergic reaction and have to stop the program and just follow strict avoidance of cashews/pistachios/walnut/pecans. There is the hope that this won’t happen, and that she’d even get to someday progress beyond the maintenance dose of one cashew and walnut a day, and possibly someday be able to free eat cashew/pistachio/walnut/pecan in addition to her medicinal cashew/walnut a day. The allergist we are working with, Dr. Shaker at Dartmouth Hitchcock Medical Center, said she might grow into this possibility in the ballpark of a five year timeline.

The way “Dartmouth Spoon Sheets” works is that we will mix the tiniest micro-dosing spoonful of cashew powder AND walnut powder into 3 ounces (or 18 teaspoons) of applesauce, and she’ll eat 1 teaspoon of this mixture on day 1. We will create this same mixture (tiniest micro-dose spoon of cashew and of walnut into 3 ounces of applesauce) each day for 25 days, and each day she’ll eat an additional teaspoon of the mixture, working up to her eating the entire 3 ounces (18 teaspoons) of this mixture on day 18. She’ll then stay at this dose of 18 teaspoons for two weeks. Then the process will start over with the medium micro-dosing spoonful of cashew powder and walnut powder—eating one teaspoon of the mixture on day 1 up to the full 18 teaspoons on day 18, and then maintain for two weeks. She’ll repeat this process with the large micro-dosing spoon and then she’ll move into mini teaspoons of cashew powder and walnut powder—repeating the process with 1/64 teaspoon of cashew powder, 1/32, teaspoon 1/16 teaspoon, 1/8 teaspoon, 1/4 teaspoon and finally 1/2 teaspoon—which is the goal dose. Nine different spoon sizes of cashew powder and walnut powder—each taking around a month minimum. Any time Julia is sick, the process will slow down, which is why Dr. Shaker advised us to plan on the full protocol taking anywhere between a year to a year and half.

This program moves slower (the increase in the amount of nut ingested is incredibly gradual) as opposed to traditional OIT where every two weeks there is a bump in dose. Additionally, when Julia moves up in spoon size, there is a period of time when she’s eating a smaller quantity of the new mixture as she works her way up to the full 18 teaspoons over 18 days where her actual dose of cashew/walnut will drop down for a period of time and then build higher as she works her way up to eating more of the less dilute mixture. The paper linked above explains how this is helpful because it builds in a dropping back solution for when Julia is sick (which no doubt will be often as it always is with kids).

The wait we were quoted in the Boston area was a year and half to start OIT because demand is so high—the allergist we saw in Boston advised us to look to see if we could begin the process sooner elsewhere as infancy is the ideal timeline for starting treatment because that is when your immune system is most flexible. We are beyond lucky that we’ll be able to get started summer of 2025 with such a fantastic treatment team, and that we will be able to do most of this protocol from home with just occasional trips to NH to check in on her progress.