Prof. Peter Kenneth Smith, MB, BS, PhD, FRACP, is a globally recognized allergist and immunologist. He serves as founder of Queensland Allergy Services and holds research leadership positions at multiple universities. With over 150 publications and nearly 4,000 citations, Prof. Smith is a frequent speaker at international conferences and contributes to several global allergy and immunology organizations.
Q. Your journey in immunology spans multiple continents and prestigious institutions. What first sparked your interest in allergies and immunology, and was there a particular moment when you knew this would be your life’s work?
That’s a great question. I originally started doing pediatrics so looking after children. Part of the reason I wanted to do that is making people better.A lot of medicine is actually holding people together whilst they become less well and stopping their decline. When I came to do my exams a component was allergy and immunology. In the institution I had, they didn’t actually have a dedicated children’s allergy unit. Allergy was not that common in Australia, we actually only had one large center in Australia in the early 90s and that was in Melbourne. When I was understanding immunology it seemed to make molecular sense, and from there because there was a lack of adequate training in Australia it gelled very well with the idea of making people better and the detective work to understand what was making people unwell. That pushed me down the allergy pathway.
Q. Your research has yielded over 150 publications and thousands of citations. Among your many contributions to the field, which breakthrough or discovery do you consider most significant, and why?
In 2007, I was reviewing why delayed feeding had become standard practice. Guidelines from WHO, American Academy of Pediatrics, and European Task Force (from ’99-2000) cited studies from San Diego. Around that time, papers from Israel about early nut exposure showed that in places where children eat nuts early (Kenya, China), they weren’t getting nut allergies. Similar patterns emerged with celiac disease and fish allergies. It didn’t make sense to be restricting foods.
When I analyzed the original 1989 San Diego study, I found they had misrepresented their own data. Their seven-year analysis showed no change in health outcomes at one, four, or seven years, yet they claimed delayed feeding reduced allergies – a dramatic misquote from their own paper. Expert groups used this misquote to write restrictive feeding guidelines.
When we analyzed that, I actually drew up what’s called the “window of tolerance.” It’s now called the “window of opportunity.” That’s subsequently been shown to be the case in dozens of studies, most prominently the LEAP study (Learning Early About Peanut) published in 2015. This study of 640 high-risk children showed that early nut exposure could reduce the risk of developing nut sensitization by several fold. Having nuts regularly cut down nut allergy at five years by three and a half fold.
After we wrote the “window of tolerance” paper in 2008 in Pediatric Allergy and Immunology, those restrictive guidelines quickly disappeared, though it took until 2017 for the American Academy of Pediatrics to change their guidelines. The WHO was incorrectly claiming early foods cause allergies. To go against the WHO and say, “Hey, you guys are wrong, you didn’t read the original paper when writing your guidelines” – that has subsequently changed global feeding policy and patterns.
It was nice to go against the tide, read the evidence, and create a framework that people now refer to as the “window of opportunity.” When the immune system is developing, with maternal antibodies from food exposure and hopefully the right gut microbiome, children have a reduction in allergies. We’ve seen that early introduction already starting to reduce rates of food allergies. That’s probably my most significant contribution.
Q. You’ve supervised over 60 Master’s and PhD candidates throughout your career. How has mentoring the next generation of immunologists influenced your own approach to research and clinical practice?
I think people doing research for research sake is very… You shouldn’t be doing it. You should be doing it for a purpose. It’s going to get the science somewhere or answer questions that are relevant. Many people start to do research and say, “Yeah, I’ve just got to do some research.” What does the question mean? What is it going to answer? What is it going to change? These are important questions.
During my time in London, I spent time at the Institute of Education. In supervising students and PhD students, I help them set goals about what is going to change for them personally as well as for the field. You need to think of your own end game. Also, the value of building strategic alliances with people. The world isn’t limited to your institution. If you haven’t got a skill set, you’re going to get faster development by collaborating with somebody already in your field and bringing that skill back to your unit, or work with the skills that you have in your unit to get the best results. Thinking about big pictures and where you’re going.
It’s probably the messages: where I’m going, where it’s going to take you, where it’s going to take the science, the frameworks that I put in. I actually helped develop a higher degree guideline for University College London, which is used for medical higher degrees, and they’ve subsequently had resistance with it. But they found when students and supervisors had good guidelines about skill development during their thesis – such as database skills, statistics skills, ethics skills, presentation skills, grant writing skills – they have a checklist, and they have something to discuss at their meetings, and they have deadlines and a format and a framework to actually work towards their end goals. Do they need to look at patent protection for what they’ve got?
That framework has, I understand, been put in digital format some 24 years after I developed it, and they’ve licensed it at many universities around the United Kingdom. That’s actually helped hundreds, if not thousands of higher-degree students.
Q. The field of allergy research seems to be experiencing rapid evolution. What developments in the last five years have most changed how you approach patient care or research?
I would say the practice of desensitization. We used to wait for children to grow out of foods. Now we facilitate that and what’s exciting is the ability to augment that as well. There are biological agents that can do that, but there are even natural foods that can do that.
This links in more of a holistic approach to allergy, of actually getting good health. We know that, for example, you’ve got a high risk of getting allergies if you’ve got low omega-3 fatty acids, if you’ve got low vitamin D. Now, the studies haven’t been done on mass. They’ve done vitamin D supplementations, but they haven’t done them properly. They haven’t used oils because oil goes into the lymphatics and lymph nodes.
As far as practice goes, my approach now is getting these foods in the kids early. The mindset of the child and the mindset of the parents is important in approaching that. Also discussing that within communication is such an important thing.
In short, desensitizing foods rather than waiting for them to grow out, and facilitating that where possible via good nutrition and good lifestyle choices, explaining that, communicating that, and being that emotional support for parents is important.
Q. Your work has taken you from Australia to the UK and across Asia. How do cultural and environmental differences affect allergy patterns and treatments in these regions?
The United Kingdom had probably a little more vitamin D deficiency. But no, we have very similar food eating styles and in fact, bad food habits with more processed food. Probably we do have fresher food here in Australia and a greater tendency to have farmers markets and access to that, which doesn’t happen in the urban environment in the UK.
But still in Australia, like the UK, we have nutritional deficiencies. If we look at vitamin C levels, at least 20% of adults are vitamin C insufficient. I’m sure that level would be very similar in the UK.
Within Asia, most of my work is as a visiting professor there. I had the opportunity as being a regional key opinion leader to go to many countries. I’ve spoken in at least a dozen countries within Asia as an expert. They’ve got different foods that they’re allergic to, but they’re gradually coming towards Western pattern. In Singapore, for example, the fifth most common food that people are allergic to is bird nest soup. The fourth is herbs and spices, but they’re quickly getting milk, egg, peanut, tree nut, shellfish pattern occurring. Same with China, that’s evolving as well.
Q. You’ve been recognized as being in the top 5% of ResearchGate members. How has the digital revolution and increased connectivity changed how allergists share information and collaborate?
I think it’s broken down barriers for international collaboration. I can be connecting with the best people in the world very easily. So we’re no longer so isolated in our silos and geographical silos. You might be having these meetings once a year. You can actually have Zoom meetings or face-to-face. Seeing a face is actually important for retention of information. So like-minded people can get together.
As far as scientific collaboration, it’s been very useful. And particularly during COVID, we were actually very productive in doing work collaboratively because we weren’t going to these conferences. So that was an exciting time. And it was a real privilege to be invited in the top 50 people in the world to do guidelines or in some cases, when they’ve chosen 10 or 12 leading experts from around the world in food allergy or anaphylaxis or severe rhinitis to be invited in that group.
Q. Food allergies, particularly in children, seem to be increasingly common. What misconceptions about food allergies do you frequently encounter, and what should parents understand about this condition?
If somebody’s had a food reaction, many people get concerned that the next one is going to be worse. So that’s important. If you know what they’re allergic to, they’re not going to have it intentionally again. You’re going to, hopefully, see a professional about it and have a plan to manage it better.
These days, more and more, we’re actually having a plan to start desensitizing, so they actually develop tolerance antibodies. So subsequently, they won’t actually have this bad reaction. They’ll actually have a plan to grow out of it.
And early, getting in early. Let’s let them grow out rather than “we’ll just avoid it.” In fact, for the majority, it’s still “let’s grow out of it”. So it’s a really exciting time in our space now to get people tolerant and build up this tolerance.
Q. What role do you see emerging technologies like AI playing in diagnosing and treating allergies in the coming decade?
There are tools that require biological assessments. I really can’t see them replacing blood tests and skin tests. They’ll be able to give positive values. We may be able to use big data depending on age, geography, gender, concurrent illness, eczema severity, rhinitis severity, asthma severity.
To look at the total IgE amount of allergic antibodies in their blood and predict the likelihood of food being an issue for a patient, what that really means, how likely it may cause problems, and how you can probably use predictive models under certain circumstances. Is this likely to be causing a problem? And are they likely to grow out of it? Or should we do interventions? We should be able to personalize that.
We’ve talked about knowing the whole DNA once the DNA got coded over 25 years ago. We had the whole sequence, the human genome project. We thought, great, we’re going to know every disease. We don’t. Within that sequence of genes, there are many genes that we have different levels of expression, which is the messenger RNA being converted to proteins.
We can have changes in those that affect our health. We still don’t understand that. But as we understand that, the cost goes down. Getting your genome done used to be over a million dollars. Now, it’s a matter of a few thousand dollars, and I expect that’s going to be cheaper and cheaper, and we’ll be able to match that up with disease states. In fact, we’re using a technology now where we can look at about under $10,000 US dollars to map the whole 18,500 human genomes in those 10,000 cells. That’s giving us some great information about diseases. We can use signatures and say which cell it is and what’s going on in that group of cells in that tissue.
Putting that information along with clinical history, I think AI may have the opportunity to revolutionize, but it’s rubbish in, rubbish out. We’ve got to get good data and understand what it means to be able to make sensible interpretations.
Q. As someone who has worked extensively with university research programs, what advice would you give to medical students considering specialization in allergy and immunology?
I think it’s certainly a growing field. We have lots of threats to our body, and our body is responding with an allergic response. I would get them to have a broad experience, make sure that they understand the upper airways, how food allergies excites people, rhinitis excites people, skin excites people, gut allergy excites people. It’s very important to come across all of that.
If they have the opportunity to do a higher degree within their training, I think that’s allowed me to think more molecularly and big picture, take a step back. But not everybody has to follow that same path. But I certainly find it more enjoyable.
I would say also invest some time in learning how to learn and learning how to teach. That’s not traditionally taught very well in medical curriculum or specialized curriculum. We need to – 90% of what we do as doctors is obtain information and transfer information. We may have better skills in doing that with AI, with our transcribing tools and communication tools that come there. That’s an exciting opportunity.
Learn your craft, learn the breadth of it, think the whole body rather than organ systems, as allergy is a disease that involves many organ systems, learn the science behind it, and learn how to teach so you can transfer information, gather information effectively for yourself, transfer to other people, and also to your peers and colleagues.
Q. Looking ahead at your career, what unsolved mystery in immunology would you most like to see addressed before you retire?
One of the areas that has driven me is… I’ve got three, actually. I’ve got a passion in itch, why we itch, and how to address the various forms of itch, and to treat that. I’ve certainly made some breakthroughs in that area and understanding itch.
Also in hypersensitivity of the airways, the neuro-inflammation. We’re thinking very much cellular inflammation and tissue inflammation. Nerves are critically involved. So a greater appreciation and intervention at the site of neural inflammation I would like to see develop.
And the excitement of augmentation of food allergy. I think there’s a really exciting area where we have allergic antibodies, where it binds to its receptors and the subsequent signaling that occurs, which is called the signal zone. There’s a lot of small molecules that are working around in that area that may change the way that we treat allergies completely in the next five years. It’s a really exciting time for us.
