Food allergies occur in approximately eight percent of kids, with peanut allergies reported in 2.2 percent of US children. Because peanut allergy is outgrown less frequently than other allergies like milk and egg, it has become an increasing public health concern, as well as a source of anxiety and common topic of conversation among parents. Surely you have sensed the “peanut panic” among some of the families in your practice, your local schools, and other places where kids eat and gather.
In response to escalating rates of food allergy, and peanut in particular, the LEAP (Learning Early about Peanut) study was initiated after its investigators observed that children who ingested peanut in infancy as part of cultural norms (like in Israel or parts of Africa) had but a fraction of peanut allergies compared with the US, UK and Australia and other countries with similar feeding practices. This randomized clinical trial resulted in an up to 86 percent reduction in peanut allergy prevalence in high risk babies by age five years.
As a result of LEAP, the National Institute of Allergy, and Infectious Disease (NIAID) formulated new guidelines for the early introduction of peanut in children – a 180º turn from the prior 2000 guidelines encouraging delayed introduction.
In practice, we have all witnessed the pendulum of medical thought swing wildly at times, and unfortunately a lot of recommendations and guidelines in the past were just that – thoughts and anecdotes not grounded in enough study participants, poor randomization, lousy study design or lacking historical reference. So our willingness to immediately embrace a groundbreaking study and implement new guidelines may understandably be hampered by our disappointment with and skepticism of past recommendations, perhaps some anxiety, fear of harming patients, the realization that more time for patient education(?) is needed in an already crowded day, and the economics of change.
A good example is a recent survey of pediatricians conducted by Ruchi Gupta, MD, MPH, and published in JAMA Open, revealing that although 93.4 percent of the 1,781 study participants reported being aware of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States, less than one third (28 percent) were implementing them fully. The limitations of this study include a low response rate (5.2 percent), reducing the generalizability of the results, possible participation bias, and these findings only represent knowledge of the US guidelines and approach to early introduction of peanut foods. Here is a summary of the guidelines and the findings in the study, and some suggestions to help you with implementation, based on the risk category of your patients.
LOW RISK INFANTS
Guideline: for an infant aged 6 months who does NOT have eczema or any food allergies, introduce peanut-containing food in accordance with family preferences and cultural practices (between 6-12 months).
Survey Results: 84 percent of pediatricians surveyed were consistently recommending peanut introduction in low risk babies, 4 percent were still recommending avoidance, 5 percent were turning to allergists, allergy testing or an in-office food challenge.
- In this era of pandemic, emphasize to patients that preventive strategies can and will reduce the chances of bad outcomes on many levels. Parents have the POWER to influence their child’s health in a positive way.
- You might have fewer ill children in your office right now and a little more time to discuss feeding during your well-care exams. It’s a perfect opportunity at the 2-4-month checkup to let parents know about introduction of ALL foods (except for honey?) in their low risk baby, and how important their intervention will be.
- If you are doing any telemedicine, gathering a cohort of parents of 2-4 month old babies over Zoom for a group feeding discussion will allow you to say things once, outside of office hours, reach many, and prep and prompt parents for questions. Early introduction of peanuts, and the incorporation of all foods (except honey) can be discussed.
- If you have an EHR, ask your programmer to add a prompt about food allergies/early introduction at the 2, 4, 6, and 9-month visits.
- Go to https://preventpeanutallergies.org/pediatrician-resources/ for posters, the NIAID guidelines, FAQs, how-to-feed, and more resources to support you and your patients.
Guideline: For an infant who has mild to moderate eczema, recommend introduction of peanut containing foods at home at around 6 months.
Survey Results: 54.7 percent of respondents recommended as advised, 7 percent advocated avoidance, a combined 31.5 percent were turning to allergists, allergy testing, or an in-office food challenge.
- Many parents are working from home now and can directly observe their babies. With the first peanut feeding, parents can try peanut-containing food early on a day when you are in the office or available by telemedicine. They can try a dab (about ¼ tsp) of peanut butter mixed with another food, wait 10-15 minutes, and give gradually more 2-3 more times as the baby allows. Let them know to call if any concerns but re-assure that if there is no reaction within 2 hours of ingestion, they are good to go.
- If there is a family member with peanut allergy, parents understandably may be reluctant to do the first feed at home. Rather than sending that family to an allergist, consider screening the baby with peanut specific IgE. Results are obtained rapidly, and if <35, indicates the baby is not sensitized, likely not allergic, and the parents can proceed with feeding sooner.
SEVERE ECZEMA AND/OR EGG ALLERGY
Guideline: Infants with severe eczema, egg allergy, or both, should have introduction of age-appropriate peanut-containing food as early as 4 to 6 months of age to reduce the risk of peanut allergy. Other solid foods should be introduced before peanut-containing foods to show that the infant is developmentally ready. Strongly consider evaluation with peanut specific IgE and/or skin prick test and, if necessary, an oral food challenge. Based on test results, introduce peanut-containing foods at home, under medical supervision, or avoid.
Survey Results: 59.8% went straight to allergy referral, 18.9% ordered peanut specific IgE, 3.2 percent performed in office food challenge and 0.4 percent conducted skin prick testing. 8.7 percent recommended introduction without testing and 6.9% recommended avoidance.
- Identify a laboratory that will run a peanut specific IgE and screen your patient first. The results will come in faster than waiting for an allergy appointment (especially if there is limited access to pediatric allergy in your community or for your patients). If the peanut-specific IgE is negative, you can reassure the family the baby has not been sensitized to peanut and proceed with the introduction of infant-safe peanut foods between 4-6 months. If peanut specific IgE is >35 or close to it, advise waiting until an allergist can partner with you.
- Identify a pediatric allergist who will work with you if a food challenge or follow-up is needed. Even though a baby may show evidence of sensitization, not every baby is clinically allergic. Your allergist can help your patient by conducting an oral food challenge, and for those babies who tolerate peanut protein, early introduction can be initiated.
It is important to remember and educate parents and caregivers that food allergy reactions in infancy are usually mild (vomiting and/or hives), but may become worse as children age, if food allergy takes hold – another reason starting early is so important.
With early introduction of peanut foods, we have a tremendous opportunity to improve the quality of life of many of our patients utilizing a primary preventive strategy. As I have conveyed to our peers many times at conferences, overcoming a day of minor fear and discomfort introducing peanut is far better than a lifetime of carrying an epinephrine injector. It is important to remember and educate parents and caregivers that food allergy reactions in infancy are usually mild (vomiting and/or hives), but may become worse as children age, if food allergy takes hold – another reason starting early is so important. Think about it. You AND your patients have the power to make this happen. Take the time, do it, and never regret that you listened to good science.
Dr. JJ Levenstein, MD, FAAP, is a pediatrician and chair of the National Peanut Board’s Food Allergy Education Advisory Council.