If you felt a sense of trepidation after reading the results of the new LEAP-On follow-up study, you’re not alone – many people in the food allergy community are going through a bout of culture shock.
There’s no denying that the results of 2015’s LEAP and this month’s LEAP-On are quite phenomenal – a 74 to 80 percent reduction in peanut allergy among children at high risk for allergy who began consuming the much-maligned legume in infancy. “I think there’s no doubt that we have prevented allergy in these children, at least so far,” said LEAP-On co-author Dr. Gideon Lack, speaking of the cohort of kids who are now 6 years old. That’s right, prevented.
So why aren’t the champagne corks flying as we contemplate a next generation of kids who may get to elude the scourge of peanut allergy by developing a taste for peanutty baby snacks? There are a couple of reasons. First, introducing such an allergenic food to an at-risk baby of only 4 to 6 months is intimidating to contemplate, and the polar opposite of the avoidance messages we have etched into our brains. And second, the whole “when to introduce foods question” has now, officially, been turned on its head. That, my friends, is a lot to absorb.
It seems only yesterday that every doctor recommended the old guidelines: don’t feed your baby at-risk of food allergy dairy products until after the age of 1, eggs until after age 2, and do avoid giving the child tree nuts, peanuts or fish until the age of 3. That questionable advice was officially tossed out by the American Academy of Pediatrics (AAP) in 2008, and at Allergic Living, we’d had a head’s up that change was in the wind a couple years before that.
The first clue was when we asked the late, great Canadian allergist Dr. Milton Gold what he thought of the curiously age-specific guidance: “It’s more than mumbo-jumbo, it’s a mess that has to change. It has no basis in science,” he said with clear frustration.
In 2008, the AAP issued guidelines that reflected the lack of science. They were honest, if un-illuminating. On the question of when to introduce solids, they essentially said there was no evidence to support avoidance of any solid foods beyond the exclusive breastfeeding-only window of up to 4 to 6 months. The message to expecting or new parents seemed to be: Avoidance isn’t working but we really don’t know what to say about solids introduction. So thanks, and see you at the next checkup!
With the arrival of 2015’s groundbreaking LEAP study, the advice to parents has changed dramatically, and it’s finally based on real and persuasive evidence. Last year, interim guidelines were crafted to allow for early peanut introduction in at-risk babies. And now, in keeping with the results of both LEAP studies, the U.S. National Institute of Allergy and Infectious Diseases (NIAID), has unveiled its official draft guidelines for the prevention of peanut allergy. You can read the specifics here, but essentially they recommend that babies of 4 to 6 months who have severe eczema or egg allergy be tested for peanut sensitivity. If there is no clear allergy but some suspicion, a doctor may additionally suggest an oral food challenge. If all is well, then let the peanut introduction begin.
But this won’t be an easy sell to a skeptical public that’s been perplexed by the epidemic-like rise of food allergies since the early 2000s – and the experts know this.
Lack and Dr. James Baker of FARE raised what they see as the need for a “change in culture” as they spoke to journalists at the LEAP-On press conference at the AAAAI annual meeting in early March.
“I think [the new approach] needs education, support, a change in culture, not just among patients, but physicians,” said Lack. He spoke of the widespread acceptance of delayed introduction that’s promoted in countless parenting books. “This instills a culture of fear in the parents and the families, and I think we need a lot more research and good advice on feeding policies in infants. So that we can go to parents and say: ‘This is what we recommend, this is how to do it,’” said Lack.
Baker picked up on the theme. “I think for a long time we vilified these [allergenic] foods, and there’s nothing inherently wrong with intake.” Of the related EAT study, which saw parents trying to introduce up to six potentially allergenic foods with mixed success but no serious reactions, Baker said that “EAT reinforces how complex and difficult it is to be a parent, and to try to feed your child and do the right thing. When you get these negative perceptions of foods, it puts a lot of stress on families. I think the good news about this information is that there’s no reason not to do this, there’s no harm that has come from early introduction.”
While food introduction is clearly winning out over avoidance as the right approach, with vulnerable babies, there remains such emotion for the parent, such a visceral need to protect. Avoidance not only hasn’t worked, but appears to have promoted allergies – yet it was so easy to buy into. There were no intimidating baby spoonfuls; baby just didn’t eat that. But if we take heart in the good safety profile of the LEAP and EAT studies, perhaps as a community we can break from this too-comfortable attachment to avoidance.
I’ve been a journalist for a long while, and I recognize a communications challenge when I see one. I predict that getting across the news of the proposed guidelines will require considerable effort, and that both parents and doctors will have many questions, including the “how-to” ones that Lack raises. NIAID assures me that once the guidelines are final, the organization will be issuing supporting materials for doctors and the public, and encouraging their dissemination.
Let’s hope they will be thorough. For starters, parents and doctors clearly will need to be educated on the strength of the LEAP studies’ evidence. Lack’s co-author, Dr. George Du Toit, says he uses that to help parents at his London clinic to make an informed decision. When considering a young infant at high risk for allergy, he will tell them that avoidance carries a potential 18 percent risk of peanut allergy. “Maybe you’ll be lucky and fall into those whose child doesn’t get the allergy, but an 18 percent rate of a troubling illness is quite high,” he says. With early introduction intervention in high-risk children, the peanut allergy odds plummet to 3 percent.
In the year ahead, people will especially want to know more about allergy approaches with the high-risk babies whose peanut skin-prick tests are moderately positive. And if we’ve had issues in the past with doubting grandparents or caregivers and food introduction, the messaging accompanying the new guidelines needs to be crystal clear: in high-risk babies, this is a prevention strategy that’s done only in consultation with a pediatrician or allergist. It is not for ad-hoc experimentation.
So take faith in this: we finally have a start on food allergy prevention, and it begins with peanut allergy. The “mumbo-jumbo” ways of old are being replaced with science-based guidelines, and now the heavy-lifting involves how to bring this new evidence home to our physicians, our food allergy families and their babies. For years, we had no proof of whether introduction of a food like peanut helped or harmed. Now we do. This is progress, but progress that will only take hold alongside a significant cultural shift.
The NIAID guidelines on peanut introduction were introduced in January, 2017. Read about them here. If you have a question for our experts about early introduction of allergenic foods, send it to firstname.lastname@example.org and write “Ask the Allergist” in the subject line. All questions are considered, though not every one can be answered.