New guidelines for the early introduction of peanut-containing foods to children as a way to prevent peanut allergy were published on January 5, 2017 in the Journal of Allergy and Clinical Immunology and other medical journals.
The impetus for the update was the ground-breaking Learning Early About Peanut Allergy (LEAP) study, published in 2015, which showed that introducing peanuts to young infants who were at risk of an allergy to that food could in fact prevent the allergy.
“Peanut allergy is common, severe and appears to be increasing in prevalence. These guidelines address preventing peanut allergy in the first place,” says Dr. Scott Sicherer, chief of allergy and clinical immunology at the Icahn School of Medicine at Mount Sinai, who was a member of the expert panel that examined the available evidence to figure out the best way to introduce peanut.
The guidelines, which were sponsored by the National Institute of Allergy and Infectious Diseases and involved 25 organizations and agencies, are an addendum to the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States. They divide young children into three allergy risk categories.
The first guideline and recommendations cover infants who face the highest peanut allergy risk – those who have severe eczema, egg allergy or both.
For this group, the new advice is that doctors “strongly consider” evaluating the patient through a blood test (specific IgE) or a skin-prick test. The results of that testing would determine whether peanuts should be introduced at home, while supervised in the doctor’s office, or with an oral food challenge in a specialized facility.
“These kids are at very high risk and therefore you would want to be able to identify whether they have any evidence of allergy already. If they do already have evidence of allergy, then you would be approaching them differently than if you had no evidence of the allergy,” explains Sicherer.
He adds, however, that if an infant is tested before introduction, it should only be for peanut.
“Allergy tests can notoriously be positive when the food can be consumed anyway. If panels of tests are done without considering the whole story and the medical history, you increase the risk that you’re going to be looking at positive tests that don’t mean anything,” he explains. “This then leads to avoiding foods and worrying about things that you wouldn’t have to worry about.”
The guidelines recommend the testing and subsequent introduction in this high-risk group of infants be done between the ages of four to six months, as they would have less of a likelihood of a positive test at this age. The LEAP study showed more of a benefit to early introduction if the child tested negative to peanut before the introduction to the food. Sicherer suggests speaking to your child’s doctor at the four-month visit to discuss the best course of action.
Despite the early age recommended for introduction, infants should already be eating solid foods and demonstrating that they can handle them. “Babies have to learn to eat solids,” says Sicherer. “Some babies just aren’t ready to eat yet so they might push food out or choke, so working with something that is not a risky food and a consistency where they can start to take the solids successfully would come before giving the peanut-containing food.”
While the recommendation to introduce solid food as early as four months goes against the American Academy of Pediatrics and World Health Organization’s guidelines on exclusive breastfeeding until six months, the expert panel notes that in the LEAP study, introduction of peanut did not affect how long or how often infants were breastfed. The practice also didn’t influence growth or nutrition. Both of the organizations have endorsed the guidelines.
Sicherer also stresses that all is not lost if this early intro period is missed, and that peanuts should be introduced as soon as possible for that infant.
The second guideline is aimed at the group of babies who have mild to moderate eczema and would be at a slightly higher risk of developing peanut allergy when compared to the general population. Therefore the recommendations are that parents introduce peanut at about six months, if the child is already eating solid foods and is developmentally ready.
While the LEAP study didn’t specifically research this category of kids, the expert panel concluded that early introduction of peanut could provide protection against the development of allergies. However, on balance these kids should be able to have the first introduction at home, without testing first.
In certain situations, testing or an in-office supervised feeding might be recommended by the doctor. Sicherer recommends parents speak to their doctor about the best course of action.
The last guideline encompasses the group of children with no eczema or food allergy. “This is an important group. This is trying to undo the misconception that you need to wait to introduce peanuts,” says Sicherer. The guidelines recommend introduction should be done at an age-appropriate time in accordance with family preferences and cultural practices.
For infants in this last group, “Peanuts shouldn’t be treated differently than any other foods,” says Sicherer.
The guidelines give information on how much peanut to introduce and how often, aimed only at the highest risk group (those with severe eczema and/or egg allergy). For the other groups of kids, peanuts can be introduced according to individual families’ practice.
Ways to Introduce: Sicherer reminds people that peanut butter and whole peanuts are choking hazards and shouldn’t be given to infants. Rather, you can dilute peanut butter, add peanut butter to a fruit puree, add peanut butter flour or powder to a fruit puree or give peanut butter snack puffs.
In the LEAP study, early consumption of peanut reduced the risk of developing peanut allergy by 86 percent for children with negative skin prick tests and by 70 percent for those who were mildly sensitized infants. “There appears to be a narrow window of opportunity to prevent peanut allergy,” LEAP co-author Dr. Gideon Lack, a professor at King’s College London, has said of these important findings that were key to the development of the new U.S. guidelines.
Expert Guidelines on Introducing Peanut to Babies (2017)
Answering Parents’ Big Questions on Safely Introducing Peanut to Babies
LEAP Co-Author: How Not to Stress Out About Early Peanut Introduction
A LEAP Into An Allergic Culture Change