Answering Parents’ Big Questions on Peanut Introduction to Babies

in Features, Food Allergy, Peanut & Tree Nut
Published: January 12, 2017
Introducing peanut to babies.Photo: Getty

Guidelines for the early introduction of peanut foods to young children as a way to prevent peanut allergy were published in 2017. In the food allergy community, this had led to concerns and many questions – since the possibility of allergic reactions in babies is anxiety-inducing.

To help answer points raised by our readers, Allergic Living breaks down the guidelines‘ information, plus takes several of your queries to pediatric allergist Dr. Scott Sicherer, chief of allergy and clinical immunology at the Icahn School of Medicine at Mount Sinai. Dr. Sicherer served on the panel of experts that crafted the new guidelines, acting as the representative of the American Academy of Pediatrics.

One reader asks: What did the guidelines change? I thought this research has been out for a while?

It is true that the research findings are not “new news”. The Learning Early About Peanut Allergy [LEAP] study, on which these guidelines were based, was published in February 2015. Then in June 2015, a consensus communication, which included interim guidelines, was published.

However, what we’re seeing now are the finalized guidelines aimed at physicians – sponsored by the National Institutes of Health and endorsed by a number of allergy and and pediatric organizations, including the American Academy of Pediatrics.

Why is the focus on such young kids? Shouldn’t I let my baby’s immune system mature before feeding her peanut?

The guidelines recommend feeding peanut to high-risk infants (those with severe eczema or egg allergy) between the ages of 4 to 6 months, because this is a window of time where they are potentially developmentally ready to eat solid foods, but have not yet been sensitized to peanut.

Keep in mind, babies don’t need to eat peanut to be sensitized to it. Research suggests children who have bad eczema could be getting exposed to peanut through the cracks in their skin, which might trigger more of an allergic response than if they were exposed to it through the mouth.

“The reason that the guidelines are focusing on this young age group is to try to not have people show up [to the clinic] with children with positive allergy tests. At which point, it might be too late,” says Dr. Sicherer.

I am concerned about introducing my young baby to peanuts. How will he tell me there is something wrong?

If your baby has an elevated risk of developing a peanut allergy (he has severe eczema or has already been diagnosed with an egg allergy) then, according to the guidelines, you should speak to your doctor about having your baby allergy-tested. If the testing is negative, a plan will be made for introducing peanut in a way that is safe and works for your family. At this point, it could also be determined that your baby appears to have a peanut allergy, in which case you wouldn’t introduce peanut at all.

If your baby has mild or moderate eczema, the guidelines suggest introducing peanut-containing food at 6 months, once he has started eating solid foods. There is the belief, extrapolated from the LEAP study, that this might lead to some protection from peanut allergy. By definition, babies with this level of eczema are not at a high risk of having a peanut allergy, and so the experts say there is no reason to be unduly worried about a reaction. However, in some cases, you or your doctor may decide to have your baby tested first, or have the first feeding in a doctor’s office. Speak to your doctor about what is best for your family.

Sicherer stresses that the results of the LEAP study indicate that if the guidelines are followed, there should be little risk.

But couldn’t my baby react on a second or subsequent ingestion, even if allergy testing was negative?

Scott SichererDr. Scott Sicherer
Yes, anything is possible, says Sicherer. But it’s not likely. He understands that people can feel anxious, but stresses the allergy prevention success in the major study.

The allergy expert notes that the guidelines give plenty of room for doctor and family discretion. He hopes, however, that people seriously consider introducing to high-risk babies at a young age.

“It’s a window of opportunity that appears to be worth taking from most people’s assessment of the data,” he says.

I’m breastfeeding and eating peanuts so my baby is getting peanuts through my breast milk. Isn’t that enough?

No, this can’t be equated to direct feeding. The amount of protein passed to the baby through breast milk is minuscule, so it’s not the same as the baby consuming it.

Sicherer stresses that there is no conclusive evidence that eating peanuts during pregnancy or breastfeeding has an impact on the baby’s development (or lack of development) of peanut allergy. This is why current food allergy practice parameters do not counsel avoidance diets for mothers-to-be and new mothers as an allergy prevention strategy.

With the LEAP study, however, there is strong evidence that introducing peanuts early could prevent peanut allergy, and so these guidelines have been developed for parents who want to take advantage of this possibility.

My baby is in the high-risk category and I want to try to prevent a peanut allergy. What do I do?

The first step is to talk to your doctor about testing. The guidelines spell out for health-care providers how to interpret test results and what the next steps should be, in terms of referring to an allergist and having supervised feedings or an oral food challenge.

If you’re given the go-ahead to feed your baby at home, the guidelines recommend the baby eat 6 to 7 grams of peanut protein per week over three or more feedings. You wouldn’t feed your baby peanut butter or whole peanuts. There are recipes in the guidelines for thinned-out peanut butter or purees.

Is peanut the first solid food I give my baby?

No, the guidelines say your baby should be developmentally ready and eating other solid foods before introducing peanut-containing foods. “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,” says Sicherer.

Making peanut a first food could also become confusing. For example, if your 4-month-old was to gag or choke on peanut-containing food, you might presume that was a reaction – when in fact her body is just not ready for food yet.

You would want to introduce anything that might be a normal first baby food (speak to your doctor if you’re not sure what that might be).

How do I actually feed the peanut?

When the doctor advises introducing peanut to your baby, you should do it at home, and only if your baby is healthy. Don’t feed her peanut if she has a cold, vomiting, diarrhea or another illness.

Make sure you (or a caregiver doing the feeding) can give her your full attention, and you’re not distracted by other children, etc. Also, you should plan to spend at least two hours with your infant afterward to watch for an allergic reaction.

Make a full portion of one of the recipes in the guidelines, which each contain 2 grams of peanut protein. Offer your baby a small amount, then wait 10 minutes. If there is no reaction, continue to slowly give the remainder of the food.

What should I look out for as possible signs of reaction?

Mild symptoms of an allergy include a new rash, or hives. If you see these, stop feeding the food and contact your doctor.

More severe symptoms would include lip swelling, vomiting, hives all over the body, face or tongue swelling, difficulty breathing, wheezing, repetitive coughing, change in skin color, or sudden tiredness or lethargy. These are signs of an anaphylactic reaction and you should call 911.

If my baby has an anaphylactic reaction, will it be safe for her to get epinephrine?

Sicherer says it’s OK to give epinephrine to infants if they have anaphylaxis, although the doses may be higher than ideal. “It’s very unlikely that you would need to do that, though.”

He explains that if you are introducing peanut to your baby at home it’s because it has been determined that there is a low risk of having a reaction, and so the likelihood of needing epinephrine is low.

On the other hand, if you’re introducing peanut at a doctor’s office because of a higher risk of allergy, then you are under doctor supervision.

In the LEAP study, reactions that happened upon the introduction of peanut were not severe.

I’ve heard people say, “My baby was allergic from the get-go and nothing could have prevented it.” Is that true?

They may be right. In fact, in the LEAP study, some infants who came in with bad eczema were tested and presumed to already have allergy and were excluded from the study. The guidelines are written in the same way: if the skin-prick test is greater then 8 mm, the child is presumed to have a peanut allergy and introducing peanut is not recommended.

These guidelines are aimed at preventing allergy in babies who are at a high risk for it, but have NOT developed it yet.

Will there be similar guidelines for introducing other allergenic foods to kids with eczema?

Sicherer doesn’t know for certain, but doesn’t expect other guidelines any time soon.

“The expert panel didn’t take on that type of extrapolation,” he says. “It may be that different foods behave differently. We don’t have the data, and I don’t think we’re ready to do a whole bunch of studies on every allergen that exists.”

My baby is older than 6 months. Is there still a benefit to introducing peanut?

Yes! says Sicherer. There is no reason to avoid peanut-containing products (unless your baby is allergic). The doctor hopes these new guidelines will help dispel the entrenched misconception that delaying peanuts is beneficial.

See also:
New Guidelines on Introducing Kids to Peanut Early
LEAP Co-Author: How Not to Stress Out About Early Peanut Introduction