Guidelines for life after LEAP
Amended recommendations identify how to introduce peanuts to infants based on specific risks.
As the number of infants and children developing peanut allergy continues to grow, so does the need for pediatricians and other primary care providers to understand current recommendations on how best to prevent this allergy.
The need for prevention is highlighted by the substantial increase in prevalence, which data show has tripled in the United States over the past 10 to 15 years, and the associated detrimental effects on health and quality of life in the children who develop this allergy.1
Despite early thinking that avoiding peanuts during infancy and young age would prevent peanut allergy later on, more recent thinking has focused on early introduction of peanuts during infancy. The success of this strategy was recently confirmed in the 2015 published results of the Learning Early About Peanut Allergy (LEAP) study, the first randomized controlled trial to compare the introduction or avoidance of peanuts in infants at high risk (defined in the study as those with severe eczema, egg allergy, or both) of developing peanut allergy. The study found that infants aged between 4 and 11 months who consumed peanuts were significantly less likely to develop peanut allergy by age 5 years than those infants who avoided consuming peanuts until age 5 years.2
Summary of NIAID guidelines
Based on these findings, specific recommendations for peanut allergy prevention were developed by an expert panel convened by the National Institute of Allergy and Infectious Diseases (NIAID) and published as an addendum3 to the NIAID’s previous 2010 guidelines on the diagnosis and management of food allergy in the United States.4
David M Fleischer, MD, director, Food Challenge Unit, University of Colorado Denver School of Medicine, Aurora, Colorado, underscored the importance of pediatricians and primary care physicians becoming familiar with and appropriately implementing recommendations in these recent addendum guidelines.
“The key for these peanut guidelines to work relies on primary care providers to discuss early introduction of peanut into infants’ diets when they see them at 4 and 6 months of age,” Fleischer says. “We as allergists do not usually see patients until they are diagnosed or suspected to have food allergy. Therefore, without the dissemination and implementation of these guidelines by primary care providers, they will not work.”
In a recently published review article, Fleischer highlights and discusses key recommendations in the addendum guideline that he encouraged pediatricians to refer to for understanding when and how to introduce peanuts during infancy.1 (A summary for clinicians of the addendum guidelines can be found at bit.ly/NIAID-2017-addendum-peanuts).
Among the recommendations discussed was introducing peanuts to infants based on 3 specific risk categories:
Children with severe eczema and/or egg allergy: Introduce peanut-containing foods as early as age 4 to 6 months after the introduction of other solid foods and after consideration of test results for peanut-specific serum immunoglobulin (Ig) E or skin-prick test (SPT), or both.
Children with mild to moderate eczema: Introduce peanut-containing foods around age 6 months.
Children with no eczema or food allergy: Introduce peanut-containing foods together with other solid foods and in accordance with family preferences and cultural practices.
Overall, Fleischer emphasizes that a simple interpretation of the 3 addendum guidelines would be to recommend that peanut-containing foods be introduced into the diet of all infants around age 6 months but not before age 4 months.
Although the recommendations provide leeway on the setting in which to introduce peanut-containing foods, whether in the provider’s office or at home (supervised or not), Fleischer recommends that infants at highest risk of developing a peanut allergy (those with early-onset eczema that is difficult to manage with standard treatment or infants with an egg allergy) may benefit from an evaluation from an allergist prior to the peanut introduction.