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    Guidelines for life after LEAP

    Amended recommendations identify how to introduce peanuts to infants based on specific risks.

     

    Here’s what to do

    For infants who are introduced to peanut-containing foods in the home setting, he highlights a number of addendum recommendations:

    • Peanuts should not be the first solid food introduced.

    • Only introduce peanuts to an infant who is healthy without an illness such as upper respiratory infection.

    • Introduce the first peanut-containing food in the home setting, not in another setting such as daycare or a restaurant

    • Ensure an adult supervisor is closely monitoring the initial peanut introduction.

    • Ensure an adult supervisor provides ample time to watch the infant after peanut ingestion.

    • Give a small portion of peanut and wait 10 minutes before gradually giving the remainder of the full serving.

    • Do not give peanut butter directly from a spoon or whole peanuts to children aged younger than 5 years.

    To help caregivers know which foods to introduce, Fleischer refers them to appendices in the addendum.3

    As far as dose and duration of peanut ingestion, Fleischer highlights the following addendum recommendations:

    • Infants at highest risk (severe eczema and/or egg allergy) should consume about 6g to 7 g of peanut protein per week divided over 3 or more feedings. However, Fleischer underscores that it remains unknown what the optimal amount and duration of peanut consumption should be once peanuts have been introduced, as this amount and frequency were the only manner studied in LEAP. As such, he emphasizes that it is not currently known if different amounts or frequencies would have similar outcomes.

    • Infants with the lower risk (moderate to mild eczema, or none) can freely consume peanut-containing foods based on family practices.

    Along with peanut introduction, Fleischer also discusses recommendations for introducing other foods into infants’ diets, such as egg, milk, seafood, and wheat. Although evidence is not conclusive yet on introducing egg early into an infant’s diet, he suggests that there are data showing that cooked egg introduced in small amounts first, such as in a baked product with egg, may be the safest approach before introducing egg in its more concentrated forms, such as hard-boiled or scrambled egg.

    Although fewer data are available on the other foods, he emphasizes that introducing multiple major allergenic foods in infancy appears safe.

    “My general feeling on all major allergens, not just peanut, is that introduction of any highly allergenic food does not need to be delayed beyond 4 to 6 months of age,” Fleischer says. ”Thus, the general recommendation I tell families is to try to get in all major food allergens before age 1 year if they can.”

    Fleischer emphasizes the need to introduce foods logically, keeping the stage development of the infant in mind. This means, for example, not giving fish to a 6-month old, but waiting until the infant is eating food with similar textures such as meats. He also says that whereas cheese and yogurt can be given before age 1 year, the American Academy of Pediatrics still recommends against giving liquid whole cow’s milk before age 1 year for reasons other than allergy.

    Overall, Fleischer emphasizes a simple message for parents and primary care providers regarding getting allergenic foods into infants’ diets: “Have infants eat allergenic foods early and have them eat these foods often,” he says.

     

    REFERENCES

    1. Fleischer DM. Life after LEAP: how to implement advice on introducing peanuts in early infancy. J Paediatr Child Health. 2017;53(Suppl 1):3-9. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jpc.13491/full. Accessed March 29, 2017.

    2. Du Toit G, Roberts G, Sayre PH, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Eng J Med. 2015;372(9):803-813. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1414850#t=articleTop . Accessed March 29, 2017.

    3. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States. Report of the National Institute of Allergy and Infectious Diseases-Sponsored Expert Panel. Available at: https://www.niaid.nih.gov/sites/default/files/addendum-peanut-allergy-prevention-guidelines.pdf. Published 2017. Accessed March 29, 2017.

    4. NAIAD-Sponsored Expert Panel; Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: a report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 suppl):S1-S58. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241964/. Accessed March 29, 2017.


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