Introducing peanut foods to children who are at different levels of risk for peanut allergies may prevent or mitigate the risk, and the strategies for clinicians are explained in new addendum guidelines issued by an expert panel sponsored by the National Institute of Allergy and Infectious Diseases.
The guidelines were published online Jan. 5 in the Journal of Allergy and Clinical Immunology (J Allergy Clin Immunol. 2017. doi: 10.1016/j.jaci.2016.10.010).
“In the majority of patients, peanut allergy begins early in life and persists as a lifelong problem,” wrote lead author Alkis Togias, MD, of NIAID in Bethesda, Md., and colleagues. Previous guidelines published in 2010 did not provide specific treatment strategies for peanut allergies because of a lack of research, but the significant results of the Learning Early About Peanut Allergy (LEAP) study suggested that early exposure to peanut-containing foods reduces the risk of developing allergies.
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The NIAID’s Guidelines Coordinating Committee conducted a literature review covering research from January 2010 to June 2016 and developed addendum guidelines, as follows:
For infants with severe eczema, egg allergies, or both, peanut-containing foods should be introduced at 4-6 months of age at the earliest, after the introduction of other solid foods to confirm developmental readiness. If the infant is developmentally ready for solids, clinicians should “strongly consider” evaluation by peanut-specific IgE (peanut sIgE) measurement and/or skin prick test before introducing peanut products to determine the potential sensitivity and need for supervised feeding vs. feeding at home.
If dietary peanut will be introduced based on the recommendations, “the total amount of peanut protein to be regularly consumed per week should be approximately 6 to 7 g over 3 or more feedings,” the authors wrote.
However, children already identified as allergic to peanut should practice strict peanut avoidance, they added. In addition, they recommend that clinicians review risks and benefits for high-risk children who may have family members with established peanut allergies.
For infants with mild to moderate eczema, the recommendation is to introduce peanut-containing foods at approximately 6 months of age, “in accordance with family preferences and cultural practices,” after the introduction of other solid foods, to help reduce the risk of peanut allergies. The expert panel recommends that infants in this moderate-risk category may receive peanut foods at home without an office visit, although caregivers or clinicians may choose an office visit for supervised feeding, evaluation, or both. Although the LEAP trial did not target infants with mild or moderate eczema, the panel has no reason to believe that the protective mechanisms are different in these children.
For infants with no eczema or any food allergies, the guidelines recommend introducing peanut-containing foods at any age, as appropriate and in keeping with a family’s preferences and cultural practices.
“The early introduction of dietary peanut in children without risk factors for peanut allergy is generally anticipated to be safe and to contribute modestly to an overall reduction in the prevalence of peanut allergy,” the researchers said.
The findings of the LEAP and accompanying LEAP-On trials were so compelling (approximately 80% relative reduction in peanut allergy at 5 years of age for peanut-exposed children, compared with standard of care) that the NIAID and expert panel “felt it was necessary to review and revise the previous recommendations from the 2010 guidelines on the diagnosis and management of food allergy,” Hugh Sampson, MD, director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai, New York, and a member of the panel, said in an interview.
“It is critical that pediatricians and family practitioners identify infants at high risk for developing peanut allergy (severe atopic dermatitis or egg allergy) between 4 and 6 months of age, evaluate them, or refer them to a food allergy specialist when necessary,” Dr. Sampson said.
“Have parents introduce peanut into the infant’s diet on a regular basis. It is important for parents to notify their pediatrician or family physician if they suspect their infant is at high risk for developing peanut allergy,” he added. “Also, once early peanut introduction is started, it is important that parents continue to provide peanut on a regular basis for several years.”
Next steps for research include pursuing other allergens, said Dr. Sampson. “Similar studies need to be done to determine if early introduction of other foods, such as milk, egg, [or] tree nuts will prevent these common food allergies in high-risk infants.”
Also, it will be important to study whether infants at mild to moderate risk for developing peanut or other food allergies as evidenced by mild to moderate eczema will experience the same benefits in allergy risk reduction seen in the highest-risk children, he added.
The panelists had no relevant financial conflicts to disclose.