Expanding early peanut introduction can increase prevention efforts

A new study suggests that extending early peanut introduction efforts can head off more allergy development.

Does gender-affirming therapy help trans individuals with sexual development?

An investigation looks into whether gender-affirming therapies allow young trans individuals to have more typical sexual and romantic development.

Allergy experts weigh in on prevention strategies

Guidance offers insight on allergy prevention strategies.

Can nebulized magnesium reduce hospitalizations because of asthma?

A new report looks at whether nebulized magnesium could impact hospitalizations due to asthma.

Articles

It was a very busy week for the Contemporary Pediatrics team.

In case you missed it: November 30 to December 4

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Although it was initially thought that COVID-19 led to only mild cases in children, the discovery of multisystem inflammatory syndrome in children (MIS-C) in April 2020 proved that COVID-19 can, in certain pediatric populations, be quite serious. A 

 examined whether Black or hispanic children have made up the bulk of MIS-C cases already seen.

The data for the study came through routine public health surveillance in New York City. The city’s Department of Health and Mental Hygiene mandated the reporting of patients aged younger than 21 years who were hospitalized in New York City with symptoms that suggested MIS-C. Epidemiologists tied patient record to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) molecular and serologic laboratory data. Participants in the study’ population-based cohort included New York City residents who met the definition of MIS-C set by the Centers for Disease Control and Prevention and were admitted to the hospital from March 1 to June 30, 2020.

A total of 223 met the MIS-C criteria with a median age of 7 years; 127 of the patients were male. Fifty of the patients had 1 or more underlying conditions with asthma (31 patients [13.9%]), obesity (20 patients [9.0%]) being the most common underlying condition. Antibodies or RNA for SARS-CoV-2 were discovered in 175 patients in the cohort. The SARS-CoV-2 test results were negative or unavailable for 48 patients, but included on the basis of epidemiological criteria. Information on race or ethnicity was available for 184 patients. Overall MIS-C incidence was 11.4 cases per 100,000 population aged younger than 20 years. Black children made up 22.2% of the population in New York City and accounted for 19.9% of hospitalizations due to COVID-19 in patients aged younger that 20 years, but 34.4% of the patients who had MIS-C were Black. Patients who were hispanic had a similar proportion between the city population and incidence of MIS-C. When compared to white children, a higher incidence of MIS-C was noted in Black (incidence rate ratio [IRR], 3.2; 95% CI, 2.0-4.9) and hispanic (IRR, 1.7; 95% CI, 1.1-2.7) children.

The researchers concluded that Black and hispanic children were more likely to suffer from MIS-C than children of other races/ethnicities, in addition to the already higher likelihood of being hospitalized because of COVID-19. Although larger studies will be needed to look at the potential link between MIS-C and race/ethnicity, they recommended that clinicians be alert to the potential increased risk for the condition among certain groups.

1. Lee E, Kepler K, Geevarughese A, et al. Race/ethnicity among children with COVID-19–associated multisystem inflammatory syndrome. 

. 2020;3(11):e2030280. doi:10.1001/jamanetworkopen.2020.30280

Multisystem inflammatory syndrome in children (MIS-C) is a serious consequence of COVID-19. Is the risk of it equal to all children or does race/ethnicity play a role?

Certain groups may be at greater risk of MIS-C

Celiac disease (CD) is an autoimmune disease in which a reaction to gluten consumption damages the small intestine. With a steadily increasing global prevalence of close to 1%

, public awareness of CD and gluten-related disorders has grown considerably over the last few decades.

Celiac disease is more common in children with the following risk factors:

A family member with CD or dermatitis herpetiformis

Celiac disease can be challenging to diagnose as patients may present with gastrointestinal and/or extraintestinal symptoms, and many are apparently asymptomatic.

 Furthermore, there is a poor correlation between gastrointestinal damage and symptoms.

Timely diagnosis of CD and optimization of nutrition is particularly important in childhood to prevent irreversible complications such as short stature and osteoporosis. All individuals with untreated CD are at risk for long-term complications, whether or not they present with symptoms.

With the growing prevalence of CD and the heterogenous, often non-specific nature of symptoms, many patients remain untested and diagnosis may be delayed by several years. Currently, it is estimated that 43% of the CD population remains undiagnosed.

Like many autoimmune diseases, the exact trigger of CD is unknown; however, the genetic risk factors (HLA-DQ2/DQ8) are well defined.

 Additional environmental factors including infant-feeding practices, gastrointestinal infections, and the intestinal microbiome may all play a role.

Whatever the cause, when the body’s immune system mounts an attack against the “invasion” of gluten, the reaction damages the villi: slight hair-like projections that line the small intestine. This damage prevents the villi from performing the function of absorbing vitamins, minerals, and other nutrients, which means the celiac patient cannot get enough nutritional value from the food they’re eating.

 This can be especially disruptive to normal growth and development in children.

Left unchecked, chronic intestinal inflammation and malabsorption from CD can cause a host of complications, including:

Cancer, especially intestinal lymphoma and small bowel cancers

Cardiac disease (myocarditis, cardiomyopathy)

All of these comorbidities represent an enormous human toll, as well as an expensive strain on the health care system.

Historically, the cornerstone of CD diagnosis has been a duodenal biopsy with histological analysis.

 Now serological tests are available, each with a role to play: tissue transglutaminase-IgA (tTG IgA), total IgA, endomysial IgA (anti-EMA), and IgG-based tests.

Given the time-consuming, expensive, and invasive nature of duodenal histology, there has been increased focus on finding the most efficient algorithm and omitting duodenal histology in patients who fulfill other CD diagnostic criteria.

Recently, both the American Gastroenterological Association (AGA) and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) released updated guidelines for diagnosing CD.

 Both reports were based on available published evidence and emphasize that the diagnosis should be made by a specialist (eg, gastroenterologist).

For pediatricians managing patients with symptoms of CD or an affected first degree relative, the recommended diagnostic approach is to begin with an initial test for total serum IgA in addition to a test for serum antitissue transglutaminase IgA antibodies (tTG IgA) as the child continues to consume a gluten-containing diet.

 This is the most clinically and cost-effective screening method. All patients with elevated serum tTG IgA should be referred to a pediatric gastroenterologist for additional testing to confirm the diagnosis of CD (see Table).

A GFD should be continued until the diagnosis is confirmed, as diagnostic testing is less reliable on a GFD. The degree of tTG IgA elevation is somewhat proportionate to the likelihood of CD, such that those with very high tTG IgA levels (>10 times the upper normal limit) may not require a duodenal biopsy for their pediatric gastroenterologist to confirm the diagnosis if the more specific anti-endomysial IgA (EMA IgA) test is also positive (see Figure A).

In these cases, the guidelines give the option to omit duodenal histology.1,2 Proceeding with a no-biopsy approach should be decided on a case-by-case basis with informed discussion among the caregivers, pediatric gastroenterologist, pediatrician, and child. In practice, this strategy may reduce the need for gastroscopy with biopsy by 30-50%.

Pediatric patients aged younger than 2 to 3 years may have a less robust presence of IgA rendering tTG IgA testing less efficient. In these cases, pediatricians may choose to test for IgG deamidated gliadin antibodies (anti-DGP IgG) in addition to the recommended tTG IgA (see Figure A). Performing both tTG IgA and DGP IgG may increase diagnostic sensitivity as some patients with CD have DGP IgG antibodies but not tTG IgA antibodies.

Other relevant, specific markers for CD are anti-endomysial antibodies (anti-EMA). Testing for anti-EMA is labor-intensive and expensive, and should be used as a confirmatory test, particularly if the non-biopsy algorithm proposed in the most recent 2020 clinical practice update is being considered (see Figure A).

Husby S, Murray JA, Katzka DA. AGA clinical practice update on diagnosis and monitoring of celiac disease-changing utility of serology and histologic measures: expert review. 

. 2019;156(4):885-889. doi:10.1053/j.gastro.2018.12.010

Husby S, Koletzko S, Korponay-Szabó I, et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition guidelines for diagnosing coeliac disease 2020. 

Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA; American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. 

. 2013;108(5):656-67. doi:10.1038/ajg.2013.79

Choung RS, Unalp-Arida A, Ruhl CE, et al. Less hidden celiac disease but increased gluten avoidance without a diagnosis in the United States: findings from the National Health and Nutrition Examination Surveys from 2009 to 2014 [published online ahead of print, 2016 Dec 5]. 

. 2016;S0025-6196(16)30634-6. doi:10.1016/j.mayocp.2016.10.012

Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. 

. 2006;131(6):1981-2002. doi:10.1053/j.gastro.2006.10.004 ​

Haines ML, Anderson RP, Gibson PR. Systematic review: The evidence base for long-term management of coeliac disease. 

. 2008;28(9):1042-1066. doi:10.1111/j.1365-2036.2008.03820.x

Hill ID, Bhatnagar S, Cameron DJ, et al. Celiac disease: Working group report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. 

. 2002;35 Suppl 2:S78-S88. doi:10.1097/00005176-200208002-00004

Since the middle of the 20th century and into the 21st century, the incidence of celiac disease has been rising significantly throughout the Western world. Here is what you need to know about this autoimmune condition.

A new diagnostic paradigm for celiac disease

Being a medically complex child can mean increased time in the hospital. A 

 of a quality improvement at a hospital in a major metropolitan area examines whether utilizing a hospital consultation service along with the typical outpatient comprehensive care clinician could lead to a reduction in hospital use and health care costs.

The investigators ran a randomized quality improvement program at the University of Texas Health Science Center at Houston with an outpatient comprehensive care clinic and tertiary pediatric hospital, Children’s Memorial Hermann Hospital. Each participant was a child with medical complexity who was high risk, which mean either ≥2 hospitalizations or ≥1 admission to the pediatric intensive care unit in the year before the child was enrolled in the study. The consultation included serial discussions between the emergency department physicians, comprehensive care clinicians, and hospitalists that covered the need to admission, inpatient treatment, and the transition back to outpatient care. The participants who did not receive the intervention were given usual pediatric care.

During the study period, there were 342 children with medical complexity who were randomized to either get the intervention, 167 children, or typical care, 175 children. In the intention-to-treat analysis, the probability that hospital consultation reduced total hospital days was 91% (2.72 vs 6.01 per child-year; Bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). When compared to usual pediatric care the probability of reduction with health consultation was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for pediatric intensive care unit days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for average total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). Following a secondary analysis using a Bayesian prior centered at RR of 0.78 and reflecting the opinion of 7 clinicians who were considered experts and were knowledgeable about medically complex children, the probability that hospital consultations reduced hospital days was 96%.

The researchers concluded that among children who were considered medically complex and were receiving comprehensive outpatient, a hospital consultation would lead to likely reductions in a number of hospital outcomes such as total hospital days and health system costs. They urge further study in other centers to provide further evidence.

1. Mosquera R, Avritscher E, Pedroza C, et al. Hospital consultation from outpatient clinicians for medically complex children. 

. December 1, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.5026

Medically complex children can spend a great deal of time in the hospital. A quality improvement program examined whether consultations could reduce hospital utilization among such children.

Using consultations to reduce hospital stays of medically complex children

Although there are many societal changes still to go to provide trans individuals with a safe, supportive environment, there have been a number of positive moves in medicine that mean trans children are more likely to go through life as their identified gender, rather than the one given to them at birth, and experience life much like their cisgender peers. An 

 looks into how early gender-affirmative treatment, which may include puberty suppression, using affirming hormones, and gender-affirmative surgeries, could have a positive impact on a trans person’s sexual and romantic development.

The researchers looked at 113 transgender teenagers who had been treated with affirmative hormones, affirmative surgery, and puberty suppression. They assessed the participants as young adults during and after their gender-affirmative therapy. Each participant was giving a questionnaire that asked about romantic experiences, sexual experiences, and subjective sexual experiences. The responses to this questionnaire were compare to a same-aged sample of the general population.

Investigators found that in the first year after surgery, young transgender adults said they had experienced a significant increase with all types of sexual activity. When comparing presurgery to post surgery responses, the investigators found that masturbation increased from 56.4% to 81.7%; petting when undressed increased from 57.1% to 78.7%; and sexual intercourse increased from 16.2% to 37.6%. Additionally, the researchers found that both transmen and transwomen in the study reported being roughly equally experienced. However, the young trans adults were still less experienced with all forms of sexual activity when compared to the general population.

In the discussion of the study’s results, the investigators mentioned that 2 of the big improvements seen through early gender-affirming therapy included psychological well-being, which can impact sexual health, as well as improving body image because trans people who have undergone early gender-affirming treatment are more likely to see who they truly are when they look in the mirror. However, they did note that many trans individuals begin engaging in sexual activity only after receiving gender-affirming therapy, which would put them behind their cisgender peers.

The researchers concluded that using early gender-affirming therapy could offer young transgender adults the chance to engage and increase their romantic and sexual experiences.

1. Bungener S, de Vries A, Popma A, Steensma T. Sexual experiences of young transgender persons during and after gender-affirmative treatment. 

. 146(6):e20191411. doi:10.1542/peds.2019-1411

Academy of Pediatrics Clinical Practice Guidelines

Screening for ADHD and Comorbidities

Collaborative Management: Pediatricians and Psychiatrists

Managing ADHD During the COVID-19 Pandemic

The Impact of COVID-19 Pandemic on Pediatrics

Practical Advice for Caregivers During COVID-19 Pandemic

Medicine Management During COVID-19 Pandemic

Unmet Needs in Pediatric ADHD Management

Stimulant Abuse in Pediatric ADHD Populations

The Future of the ADHD Treatment Landscape

Videos

A discussion on the multidisciplinary management of ADHD, challenges in treatment during COVID-19, and the impact of human abuse potential of ADHD medications.

ADHD: Strategies for Developing a Further Dialogue

Dr Farber is a pediatrician in Woodbridge, Virginia.

Though physicians sometimes empirically prescribe acid inhibitors for infant distress, nonacid re­flux causes at least as much—and perhaps more—pain and distress in infants than acid re­flux, according to a study in 62 children with persistent unexplained fussiness or distress and a median age of 3.5 months.

The prospective study included all children aged younger than 24 months referred to a European hospital for 24-hour multiple intraluminal impedance-pH (MII-pH) monitoring because of recurrent unexplained inconsolable distress thought to be a symptom of gastroesophageal reflux (GER). In addition to the monitoring, parents filled in a symptom diary and the Face, Legs, Activity, Cry, Consolability (FLACC) scale, a measurement for assessing pain in infants and young children. The scale ranges from 0 to 10 with 0 representing “relaxed and comfortable” and 7-10 “severe discomfort/pain.” Investigators then analyzed the FLACC scores in relation to the presence or absence, duration, chemical composition, and esophageal extension of GER episodes.

During the MII-pH monitoring, 452 episodes of distress were recorded, which parents scored with the FLACC scale. The number of episodes ranged from 1 to 32 per child, with a mean of 7.3. Fewer than half of the episodes (48%) were associated with GER. When associated with symptoms, GER occurred significantly more often before an episode of distress than it did simultaneously or after such an episode.

The median FLACC score did not differ significantly between the distress episodes that were associated with GER and those that did not. Overall, 361 (80%) distress episodes were in patients with an acid reflux index <7% and 91 (20%) in those with a pathologic acid reflux index. Episodes of distress associated with nonacid reflux presented a significantly higher FLACC than those with acid content (FLACC 6 vs 5). In addition, the median FLACC value was significantly lower in the 12 (19%) infants with a pathologic reflux index compared with the 50 infants (81%) with a normal reflux index (

Acid reflux is often blamed, incorrectly, for fussiness in infants. I have commented previously on the risk of anti-reflux medicines (

). I am not advocating for pH probes in fussy children, but rather for innocuous treatments that support parents through the fussy period.

When faced with a fussy infant, it's common to think acid reflux is the cause, but a recent report indicates that it may be time to think of other causes.

When it comes to infant distress, acid reflux often gets a bum rap!

, ran an article written by a 15-year-old high school girl, who wanted to share her experiences trying to connect with other students in this most unusual of school years. In it, she talks about how, even without being able to physically hug or high-five fellow classmates and friends, the students have been able to come together as both peers and mentors, sharing a variety of topics, from the presidential debates this past Fall to creating mental health breaks through a Walking Club.

We found this article offering much needed inspiration for young people trying to navigate being a teenager (a pinnacle time for socializing and learning relationships skills of all kinds) in the era of COVID. You can read (and share with your patients) the entire article 

A teenager shares how students can connect, even in the COVID era.

How teens are connecting in high school, despite COVID restrictions

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

The American Academy of Allergy, Asthma, and Immunology (AAAAI) has unveiled 

 on preventing allergies and asthma in children.

 The guidance, updated in September, reviews a number of strategies to prevent, or even delay, the development of several types of allergies.

Food allergies are a big deal in children, who aren’t always able to be choosy when it comes to what they eat. Children can have a difficult time discerning the content of some foods, and parents can’t always be with them. This makes prevention key when it comes to food allergies, which can be triggered by a number of foods like peanuts, cow’s milk, eggs, and more.

Infants who have a sibling or at least 1 parent with an allergic condition are particularly at risk of developing food allergies, especially if they already show symptoms of foods allergies like atopic dermatitis, allergic rhinitis, or asthma.

There are a number of methods that help—and others that don’t—that were reviewed in the guidance.

FALSE—Food avoidance. Food avoidance is one method to prevent the development of food allergies. Mothers may restrict their diets during pregnancy or breastfeeding in an attempt to prevent the development of food allergies, but AAAAI says these strategies are not recommended. There are not data to support avoidance of highly allergenic foods during pregnancy or during breastfeeding to prevent allergy development, the guidance notes.

TRUE—Breastfeeding. Breastfeeding is seen as the best way to feed an infant, AAAAI notes, because breast milk is easy to digest and is the least likely to trigger allergic reactions. Studies show breastfeeding in the first 4 to 6 months of life can also help to reduce prevalence of early eczema, wheezing, and cow’s milk allergies, the guidance notes.

TRUE—Careful Introduction. Introducing solid foods gradually to monitor for any allergic reactions is a good strategy, but allergenic foods shouldn’t be avoided, either. The AAAAI supports the gradual introduction of egg, dairy, tree nuts, peanuts, fish, and shellfish in the first 4 to 6 months of solid food introduction, after other less allergenic foods have been attempted.

There are a number of environmental factors that can trigger allergies, too. However, unlike foods, early contact with environmental allergens can make allergies worse. Research is the most robust when it comes to dust mites, according to AAAAI, which suggests working to control dust mites early to prevent allergy problems. Some solutions to control environmental allergens recommended in the guidance include:

using zippered covers on pillows and mattresses that are made to control allergens

remove upholstered furniture and carpeting from infant bedrooms, if possible

avoid exposing children to secondhand tobacco smoke.

Pet are different, though, according to AAAAI, with recent research suggesting that early exposure to pets can actually help protect children from developing allergies.

The AAAAI also offered guidance on when to get help and where. If possible, the organization recommends finding an allergist specifically, as they have received specialized training in allergy and immunology. Allergy testing by a specialist can give detailed information about an allergy, and the best methods for treatment, according to AAAAI. On the other hand, AAAAI recommends against massive allergy screening tests done in retail sites, applied kinesiology, or testing through muscle relaxation, cytotoxicity testing, skit titration, provocative and neutralization testing, or sublingual provocation.

Kari Christine Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics and director of the Sean N. Parker Center for Allergy and Asthma Research at Stanford University in Palo Alto, California says it’s important that advice be given on science and epidemiological studies. In terms of allergy prevention, research studies show that a diversification of diets with a variety of proteins from different food sources introduced all at once—rather than staged as suggested by AAAAI—can decrease the risk of allergy and asthma development.

There are a number of other tips she offers for allergy prevention, including:

Nadeau also makes it clear that vaccination avoidance is not a prevention strategy for allergens, and that allergy prevention can begin at any age.

1. American Academy of Allergy, Asthma & Immunology. Prevention of allergies and asthma in children. Reviewed September 28, 2020. Accessed December 2, 2020. 

https://www.aaaai.org/conditions-and-treatments/library/allergy-library/prevention-of-allergies-and-asthma-in-children

Early peanut introduction has been recommended to pre-emptively address peanut allergies in at-risk children with positive skin prick tests for some time now, but a new study reveals the potential of peanut introduction as a preventive tool in other groups, as well.

The Learning Early About Peanut Allergy (LEAP) trial and other studies have shown the benefit of early peanut introduction in helping children aged younger than 5 years who are at-risk of developing a peanut allergy. However, these studies have excluded infants whose skin prick tests were greater than 4 mm. Additionally, current guidelines for early peanut introduction recommend oral food challenges only in infants who have skin prick tests ≤7 mm. There is no guidance for infants whose skin prick tests are >7 mm or who have high peanut immunoglobulin E (IgE) levels. Adding to the difficulty in addressing oral food challenges in these populations is the lack of standardized values for skin prick testing and IgE levels in infants with peanut allergies.

Annals of Allergy, Asthma, and Immunology

, sought to test oral food challenges in a wider group than had previously been allowed under current guidelines.

 Specifically, the research team investigated whether smaller, 1-gram doses of peanut would be tolerated in children who typically are not offered oral food challenges.

“We've seen that strict avoidance at a young age does not prevent peanut allergy and may promote it in some at-risk children,” says lead author Adora A. Lin, MD, PhD, FAAAAI, principal investigator for the Center for Cancer and Immunology Research at the Children’s National Research Institute and attending physician at Children’s National Hospital in Washington, DC. “The exact mechanisms are unknown, but the general idea is that allergen exposure through the gut can lead to a tolerizing immune response, whereas allergen exposure through the skin—especially eczema-inflamed skin—can lead to an allergic immune response. We see low dose peanut introduction as a strategy to allow more children get peanut in the diet at a young age to hopefully prevent peanut allergy.”

From an allergist's perspective, many allergists are fearful to offer peanut food challenges to infants with larger peanut skin prick tests, and require them to consume doses larger than 1 gram to "prove" that they are not allergic, Lin reveals.

“We see peanut food challenges with a lower dose as an opportunity to facilitate peanut introduction in some at-risk patients,” she says.

Lin referenced a 2019 survey that showed several barriers to peanut introduction in infants, including fear of reactions, choking, and a lack of infant-safe forms of peanut.

“In the same survey, only 60% of physicians provided recommendations consistent with National Institute of Allergy and Infectious Disease (NIAID) guidelines, with physician-perceived barriers of parental acceptance of guidelines and fear of giving peanut, and identified educational handouts and access to infant-safe forms of peanut as needed resources,” Lin says. “The data suggest that both families and physicians would benefit from further education on practical aspects of peanut introduction.”

The research team tested the tolerance of a one-gram peanut challenge in infants regardless of skin prick test size or peanut IgE results over a 2-year period in the retrospective study. Of the infants with a skin prick test equal to or smaller than 4 mm, 97% were tolerant of low-dose challenges. In children with skin prick tests larger than 4 mm, 63% were low-dose tolerant. Additionally, the researchers found that Ara h2 IgE levels were significantly lower in the children who did well with the tests compared to those who were not tolerant to the oral challenge. This suggests that Ara h2 IgE levels might be predictive to tolerance of oral food challenges in some infants, the study notes. In this regard, the study concludes that low dose peanut oral food challenges with a gradual increase in dosing may help prevent peanut allergies in a larger number of children at risk of developing these allergies.

“Current NIAID guidelines for early peanut introduction recommend peanut introduction or supervised oral food challenge for infants with peanut skin prick tests ≤7 mm in size and do not specifically address management of infants with peanut skin prick tests ≤7 mm,” Lin says. “Based on previous studies, these infants are typically advised to avoid peanut. However, in our study, we showed that over 50% of these infants can tolerate a low dose of peanut and can increase the dose at home.”

This means that supervised introduction of a low dose of peanut can be done safely for a wider population of infants than previously thought—potentially benefiting a larger population of infants—and that families can gradually increase the dose of peanut their infants eat at home, Lin says.

“Multiple studies have provided evidence that early introduction of peanut can decrease the incidence of peanut allergy, leading to guidelines from NIAID, the American Academy of Pediatrics, and clinical organizations around the world to recommend early introduction of peanut. However, due to certain risk factors and test results, many physicians may be hesitant to offer introduction of peanut to certain infants,” Lin notes. “In addition, infants developing feeding skills and preferences may have difficulties eating larger quantities of solid food. We encourage allergists to consider offering supervised introduction of peanut to infants with large peanut skin prick tests, and present the low—1 gram—dose and home increase in the dose as a strategy that will allow incorporation of peanut into the diet in a developmentally accommodating manner.”

New guidelines from the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology are on the way, Lin reveals, adding that she hopes the report will encourage allergists to offer oral food challenges to infants with large skin prick tests who would otherwise be advised to avoid oral food challenges.

“Although risks still exist, our approach allows a wider population of infants to undergo dietary introduction of peanut in a supervised setting, with continued dietary incorporation at home and potentially decreasing the risk of developing peanut allergy in more infants,” Lin says.

1. Lin A, Uyguygil B, Robbins K, Ackerman O, Sharma H. Low-dose peanut challenges can facilitate infant peanut introduction regardless of skin prick test size. 

. 2020;125(1):97-99. doi:10.1016/j.anai.2020.03.026