New guidelines for early peanut exposure


New recommendations for infant exposure to peanuts to prevent peanut allergy address something many pediatricians have long suspected: Early exposure to peanuts, even in infants that have eczema, could prevent development of peanut allergy.

Bernard Cohen, MD, professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, says new recommendations for infant exposure to peanuts to prevent peanut allergy address something many pediatricians have long suspected: Early exposure to peanuts, even in infants that have eczema, could prevent development of peanut allergy.

“Many of us were concerned about delaying exposure to all sorts of allergens, the idea being that, if kids are exposed early on, they become tolerant and do fine,” Cohen says.

The pivotal point in that thinking regarding peanut allergy came with results from the landmark Learning Early About Peanut Allergy (LEAP) trial, according to Cohen. In that study of 640 infants, aged from 4 to 11 months, with severe eczema and/or egg allergy, researchers found it was better to expose even higher risk babies to peanuts early to prevent the allergy later in life.1

The new


2 to the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel,3 includes 3 guidelines for infants at different levels of risk for developing peanut allergy-all of which take in account whether or not infants have eczema.

“We know that children with atopic dermatitis [AD] have a higher rate of developing food allergies than those without AD-with about 15% of milder AD patients having 1 clinically relevant food allergy (meaning a consistent clinical reaction, not just a positive test to food) by a few years of age, and around 40% of the more severe patients,” says Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, and chief of pediatric and adolescent dermatology, University of California, San Diego School of Medicine and Rady Children's Hospital, San Diego. Eichenfield represented the American Academy of Dermatology (AAD) on the coordinating committee for the new clinical guidelines on the prevention of peanut allergy and was a member of the expert panel. “It is important to recognize this connection, and that the xerosis and impaired skin barrier associated with eczema may allow more sensitization to allergens through the skin,” he says.

The recommendations

The first of the 3 guidelines focuses on infants with severe eczema, egg allergy, or both that are, therefore, believed to be at high risk of peanut allergy. To reduce the risk of developing peanut allergy, pediatricians and other healthcare providers should recommend that parents feed these infants peanut-containing foods as early as ages 4 to 6 months. Providers might elect to perform tests to help determine how to safely introduce peanuts into infants’ diets, according to the first guideline.

The second guideline recommends that infants with mild or moderate eczema can reduce their risk for peanut allergy by having peanuts introduced into their diets at about 6 months of age.

The third guideline says that for infants without eczema or food allergies, parents can freely introduce peanut-containing foods into infants’ diets.

Parents should feed infants other solid foods before peanut-containing foods in all cases, according to the guidelines.

The National Institutes of Health (NIH) sponsored the expert panel representing 26 professional organizations, advocacy groups, and federal agencies to develop the Addendum Guidelines. The panel referred to results from the landmark LEAP study, published February 2015 in the New England Journal of Medicine,1 which showed infants with severe eczema, egg allergy, or both who regularly consumed peanut-containing foods in infancy through age 5 years were 81% less likely to develop peanut allergy than infants who avoided exposure to peanuts in their diets.

More: New recommendations for preventing food allergies

“The population at highest risk is children in the first year of life with severe atopic dermatitis . . . as well as those with egg allergy. Early evaluation (with serum immunoglobulin [Ig] E screening) or referral to allergy (specifically for skin testing for peanut) is important to allow this group of patients to benefit from the tolerance that can be developed with early feeding,” Eichenfield says.

Putting guidelines into practice

The latest recommendations are to identify children in the first year of life with severe atopic dermatitis or egg allergy and to get them evaluated, so that these children can get early peanut feeding.

Eichenfield says that although children with mild to moderate eczema may be introduced to peanuts at 6 months of age or older, without any specific allergy evaluation, the introduction should generally be with dilute peanut butter. Peanuts can be dangerous, as they can be aspirated, he says.

Cohen recommends a product called Bamba, a snack made in Israel by [Osem Group], for safe exposure. Israeli news source Haaretz covered a story on Bamba on the heels of a study published in the New England Journal of Medicine suggesting Israeli children suffer from peanut allergies at one-tenth the rate of Western children with similar genetic backgrounds.4 One reason could be early exposure to peanuts by eating (and teething on) Bamba, a peanut-flavored snack considered a staple of Israeli childhood, according to the article.5

“At one point I was recommending that babies be exposed to a small amount of smooth peanut butter, but I recognize there could be some aspiration concern with that, so something like Bamba could be a lot safer,” Cohen says.

As for who should be considered as having severe eczema, Eichenfield says the expert panel used this definition: “Severe eczema is defined as persistent or frequently recurring eczema with typical morphology and distribution assessed as severe by a healthcare provider and requiring frequent need for prescription-strength topical corticosteroids, calcineurin inhibitors, or other anti-inflammatory agents despite appropriate use of emollients.”

In essence, Eichenfield says, infants with atopic dermatitis that are judged by providers to be severe and that need frequent prescription-based treatments are the targeted patients to get evaluated.

“It should be stressed that the guidelines do not suggest general food allergy testing for common foods, recognizing that both skin testing and serum IgE testing has many false positive tests, and that food avoidance based on these tests is not a very successful strategy unless children have clinical reactions to specific foods,” Eichenfield says. “The guidelines are specific in recommending evaluation for specific IgE for peanut by blood test as a screen.”

Cohen says that babies with severe eczema or a family history of anaphylaxis to peanut allergen should have their first exposures in pediatricians’ offices. “But the kids who have mild to moderate eczema, with no family history of anaphylaxis, I think it makes sense for the families to do this at home,” he says.

NEXT: Is the change in thought premature?


Too soon?

Peter Lio, MD, assistant professor of clinical dermatology and pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and director of the Chicago Integrative Eczema Center, notes the Addendum Guidelines are really based on 1 study: the LEAP study. Whereas the study’s results were impressive, he says, it may be premature to make such a bold statement based on 1 study.

“We are frequently cautioned against this in medicine, and it certainly seems possible that this will not be true-or ‘as true,’ perhaps-for all populations. That said, I think it reasonable and is likely to be the correct way forward; I just wish we had a few other corroborating studies,” Lio says.

Lio points out that there is no standardized way to delineate "severe" eczema from "moderate" eczema; yet, this is an important distinction for these guidelines because severe eczema warrants “evaluation with peanut-specific IgE and/or skin prick test,” while moderate disease would warrant introducing peanut-containing foods without testing, he says.

“This is very tough because what we as dermatologists would call ‘severe’ might be considerably different than how pediatricians define it, possibly resulting in much more allergy testing than is warranted,” Lio says. “For me, this is exciting because it really does seem to be a breakthrough in understanding, and we truly need this advancement. It is also a little bit scary, because I see myself referring an incredible number of patients to allergists for testing now, as I am worried that my definition of moderate may be someone else's definition of severe, and I fear recommending peanut-containing foods in those who may already be allergic.”

Next: Why gluten free isn't for every child

Cohen isn’t concerned about the distinction, and is confident that savvy pediatricians can distinguish between mild and moderate to severe eczema. He says that by taking necessary precautions-exposing severe patients and those with a family history to peanuts in the office and using approaches or products, such as Bamba, aimed at preventing aspiration-pediatricians should consider being onboard with the new recommendations.

The takeaway for pediatricians, Cohen says, is to be aware of the LEAP trial and the amended guidelines, which were written with representation by the American Academy of Pediatrics.

Disclosures: Drs Cohen, Eichenfield, and Lio report no relevant conflicts.



1. 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 Engl J Med. 2015;372(9):803-813. Erratum in: N Engl J Med. 2016;375(4):398.

2. National Institute of Allergy and Infectious Diseases. Addendum guidelines for the prevention of peanut allergy in the United States: summary for clinicians. Available at:

. Published January 2017. Accessed February 7, 2017.

3. Boyce JA, Assa'ad A, Burks AW, et al; NIAID-Sponsored Expert Panel. Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-sponsored Expert Panel Report. J Allergy Clin Immunol. 2010;126(6):1105-1118.

4. Gruchalla RS, Sampson HA. Preventing peanut allergy through early consumption-ready for prime time? N Engl J Med. 2015;372(9):875-877.

5. Haaretz; Associated Press. Popular snack Bamba may explain why so few Israeli kids are allergic to peanuts. Available at: Published February 24, 2015. Accessed February 7, 2017.

Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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