The new guidelines time squeeze

May 29, 2019

What's the reason behind the lack of following the newest peanut introduction guidelines? Brent Smith, PA-C, MMS, NCCPA, argues that the recurring reasons come back to a lack of time and understanding.

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science.

In addition to membership in SPAP, Mr. Smith is also a member of the Georgia Association of Physician Assistants, American Academy of Physician Assistants, and the American Academy of Pediatrics. He is credentialed at Piedmont Columbus Regional Hospital where he chairs the Pediatric Preparedness Committee. He also is a Co-Trainer for the Pediatric Readiness Quality Collaborative, a national program through the Emergency Medical Services for Children.

In December of 2014, Mr. Smith earned a Certificate of Added Qualifications in Pediatrics from the National Commission on Certifications of Physician Assistants (NCCPA). This certification is in addition to his certification from the NCCPA and demonstrates knowledge and skills specific to pediatrics. He is married to Renee Smith, also a Physician Assistant, and they have one child, Emma.

I literally grew up between peanut fields in southwest Georgia and didn’t know anyone who had a peanut allergy.  It was a foreign concept in the area I lived. Granted this was a few years ago, but it does bring up the question about early exposure to peanuts and other allergens. Dust from peanuts being picked blew everywhere not to mention that just about every parent fed their child peanuts in some form. Was this enough exposure early in life to prevent an allergy to peanuts? New guidelines calling for earlier exposure to peanuts and our lack of utilizing these guidelines are discussed this month in an article by Rachael Zimlich, RN, BSN, entitled “Paradigm shift on peanut introduction tough to swallow.” The guidelines may be new, but the issues related to them are not. Time and understanding seem to be the recurring reasons for lack of implementation for most new guidelines.

The REAL barrier

Well checks are busy. There is no way around this fact. There are many things that must be accomplished in 20 minutes. I was told recently by a parent that we were killing her with “death by a thousand surveys”. In our office, the 4-month checkup has 5 surveys the parent must complete and the 6-month has 6, all with multiple questions. Adding another survey or guideline is not going to be easy. A provider can easily spend the allotted 20 minutes given for the well check just going over surveys.

The first and third abstracts reviewed in the article addressed the reluctance to implement current allergy guidelines. The main barrier here seems to be time and not reluctance to adopt to new guidelines. However, I think there is a measure of reluctance to take on the responsibility of addressing a topic that the provider is potentially uncomfortable discussing.

Rational referral

The second abstract reviewed discussed a retrospective study of 100 infants aged younger than 11 months who were tested for peanut allergies. This study seems to be of limited use in determining if guidelines are met since the inclusion criteria was only if the patients were tested for peanut allergies without mention of whether the provider who referred the patient was aware of the guidelines.

Only 40% of those referred met the National Institute of Allergy and Infectious Disease screening guidelines, but 100% had mild-to-moderate eczema. Per the addendum, severe eczema is a reason to do skin prick or immunoglobulin E testing. Determining moderate from severe eczema is a very subjective thing. Also, many primary care providers are not set up to do skin prick testing and parents are reluctant to have blood drawn for any reason. I think most providers would refer patients who have significant eczema and a concern about peanut allergies to their local allergist. The abstract also mentions that 52% were referred for a family history of peanut allergies which seems to be logical. Referrals in these patients do not seem out of place and are probably to allay parental concerns.

Reversing course

 

Change is often slow, and these new guidelines are a significant shift from previous recommendations. The strains and time constraints placed on providers are not going away and new recommendations and requirements, such as fluoride varnish that I discussed in my previous commentary, will need to be incorporated into our visits. Change will happen, but probably not as fast as many would like. I do find it ironic that, looking back, the rise in peanut allergies in the public may be because we told parents not to give their children peanuts until later in life, which is the opposite from the findings of the Learning Early About Peanut Allergy (LEAP) study. So now, we need to work on fixing our mistakes.