NIAID guidelines on peanuts may apply to other foods

Michael Pistiner, MD, MMSc, FAAP

David R. Stukus, MD

Currently, the only guidelines on the early introduction of foods in children to prevent food allergy is specific to peanuts. In 2017, the National Institute of Allergy and Infectious Diseases (NIAID) issued the Addendum Guidelines for the Prevention of Peanut Allergy in the United States that provides very specific guidelines on the early introduction of peanuts.¹

The updated guidelines were changed based on the results of the Learning Early About Peanut (LEAP) allergy study, a groundbreaking trial because of its methodologic rigor and solid science, according to Michael Pistiner, MD, MMSc, FAAP, pediatric allergist and director of Food Allergy Advocacy, Education, and Prevention at MassGeneral Hospital for Children Food Allergy Center, Harvard Medical School, Boston, Massachusetts, who says that the NIAID guidelines are consistent with the findings of LEAP and were written to apply to all babies.

“This study was a good first step forward when it comes to allergy and food introduction in general,” he says. “Since then, there have been other people looking at and thinking about other food allergens, such as eggs, which seem to have a similar trend.”

However, he emphasizes that no consensus recommendations yet exist for any other food allergy introductions except for the NIAID guidelines on peanuts.

Pistiner spoke on the recommendations of the NIAID guidelines at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida, in a session titled “Beyond peanuts: Early introduction of foods to prevent food allergy” on November 3. His talk also provided some practical advice on how pediatricians can approach early introduction of other potential food allergens in children.

More study is needed

During his session, Pistiner explained what is known about peanut allergies (ie, the NIAID’s Addendum Guidelines) and other trends in the introduction of food allergies that as of yet have no firm consensus on timing and approach.

“All pediatricians and allergists are waiting for more hard recommendations from the NIAID, so until then, we use our best efforts and judgements based on the available science to practically give advice to the introduction of other potentially allergenic foods in the babies that we manage,” Pistiner said.

Given that the only solid recommendations come from the guidelines on peanuts, Pistiner detailed that the current NIAID Addendum Guidelines apply to all infants and are divided into 3 main groups:

1. Children at high risk of developing a peanut allergy, defined as those with severe eczema and/or egg allergy: These kids should be screened either by an allergist using skin testing or using peanut-specific immunoglobulin E (IgE) blood testing prior to the introduction of peanuts. The goal in these kids is to introduce peanuts at 4 to 6 months of life.

2. Children with mild/moderate eczema: These kids don’t need to be screened, with a goal of introducing peanuts at age 6 months at home.

3. Kids without higher risk: These kids can be fed peanuts when the parents/family feel it is appropriate culturally. No screening is necessary.

Pistiner emphasizes that pediatricians need to take these guidelines seriously. “Implementing these NIAID Addendum Guidelines for the Prevention of Peanut Allergy in the United States does help pediatricians approach the introduction of other foods as well,” he says. “Having a system to educate families and getting access to allergists who can answer important questions about eczema and other allergies can expedite the appropriate care of these kids and give the opportunity for early introduction of foods that go beyond peanuts that are developmentally appropriate,” he notes.

In his talk, Pistiner provided some practical advice about how to introduce these other foods by talking about what he does and some of the research trends. One tip for pediatricians and families is to make sure that the form of the food is developmentally appropriate. For example, he said to keep in mind that loose nuts and some other forms can be a choke risk. “The NIAID’s Guidelines offer easy tips to safely introduce developmentally appropriate forms of peanuts,” he told attendees.

Reference

1. 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. J Allergy Clin Immunol. 2017;139(1):29-44.

Commentary

The presentation given by Michael Pistiner, MD, MMSc, FAAP, highlights an emerging and important area of food allergy prevention that all pediatricians need to better understand. Prior infant feeding recommendations advised that infants avoid allergenic foods such as peanuts and eggs until they were aged at least 2 years. Those recommendations were based upon expert opinion without supporting evidence.

During the past few years, new evidence reverses that prior thought process. Instead of avoiding food allergy by delaying introduction, clinical trials have now demonstrated that early introduction of peanut (and likely egg) to infants prior to 12 months of age can substantially decrease food allergy development.

New guidelines published by the National Institute of Allergy and Infectious Diseases (NIAID) in 2017 recommend active introduction of peanut to all infants prior to age 1 year, beginning around 4 to 6 months. Infants with moderate-to-severe eczema and/or existing egg allergy are at highest risk to develop peanut allergy, and guidelines recommend a peanut allergy test in this select cohort prior to introduction. All other infants should have peanut introduced into their diet without any testing. Of note, other countries including Australia and the United Kingdom do not advocate for any testing prior to introduction because of concern for limited resources, overuse of allergy testing, and potential for misinterpretation of test results.

This new information contradicts prior recommendations and long-held beliefs by parents and pediatricians. For reasons not fully understood, rates of food allergy among children have doubled over the past decade. This is our opportunity as pediatricians and allergists to halt the rise in food allergy and potentially prevent a generation of infants from developing food allergies at all.

Implementation of these guidelines will require a sustained multidisciplinary effort to help reverse firm beliefs from parents and pediatricians. In addition to education and awareness campaigns, pediatricians will need to actively discuss these recommendations with families at all well-child visits during infancy. Pediatricians will also need to maintain vigilance for infants with moderate-to-severe eczema who are at greatest risk to develop food allergy, and also the group most likely to benefit from early and sustained introduction.

Dr. Pistiner’s presentation highlights the evidence surrounding these current recommendations and the need to adopt a new approach to actively try and impact the food allergy epidemic on a population level, and provides practical tips for pediatricians to implement in their practice as soon as possible.

David R. Stukus, MD, is associate professor of Pediatrics, Division of Allergy and Immunology, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, Ohio.