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Expert weighs in on adoption of early feeding guidelines for peanut allergy avoidance.
Evidence-based guidelines to prevent peanut allergies were released in 2017, but a new report shows that parents, time, and training are major barriers to the implementation of those recommendations, according to a leading researcher at the virtual 2020 American Academy of Pediatrics (AAP) National Conference and Exhibition.
Ruchi S. Gupta, MD, MPH, professor of pediatrics at the Northwestern University Feinberg School of Medicine and director of the Center for Food Allergy and Asthma Research at the Ann & Robert H. Lurie Children’s Hospital of Chicago, led a session titled, “Infant Feeding in the Prevention of Food Allergy.”
The goal of the session was to review a study Gupta and her colleagues conducted to better understand what recommendations pediatricians are making to parents about solid food introduction, and to summarize current pediatric implementation guidelines and the barriers to using them. Gupta started her session by reviewing the path pediatricians took to the current guidelines, beginning with the old recommendations to avoid peanuts altogether until age 3 years in order to avoid allergic reactions to peanuts.
“We were seeing peanut allergies increase dramatically,” Gupta notes.
In 2008, she says it was decided that there really wasn’t enough evidence to support avoidance of peanuts as a way to prevent allergies, so the guidelines were changed to a “do what you think is best,” approach of neither suggesting early feeding or delayed feeding of peanuts.
Most pediatricians responded to this non-recommendation by continuing to tell parents to avoid feeding infants peanuts, just to be safe, Gupta says. When the Learning Early about Peanut Allergy (LEAP) clinical trial was published in 2015, however, stakeholders had new data to craft evidence-based guidelines. Following the LEAP study, which supported the efficacy of early introduction to fight the development of peanut allergies, the National Institute of Allergy and Infectious Diseases (NIAID) updated its recommendations in 2017 to include early peanut introduction as an allergy prevention strategy.
The study conducted by Gupta and her colleagues and published in the Journal of Allergy and Clinical Immunology, examined how pediatricians were doing when it came to enacting those recommendations. The AAP Section on Breastfeeding and Committee on Nutrition has recommended that introduction of solid foods beginning around 6 months of age, depending on the infant’s interest in food, head control, and ability to sit upright. Alongside that recommendation, the Centers for Disease Control and Prevention (CDC) suggests feeding infants 1 new food type at a time, observing them for reactions for a few days between. This study was the first to really look at how pediatricians were using the guidelines from these organizations, and the new data on allergy prevention.
“It’s really unclear what pediatricians are recommending for their patients,” Gupta says. “So we decided to ask pediatricians.”
The electronic survey was sent primarily to pediatricians, but also to medical residents and nurse practitioners that advise parents on infant feeding practices.
“More pediatricians recommended early introduction if they were not exclusively breastfed,” Gupta notes. “If they are exclusively breastfed, that reversed a bit.”
Gupta says this trend was interesting because it is a little different than the current recommendations.
“We also asked what food they typically recommend introducing first, and the majority—about 40%—said they don’t have a recommendation,” she says. Cereals and fruits were among the top recommendations for first foods when one was made, she adds.
Recommendations for early introduction of allergens and first food offerings differed when infants had older siblings with food allergies, a family history of food allergies, or eczema. In these cases, pediatricians would more frequently recommend waiting longer than 3 days to try different foods in children at a higher risk of developing food allergies, Gupta says. “It actually goes against what we know about food allergies,” she says.“By introducing them early [to children whose siblings have allergies], we have a higher chance of developing food allergies.”
The number of food allergy reactions pediatricians were seeing didn’t match their recommendations, either, Gupta adds. According to the study, 55% of pediatricians said they saw food allergy reactions in less than 5% of the infants they saw, compared to just 20% who saw food allergy reactions in 5% to 10% of their infant patient population.
“Very few infants are having these reactions to food,” Gupta notes, adding that when food reactions happen, they tend to happen quickly. “This whole idea of waiting 3 to 5 days between introduction of new foods is causing decreased diet diversity in these infants, and could increase their risk of developing food allergies.”
Gupta says given the results of the implementation study, she recommends bringing stakeholders back together to reassess and think about guidelines on feeding practices and wait times between new food introductions.
“There is no data showing 3 to 5 days is an ideal time. Diet diversity is increasingly being found to be important to preventing food allergies,” she says.
There is also some new evidence that oral exposure can prevent the development of allergies from skin—or subcuteanous—exposure to peanuts, Gupta adds. Children with severe eczema have the risk of being exposed to allergens through their skin before they are exposed orally, she says. The big push now is to expose those children to allergens through their gut to put them on the right immunity track and become immune to the allergen before skin exposure, Gupta adds.
In summary, the new guidelines tell clinicians to look for eczema, order an immunoglobulin E (IgE) test for peanut allergies if eczema is present, and advocate for feeding the infant peanut products if the IgE test is negative or there is no eczema. If the IgE test is positive, the clinicians should refer the infant to an allergist for skin prick test, and possibly an oral food challenge to peanuts, she says.
“The main thing pediatricians need to look out for is to identify kids with severe eczema early for a higher chance to prevent peanut allergies,” Gupta says.
For infants with mild or no eczema, pediatricians should encourage early peanut introduction around 6 months of age, after a few other foods have been introduced. Gupta recommends avoiding whole peanuts due to choking risk, and mixing peanut butter with a little water to help make the consistency less sticky. The key is not just introducing peanuts, but also keeping them in an infant’s diet, she adds. Feeding about 2 teaspoons per week fed 3 times each week is ideal, Gupta says.
Going forward, Gupta suggested there should be better support and educational material provided to pediatricians to help them—and parents—navigate these new recommendations.