The Peanut Controversy: American Paediatric Guidelines Now Recommend Introduction of Peanuts as Early as 4 Months

Andrei Dan

In January 2017, an addendum was added to the 2010 American Paediatric Guidelines for the prevention of peanut allergy in the United States (1). According to the update, peanut-containing foods should be introduced as early as at four or six months of age. For patients with severe eczema, serum IgE measurement or skin prick testing is recommended prior to introduction of peanuts. If the test results are negative, parents are encouraged to introduce peanuts to children as early as at four months of age. This addendum contradicts the earlier guideline that recommended avoiding peanuts in infants. How did we come to this drastic change?

 

Infant criteria

Recommendations

Earliest age of peanut introduction

Severe eczema, egg allergy, or both

Strongly consider evaluation by sIgE measurement and/or SPT and, if necessary, an OFC. Based on test results, introduce peanut-containing foods.

4-6 months

Mild-to-moderate eczema

Introduce peanut-containing foods

Around 6 months

No eczema or any food allergy

Introduce peanut-containing foods

Age appropriate and in accordance with family preferences and cultural practices

*Adapted from Togias A al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases (1)

Peanut allergies can induce serious, sometimes fatal anaphylactic reactions. Around 1.00% – 1.85% of Canadians are suspected to have peanut allergies. Such high prevalence makes peanut allergy induced anaphylaxis relatively common (2). With proper counselling and vigilance, anaphylaxis can be avoided. The burden, however, of these lifestyle modifications is still significant, as is the cost of epinephrine auto-injectors.

Despite the revised recommendation in 2008 by the American Academy of Paediatrics reporting that the risks of severe peanut allergy were originally overstated, parents in most Western countries have been keeping their children away from peanut containing food at a young age.

Israel, however, stands out as an exception. Israelis commonly feed Bamba to their children at a very young age (3). Bamba is a corn and peanut butter snack that is incredibly popular in the country and is often fed to children when solid food is introduced into their diet. This makes Israel a large, natural cohort for the study of early peanut exposure and peanut allergy rates. Israel has a peanut allergy incidence of 0.17%, about one tenth of that in Canada (2).

Gideon Lack, a pediatric immunologist at King’s College London, took note of the correlation between early exposure to peanuts and low incidence of peanut allergies in Israel . His observation led him to conduct the Learning Early About Peanut allergy (LEAP) Trial. Published in the New England Journal of Medicine in 2015, this trial looked at 530 atopic infants between four and eleven months of age and randomly assigned them to peanut avoiding and consuming groups (3). The rational for enrollment was that atopic infants would have eczema, egg allergy, or both, which would put them at increased risk of having a peanut allergy. They found that the prevalence of peanut allergy was 13.7% in the avoidance group as opposed to only 1.9% in the consumption group (P<0.001), nearly a ten fold difference. Furthermore, they found no significant differences in the incidence of serious adverse events, which was a primary concern.

The findings of this trial provided strong evidence that ultimately led to the changes in guidelines. Health care workers should help counsel parents to follow the updated guidelines, in the hope that such interventions will help peanut allergy rates fall.

 

References

  1. Togias A, Cooper SF, Acebal ML, Assa’ad A, Baker JR, Jr., Beck LA, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases&#x2013;sponsored expert panel. Annals of Allergy, Asthma & Immunology.
  1. Ben-Shoshan M, Harrington DW, Soller L, Fragapane J, Joseph L, St Pierre Y, et al. A population-based study on peanut, tree nut, fish, shellfish, and sesame allergy prevalence in Canada. J Allergy Clin Immunol. 2010;125(6):1327-35
  1. Stein, Rob. “Feeding Babies Foods With Peanuts Appears To Prevent Allergies.” NPR. NPR, 23 Feb. 2015. Web. 25 Jan. 2017. http://www.npr.org/sections/thesalt/2015/02/23/388450621/feeding-babies-foods-with-peanuts-appears-to-prevent-allergies
  1. Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine. 2015;372(9):803-13.