New US guidelines support infant exposure to peanuts

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In a significant reversal, US National Institute of Allergy and Infectious Diseases guidelines call for parents to give their children foods containing peanuts early and often, starting when they’re infants, to help avoid life-threatening peanut allergies.

The New York Times reports that the new guidelines, issued by the National Institute of Allergy and Infectious Diseases, recommend giving babies puréed food or finger food containing peanut powder or extract before they are 6 months old, and even earlier if a child is prone to allergies and doctors say it is safe to do so. One should never give a baby whole peanuts or peanut bits, experts say, because they can be a choking hazard.

If broadly implemented, the new guidelines have the potential to dramatically lower the number of children who develop one of the most common and lethal food allergies, said Dr Anthony Fauci, the institute’s director, who called the new approach “game changing.”

Could the new guidelines mark the end of the peanut-butter-and-jelly sandwich bans so common in school lunchrooms? “If we can put this into practice over a period of several years, I would be surprised if we would not see a dramatic decrease in the incidence of peanut allergies,” Fauci is quoted in the report as saying.

Peanut allergies are responsible for more deaths from anaphylaxis, or constriction of the airways, than any other food allergy. The report says although deaths are extremely rare, children who develop a peanut allergy generally do not outgrow it and must be vigilant to avoid peanuts for the rest of their lives.

“You have the potential to stop something in its tracks before it develops,” said Dr Matthew Greenhawt, chair of the American College of Allergy, Asthma and Immunology’s food allergy committee, and one of the authors of the new guidelines. It appears there “is a window of time in which the body is more likely to tolerate a food than react to it, and if you can educate the body during that window, you’re at much lower likelihood of developing an allergy to that food,” Greenhawt said.

The report says the guidelines represent an about-face from the advice given out by the American Academy of Paediatrics as recently as 2000, when parents were told to withhold peanuts from children at high risk for allergies until they were 3 years old.

Despite those recommendations, the prevalence of peanut allergies kept increasing. Ten years later, around 2% of children in the US had the allergy, up from less than half of 1% in 1999, and the academy started retreating from its advice, which didn’t seem to be working.

The report says the new guidelines grow out of several studies conducted in recent years that challenged the advice to ban peanuts in infancy, long a standard practice in the UK, Australia and the US.

One report was carried out by scientists intrigued by anecdotal reports that Jewish children in Israel rarely suffered from peanut allergies. Dr Gideon Lack, the senior author of the study and a professor of paediatric allergy at King’s College London, compared the allergy rates of Israeli Jewish children with those of Jewish children in Britain, and found that British children were 10 times as likely to have peanut allergies as Israeli children, a disparity that could not be explained by difference in genetic background, socioeconomic class or tendency to develop other allergies.

One of the main differences between the two populations was that starting in infancy, Israeli children ate foods containing peanuts, often in the form of Bamba, a popular peanut-butter puffed corn snack that has the consistency of a cheese puff but is 50% peanuts, according to the manufacturer, Osem Group. Was it possible that early exposure to peanuts actually protected the Israeli kids from allergies?

The report says Lack and fellow scientists tested the hypothesis in a large clinical trial in England. They recruited hundreds of infants aged 4 to 11 months, all of whom were deemed at high risk of developing a peanut allergy because they had eczema or an allergy to eggs. After running skin-prick tests on the babies and excluding those who were already allergic to peanuts, they randomly assigned some babies to be regularly fed peanut products, and others to be denied all peanut-containing foods.

By the time they turned 5, only 1.9% of 530 allergy-prone children who had been fed peanuts had developed an allergy, compared with 13.7% of the children who were denied peanuts. Among another group of 98 babies who were more sensitive to peanuts at the start of the study, 10% of those who were given peanuts developed an allergy, compared with 35% of those denied peanuts. The findings, published in 2015, “shook the foundation of the food allergy world,” Greenhawt said.

The new guidelines divide children by risk. Low-risk infants, who don’t have eczema or an egg allergy and who have started solid foods, can be introduced to peanut-containing foods around 6 months at home by their parents. So can moderate risk children, who have mild eczema.

High-risk infants, who have severe eczema or an egg allergy, should be introduced to peanut-containing foods as early as 4 to 6 months, after they start other solid foods and are evaluated by a doctor for safety.

If your baby is determined to be high-risk, the guidelines recommend an evaluation by an allergy specialist, who may order allergy testing and introduce a peanut food in the doctor’s office, Greenhawt said. Even if allergy tests show sensitivity to peanuts, the baby isn’t necessarily allergic and may benefit from eating peanut foods, he said. A baby with a stronger reaction to the skin test may already be allergic, however, and the doctor may decide to recommend complete avoidance.

One way to introduce your baby to peanuts safely is to mix a couple of teaspoons of smooth peanut butter with a couple of teaspoons of warm water and stir until it has a smooth soupy or purée-like consistency, suggested Dr J Andrew Bird, paediatric allergist with UT Southwestern Medical Centre and Children’s Medical Centre in Dallas, is quoted in the report as saying.

Foods containing peanuts should not be the first solid a baby eats, Greenhawt said. It’s also important to continue feeding the peanut-containing food regularly, aiming for three times a week, through childhood.

The report says he acknowledged the new recommendations may face resistance. “The nuts and bolts of getting everyone to buy in to this and trust the recommendation and the data is a big unknown,” Greenhawt said. But the potential, he says, is enormous.

“This won’t outright prevent every single case of peanut allergy – there will still be some cases – but the number could be significantly reduced by tens of thousands,” Greenhawt said. “In the best case scenario, every allergist across the US could be seeing fewer cases of peanut allergy — and that’s a good problem to have.”

Abstract 1
Background: Despite guidelines recommending avoidance of peanuts during infancy in the United Kingdom (UK), Australia, and, until recently, North America, peanut allergy (PA) continues to increase in these countries.
Objective: We sought to determine the prevalence of PA among Israeli and UK Jewish children and evaluate the relationship of PA to infant and maternal peanut consumption.
Methods: A clinically validated questionnaire determined the prevalence of PA among Jewish schoolchildren (5171 in the UK and 5615 in Israel). A second validated questionnaire assessed peanut consumption and weaning in Jewish infants (77 in the UK and 99 in Israel).
Results: The prevalence of PA in the UK was 1.85%, and the prevalence in Israel was 0.17% (P < .001). Despite accounting for atopy, the adjusted risk ratio for PA between countries was 9.8 (95% CI, 3.1-30.5) in primary school children. Peanut is introduced earlier and is eaten more frequently and in larger quantities in Israel than in the UK. The median monthly consumption of peanut in Israeli infants aged 8 to 14 months is 7.1 g of peanut protein, and it is 0 g in the UK (P < .001). The median number of times peanut is eaten per month was 8 in Israel and 0 in the UK (P < .0001).
Conclusions: We demonstrate that Jewish children in the UK have a prevalence of PA that is 10-fold higher than that of Jewish children in Israel. This difference is not accounted for by differences in atopy, social class, genetic background, or peanut allergenicity. Israeli infants consume peanut in high quantities in the first year of life, whereas UK infants avoid peanuts. These findings raise the question of whether early introduction of peanut during infancy, rather than avoidance, will prevent the development of PA.

Authors
Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki SJ, Fisher HR, Fox AT, Turcanu V, Amir T, Zadik-Mnuhin G, Cohen A, Livne I, Lack G

Abstract 2
Background: The prevalence of peanut allergy among children in Western countries has doubled in the past 10 years, and peanut allergy is becoming apparent in Africa and Asia. We evaluated strategies of peanut consumption and avoidance to determine which strategy is most effective in preventing the development of peanut allergy in infants at high risk for the allergy.
Methods: We randomly assigned 640 infants with severe eczema, egg allergy, or both to consume or avoid peanuts until 60 months of age. Participants, who were at least 4 months but younger than 11 months of age at randomization, were assigned to separate study cohorts on the basis of preexisting sensitivity to peanut extract, which was determined with the use of a skin-prick test–one consisting of participants with no measurable wheal after testing and the other consisting of those with a wheal measuring 1 to 4 mm in diameter. The primary outcome, which was assessed independently in each cohort, was the proportion of participants with peanut allergy at 60 months of age.
Results: Among the 530 infants in the intention-to-treat population who initially had negative results on the skin-prick test, the prevalence of peanut allergy at 60 months of age was 13.7% in the avoidance group and 1.9% in the consumption group (P<0.001). Among the 98 participants in the intention-to-treat population who initially had positive test results, the prevalence of peanut allergy was 35.3% in the avoidance group and 10.6% in the consumption group (P=0.004). There was no significant between-group difference in the incidence of serious adverse events. Increases in levels of peanut-specific IgG4 antibody occurred predominantly in the consumption group; a greater percentage of participants in the avoidance group had elevated titers of peanut-specific IgE antibody. A larger wheal on the skin-prick test and a lower ratio of peanut-specific IgG4:IgE were associated with peanut allergy.
Conclusions: The early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts.

Authors
Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G; LEAP Study Team

The New York Times report
NIAID guidelines
Journal of Allergy and Clinical Immunology abstract
New England Journal of Medicine abstract


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