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NIH Panel Recommends Early Peanut Introduction for High-Risk Infants

Babies as young as 4 months can be exposed to peanuts

File photo: Administering immunization to a child

Babies at high risk for developing peanut allergies should be introduced to peanut-containing foods in a controlled way as early as 4 to 6 months of age, according to new guidelines from an expert panel sponsored by the National Institute of Allergy and Infectious Disease (NIAID).
Early peanut introduction was shown to dramatically reduce the risk for allergic sensitization in high-risk infants in the landmark LEAP trial. The new guidelines are largely based on findings from the 2015 study, which showed early introduction of peanut protein to be associated with an 81% reduction in peanut allergy among high-risk children.Infants with severe eczema, egg allergy, or both are considered to have a high risk for peanut and other food allergies. The revised guidelines recommend that parents or caregivers introduce peanut-containing foods as early as 4-6 months to high-risk babies who have already started solid foods, after evaluation by the baby’s healthcare provider or a specialist.
The expert panel recommended that evaluation with peanut-specific IgE measurement, skin prick testing, or both be “strongly considered before the introduction of peanut to determine if peanut should be introduced and, if so, the preferred method of introduction.”
“To minimize a delay in peanut introduction for children who may test negative, testing for peanut-specific IgE may be the preferred initial approach in certain healthcare settings, such as family medicine, pediatrics, or dermatology practices, in which skin prick testing is not routine. Alternatively, referral for assessment by a specialist may be an option if desired by the heathcare provider and when available in a timely manner,” the guidelines state.
The revised guidelines were published simultaneously Jan. 5 in the Annals of Allergy, Asthma & Immunology and related journals. The NIAID’s expert panel, which included representatives from 25 professional organizations, federal agencies, and patient advocacy groups, included separate guidelines for infants with different peanut allergy risks.
Pediatric allergist and panel member Hugh Sampson, MD, of New York City’s Icahn School of Medicine at Mount Sinai, said infants with peanut IgE levels of less than 0.35 kUA/L are considered to have a low likelihood of peanut sensitivity. It is recommended that peanuts be introduced into the diet of these babies soon after testing.Babies with IgE levels of 0.35 or greater should be referred to a specialist for more testing, Sampson added.
The panel defined three categories of sensitivity risk associated with skin prick testing with peanut extract:
A wheal diameter of 2 mm or less with skin prick testing is indicative of low risk, and the panel recommended peanut introduction soon after testing
Wheal diameter of 3 to 7 mm reflects medium likelihood of peanut allergy; supervised peanut feeding or an oral food challenge at a specialist’s office or specialized facility can be employed
A wheal diameter of 8 mm or more is indicative of a high likelihood of allergy, and children in this category should be evaluated and managed by a specialist
Sampson said parents and caregivers who introduce peanuts at home should initially give two teaspoons of peanut butter diluted in warm water or a warm puree that the baby enjoys, followed by two more such feedings over the course of a week for a total of roughly six grams of peanut protein. The schedule should be repeated weekly.
“This needs to be done pretty consistently to establish tolerance, at least based on what we know from the LEAP trial,” he told MedPage Today.
He added that babies at high risk for peanut allergies often become allergic before the age of 12 months, which is why early peanut introduction is so important.”We haven’t really appreciated until recently the amount of food protein in the environment. It is present in house dust or on the hands of parents or siblings,” he said.
Sampson added that it is now widely believed that children with eczema have a high risk for food allergies, in part, because these proteins are introduced through inflamed skin.
The guidelines call for infants with a moderate risk for peanut allergy to have peanut-containing foods introduced around 6 months of age, while no specific feeding schedule is recommended for infants with a low peanut allergy risk.
While the LEAP trial findings unequivocally showed a benefit for introducing peanuts at about 4-6 months of age in high-risk infants, results from studies evaluating the impact of early feeding for the prevention of other food allergies have been mixed.
Sampson said it may be that age 4-6 months represents the optimal window for avoiding sensitivity to peanuts, but not other foods. “This may be too late for milk and eggs,” he said.John Andrew Bird, MD, director of the Food Allergy Clinic at UT Southwestern’s Children’s Medical Center in Dallas, said the new guidelines should have a major impact on clinical practice, especially among pediatricians.
“Allergists have been aware of this since LEAP, but now that there are clear guidelines, the hope is that pediatricians and family practitioners will come on board,” Bird told MedPage Today.

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