For over a decade, many pediatricians followed guidance set forth by the American Academy of Pediatrics to delay the introduction of highly allergenic foods, like peanut, to children at risk of developing food allergies. In early 2015, the landmark LEAP (Learning Early About Peanut) study demonstrated that the prior recommendations may have missed the mark. Gideon Lack and colleagues performed a large prospective study on infants at risk of developing peanut allergy (severe eczema and/or egg allergy). They found that in this high-risk group, early introduction of peanut containing food between 4 and 11 months of age, could drop the risk of developing peanut allergy by 80 percent.
This about-face offers an amazing, yet challenging opportunity to decrease peanut allergy prevalence and stop a food allergy before it starts.
Give babies peanut? What do the experts say?
In response to the LEAP findings, the National Institute of Allergy and Infectious Diseases, commonly known as NIAID, created an expert panel to develop comprehensive recommendations and update existing guidelines. The panel, comprised of clinicians and researchers, released the Addendum Guidelines for the Prevention of Peanut Allergy in the United States in February 2016. Three guidelines, each applying to a different infant risk group, were released: high, moderate and low risk.
Infants with severe eczema and/or egg allergy should have age-appropriate forms of peanut introduced at 4 to 6 months of age, or as soon as possible if delayed, after appropriate screenings. This could include an evaluation with possible skin testing and oral challenge or supervised feeding performed by allergist; or negative immune-cap-specific IgE to peanut only, if poor access to an allergist. Prior to feeding, other age appropriate solids should already be tolerated.
Those with mild/moderate eczema do not require allergist evaluation or any prior testing. Keeping in mind family and cultural practice and preference, these children should have age appropriate forms of peanut introduced around 6 months of age. If caregivers or health care providers desire a supervised feeding, allergist evaluation, or both, then the family should request an allergy referral.
Low risk infants are those without eczema or any food allergy. Also without screening, they can have age-appropriate forms of peanut introduced into their diet together with other solids in accordance with family and cultural preferences and practices.
Annals of Allergy, Asthma & Immunology; Volume 118, Issue 2, Pages 166-173.e7 (February 2017)
Sounds easy enough, but how do we implement?
Pediatricians must be familiar with current NIAID Addendum Guidelines to properly screen for risk factors. Infants appropriately identified will require access to testing and board certified allergists comfortable with treating infants.
Allergists should also ensure their teams are familiar with the recommendations and are equipped to caring for infants. They must prioritize at-risk children and have access to oral food challenges in a timely fashion and in a safe environment.
The MassGeneral Hospital for Children Food Allergy Center’s Approach
Strong collaborations between primary care pediatrics and the Food Allergy Center are key to successfully implementing the NIAID guidelines at MGHfC. In July 2017, the Food Allergy Center launched its Food Allergy Prevention Program to help foster working relationships with pediatricians that will allow for increased access to risk factor screenings for all infants within the MGH and Partners HealthCare system that warrant further testing and/or evaluation by a pediatric allergist. In addition to creating screening protocols, the Food Allergy Prevention Program will develop a pediatric-wide education and system wide strategy aimed at decreasing the prevalence of peanut allergy in the children that we care for.
The program’s ability to perform food challenges in a timely manner is vital to a child’s future success. This important systemized procedure is the gold standard to determine if a person is truly allergic to a food.
In most cases, a food challenge helps determine that a patient is not allergic and can safely eat a food without experiencing a reaction. These procedures necessitate appropriate space for observation and treatment of allergic reactions, if needed; in addition to well trained staff. In fall 2017, oral food challenges for young children will be offered weekly at Massachusetts General Hospital in the White building, floor 12.
While the NIAID guidelines are a vital step in preventing the next generation of food allergic children, our work is not yet complete. The Food Allergy Prevention Program and its collaborators look to bettering care for children with other or multiple food allergies, such as tree nuts, those over 1 year of age, and those with a familial allergic tie.
The MGH Food Allergy Center Prevention Program is uniquely positioned to implement the NIAID recommendations and use its experience to educate and inform clinicians across the nation. To learn more about the program or schedule an infant food allergy evaluation, call the MGH Food Allergy Center at 617-643-6834.
Complete Addendum Guidelines
Addendum Summary for Clinicians
Addendum Summary for Parents and Caregivers
Instructions for Parents and Caregivers on Feeding Peanut Protein to Your Infant
Introducing Peanuts to Your Baby: A Guide for Families (from the Food Allergy Center at MGHfC)