Kate Johnson

February 24, 2015

HOUSTON — Within hours of the release of the Learning Early About Peanut (LEAP) study results, experts were debating the logistics and magnitude of the changes recommended for the management of infants considered to be at high risk for peanut allergy.

Parents should not simply hear a "consume peanut" message, said James Baker, MD, chief executive officer of Food Allergy Research & Education. "We hope that parents understand this isn't something you do without consulting a physician and making absolutely sure the child is not allergic first," he said during a news conference here at the American Academy of Allergy, Asthma & Immunology 2015.

The finding that consumption, not avoidance, reduces the risk of developing peanut allergy by the age of 5 led the LEAP investigators to call for new guidelines to be drafted.

"Timing here is key; there's a narrow window of opportunity to intervene early," said LEAP investigator Gideon Lack, MB BCh, from King's College London and Guy's and St. Thomas' National Health Service Foundation Trust, United Kingdom.

All at-risk infants should receive skin-prick testing for peanut, the LEAP team suggests. Those with a negative test should proceed to normal peanut consumption. Those with a positive test should undergo an oral food challenge and, depending on the results, proceed to normal peanut consumption with careful supervision or avoidance.

When asked about the logistics of such an approach, Dr Lack acknowledged it will be a challenge.

Timing here is key.

"To actually put this into practice is really going to take a coordinated strategy between all the stakeholders, health professionals, and departments of health in different countries," Dr Lack told Medscape Medical News.

However, he said, the about-face on infant peanut consumption will likely be well received in the medical community.

"One of the things about coming out of medical school is that you realize the learning curve has just started. We have to re-educate ourselves all the time, and that's key. As we acquire more evidence, things change," he explained.

"We believe there's an urgent need for clinicians to be skilled in identifying the at-risk population," said LEAP investigator George Du Toit, MB BCh, from King's College London and Guy's and St. Thomas' NHS Foundation Trust.

Managing Risk

"This means a basic knowledge about atopic eczema, egg allergy, and milk allergy, which are all risk factors for peanut allergy, and then of course skin-prick testing, which in the LEAP study we found to be invaluable for dissecting risk categories," Dr Du Toit explained. "Worldwide, not all patients — in fact a real minority of allergic patients — have access to even those basic diagnostic skills."

On top of that, although infants in the LEAP cohort had only mild to moderate allergic reactions, and no hospitalizations or epinephrine were required, "clinicians need to be able to deal with young infants who have an allergic reaction," he said.

"If any high-risk challenges were to take place, they should only occur in experienced hands and in the appropriate setting with resuscitation skills and facilities," Dr Du Toit explained.

New guidelines are urgently needed to reflect these findings, said Daniel Rotrosen, MD, from the National Institute of Allergy and Infectious Diseases. However, "even with a landmark study like this, and obvious improvement, it's difficult to move to implementation," he explained.

Pediatricians, dermatologists, and family practitioners will be urged to work toward updating the guidelines. "I don't think it should become a turf issue," said Dr Lack. "What matters is expertise. It could be a pediatrician, a family doctor, or a dermatologist who assesses the child and does a skin-prick test. The important thing is training in these procedures, and recognition."

Matthew Greenhawt, MD, from the University of Michigan in Ann Arbor, said he has concerns about the sudden change suggested by LEAP investigators and other experts.

Leaping to Conclusions

Should policy be changed on the basis of one study, "even one study with truly remarkable results?" Dr Greenhawt asked.

"I'd love to see this replicated in the United States, and I'd love to know whether you need to do this for 5 years or 3 years or 12 months," he told Medscape Medical News.

This study was small, Dr Greenhawt pointed out. "You would never change cholesterol recommendations based on one study of 500 patients, and the suggestion being made is that we need to act on this now," he explained.

"I certainly understand the logic and I think we are on the right track, but are we putting the cart before the horse? If you're going to make a recommendation like that, there should be an infrastructure in place to handle the volume of patients that we're going to see," Dr Greenhawt warned.

Dr Baker recently served as senior vice president and global vaccine head at Merck Corporation. Dr Lack reports holding stock and stock options in DBV Technologies. Dr Du Toit and Dr Rotrosen have disclosed no relevant financial relationships. Dr Greenhawt has reported that he is a member of the Educational Advisory Council for the National Peanut Board and has served as a consultant for Deerfield Industries.

American Academy of Allergy, Asthma & Immunology (AAAAI) 2015. Presented February 23, 2015.


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