Updated Guidelines for Prevention of Peanut Allergy

Nicola M. Parry, DVM

January 05, 2017

The National Institute of Allergy and Infectious Diseases (NIAID) has released updated guidelines for peanut allergy prevention, with specific strategies for infants at various levels of risk. The evidence-based recommendations highlight data from key publications, including original research articles, editorials/letters, and systematic reviews.

The guidelines focus, in particular, on early introduction of peanut-containing foods into the diets of infants. The recommendations will allow healthcare providers to guide parents on how to proceed with introduction based on an individual child's risk of developing a peanut allergy.

Alkis Togias, MD, from NIAID, Bethesda, Maryland, and colleagues published the updated clinical guidelines online today in the Journal of Allergy and Clinical Immunology. The guidelines were copublished in the Annals of Allergy, Asthma, and Immunology; Journal of Pediatric Nursing; Pediatric Dermatology; World Allergy Organization Journal; and Allergy, Asthma, and Clinical Immunology.

"Topics addressed include the definition of risk categories, appropriate use of testing (specific [immunoglobulin E (IgE)] measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider's office or at home," the authors write.

Development of these addendum guidelines was spurred by findings from the Learning Early About Peanut Allergy (LEAP) study, which was the first randomized trial to investigate early allergen introduction as a strategy to prevent peanut allergy.

As previously reported by Medscape Medical News, data from the LEAP study showed that introduction of peanut to the diets of infants within the first 11 months of life significantly reduced their risk of developing peanut allergy by age 5 years.

"It is unusual for guidelines to stem from a single study," Dr Togias told Medscape Medical News. "However, we felt compelled to write these guidelines because of the significant effect size from this well-designed study. And we moved fast to produce them, to prevent development of peanut allergy in as many children as possible."

The new recommendations, which supplement the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States, target a wide range of healthcare providers. They offer three separate guidelines for managing infants based on their level of risk of developing peanut allergy.

High Risk

"The guidelines focus, in particular, on high-risk infants," Dr Togias said. "These are the kids with severe atopic allergy and/or egg allergy, and they comprise about 75% of peanut allergy cases."

To reduce the risk of these infants developing peanut allergy, the new guidelines recommend that peanut-containing foods should be introduced into their diets as early as 4 to 6 months of age.

However, before introducing these foods, Dr Togias stressed that clinicians should first perform allergy testing in these children. "Many of these children may already have established peanut allergy, so prevention is not possible for these individuals. And we want to avoid introducing peanut-containing foods into their diet at home and potentially having to deal with major reactions," he said.

Pediatricians or family practitioners can perform the first level of testing when they see a child with severe eczema, added Dr Togias. At this point, the provider should perform an allergy blood test to detect peanut-specific IgE (sIgE). "We know that this test has a good negative predictive value," he noted. "So, a negative test result means the chances of the child having an allergic reaction to peanut are small. And even if the child does have a reaction, it is usually mild."

According to the updated guidelines, if the peanut sIgE level is less than 0.35 kUA/L, peanut should be introduced into the infant's diet soon after, providing a cumulative dose of approximately 2 g peanut protein in the first instance. Although this introduction can occur at home, if parents or the healthcare provider have any concerns, the first feeding of peanut can take place in the specialist's office.

However, if the peanut sIgE level is 0.35 kUA/L or greater, the provider should refer the infant to a specialist for assessment and additional tests, such as a skin prick test with peanut extract. After skin prick test, for infants who develop a wheal with a diameter of 2 mm or less above saline control, peanut should be introduced into the diet soon after, providing a cumulative dose of approximately 2 g peanut protein in the first instance. This too can either take place at home or in the provider's office.

In contrast, infants who develop a wheal 3 to 7 mm in diameter should undergo supervised peanut feeding first at a specialist's office. However, those who develop a wheal 8 mm or greater in diameter have a high chance of a preexisting peanut allergy.

In this case, specialists may consider not introducing peanut to the infant's diet, and instead might advise the child avoid peanuts completely.

Moderate Risk

For infants with mild or moderate eczema, the guidelines recommend that parents introduce peanut-containing foods into the children's diets at about 6 months of age, either at home or in the provider's office.

Low Risk

Infants with no eczema or egg allergy are considered at low risk of developing peanut allergy. Peanut-containing foods can be freely introduced into their diet with other solid foods, according to the family's preference, also at around 6 months of age.

Dr Togias acknowledged that some clinicians may be reluctant to introduce peanut into children's diets before 6 months of age because of potential concern that this may reduce breast-feeding duration.

In this respect, he realizes that the updated guidelines may appear to contradict recommendations from the World Health Organization for mothers to exclusively breast-feed infants for the first 6 months of life. However, the LEAP study showed that early introduction of peanut into children's diets did not cause any nutritional problems for the children, he emphasized. It also did not negatively affect the duration of breast-feeding.

Dr Togias also acknowledged that, despite the strength of the data from the LEAP study, some questions remain unanswered, and therefore are unaddressed by the updated guidelines. "It remains unknown as to whether other risk groups may exist," he said. "For example, if the family has had cases of food allergy, is this a risk?"

In addition, although the LEAP study showed that feeding peanut-containing foods to a child for 5 years is sufficient to prevent peanut allergy, he wonders whether feeding peanut for a shorter duration of time might also be sufficient.

"We just don't have adequate data yet, but as a focus for future, we hope to be able to answer questions like these," Dr Togias concluded.

Several coauthors have reported various financial relationships with various companies and organizations: Adamis Pharmaceuticals Corporation; Aimmune; the Allergy and Asthma Network; Allertein Therapeutics; Anacor; Antera Therapeutics; Astellas; BEFORE Brands; Createspace Independent Publishing Platform; Danone; DBV Technologies; Elsevier; Epidermolysis Bullosa Research Partnership; Food Allergy Research & Education (FARE); Genentech/Roche; GlaxoSmithKline; Grand Rounds; HAL Allergy; the Hawaii Dermatology Seminar; the Immune Tolerance Network; INSYS Therapeutics; Intrommune Therapeutics; Kaleo Pharma; Mead Johnson; Meda; Medscape; Menarini; Merck; Monsanto Company; Mylan LLC; the National Peanut Board; Nestle/Gerber; Nestle Nutrition Institute; Novartis; Nutricia; Pfizer; Reach MD; Roche; Sanofi; Stallergenes; Stanford Foundation; TEVA Pharmaceuticals; Thermo Fisher Scientific; University Physicians; and UpToDate. Several coauthors have also reported serving as members of: the Board of Directors for the American Academy of Allergy, Asthma, & Immunology; the FAACT Medical Advisory Board; the FARE Medical Advisory Board; the National Peanut Board; PhARF Award Selection Committee for Thermo Fisher; the Medical Advisory Board for FARE; the Research Advisory Board for FARE; the Scientific Advisory Board for Aimmune; and the World Allergy Organization.

Ann Allergy Asthma Immunol. Published online January 5, 2017. Full text

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