Marcia Frellick

October 29, 2017

BOSTON — Few pediatricians are implementing the new guidelines on early introduction of peanut-containing foods into the diets of low-risk infants to help prevent peanut allergies, new research shows.

"Our study revealed that although pediatricians have been introduced to the new guidelines, they're not yet putting them into practice," lead author Bryce Hoffman, MD, a fellow in allergy/immunology at National Jewish Health in New York City, said in a press release.

According to the guidelines, children at moderate risk (those with mild to moderate atopic dermatitis who have already started solid foods) do not need to be tested and can have peanut-product foods introduced at home starting around 4 to 6 months of age.

If a child is at high risk (those with an egg allergy history or severe atopic dermatitis), the guidelines recommend getting tested by an allergist.

Not only are many pediatricians not having the necessary discussions with parents, but they are also not referring high-risk infants to specialists for testing before peanut introductions, Dr Hoffman and colleagues report in their study abstract, to be presented here at the American College of Allergy, Asthma & Immunology (ACAAI) 2017 Annual Scientific Meeting.

The abstract also appears in the November issue of the Annals of Allergy, Asthma and Immunology.

The researchers sent surveys to 188 pediatricians, and 79 responded (42% response rate). Of those, 38% scored 1 or less on a 0 to 4 scale, where 4 is highest in following the guidelines. Only 11% scored a 4. In addition, 44% of survey respondents reported not testing or referring high-risk children before peanut introduction.

We have to figure out how to help pediatricians fit this in. Dr. Ruchi Gupta

The guidelines are a bit complex, and some pediatricians may be confused by what constitutes severe atopic dermatitis, said Ruchi Gupta, MD, MPH, associate professor of pediatrics and medicine at Northwestern Medicine in Chicago, Illinois.

Another struggle is finding a way to add that discussion, which may then involve education and referral, into the already-packed 4- and 6-month visits, she told Medscape Medical News.

"We have to figure out how to help pediatricians fit this in," she said.

To that end, Dr Gupta and colleagues have developed an intervention currently being piloted that creates a clinical decision support system that inserts templates into the electronic health record. They have also developed handouts for low-risk patients that include the after-visit summary so pediatricians can simply give them to parents as they leave.

"So far, [pediatricians] are really liking it," said Dr Gupta, "If it's successful, we hope we can test it more broadly."

The Peanut Story

David Stukus, MD, an allergist at Nationwide Children's Hospital in Columbus, Ohio, agreed that buy-in from colleagues, primary care providers, and parents and caregivers will be key in wide implementation of the guidelines.

One way to convince others, he said, is to tell the peanut story, which started more than a decade ago.

George Du Tois, MD, a pediatric allergy consultant in London and colleagues, recognized that the prevalence of peanut allergy in the Israeli population was 10-fold less than that in the United Kingdom. The researchers discovered that many infants in Israel were snacking on a peanut snack called Bamba,, and were thus being introduced to peanuts in infancy, whereas infants in the UK were kept from peanut products until they were a year old.

This epidemiologic and association data led to the landmark Learning Early About Peanut (LEAP) study, previously reported by Medscape Medical News.

"I encourage you all to become comfortable with the story, embrace it, and tell it," said Dr Stukus.

Some parents who have an older child with peanut allergy will be very wary of introducing peanut products to an infant in the same home, he said. They may also be angry that they were told not to give peanut products when they had the older child, and now they learn that peanuts may prevent allergy.

Healthcare providers should confront this proactively, acknowledge the misgivings, and let parents know airborne reactions to peanuts are extremely rare, "and casual contact causes mild reactions if anything," he advised.

"Soap and water or commercial detergent wipes can effectively remove peanut protein from surfaces and utensils," he added.

Parents will have many questions, and providers should have talking points and handouts ready, said Dr Stukus. Talking through this can help increase parents' comfort levels. The introduction to peanuts can also be conducted away from the home.

Ultimately, if parents are still fearful, children can be referred to an allergist, Dr Gupta added.

New Labels for Peanut Products

Special kits have already hit the market to help parents make the introductions.

"We're going to see more and more of this," Dr Stukus said.

In addition, in September of this year, the US Food and Drug Administration came out with new guidance for labels for packaged peanut products that allow a qualified health claim.

The claim "will recommend that parents check with their infant's healthcare provider before introducing foods containing ground peanuts. It will also note that the claim is based on one study," according to the US Food and Drug Administration announcement.

ACAAI provides more information on how to introduce peanut-containing products to infants in this video.

Dr Gupta reports consulting fees from Before Brands and Kaleo and conducts research for Mylan and Thermo Fisher Scientific. Dr Stukus helped develop the new peanut introduction guidelines. Dr Hoffman has disclosed no relevant financial relationships.

American College of Allergy, Asthma & Immunology (ACAAI) 2017 Annual Scientific Meeting: Abstract 5189. Presented October 30, 2017.

Ann Allergy Asthma Immunol. 2017;119:S20. Abstract

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