Telemedicine-Supported Peanut Introduction Feasible for At-Risk Infants

By Lisa Rappaport

July 13, 2020

(Reuters Health) - It may be possible to use telemedicine to help introduce peanuts to babies at high risk for severe allergic reactions, a report of three cases suggests.

Although treatment for some allergic conditions may be postponed when in-office visits aren't possible - a widespread reality during the global COVID-19 pandemic - guidelines recommend against waiting to introduce peanuts in high-risk infants, the study team notes.

In April 2020, while in-person visits were halted due to the COVID-19 pandemic, researchers conducted telemedicine visits in a private practice allergist setting to identify infants who were considered at high risk for peanut allergy. Using shared decision-making tools, they recruited parents of three infants to participate in the study, obtained verbal consent, and prescribed an epinephrine autoinjector and rupatadine.

Families then had a telemedicine visit to receive counseling on food introduction, details on possible allergy symptoms and how to treat these, and instructions for preparing peanut butter for peanut introduction. Parents gradually fed babies 2 grams of peanut protein over 45 minutes to an hour, with instructions to immediately contact a physician via telemedicine if they saw an allergic reaction.

No severe reactions occurred in these three cases, researchers report in the Journal of Allergy and Clinical Immunology: In Practice.

"While barriers exist during this pandemic, peanut introduction can still be safely performed despite a lack of in-office access," said lead study author Dr. Douglas Mack, an assistant clinical professor at McMaster University in Hamilton, Ontario.

"Virtually supported home peanut introduction represents an option that parents and clinicians can implement to prevent peanut allergy in these at-risk infants," Dr. Mack said by email.

During all three cases of at-home peanut introduction, families interacted with a physician virtually at the beginning of introduction and one or two more times during the procedure itself. Researchers described these interactions as brief and not burdensome to clinicians.

The first case involved a 10-month old infant with severe eczema who had been pre-emptively tested for several food allergies. While the baby's parents were worried about respiratory risks of virtually-supervised peanut introduction, the baby didn't show any signs of distress and had a normal respiratory rate, no accessory muscle use, and no cutaneous lesions.

In this first case, peanut introduction occurred with no reaction, but the parents stopped after 1 gram of peanut protein was administered and switched to peanut puffs. Since the initial peanut introduction, parents kept regularly giving the baby peanut at home without incident.

In the second case, parents tried virtual peanut introduction with a 7-month old with mild eczema and a sibling with peanut allergy. Parents applied a barrier cream around the mouth then introduced peanut without difficulty. During introduction, the parents followed up with the physician virtually to clarify the amount of peanut to be introduced. Afterward, parents continued to give peanut at home without any issues.

The third case involved a 6-month old baby with mild eczema who had experienced anaphylaxis and required two doses of epinephrine after sesame introduction. During peanut introduction, this baby expressed distaste for the food and the full amount was not administered.

However, parents in this third case continued to offer small amounts of peanut at home, and reported feeling more comfortable introducing tree nuts. Subsequently, the parents successfully introduced almond at home.

Even before COVID-19, access to allergy specialists often posed barriers to peanut introduction for at-risk infants, the study team writes. They conclude that virtual introduction may help bridge this gap in care during the pandemic, as well as later.

"This is very interesting as a concept and merits larger study with additional outcomes added to help demonstrate the value of the approach," said Dr. Matthew Greenhawt, an associate professor of pediatrics and director of the Food Challenge and Research Unit at the Children's Hospital Colorado and the University of Colorado Denver School of Medicine.

It's possible that decision-making might be leveraged differently during a pandemic than it would be in other circumstances, and it's also possible that not all physicians and patients would be able to access telehealth, Dr. Greenhawt, who wasn't involved in the study, said by email.

"This is posed as an idea to help still accomplish early introduction, but make use of a unique resource that can still help deliver high-quality healthcare given the unusual pandemic circumstances, where care may be rationed or there is a significant risk of contracting coronavirus from going to the doctor for routine care," Dr. Greenhawt said.

SOURCE: Journal of Allergy and Clinical Immunology: In Practice, online June 9, 2020.