Many Pediatricians Don't Fully Implement Infant Peanut Allergy Prevention Guidelines

By Marilynn Larkin

July 27, 2020

NEW YORK (Reuters Health) - Although most pediatricians are aware of guidelines for the prevention of peanut allergies in infants, less than a third fully implement them, a nationwide survey reveals.

The U.S. National Institutes of Health (NIH) Addendum Guidelines for the Prevention of Peanut Allergy, issued in 2017, are based on results from the LEAP study (, in which early introduction of peanut-containing foods to high-risk infants decreased peanut allergy development by 80%.

"We were reassured to know that... 93% (of respondents) were aware of the guidelines, considering the survey was administered only 1.5 years after the guidelines were published," Dr. Ruchi Gupta of Northwestern University Feinberg School of Medicine in Chicago told Reuters Health by email. "However, only 29% were fully implementing the guidelines...while 64% were partially implementing the guidelines, which means they were only using select parts."

The addendum added three recommendations:

1- Infants with severe eczema and/or egg allergy should be evaluated with a specific IgE test and/or skin prick testing and, if needed, an oral challenge. Based on the results, peanuts should be introduced as early as ages four to six months.

2- Infants with mild-to-moderate eczema should begin consuming peanuts around age six months.

3- Infants with no eczema or food allergy may consume peanuts when age-appropriate, in accordance with family preference and cultural practices.

As reported in JAMA Network Open, in the second half of 2018 the researchers invited roughly 41,000 pediatricians to complete a 29-item electronic survey. Guideline implementation prevalence was measured by one survey item about awareness followed by a second item about implementation.

Among the 1,781 pediatricians who were eligible to participate and completed the survey, most self-identified as white (72.5%) and female (67.4%).

Overall, as Dr. Gupta noted, 1,725 (93.4%) pediatricians reported being aware of the guidelines, with 497 (28.9%) reporting full implementation and 1,105 (64.3%), partial implementation.

When asked to specify peanut introduction recommendations for patients of the varying peanut allergy risk categories, 40.6% correctly answered all three scenarios. Most (84.4%) said that when presented with a six-month-old infant without eczema or any food allergies (scenario 1), they would recommend the introduction of peanut-containing food in accordance with family preferences and cultural practices.

For infants with mild-to-moderate eczema (scenario 2), 54.7% said they would recommend introducing peanut products in accordance with the guidelines.

For infants with severe eczema and/or egg allergy (scenario 3), 59.8% said they would refer the infant to an allergist and 18.9% would order a peanut-specific IgE test - both approaches that are consistent with the guidelines.

However, 20.8% indicated they would pursue approaches not consistent with the guidelines - e.g., introducing peanuts without testing.

Common barriers to implementation included parental concerns about allergic reactions (36.6%), uncertainty in understanding and correctly applying the guidelines (33.2%), and conducting in-office supervised feedings (32.4%). Many (68.4%) said they need more training on the guidelines.

Dr. Gupta said, "Ultimately, the responsibility of improving guideline implementation through training and eliminating barriers falls onto multiple groups, including the NIH, the American Academy of Pediatrics, local institutions, advocacy organizations and pediatricians themselves. It is the collective efforts of all stakeholders that will successfully ensure guideline implementation, and the dream of preventing peanut allergy incidence in children."

Dr. Marcus Shaker of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, coauthor of a related editorial, commented in an email to Reuters Health, "Time is of the essence to prevent peanut allergy. The U.S. remains the only country to recommend screening prior to potential food allergen introduction to infants. This recommendation was well-intended to prevent babies from having a life-threatening reaction with first peanut exposure."

"However, while this is possible, fatal anaphylaxis from first peanut introduction has never been reported," he said. "The rate of fatal anaphylaxis from first peanut introduction is so low that the risk of a fatal car accident from traveling to and from clinic for testing may actually be higher than simply introducing peanut at home."

"Also, it is not at all clear that screening decreases the overall rate of severe peanut reactions over the long-term, because screening leads to more cases of peanut allergy from failure to introduce peanut early," he added.

"Given recent experience from the Australian HealthNuts study ( that infant peanut introduction without screening is safe and effective, the time has come to question who, if anyone, should have screening before trying peanut for the first time," Dr. Shaker concluded.

SOURCE: and JAMA Network Open, online July 15, 2020.