How to Help Pediatricians Apply Peanut Allergy Guidelines

Esther Landhuis

March 02, 2023

Despite the profound shift in guidelines for preventing peanut allergies in infants after the landmark LEAP study, national surveys in 2021 showed that 70% of parents and caregivers said that they hadn't heard the new recommendations, and fewer than one third of pediatricians were following them.

Now, in a 5-year National Institutes of Health–funded study called iREACH, researchers are testing whether a two-part intervention, which includes training videos and a clinical decision support tool, helps pediatricians follow the guidelines and ultimately reduces peanut allergy.

Early results from iREACH, presented at the American Academy of Allergy, Asthma and Immunology (AAAAI) 2023 Annual Meeting in San Antonio, showed mixed results with a sharp rise in clinician knowledge of the guidelines but only a modest increase in their real-world implementation with high-risk infants.

Raising a food-allergic child while working as a pediatrician herself, Ruchi Gupta, MD, MPH, director of the Center for Food Allergy and Asthma Research at Northwestern University Feinberg School of Medicine in Chicago, understands the importance and challenge of translating published findings into practice.

During a typical 4- to 6-month well-child visit, pediatricians must check the baby's growth, perform a physical exam, discuss milestones, field questions about sleep and poop and colic and — if they're up on the latest guidelines — explain why it's important to feed peanuts early and often.

"Pediatricians get stuff from every single specialty, and guidelines are always changing, she told Medscape Medical News.

The current feeding guidelines, published in 2017 after the landmark LEAP study, switched from "'don't introduce peanuts until age 3' to 'introduce peanuts now,'" said Gupta. 

But the recommendations aren't entirely straightforward. They require pediatricians to make an assessment when the baby is around 4 months old. If the child is high-risk (has severe eczema or an egg allergy), they need a peanut-specific immunoglobulin E (IgE) test. If the test is negative, the pediatrician should encourage peanut introduction. If positive, they should refer the child to an allergist.

"It's a little complicated," Gupta said.

To boost understanding and adherence, Gupta's team created the intervention tested in the iREACH study. It includes a set of training videos, a clinical decision support tool that embeds into the electronic health record (EHR) with pop-ups reminding the physician to discuss early introduction, menus for ordering peanut IgE tests or referring to an allergist if needed, and a caregiver handout that explains how to add peanut to the baby's diet. (These resources can be found here.)

The study enrolled 290 pediatric clinicians at 30 local practices, examining 18,460 babies from diverse backgrounds, about one quarter of whom were from families on public insurance. About half of the clinicians received the intervention, whereas the other half served as the control arm.

The training videos seemed effective. Clinicians' knowledge of the guidelines rose from 72.6% at baseline to 94.5% after the intervention, and their ability to identify severe eczema went up from 63.4% to 97.6%. This translated to 70.4% success with applying the guidelines when presented various clinical scenarios, up from 29% at baseline. These results are in press at JAMA Network Open.

The next set of analyses, preliminary and unpublished, monitored real-world adherence using natural language processing to pull EHR data from 4- and 6-month well-check visits. It was "AI [artificial intelligence] for notes," Gupta said.

For low-risk infants, the training and EHR-embedded support tool greatly improved clinician adherence. Eighty percent of clinicians in the intervention arm followed the guidelines compared with 26% in the control group.

Impact in High-Risk Infants

In high-risk infants, the impact was much weaker. Even after the video-based training, only 17% of pediatric clinicians followed the guidelines — ie, ordered a peanut IgE test or referred to an allergist — compared with 8% in the control group. 

Why such a low uptake?

Pediatricians are time-pressed. "How do you add [early introduction] to the other 10 or 15 things you want to talk to a parent about at the 4-month visit?" said Jonathan Necheles, MD, MPH, a pediatrician at Children's Healthcare Associates in Chicago.

It can also be hard to tell if a baby's eczema is "severe" or "mild to moderate." The EHR-integrated support tool included a scorecard for judging eczema severity across a range of skin tones. The condition can be hard to recognize in patients of color. "You don't get the redness in the same way," said Necheles, who worked with Gupta to develop the iREACH intervention.

Curiously, even though the AI analysis found that less than one fifth of pediatricians put the guidelines into action for high-risk infants, 69% of them recommended peanut introduction.

One interpretation is that busy pediatricians may be "doing the minimum" — introducing the concept of early introduction and telling parents to try it "but not giving any additional sort of guidance as far as who's high risk, who's low risk, who should see the allergist, who should get screened," said Edwin Kim, MD, allergist-immunologist and director of the Food Allergy Initiative at the University of North Carolina in Chapel Hill. 

The ultimate impact of iREACH has yet to be seen. "The end goal is, if pediatricians recommend, will parents follow, and will we reduce peanut allergy? Gupta said.

Gupta consults or serves as an advisor for Genentech, Novartis, Aimmune LLC, Allergenis LLC and Food Allergy Research & Education (FARE); receives research funding from Novartis, Genentech, FARE, Melchiorre Family Foundation and Sunshine Charitable Foundation; and reports ownership interest from Yobee Care, Inc.

Necheles reports no financial disclosures.

Kim reports consultancy with Allergy Therapeutics Ltd, Belhaven Biopharma, Duke Clinical Research Institute, Genentech, Nutricia, and Revolo; advisory board membership with ALK, Kenota Health, and Ukko Inc; and grant support from the NIH's National Institute of Allergy and Infectious Diseases, Immune Tolerance Network, and Food Allergy Research and Education.

American Academy of Allergy, Asthma, & Immunology (AAAAI) 2023 Annual Meeting. Presented February 25, 2023. Symposium 2521

Esther Landhuis is a freelance science & health journalist in the San Francisco Bay Area. She can be found on Twitter @elandhuis.

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