New Peanut Guidelines: Q&A With OKC Physician
The staff at MetroFamily learned about the recent guideline changes regarding peanut allergies in infants/kids and had immediate questions about how to help our local families implement these new guidelines. We reached out to Oklahoma Institute for Allergies & Asthma and one of their allergists, Dr. Jason M. Bellak, responded with these answers.
Can you explain the basis for the new guidelines concerning peanut allergies in kids? Why were they needed? How will following these procedures help keep my baby from developing an allergy to peanuts?
In 2000, the American Academy of Pediatrics (AAP) Committee on Nutrition recommended to avoid feeding children peanut products until after age 3. For the next 10 years, the prevalence of peanut allergy continued to rise dramatically from 0.7 percent to approximately 2 percent in children. Due to increases in peanut allergy with delayed introduction recommendation, the AAP in 2008 recommended that the introduction of solid foods, including potentially allergenic foods, should not be delayed beyond 4 to 6 months of age. This statement was echoed by the National Institute of Allergy and Infectious Disease (NIAID)-sponsored guidelines for the diagnosis and management of food allergies published in 2010. This guideline did not offer food allergy prevention guidance.
An addendum to the NIAID-sponsored guidelines specifically regarding the prevention of peanut allergy was published Jan. 5, 2017, due to recent quality research evidence from the Learning Early About Peanut Allergy (LEAP) study. Based on an observation that Israeli children in the United Kingdom (UK) not eating peanut products were much more likely to have peanut allergy than Israeli children living in Israel who regularly ate a peanut flour containing snack puff starting in infancy, a landmark clinical trial funded by the NIH and performed in the UK called LEAP was conducted. The results of LEAP were published in the New England Journal of Medicine in 2015. LEAP results showed that regularly feeding children at high risk for developing peanut allergy peanut protein starting at 4-6 months of age reduced development of peanut allergy by age 5 by 81% compared to children avoiding peanut ingestion.
What specifically are the new guidelines?
1. For infants 4-6 months old at highest risk for developing peanut allergy (severe eczema, egg allergy or both), strongly consider an evaluation by blood and/or skin tests for peanut allergy and, if necessary, an in-office food challenge. Based on test results, introduce peanut containing foods.
2. For infants with mild-to-moderate eczema, introduce peanut containing foods around 6 months of age.
3. For infants without eczema or any food allergy, introduce peanut-containing foods when is age appropriate and in accordance with family preferences and cultural practices.
Importantly, the guidelines recommend referral to an Allergy and Immunology Specialist for high risk children, especially if their blood test for peanut allergy if done by their primary provider is elevated. In addition, the guidelines recommend against food allergy panel testing for foods other than peanut because of their poor positive predictive value, which could lead to misinterpretation, over diagnosis of food allergy and unnecessary dietary restrictions.
Can you give us any more practical precautions about introducing peanuts to babies/young children?
As noted in the addendum guidelines above, infants with severe eczema and/or egg allergy need to be evaluated by allergy testing and, if necessary, through an in-office challenge. If the infant already has peanut allergy as demonstrated by specific peanut allergy test results and/or food challenge, peanut products should be avoided and additional guidance provided by an Allergy and Immunology Specialist.
Once the decision has been made to introduce peanut into an infant’s diet, the total amount of peanut protein to be consumed per week should be 6-7 grams split over 3 or more feedings. Parents should be aware of choking risks and not give whole nuts to children less than 5 years old and peanut butter given directly from a spoon or in lumps should not be given to children less than 4 years of age. If peanut butter is used, 2 teaspoons of peanut butter (approximately 2 grams of peanut protein) should be thinned in 2-3 teaspoons of water until well blended before feeding.
What observations should I be making once I introduce peanuts to my child? What would be a reason to have my baby checked for problems from the peanut introduction?
Look for evidence of an allergic reaction. Mild symptoms may include a new rash or a few hives around the mouth and face. More severe symptoms of an allergic reaction include swelling of lips, tongue or face, diffuse hives on body, vomiting and/or diarrhea, coughing, wheezing or shortness of breath, change in skin color, and sudden tiredness, lethargy, or seeming limp. If a child has any of these symptoms, they should be seen by a medical provider. For more severe symptoms, parents need to seek immediate medical attention, calling 911.
If I have an older baby or toddler and she/he has not yet been given peanuts yet, are there any tips that would help me or is it the same warning signs and cautions for any age of child?
The same cautions exist for any child who has not ingested peanut products. However, in infants 4-6 months of age with high risk for developing peanut allergy, we now have evidence of a unique opportunity to intervene when their immune system is at a key point of development to possibly prevent peanut allergy. These new guidelines will have important effects in terms of improving public health, reducing personal suffering, and decreasing health care use and costs.