Guidelines for life after LEAP

REVIEWED BY DAVID M FLEISCHER, MD.

As the number of infants and children developing peanut allergy continues to grow, so does the need for pediatricians and other primary care providers to understand current recommendations on how best to prevent this allergy.

The need for prevention is highlighted by the substantial increase in prevalence, which data show has tripled in the United States over the past 10 to 15 years, and the associated detrimental effects on health and quality of life in the children who develop this allergy.¹

Despite early thinking that avoiding peanuts during infancy and young age would prevent peanut allergy later on, more recent thinking has focused on early introduction of peanuts during infancy. The success of this strategy was recently confirmed in the 2015 published results of the Learning Early About Peanut Allergy (LEAP) study, the first randomized controlled trial to compare the introduction or avoidance of peanuts in infants at high risk (defined in the study as those with severe eczema, egg allergy, or both) of developing peanut allergy. The study found that infants aged between 4 and 11 months who consumed peanuts were significantly less likely to develop peanut allergy by age 5 years than those infants who avoided consuming peanuts until age 5 years.²

Summary of NIAID guidelines

Based on these findings, specific recommendations for peanut allergy prevention were developed by an expert panel convened by the National Institute of Allergy and Infectious Diseases (NIAID) and published as an addendum³ to the NIAID’s previous 2010 guidelines on the diagnosis and management of food allergy in the United States.⁴

David M Fleischer, MD, director, Food Challenge Unit, University of Colorado Denver School of Medicine, Aurora, Colorado, underscored the importance of pediatricians and primary care physicians becoming familiar with and appropriately implementing recommendations in these recent addendum guidelines.

“The key for these peanut guidelines to work relies on primary care providers to discuss early introduction of peanut into infants’ diets when they see them at 4 and 6 months of age,” Fleischer says. “We as allergists do not usually see patients until they are diagnosed or suspected to have food allergy. Therefore, without the dissemination and implementation of these guidelines by primary care providers, they will not work.”

In a recently published review article, Fleischer highlights and discusses key recommendations in the addendum guideline that he encouraged pediatricians to refer to for understanding when and how to introduce peanuts during infancy.¹ (A summary for clinicians of the addendum guidelines can be found at bit.ly/NIAID-2017-addendum-peanuts).

Among the recommendations discussed was introducing peanuts to infants based on 3 specific risk categories:

• Children with severe eczema and/or egg allergy: Introduce peanut-containing foods as early as age 4 to 6 months after the introduction of other solid foods and after consideration of test results for peanut-specific serum immunoglobulin (Ig) E or skin-prick test (SPT), or both.

• Children with mild to moderate eczema: Introduce peanut-containing foods around age 6 months.

• Children with no eczema or food allergy: Introduce peanut-containing foods together with other solid foods and in accordance with family preferences and cultural practices.

Overall, Fleischer emphasizes that a simple interpretation of the 3 addendum guidelines would be to recommend that peanut-containing foods be introduced into the diet of all infants around age 6 months but not before age 4 months.

Although the recommendations provide leeway on the setting in which to introduce peanut-containing foods, whether in the provider’s office or at home (supervised or not), Fleischer recommends that infants at highest risk of developing a peanut allergy (those with early-onset eczema that is difficult to manage with standard treatment or infants with an egg allergy) may benefit from an evaluation from an allergist prior to the peanut introduction.

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For infants who are introduced to peanut-containing foods in the home setting, he highlights a number of addendum recommendations:

• Peanuts should not be the first solid food introduced.

• Only introduce peanuts to an infant who is healthy without an illness such as upper respiratory infection.

• Introduce the first peanut-containing food in the home setting, not in another setting such as daycare or a restaurant

• Ensure an adult supervisor is closely monitoring the initial peanut introduction.

• Ensure an adult supervisor provides ample time to watch the infant after peanut ingestion.

• Give a small portion of peanut and wait 10 minutes before gradually giving the remainder of the full serving.

• Do not give peanut butter directly from a spoon or whole peanuts to children aged younger than 5 years.

To help caregivers know which foods to introduce, Fleischer refers them to appendices in the addendum.³

As far as dose and duration of peanut ingestion, Fleischer highlights the following addendum recommendations:

• Infants at highest risk (severe eczema and/or egg allergy) should consume about 6g to 7 g of peanut protein per week divided over 3 or more feedings. However, Fleischer underscores that it remains unknown what the optimal amount and duration of peanut consumption should be once peanuts have been introduced, as this amount and frequency were the only manner studied in LEAP. As such, he emphasizes that it is not currently known if different amounts or frequencies would have similar outcomes.

• Infants with the lower risk (moderate to mild eczema, or none) can freely consume peanut-containing foods based on family practices.

Along with peanut introduction, Fleischer also discusses recommendations for introducing other foods into infants’ diets, such as egg, milk, seafood, and wheat. Although evidence is not conclusive yet on introducing egg early into an infant’s diet, he suggests that there are data showing that cooked egg introduced in small amounts first, such as in a baked product with egg, may be the safest approach before introducing egg in its more concentrated forms, such as hard-boiled or scrambled egg.

Although fewer data are available on the other foods, he emphasizes that introducing multiple major allergenic foods in infancy appears safe.

“My general feeling on all major allergens, not just peanut, is that introduction of any highly allergenic food does not need to be delayed beyond 4 to 6 months of age,” Fleischer says. ”Thus, the general recommendation I tell families is to try to get in all major food allergens before age 1 year if they can.”

Fleischer emphasizes the need to introduce foods logically, keeping the stage development of the infant in mind. This means, for example, not giving fish to a 6-month old, but waiting until the infant is eating food with similar textures such as meats. He also says that whereas cheese and yogurt can be given before age 1 year, the American Academy of Pediatrics still recommends against giving liquid whole cow’s milk before age 1 year for reasons other than allergy.

Overall, Fleischer emphasizes a simple message for parents and primary care providers regarding getting allergenic foods into infants’ diets: “Have infants eat allergenic foods early and have them eat these foods often,” he says.

REFERENCES

1. Fleischer DM. Life after LEAP: how to implement advice on introducing peanuts in early infancy. J Paediatr Child Health. 2017;53(Suppl 1):3-9. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jpc.13491/full. Accessed March 29, 2017.

2. Du Toit G, Roberts G, Sayre PH, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Eng J Med. 2015;372(9):803-813. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1414850#t=articleTop . Accessed March 29, 2017.

3. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States. Report of the National Institute of Allergy and Infectious Diseases-Sponsored Expert Panel. Available at:

. Published 2017. Accessed March 29, 2017.

4. NAIAD-Sponsored Expert Panel; Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: a report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 suppl):S1-S58. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241964/. Accessed March 29, 2017.

Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has over 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.