Paradigm shift on peanut introduction tough to swallow

Ruchi S. Gupta, MD, MPH

David R. Stukus, MD

Peanut allergies are a growing concern in pediatrics, but recent research indicates that few primary care practices are following existing peanut-allergy related guidelines.

It’s not that they don’t want to, but with so much to do in so little time, clinicians reveal they have a hard time figuring out how to incorporate the guidelines into practice and how to sell parents on the process.

Three separate abstracts recently presented at the American Academy of Allergy, Asthma, and Immunology (AAAAI) Annual Meeting in San Francisco, California, showed that pediatricians are not using the screening tools available to them-either for lack of time and understanding about the guidelines, or because of hesitation from parents.

Peanut allergies are a growing problem in the pediatric population, increasing from 0.4% of children in 1999 to 2% by 2010, according to the 2017 National Institute of Allergy and Infectious Diseases (NIAID) addendum guidelines for the prevention of peanut allergy.¹ Peanut allergies are also the leading cause of death related to food-induced anaphylaxis. Whereas mortality is low in these reactions, there is high level of fear among parents and patients that contributes to the cost and burden of disease in these cases, according to the guidelines.

Unfamiliarity with new peanut-use guidelines

The

recommend that clinicians perform an assessment of peanut allergy risk for infants at age 4 to 6 months before early introduction of peanut-containing foods.² However, in the first abstract (no. 258; Gupta RS, et al) addressed at the AAAAI meeting, Ruchi S. Gupta, MD, MPH, Northwestern University Feinberg School of Medicine and Anne and Robert H. Lurie Children’s Hospital, Chicago, Illinois, and colleagues revealed that 11% of the 369 pediatricians who participated in e-mailed surveys about the use of the guidelines actually did not use them at all.³

Gupta’s abstract also noted that while 92% of pediatricians were aware of existing guidelines, 62% were using only portions of the guidelines. Forty-one percent of those who used all or parts of the guidelines stated that parental concerns about allergic reactions were one barrier; 35% revealed that they didn’t fully understand the guidelines; and 30% cited a lack of clinic time as a barrier to using the guidelines. Of those clinicians who did not use the guidelines, 67% cited a lack of understanding about the guidance.

Although the abstract’s findings seem to focus on the fact that pediatricians are not using the guidelines to their full potential, Gupta says the bigger takeaway is the identification of the barriers pediatricians are facing in implementing the guidelines and what they need to be more successful. Gupta, a general practice pediatrician herself and co-author of the guidelines, has been working to implement the guidelines in her own practice, and admits that it can be difficult. There is already so much to accomplish at the 4- and 6-month well visits, and the guidelines are such a departure from previous recommendations, that it can be a difficult transition to make for both pediatricians and parents, she says.

“I’m hoping by understanding the barriers that pediatricians are facing that we can address them,” Gupta says. “I really want the message not to be what pediatricians aren’t doing, but how do we help facilitate this for pediatricians who are so busy.”

Allergy screenings miss at-risk infants

In a second abstract (no. 809; Volertas S, et al) presented at the AAAAI meeting, another team of researchers reviewed the results of the

² with screening for specific at-risk populations. The review was conducted using retrospective records of children aged younger than 11 months between January 2017 and February 2018.

Researchers found that 100 infants had testing performed for peanut allergies-81 as a screening and 19 after reaction concerns.⁴ Of the 81 infants screened, 67 were referred by pediatricians, but just 40% met NIAID screening guidelines. Of those referrals that did not meet criteria, 52% were made as a result of family histories of food allergies, and 100% were made as a result of mild-to-moderate cases of eczema. The study concluded that most infants screened in allergy clinics did not meet NIAID screening guidelines and, in fact, there were infants who met screening criteria that were missed.

Unmet need to educate about peanut allergy

A third abstract (no. 830; Tapke DE, et al) presented at the AAAAI meeting found that in implementation of the NIAID guidelines, there were few instances of discussion about early peanut introduction in at-risk infants in the primary care setting.⁵ The study involved a retrospective review of infants who had suspected allergies based on the presence of eczema.

Discussion of early peanut introduction occurred in just 3.3% of 4-month visits, 3.3% of 6-month visits, and 3% of 9-month visits. Additionally, the research team noted that early peanut introduction was discussed only 21 times in 17 unique patient visits, and always ended with a referral to an allergist. Eczema care was discussed in roughly half the visits reviewed in the study, but researchers highlight the missed opportunities for education about peanut-allergy screenings and early peanut introduction.

Paradigm shift in guidance has come

Missed opportunities and confusion about the guidelines is expected given the complete shift from traditional guidance, says David R. Stukus, MD, associate professor of Pediatrics in the Section of Allergy/Immunology at Nationwide Children’s Hospital, Columbus, Ohio. and co-author of the 2017 NIAID guidelines. Stukus says there has been a huge paradigm shift in recommendations for feeding allergenic foods.

“What we are really trying to do is change the recommendation pediatricians give to all children with food allergies,” Stukus says. “This is very different than what we’ve recommended for decades.”

Traditionally, the recommendation has been to wait until at least 2 to 3 years of age to introduce highly allergenic foods, Stukus says, but new research shows that by introducing these foods at younger ages-4 to 6 months-and offering them regularly in the child’s diet, food allergies might be avoided altogether.

“We now have good evidence that shows if we actively feed babies allergenic foods around 4 to 6 months of age, we can dramatically reduce the development of food allergies,” Stukus says. The biggest hurdle, he notes, is getting both parents and pediatricians on board with the new recommendations.

“There are some pervasive misconceptions among parents as well as pediatricians,” Stukus says. “This should be seen as a standard of care, and we are not going to make any difference in the rate of peanut allergy unless we have pediatricians on board with this.”

Whereas pediatricians may not be comfortable offering early peanut introduction in their practices, Stukus says, delays to see allergists could impede the benefit of the intervention. “If we delay introducing peanut, even by just a month or two, it can make a dramatic impact on those who can tolerate it,” he says.

For infants with no eczema, mild eczema not requiring topical treatments, or for whom there is no suspicion of a peanut allergy, Stukus says pediatricians should be recommending the feeding of peanut-containing foods at home. For children with mild to severe eczema, pediatricians are advised to conduct a peanut allergy test through a blood test or skin-prick test. If the testing is negative, those children can be fed peanut-containing foods at home. Milder cases should be offered peanut-containing foods under clinician supervision, such as in a medical office, he says. Only when testing reveals a high sensitivity to peanuts should pediatricians recommend complete avoidance, Stukus says.

The challenge for pediatricians is in having the time and education to understand the new guidelines to the point where they are comfortable using them, and to be able to educate parents when there is so much else to cover in a well visit. Gupta says her research made it clear that pediatricians need more education and resources for themselves, clear algorithms to use in practice, and better education and handouts to help parents.

Stukus agrees. “We know that it takes years before clinical guidelines are put into practice. We need people to understand the science and buy into it,” he says. “We need to help people understand and continue to educate. This is a huge development in our specialty.”

Stukus recommends pediatricians learn more about the guidelines,

to help explain the process to parents, and enlist ancillary staff to help provide education to families.

References:

1. 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. World Allergy Organ J. 2017;10(1):1.

2. National Institute of Allergy and Infectious Diseases. Addendum guidelines for the prevention of peanut allergy in the United States. Summary for clinicians. Available at:

. Accessed April 4, 2019.

3. Gupta RS, Jiang J, Bozen A, et al. Implementation, practices, an barriers to the 2017 peanut allergy prevention guidelines among pediatricians. Abstract 258. J Allergy Clin Immunol. 2019;143(2):82. Available at https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymai/2019_Saturday_February_23-1549294262280.pdf. Accessed April 4, 2019.

4. Volertas S, Coury M, Sanders GM, McMorris MS, Gupta M. infant peanut allergy testing in the post-LEAP world. Abstract 809. J Allergy Clin Immunol. 2019;143(2):51. Available at https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymai/2019_Monday_February_25-1549294250157.pdf. Accessed April 3, 2019.

5. Tapke DE, Stukus DR, Prince BT, Scherzer R, Mikhail I. Implementation of early peanut introduction guidelines among pediatricians. Abstract 830. J Allergy Clin Immunol. 2019;143(2):88. Available at: https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymai/2019_Monday_February_25-1549294250157.pdf. Accessed April 4, 2019.