Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US Allergists, A Survey Conducted by the NIAID, in Collaboration With the AAAAI

Abstract

To assess peanut feeding guideline implementation by US allergists who manage infants with food allergies.US allergists within the American Academy of Allergy, Asthma, and Immunology database.This was a cross-sectional survey conducted electronically between September and October 2018. The survey consisted of 31 questions, of which 4 were used to screen out those who were not practicing, did not see infants ≤12 months old, did not manage food allergy, and were not board certified. The survey was performed ∼21 months after the guidelines were published and ∼3 and one-half years after publication of the Learning Early About Peanut Allergy (LEAP) study.Over 3200 surveys were delivered by e-mail. There was a return rate of 29% (n = 825), of which 789 were completed enough for analysis. Nearly all respondents (99%) advised parents on peanut allergy prevention and performed in vitro or in vivo testing for peanut-specific immunoglobulin E. Nearly all strongly agreed (69%) or agreed (28%) that early introduction was effective in preventing peanut allergy. A total of 97% were aware of the guidelines. Of those, 65% reported rare deviation from the guidelines, and 34% reported partial implementation. The deviations reported erred on the side of caution, not nonchalance. Three clinical scenarios of severe eczema and a positive skin-prick test (SPT) result to peanut were described and included in the survey. Respondents fully adhered to the guidelines when the diameter of the peanut SPT was small (0–2 mm; 75.4%) or large (≥8 mm; 78%). Somewhat fewer (68.6%) fully adhered when the peanut SPT was 3 to 7 mm diameter. Only 44% fully adhered to the guidelines in all 3 scenarios. As compared with older allergists (≥31 years since med school graduation), younger allergists (0–10 years since graduation) were more likely to use the guidelines as published (P = .012), perform graded oral peanut challenges (P < .0001), perform single dose in-office challenges (P = .0012), strongly agree that early peanut introduction conferred protection against the development of allergy (P = .0003), and have read the full guideline (P = .0008). Older respondents were more likely to desire more training on the guidelines (P = .001) and report that conducting graded challenges (P = .0008) and reimbursement (P < .0001) were barriers to implementation. Allergists in academic institutions were more aligned with the younger allergists but identified a lack of clinic time as a barrier to implementation (P < .0001). In contrast, nonacademically affiliated allergists were more likely to identify concern about allergic reactions (P < .0001) and legal liability (P < .0001) as barriers.Most allergists are aware of and implement guidelines regarding early introduction of peanut, but barriers to full implementation remain.One can look at these results as good news that so many allergists generally adhered to the guidelines ∼21 months after publication or as bad news that so many more did not. Because the LEAP study was published 2 years before the guidelines, many allergists had already started to adjust practices by the time the guidelines were published. I will say the glass is half full because implementation of these guidelines was much faster than implementation of guidelines for asthma care when the first expert panel report was published 30 years ago. One weakness of this study published in 2020 is that the survey was conducted 2 years before publication. The results might differ by now, but how? Guidelines are just that: advice based on scientific principles. They are not rules or laws, so they must be open to interpretation and adjustment as knowledge evolves and experience grows. Finally, as someone who graduated from medical school 38 years ago, I found it interesting that older allergists were less likely to follow the guidelines than those who were more recently trained. Might it be because their greater experience made them interpret the nuances of the guidelines differently? Or might it be that greater efforts should be made to target older and nonacademically affiliated allergists when new guidelines are published? If either of those or any other explanation is correct, I would not extrapolate from peanut allergy and allergists to other guidelines or specialties.