Early Peanut Introduction Research Articles

Knowledge assessment of early peanut introduction in a New York City population

Clinical implications—despite the well-established early peanut introduction guidelines from the Learning Early About Peanut Allergy (LEAP) trial, our study suggests that there remains a clinically significant deficit in awareness of these guidelines by parents, pediatric residents, and attendings serving this Black population.

Pearls and pitfalls of implementing LEAP strategy for peanut: A case report.

Early introduction of peanut in infants at high risk has been widely adopted and implemented in pediatric outpatient clinics since 2017. It is often overlooked that almost 2% of infants went on to develop peanut allergy despite regular consumption in a previous study. Here we described a case of anaphylaxis to peanut in a 6-month-old infant after a negative skin-prick test result, supervised introduction in the clinic, and successful home consumption, which, to our knowledge, has only previously been described once in the literature.

Learning Early About Peanut worries: Evaluation of parental PROMIS-29 anxiety scores during early peanut introduction clinics

Peanut allergy negatively affects health-related quality of life for patients and their caregivers.1-3 The National Institute of Allergy and Infectious Diseases (NIAID) addendum guidelines4 for early introduction of peanut represent a marked advancement in peanut allergy prevention. Nevertheless, appropriate application of NIAID guidelines remains difficult.5 Recent consensus statements for food allergy prevention6 suggest that screening for allergy in at-risk infants is not necessary. In addition, parental anxiety after implementation of these guidelines remains understudied.

Knowledge of Early Peanut Introduction Guidelines Among Parents of Patients in a General Pediatric Clinic in an Inner-City Hospital

Peanuts are the primary cause of death from food-induced anaphylaxis. Most patients develop peanut allergy at an early age. The 2015 Learning Early About Peanut Allergy (LEAP) landmark study led to the 2017 Addendum Guidelines, in which early peanut introduction is highly recommended for infants with severe eczema and/or egg allergy. It is unclear to what extent general pediatricians follow and how much parents understand these guidelines.

US Caregiver Beliefs, Attitudes, and Considerations for Early Introduction of Peanut

Previously, clinicians reported caregiver fear as a common barrier to adherence to the 2017 Prevention of Peanut Allergy (PPA) Guidelines. This study aims to explore caregiver beliefs and attitudes toward early peanut introduction.

Peanut-Induced Food Protein Induced Enterocolitis (FPIES)

Peanut is now becoming a frequent trigger for food protein induced enterocolitis syndrome (FPIES). This increase in incidence seems to have correlated with the change in guidelines recommending early introduction of peanut in the diet of infants. We aimed to better describe the characteristics of patients presenting with peanut (PN)-induced FPIES.

Racial and Ethnic Differences in Infant Peanut Introduction Beliefs and Practices Among Parents/Caregivers in the United States

Early introduction of peanut reduces the frequency of peanut allergy development among children. However, timing of peanut introduction among infants may vary by race. This study aims to explore potential racial and ethnic differences in infant peanut introduction practices amongst US parents/caregivers.

Current Peanut Introduction Practices amongst a Large, Representative Sample of US Households

The NIAID-sponsored guidelines recommending early peanut introduction amongst infants at high risk for developing peanut allergy in 2017. Assessing guideline awareness and peanut introduction practices amongst a national cohort of caregivers has not since been evaluated.

Early peanut introduction wins over the HLA-DQA1*01:02 allele in the interplay between environment and genetics.

The rising incidence of food allergy in children underscores the importance of environmental exposures; however, genetic factors play a major role. How the environment and genetics interact to cause food allergy remains unclear. The landmark Learning Early About Peanut Allergy (LEAP) clinical trial established that early peanut introduction protects high-risk infants, consistent with the tolerizing effects of gut exposure. In this issue of the JCI, Kanchan et al. leveraged the LEAP trial data to examine molecular genetic mechanisms of early sensitization. A previously identified HLA risk allele for peanut allergy (DQA1*01:02) was associated with peanut-specific IgG4 levels in consumers. Notably, IgG4 antibodies likely provide protection by reducing the binding of allergen to IgE. The association of the same allele with peanut allergy in avoiders while potentially conferring protection in consumers reinforces the need to integrate genetic information toward a personalized therapeutic strategy for the best outcome in addressing food allergies.

Real-world peanut OIT in infants may be safer than non-infant preschool OIT and equally effective

Early introduction of peanut reduces the risk for peanut allergy, as noted in the landmark Learning Early About Peanut Allergy study1; however, some infants fail primary prevention and still develop peanut allergy.2 There is evidence that preschoolers tend to have milder, more modifiable food allergy,3 which may make them excellent candidates for immunotherapy.4 Real-world data from our group have shown peanut oral immunotherapy (P-OIT) to be particularly safe and effective in preschoolers (aged <70 months),5,6 but there was no specific focus on infants (aged <12 months).

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

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.

P174 PREVENTING FOOD ALLERGY BY EDUCATING FIRST-YEAR PEDIATRIC RESIDENT PHYSICIANS

Practice guidelines regarding early introduction of peanut and other allergenic solid foods have shifted in the last decade. We hypothesized that knowledge gaps and discomfort about these topics existed among first-year pediatric resident physicians at a pediatric tertiary care center.

M224 A CASE OF PEANUT-INDUCED FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME (FPIES)

Early peanut introduction in children with severe atopic dermatitis has been shown to decrease the incidence of peanut allergy. Food Protein Induced Enterocolitis Syndrome (FPIES) is a rare food allergy typically seen in infants with symptoms of vomiting, pallor, and dehydration typically provoked by cow’s milk, soy, rice, and oat. We present a case of peanut-induced FPIES linked to early introduction.

P109 IMPROVING IMPLEMENTATION OF EARLY PEANUT INTRODUCTION GUIDELINES AMONG PEDIATRIC HOUSE STAFF IN AN INNER-CITY HOSPITAL

The 2015 Learning Early About Peanut Allergy (LEAP) landmark study led to the 2017 Addendum Guidelines, which recommend early peanut introduction to infants at increased risk of developing peanut allergy. Educating pediatric house staff and attendings will result in increased knowledge of these guidelines and eventually lead to reduced development of peanut allergy.

Early Introduction of Food Allergens and Risk of Developing Food Allergy.

There is increasing evidence that early introduction of allergenic foods may decrease the risk of developing IgE-mediated food allergy. Patterns of food introduction before the 2015 publication of the Learning Early about Peanut Allergy (LEAP) trial are not well-studied, but are important as a baseline for evaluating subsequent changes in infant feeding practices and potentially food allergy. We performed a retrospective longitudinal study using data from a multicenter cohort of infants hospitalized with bronchiolitis between 2011–2014. The primary outcomes were IgE-mediated egg or peanut allergy by age 3 years. Of 770 participants included in the analysis, 635 (82%) introduced egg, and 221 (27%) introduced peanut by age 12 months per parent report. Four participants had likely egg allergy, and eight participants had likely peanut allergy by age 3 years. Regular infant egg consumption was associated with less egg allergy. The association was suggestive for infant peanut consumption with zero peanut allergy cases. Overall, our results suggest that early introduction of peanut was uncommon before 2015. Although limited by the small number of allergy cases, our results suggest that early introduction of egg and peanut are associated with a decreased risk of developing food allergy, and support recent changes in practice guidelines.

Timing of food introduction to the infant diet and risk of food allergy: a systematic review and Meta-analysis

Objective: To evaluate the relationship between the timing of complementary feeding for infants and the occurrence of food allergy. Methods: The PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), and WanFang Data database were searched for randomized controlled trials (RCTs) about the effects of early introduction of complementary foods in infants on the occurrence of food allergy. Papers published from the establishment of the databases to December 31, 2019 were extracted. The quality of the selected literature was evaluated using the risk-of-bias (ROB) tools in the Cochrane Handbook, and the RevMan 5.3 software was used for meta-analysis. For the complementary food analyzed in a few reports in literature, a systematic review was conducted. Results: A total of 8 RCTs were extracted, and the systematic review and Meta-analysis were carried out according to food types. The results of Meta-analysis showed that compared with late introduction (after 6 months of age), early introduction (before 6 months of age) of eggs (RR=0.60, 95%CI 0.46-0.79) could reduce the risk of egg allergy in infants. The subgroup analysis of the six studies about eggs demonstrated that in infants with a prior or family history of allergic diseases, the introduction of eggs before 6 months of age was associated with reduced risk of egg allergy (RR=0.55, 95%CI 0.40-0.75), and the introduction of raw eggs (RR=0.67, 95%CI 0.49-0.93) and small amount of eggs (equivalent to weekly protein 0-4 g) (RR=0.55, 95%CI 0.36-0.85) before 6 months of age were also associated with reduced risk of egg allergy. In addition, egg supplementation during 4-6 months of age reduced the occurrence of egg allergy compared with supplementation before 4 months of age (RR=0.58, 95%CI 0.43-0.78). The systematic review found no conclusive relationship between early peanut introduction and peanut allergy, nor the correlation between early cow's milk protein introduction and cow's milk protein allergy (P>0.05). Conclusion: Early introduction (before 6 months of age) of eggs in infants' complementary foods can prevent infant egg allergy, but the limitations of the study need to be considered.

Oral immunotherapy in infants

Immunoglobulin E (IgE)–mediated food allergy presents an increasing public health burden in the developed world.1 An estimated 4% to 10% of children have an IgE-mediated food allergy by 1 year of age.2-4 The Learning Early About Peanut Allergy trials revolutionized our understanding of food allergy development and shifted recommendations toward early introduction of peanut into the diet as a preventative measure.5,6 Early introduction has also revealed promising results for the prevention of egg allergy.

Increased Rates of Peanut and Tree Nut Aspiration as a Possible Consequence of Allergy Prevention by Early Introduction

Pediatric airway foreign bodies (FBs) are a surgical emergency, and peanuts and tree nuts (PN/TNs) can pose a significant aspiration risk in young children. In 2015, the Learning Early About Peanut allergy (LEAP) trial established that early introduction of peanuts in high-risk infants reduced the risk of developing a peanut allergy. Infant feeding guidelines were subsequently modified to actively encourage the introduction of allergenic foods for all infants. The impact of this shift in feeding advice on the incidence of PN/TN inhalation has not been previously studied. To determine the incidence of PN/TN inhalation presentations to a quaternary pediatric hospital between 2008 and2018. A retrospective cohort study of children who were diagnosed with an airway FB by rigid bronchoscopy. There were 200 cases of FB inhalation (35% PN/TN, 34% other foods, and 31% inorganic material). There was a rise in the total incidence of FB inhalation over the study period (incidence ratio rate [IRR], 1.09; P < .001). The rise was due to PN/TN (IRR, 1.16; P < .002) and other food inhalation (IRR, 1.12; P= .01), with no significant increase in inorganic FB aspiration (IRR, 1; P= .94). Between pre-LEAP (2008-2014) and post-LEAP (2015-2018) periods, there was a trebling, doubling, and no increase in the rate of PN/TN, other food, and inorganic FB inhalation, respectively. Since the publication of the LEAP study, there has been a rise in PN/TN and other hard solid food inhalation at our institution. This study highlights the urgent need to engage the public to promote safe introduction of hard foods in young children.

Treatment of Peanut Allergy.

1. Amy Burris, MD*,† 2. Theresa Bingemann, MD*,† 1. *Department of Medicine: Allergy, Immunology, and Rheumatology and 2. †Division of Pediatric Allergy and Immunology, University of Rochester Medical Center, Rochester, NY Peanut allergy (PA) affects 0.5% to 2% of children and is often a persistent condition that poses the risk of life-threatening reactions on exposure to peanut. It is the most common food allergy to cause anaphylaxis and death. Because allergy testing does not predict the severity of reactions, it is imperative that peanut-allergic children have access to epinephrine autoinjectors at all times. Although cutaneous reactions, including generalized urticaria, angioedema, and atopic dermatitis, are the most common, anaphylaxis accounts for more than one-third of reactions. Recently, research has focused on prevention strategies for PA. In high-risk infants, early introduction of peanut at younger than 11 months of age plays a crucial role in preventing PA. Conversely, avoidance of peanut is associated with increased risk of PA. Guidelines recommend early introduction of peanut to infants with no eczema or mild to moderate eczema. Infants with severe eczema should be promptly referred to an allergist for evaluation of peanut sensitization before introduction. Disruption of the skin barrier, as with eczema, plays a role in the development of food allergy. Transcutaneous exposure of food allergens may promote allergic sensitization, whereas allergen exposure through the gut may promote tolerance. Studies show that increased environmental peanut exposure leads to increased risk of PA, especially in children with eczema. Aggressive emollient therapy early in life may decrease the risk of developing eczema. Studies examining the role of early emollient therapy and development of food allergy are ongoing. The cross-reactivity between peanut allergens and environmental allergens means that apparent sensitization to peanut does not necessarily …

Learning early about peanut-triggered food protein-induced enterocolitis syndrome.

Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E mediated food allergy that typically presents with repetitive emesis and may be associated with lethargy, marked pallor, hypotension, hypothermia, and/or diarrhea. Although many foods are known to cause FPIES, peanut-triggered FPIES is emerging due to changes in the feeding practice guidelines, which recommends early peanut introduction in infants. We aimed to characterize peanut-triggered acute FPIES cases in our pediatric population and to describe their attributes, treatment, and outcomes. We hypothesized that increases in the incidence of peanut-triggered FPIES coincided with implementation of the guidelines for early peanut introduction. A retrospective chart review was conducted of pediatric patients who presented to Phoenix Children's Hospital Emergency Department and subspecialty clinics during a 6-year period (January 2013 to September 2019). Thirty-three cases of patients with acute FPIES were identified, five of which were peanut triggered. In those patients with peanut-triggered FPIES, the median age for peanut introduction was 7 months (range, 5-24 months). Two patients had positive peanut skin-prick test results. All five cases were identified in the past 2 years (2018 to 2019). No peanut-triggered reactions were documented in the preceding 4-year period (2013 to 2017). Peanut may be an emerging trigger of acute FPIES, coinciding with an earlier introduction of peanut in the infant diet after implementation of the new addendum guidelines for the prevention of peanut allergy. Oats and rice were the most common triggers of acute FPIES in our cohort. Further study will help clarify the significance and reproducibility of these findings.