Food allergies are a growing health concern with a significant increase in reported prevalence. Allergic reactions to food can produce life-threatening anaphylaxis. Peanut allergy in particular is a significant public health problem with no proven treatment nor a cure at the present time. Peanut allergy often remains a life-long problem for many individuals, as less than 25% of peanut allergic patients are expected to regain tolerance. Current recommendations for management include strict avoidance and a prescription for an auto-injectable form of epinephrine.
The increase in prevalence of peanut allergy occurred during a period of time when there was conflicting guidance regard- ing preventative measures for the development of peanut allergy. Prior to the year 2000, there were no guidelines regarding the timing for the introduction of peanut-containing products nor were there any purposeful strategies to delay the introduction of peanut-containing products to try to prevent the development of allergic disease. But in 2000, the American Academy of Pediatrics recommended that “solid foods should not be introduced into the diet of high-risk infants until 6 months of age…and peanuts…until 1 years of age.”
This recommendation was reversed in 2008. At that time, AAP recommended that “the introduction of solid foods not be delayed past 4-6 months of age”. However they did not make any updated recommendations regarding the introduction of peanut-containing products.
The Learning Early About Peanut allergy (LEAP) study demonstrated that peanut-containing products can be safely introduced to high-risk infants between the ages of 4 to 11 months and that there is a monumental potential for peanut allergy prevention. The National Institutes of Allergy and Infectious Diseases (NIAID) recently published an addendum guideline regarding the prevention of peanut allergy in the US based on the findings from the LEAP study. [Togias A et al. Addendum guidelines for the prevention of peanut allergy in the United States. J Allergy CliniImmunol. 2017 Jan;139(1):29-44.]
The NIAID-sponsored guidelines include the following three addendum recommendations:
Infants with severe eczema, egg allergy, or both should have introduction of age-appropriate peanut-containing food as early as 4 to 6 months of age to reduce the risk of peanut allergy. The Expert Panel recommended to strongly consider evaluation by in vitro specific IgE testing and/or skin prick testing, and if necessary an oral food challenge. Then based on these results, introduce peanut-containing foods.
Infants with mild-to-moderate eczema should have introduction of age-appropriate peanut-containing food around 6 months of age, in accordance with family preferences and cultural practices, to reduce the risk of peanut allergy. The Expert Panel recommended that infants in this cate- gory may have dietary peanut introduced at home without an in-office evaluation. The Expert Panel recognized that some caregivers and healthcare providers may desire an office supervised feeding and/or evaluation.
Infants without eczema or any food allergy may have age-appropriate peanut-containing food freely introduced in their diet, together with other solid foods, and in accordance with family preferences and cultural practices. There is an algorithm in the addendum guidelines to aid in assessing the high-risk infants in recommendation one. For these high-risk infants, it is recommended that they be evaluated and undergo skin testing by a specialist before the introduction of peanut-containing products.
The Expert Panel did recognize that for those high-risk infants who do not have access to a specialist that testing for peanut-specific immunoglobulin E (sIgE) may be the preferred initial approach in certain instances.
The recommendations regarding when to introduce pea- nut-containing products into the diet have changed. New research demonstrated that early introduction of peanut- containing products around 4 to 6 months of age significantly reduced the risk of development of peanut allergy.