Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants

doi:10.1016/j.jaci.2015.06.001

Journal of Allergy and Clinical Immunology

Volume 136, Issue 2, August 2015, Pages 258-261

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https://doi.org/10.1016/j.jaci.2015.06.001 Get rights and content

The purpose of this brief communication is to highlight emerging evidence to existing guidelines regarding potential benefits of supporting early, rather than delayed, peanut introduction during the period of complementary food introduction in infants. This document should be considered as interim guidance based on consensus among the following organizations: American Academy of Allergy, Asthma & Immunology, American Academy of Pediatrics, American College of Allergy, Asthma & Immunology, Australasian Society of Clinical Immunology and Allergy, Canadian Society of Allergy and Clinical Immunology, European Academy of Allergy and Clinical Immunology, Israel Association of Allergy and Clinical Immunology, Japanese Society for Allergology, Society for Pediatric Dermatology, and World Allergy Organization. More formal guidelines regarding early-life, complementary feeding practices and the risk of allergy development will follow in the next year from the National Institute of Allergy and Infectious Diseases-sponsored Working Group and the European Academy of Allergy and Clinical Immunology.

Section snippets

Introduction and rationale

Peanut allergy is an increasingly troubling global health problem affecting between 1% and 3% of children in many westernized countries. Although multiple methods of measurement have been used and specific estimates differ, there appears to have been a sudden increase in the number of cases in the past 10- to 15-year period, suggesting that the prevalence might have tripled in some countries, such as the United States. Extrapolating the currently estimated prevalence, this translates to nearly

Summary of new evidence

In the Learning Early About Peanut Allergy (LEAP) trial, 640 high-risk United Kingdom infants (see Box 1) between the ages of 4 and 11 months were randomized to consume peanut products at least 3 times a week (6 g of peanut protein, which is equivalent to 24 g peanuts or 3 teaspoons of peanut butter per week) or to completely avoid peanut products for the first 5 years of life. This included 542 infants found to have negative skin prick test (SPT) responses to peanut at study entry and 98

How does the LEAP trial affect present guidance for early complementary feeding practices?

Existing guidelines pertaining to the early introduction of complementary foods have indicated that the introduction of highly allergenic foods, such as peanut, need not be delayed past 4 or 6 months of life. However, they do not actively recommend introduction of peanut between 4 and 6 months of age in high-risk infants, and some of these guidelines specify that certain infants considered at high risk for allergic disease are recommended to first consult an expert.8, 9, 10, 11, 12, 13, 14

The

Interim guidance regarding early peanut introduction

Based on data generated in the LEAP trial and existing guidelines, the following interim guidance is suggested to assist the clinical decision making of health care providers:

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There is now scientific evidence (Level 1 evidence from a randomized controlled trial) that health care providers should recommend introducing peanut-containing products into the diets of “high-risk” infants early on in life (between 4 and 11 months of age) in countries where peanut allergy is prevalent because delaying

Rationale for evaluating and applying this policy to a high-risk population

The LEAP trial demonstrates that early peanut introduction can be successfully carried out in a high-risk population, such as the population defined in the LEAP trial. However, without intervention by health care providers, there is the potential that such high-risk infants will remain at risk for delayed introduction of solids and allergenic foods into their diet because of the widespread belief that such foods can exacerbate eczema.

There will be more extensive guidelines in the near future

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The promise and peril of knowledge translation for food allergy prevention
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Early Peanut Introduction in Primary Care: Evaluation of a Multicomponent Intervention
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To determine whether a multicomponent intervention focused on early peanut introduction was associated with a lower peanut allergy incidence in young children.
The study cohort comprised all children born January 1, 2013 through December 31, 2018 receiving care at a large health care organization. Intervention activities occurred over 16 months and included provider educational programs, electronic health record tools, and new patient instructions. We used an interrupted time series design to assess whether peanut allergy incidence differed across 3 time periods (preintervention, interim, postintervention) among high- and low-risk children. The primary outcome was incident peanut allergy by age 24 months, defined as peanut allergy in the allergy field or active problem list plus a positive supportive test. Severe eczema and/or egg allergy presence defined high-risk. Because the study was conducted as part of routine care, it was not feasible to measure what counseling clinicians provided, or how and when parents fed their children peanut-containing foods.
In a cohort of 22,571 children, the percent with peanut allergy by age 24 months was 17.3% (116 of 671) among high-risk and 0.8% (181 of 21,900) among low-risk children. In multivariate analyses, the adjusted peanut allergy rate per 100 person-years was not significantly different across study periods among high-risk (9.6 preintervention, 11.7 interim, and 9.9 postintervention, P = .70) or low-risk (0.5 preintervention, 0.7 interim, and 0.5 postintervention, P = .17) children.
In a community-based setting, the incidence of peanut allergy did not decline following a multicomponent intervention focused on early peanut introduction.
Changes in Australian food anaphylaxis admission rates following introduction of updated allergy prevention guidelines
2022, Journal of Allergy and Clinical Immunology
Food anaphylaxis admission rates have increased steadily in recent decades. Global food allergy prevention guidelines recommending early introduction of allergenic foods were introduced in 2015-2016. Australian guidelines to not delay the introduction of allergenic foods were introduced in 2007-2008.
Our aim was to examine whether introduction of Australian guidelines (2007-2008) and global allergy prevention guidelines (2015-2016) were associated with reductions in food anaphylaxis admission rates.
We compared food anaphylaxis admission rates across 3 periods: 1998-1999 to 2006-2007, 2007-2008 to 2014-2015, and 2015-2016 to 2018-2019.
Annual food anaphylaxis admission rates increased 9-fold between 1998-1999 and 2018-2019, from 2.0 per 10⁵ population to 18.2 per 10⁵ population; the highest absolute rates were in those younger than 1 year. When year-on-year rates of change were examined across the 3 time periods, the annual rate of increase slowed after 2007-2008 in those aged 1 to 4 years (17.6%, 6.2%, and 3.9% per year, respectively) and those aged 5 to 9 years (22%, 13.9%, and –2.4%, respectively), and after 2015-2016, in those aged 10 to 14 years (17.5%, 18.0%, and 10.8%, respectively). By contrast, the year-on-year rate of increase accelerated in those younger than 1 year (5.2%, 8.0%, and 18.0%, respectively) and in all age groups older than 15 years.
Although food anaphylaxis continues to increase overall, there is preliminary evidence indicating a slowing in the year-on-year rate of increase among those aged 1 to 4, 5 to 9, and 10 to 14 years, coinciding with introduction of updated infant feeding and allergy prevention guidelines in 2007-2008 and 2015-2016. Changes to the guidelines may have contributed to an attenuated rate of increase in food anaphylaxis in these age groups, as well as to increased rates in those younger than 1 year.
Atopic Dermatitis and Food Allergy: Best Practices and Knowledge Gaps—A Work Group Report from the AAAAI Allergic Skin Diseases Committee and Leadership Institute Project
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Allergists are often asked to evaluate children with atopic dermatitis (AD) for allergen triggers to disease. Testing, particularly for food triggers, often leads to elimination diets in an effort to improve AD control. However, the dual exposure hypothesis suggests that oral tolerance to food antigens is promoted through high-dose oral exposure, where sensitization occurs through lower dose cutaneous exposure. This suggests that strict elimination diets may pose some risks in children with AD. In addition, emerging evidence suggests an important role of skin inflammation in further allergic disease and the importance of dietary exposure to maintain oral tolerance. This work group report reviews current guidelines-based management for children with moderate-to-severe AD, the evidence for current recommendations for the evaluation and management of these children, provides a nuanced examination of these studies, and addresses current knowledge gaps in the care of these children.
Doses of Specific Allergens in Early Introduction Foods for Prevention of Food Allergy
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Consumption of common allergenic foods, such as peanut, in early life can reduce the risk of food allergy among high-risk children and is recommended in revised clinical guidelines. Commercial early allergen introduction foods (EIF) containing single or multiple allergenic foods for feeding infants are promoted to consumers and health care providers as aids to prevent food allergy.
To determine the concentration and doses of major food allergens in EIF.
Extracts from 32 EIF and 4 control foods were analyzed for 17 allergens: Ara h 1, Ara h 3, Ara h 6, Bos d 5, Bos d 11, Gal d 1, Gal d 2, Ana o 3, Cor a 9, Jug r 1, Gly m 5, Ses i 1, Api g 1, Sin a 1, Cyp c 1, shrimp tropomyosin, and Tri a 19 using a validated fluorescent multiplex array. Ara h 2 was measured by enzyme-linked immunosorbent assay.
The EIF comprised 1-8 samples of 32 foods (n = 86). Combined peanut allergen levels of up to 26,000 μg/g were measured in peanut puffs (doses of 65-182 mg per 7 g serving). Peanut allergens were not detected in mixed food blend puffs. Major allergen levels of >10,000 μg/g were found in several milk, egg, and peanut powders, or combinations thereof, with cumulative allergen doses of 159-2946 mg in the EIF. Mixed food blend powders, puffs crackers, and fruit sauces contained much lower allergen levels, often <10 μg/g, and some had undetectable allergens. The allergen concentration in these EIF varied over a >3 log range and provided lower cumulative doses of allergen.
Significant variability in allergen composition, concentration, and dose per serving were observed in EIF containing the same foods. The doses of allergens consumed by potentially at-risk infants in early life were EIF dependent. Guidelines should be established to enable consumers and health care providers to make informed decisions about EIF and to improve the formulation and standardization of EIF for prevention of food allergy.

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: Published on behalf of the American Academy of Allergy, Asthma & Immunology; American Academy of Pediatrics; American College of Allergy, Asthma & Immunology; Australasian Society of Clinical Immunology and Allergy; Canadian Society of Allergy and Clinical Immunology; European Academy of Allergy and Clinical Immunology; Israel Association of Allergy and Clinical Immunology; Japanese Society for Allergology; Society for Pediatric Dermatology; and World Allergy Organization. Copublished in the Journal of Allergy and Clinical Immunology; Annals of Allergy, Asthma & Clinical Immunology; Allergy; Pediatrics; Allergy, Asthma & Clinical Immunology; World Allergy Organization Journal; Journal of Paediatrics and Child Health; and Pediatric Dermatology.

¹: American Academy of Allergy, Asthma & Immunology (AAAAI)

²: American Academy of Pediatrics (AAP)

³: American College of Allergy, Asthma & Immunology (ACAAI)

⁴: Australasian Society of Clinical Immunology and Allergy (ASCIA)

⁵: Canadian Society of Allergy and Clinical Immunology (CSACI)

⁶: European Academy of Allergy and Clinical Immunology (EAACI)

⁷: Israel Association of Allergy and Clinical Immunology (ISACI)

⁸: Japanese Society for Allergology (JSA)

⁹: Society for Pediatric Dermatology (SPD)

¹⁰: World Allergy Organization (WAO)

¹¹: Rho Federal Systems Division, Inc

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Reviews and feature articleConsensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants

Section snippets

Introduction and rationale

Summary of new evidence

How does the LEAP trial affect present guidance for early complementary feeding practices?

Interim guidance regarding early peanut introduction

Rationale for evaluating and applying this policy to a high-risk population

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol Pract

The epidemiology of food allergy in Europe: a systematic review and meta-analysis

Allergy

Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants

J Allergy Clin Immunol

Time trends in the prevalence of peanut allergy: three cohorts of children from the same geographical location in the UK

Allergy

Reviews and feature article
Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants