Although previous guidance had called for avoiding peanuts and any foods containing them until later in childhood, the 2017 update noted there wasn’t enough evidence to warrant that approach. Instead, it called for pediatricians to assess risk and introduce peanuts into the diet at 4 to 6 months of age. Survey results just published in JAMA Network Open finds that the prevailing response among U.S. clinicians has been lackluster. The survey asked 1,781 pediatricians if they were aware of the guideline change, and if they were implementing it. Awareness was high, at 93%, but that doesn’t mean adherence was similar. In fact, of that group, only 29% were fully implementing the guidelines, while 64% reported partially implementing them. “We have strong evidence demonstrating that avoidance of peanuts is linked with food allergy development, whereas early introduction, along with ongoing inclusion in the diet, is an effective prevention strategy for many infants,” says David Stukus, MD, specialist in allergy and immunology in Columbus, Ohio, and advisor to the Asthma & Allergy Foundation of America. “That said, I’m not surprised by these recent findings, and it echoes what I’ve seen as well.”
Why They Skip It
Even with compelling evidence that avoidance of peanut allergies posing a potential risk, there are many reasons why pediatricians might be aware of these guidelines and choose not to follow them, Stukus says. Although some may be hesitant due to past experience with negative peanut reactions in infants—which Stukus says can create bias and a higher degree of caution—the majority simply don’t have time during the appointment to cover food allergies, as well as everything else that needs to be discussed during an infant wellness visit. Often, doctors may find it challenging to even remember or address feeding recommendations, so the the current findings reflect limitations with time rather than conscious pushback about following the guidelines. Not every baby would benefit from peanut introduction, however. The guidelines state that caution should be used for children who have:
Severe eczemaEgg allergyParents or siblings with peanut allergies
Peanut Allergy Testing
Even though a conversation about peanut allergies doesn’t take much office time, the actual protocol of assessing risk in an infant is another story. As the 2017 guidelines describe, it can involve:
Skin prick testing or blood testing, also called slgE testsAvailability of rescue medication if neededHaving four different peanut preparations on handGiving one dose of a preparation to an infant, then waiting for reactivity for 15 to 20 minutesIf no symptoms appear, dose 2 is given, for another 15 to 20 minutesThis is repeated for dose 3, 4, and 5
If all the instructions are followed, risk assessment would be at least two hours, and would involve a fairly high degree of observation for any allergic reactions. Also, not every pediatrician has access to a peanut slgE test, adds Mitchell Grayson, MD, advisor to the Asthma and Allergy Foundation of America and specialist in pediatric allergy, asthma and immunology at Nationwide Children’s Hospital. “There may well be a fraction of providers who are simply trying to ‘play it safe’ and therefore, not introducing the peanuts per the guidelines.”
