Early Peanut Feeding Guidelines Still Not Reaching Families

Esther Landhuis

November 07, 2021

Four years after new infant feeding guidelines were issued to prevent allergies to peanut and other foods, 70% of surveyed parents and caregivers in the United States said they had never heard about the new recommendation.

Food allergies in developed countries have doubled in each of the last decades and now affect 7.6% of US children. About 1 in 50 are allergic to peanut. Data from the 2015 LEAP study and other research has convincingly shown that early, sustained feeding of peanuts, eggs and other allergens can prevent babies from developing allergies to these foods.

Based on those findings, the National Institute of Allergy and Infectious Diseases (NIAID) updated its feeding guidelines in 2017, urging parents to introduce these foods to babies around 4-6 months of age rather than wait until 1-3 years of age, as previously recommended. The American Academy of Pediatrics approved those guidelines too, and in 2019 changed its own feeding recommendations.

To assess awareness of this new guidance and to what extent these recommendations are being translated into clinical practice, researchers surveyed a demographically representative US sample of 3062 parents and caregivers with children between 7 months and 3½  years old. The survey was conducted in English and Spanish over the web or by phone.

More than one third reported that their child's primary care physician never discussed when to start feeding peanut-containing foods. And among those whose doctors did offer guidance, fewer than 1 in 4 specifically recommended introducing peanut by 6 months of age.

These data show that "despite strong evidence that early introduction of peanut within the first year of life can prevent the development of peanut allergy, this evidence is simply not making its way to parents of infants," said Christopher Warren, PhD, assistant professor of preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. Warren led the study and presented the findings on a poster at this year's American College of Allergy, Asthma & Immunology annual meeting in New Orleans.

In addition to caregivers, the Northwestern team surveyed US allergists and pediatricians about the new feeding guidelines. Uptake was fairly good among allergists, with 65% reporting full implementation. On the other hand, while most pediatricians seemed familiar with the 2017 recommendations, fewer than one third said they were following them.

"What's unique about this challenge is that it's not just a guideline change — it's a guideline reversal," said Wendy Sue Swanson, MD, chief medical officer for SpoonfulONE, a company that makes mix-ins and other products for multi-allergen feeding. After telling families for years to avoid these allergens in early life because food allergies were rising, "it's harder advice to say, actually, we were wrong. Not only should you not wait, you should get peanut in while your baby's immune system has this critical moment to learn and develop, and you should keep getting it in," Swanson told Medscape Medical News.

Making matters worse, pediatricians are time pressed. Typically, at 4- to 6-month-old well-check visits, "they're talking about sleep and development and feeding and milestones," said Ruchi Gupta, MD, MPH, professor of pediatrics and medicine at Northwestern Feinberg, who led the allergist and pediatrician analyses.

Another challenge: Guidelines differ depending on the child's level of food allergy risk, so it's hard to explain them clearly and quickly. Babies at highest risk — as judged by having severe eczema, egg allergy, or both — should get peanut IgE blood testing and, if negative, begin regular consumption of peanut by 4-6 months. Intermediate-risk babies who have mild-to-moderate eczema are recommended to start peanut-containing foods by 6 months. And for low-risk babies with no eczema or known food allergies, the guidance is simply to introduce peanut-containing foods "in accordance with family preferences and cultural practices."

As for pediatricians who say it's hard to distinguish mild-to-moderate from severe eczema, "any eczema puts you at some risk," Gupta told Medscape Medical News. "If they've required steroid creams to clear up their skin, or if you look at their skin and you think it's severe, don't hesitate. Go ahead and draw the IgE and send them to an allergist."

Australia, which has the highest rate of confirmed food allergy, has had more success implementing early feeding guidelines, said Swanson. Unlike the United States' tiered approach, she said, they "had a national guideline that very crisply, years ago, told parents what to do." Australia also has nurse educators that follow up with new moms to make sure they understand and follow the recommendations.

Gupta receives research support from the National Institutes of Health, Food Allergy Research and Education, the Melchiorre Family Foundation, the Sunshine Charitable Foundation, the Walder Foundation, the UnitedHealth Group, Thermo Fisher Scientific, and Genentech. She serves as a medical consultant/advisor for Genentech, Novartis, and Food Allergy Research and Education. Swanson serves as chief medical officer for SpoonfulONE.

American College of Allergy, Asthma & Immunology: ePoster P104. Presented November 5, 2021.

Esther Landhuis is a freelance science journalist in the San Francisco Bay Area. She can be found on Twitter  @elandhuis .

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