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Infants with eczema may require different approaches to preventing food allergies, including early introduction of peanuts to increase oral exposure to allergens before skin exposure.
New guidelines on food allergy prevention suggest that children with severe eczema should be exposed to allergens through their gut before being exposed to them through their skin, says Ruchi S. Gupta, MD, MPH.
“There is some new evidence that oral exposure can prevent the development of peanut allergies,” says Gupta, professor of pediatrics at the Northwestern University Feinberg School of Medicine and director of the Center for Food Allergy and Asthma Research at the Ann & Robert H. Lurie Children’s Hospital of Chicago.
A recent study1 by Gupta and her fellow researchers on infant feeding and food allergy prevention, which she presented at the American Academy of Pediatrics (AAP) Experience Virtual 2020 Conference and Exhibition, reveals that children with severe eczema risk being exposed to allergens through their skin before they are exposed orally.
Evidence-based guidelines to prevent peanut allergies were released in 2017, but this new report1 shows that parents, time, and training are major barriers to the implementation of those recommendations, according to Gupta.
She and her colleagues conducted the study to better understand what recommendations pediatricians are making to parents about solid food introduction and to summarize current pediatric implementation guidelines and the barriers to using them. “We were seeing peanut allergies increase dramatically,” she notes.
For years, the conventional wisdom advocated avoiding introduction of peanuts until age 3 years in order to avoid allergic reactions to peanuts. In 2008, she says it was decided that there really wasn’t enough evidence to support avoidance of peanuts as a way to prevent allergies, so the guidelines were changed to a “do what you think is best,” approach of neither suggesting early feeding or delayed feeding of peanuts.
Most pediatricians responded to this non-recommendation by continuing to tell parents to avoid feeding infants peanuts, just to be safe, Gupta says. Following a study2 published in 2015, however, stakeholders had new data to craft evidence-based guidelines. That study supported the efficacy of early introduction to fight the development of peanut allergies, the National Institute of Allergy and Infectious Diseases (NIAID) updated its recommendations in 2017 to include early peanut introduction as an allergy prevention strategy.
The study conducted by Gupta and her colleagues examines how pediatricians were doing when it came to enacting those recommendations. The AAP Section on Breastfeeding and Committee on Nutrition has recommended that introduction of solid foods beginning around 6 months of age, depending on the infant’s interest in food, head control, and ability to sit upright. Alongside that recommendation, the Centers for Disease Control and Prevention (CDC) suggests feeding infants one new food type at a time, observing them for reactions for a few days between. This study was the first to look at how pediatricians were using the guidelines from these organizations, and the new data on allergy prevention, according to Gupta.
“It’s really unclear what pediatricians are recommending for their patients,” she says. “So we decided to ask pediatricians.”
The electronic survey was sent primarily to pediatricians, but also to medical residents and nurse practitioners that advise parents on infant feeding practices.
“More pediatricians recommended early introduction if they were not exclusively breastfed,” Gupta notes. “If they are exclusively breastfed, that reversed a bit.”
Gupta says this trend is interesting because it is a little different than the current recommendations.
“We also asked what food they typically recommend introducing first, and the majority—about 40%—said they don’t have a recommendation,” she says. Cereals and fruits were among the top recommendations for first foods when one was made, she adds.
Recommendations for early introduction of allergens and first food offerings differed when infants had older siblings with food allergies, a family history of food allergies or eczema. In these cases, pediatricians would more frequently recommend waiting longer than three days to try different foods in children at a higher risk of developing food allergies, Gupta says. “It actually goes against what we know about food allergies,” she says. “By waiting longer, you delay introducing these infants to allergens earlier This delay increases your risk of developing food allergies.”
The number of food allergy reactions pediatricians were seeing didn’t match their recommendations, either, Gupta adds. According to the study, 55% of pediatricians said they saw food allergy reactions in less than 5% of the infants they saw, compared to just 20% who saw food allergy reactions in 5% to 10% of their infant patient population.
“Very few infants are having these reactions to food,” Gupta notes. Another important point she made was that when food reactions happen, they tend to happen quickly. “This whole idea of waiting three-to-five days between introduction of new foods because you need to monitor for reactions does not correlate with what we know about allergic reactions. Most reactions happen within minutes or at most a few hours. Waiting days in between new foods is not necessary and is may cause decreased diet diversity in these infants, and that could actually increase their risk of developing food allergies.”
Gupta says given the results of these national surveys as well as the advancements in our understanding of food allergy development, she recommends bringing stakeholders back together to reassess and think about guidelines on feeding practices and wait times between new food introductions.
“There is no data showing three-to-five days is an ideal time. Diet diversity is increasingly being found to be important to preventing food allergies,” she says. These wait times may also delay early peanut introduction, which further increases the risk of developing peanut allergy.
Specific to peanut allergy, the new guidelines tell clinicians to look for eczema, order an immunoglobulin E (IgE) test for peanut allergies if eczema is present and advocate for feeding the infant peanut products if the IgE test is negative or there is no eczema. If the IgE test is positive, the clinicians should refer the infant to an allergist for skin prick test, and possibly an oral food challenge to peanuts, she says.
“The main thing pediatricians need to look out for is to identify kids with severe eczema in order to prevent peanut allergies,” Gupta says.
For infants with mild or no eczema, pediatricians should encourage early peanut introduction around six months of age, after a few other foods have been introduced. Gupta recommends avoiding whole peanuts due to choking risk and mixing peanut butter with a little water to help make the consistency less sticky. The key is not just introducing peanuts, but also keeping them in an infant’s diet, she adds. Feeding about a total of 2 teaspoons per week is ideal, Gupta says.
Going forward, Gupta suggested there should be better support and educational material provided to pediatricians to help them—and parents—navigate these new recommendations.
This story originally appeared on Contemporary Pediatrics.
Dr. Gupta reports receiving grants from the National Institutes of Health (grant nos. R21 ID# AI135705, R01 ID# AI130348, and U01 ID# AI138907), Rho, Inc, Stanford Sean N. Parker Center for Allergy Research, UnitedHealth Group, Thermo Fisher Scientific, Genentech, and the National Confectioners Association; and serves as a medical consultant/advisor for Before Brands, Kaléo, Inc, Genentech, Institute for Clinical and Economic Review, Food Allergy Research & Education, Aimmune Therapeutics, and DBV Technologies. The rest of the authors declare that they have no relevant conflicts of interest.
1. Johnson JL, Gupta R, Bilaver L, et al. Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI. J. Allergy Clin. Immunol. 2020;146:875-883. doi: 10.1016/jaci.2020.07.020.
2. Du Toit G, Roberts G, Sayre P, et al. for the LEAP Study Team. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med.2015; 372:803-813. DOI: 10.1056.