Guidelines recommend early peanut introduction

Lawrence F. Eichenfield, M.D.Clinical guidelines released January 5 are banking on recent research suggesting that peanut allergies can be prevented by introducing peanut-containing foods into the diet during infancy.

The

to the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel features three guidelines for infants at different levels of risk for developing peanut allergy-all of which take in account whether or not infants have eczema.

“We know that children with atopic dermatitis [AD] have a higher rate of developing food allergies than those without AD--with about 15 percent of milder AD patients having one clinically relevant food allergy (meaning a consistent clinical reaction, not just a positive test to food) by a few years of age, and around 40 percent of the more severe patients,” Lawrence F. Eichenfield, M.D., professor of dermatology and pediatrics, chief of pediatric and adolescent dermatology, University of California, San Diego and Rady Children's Hospital, San Diego, tells Dermatology Times. Dr. Eichenfield represented the American Academy of Dermatology (AAD) on the coordinating committee for the new clinical guidelines on the prevention of peanut allergy and was a member of the expert panel. “It is important to recognize this connection, and that the xerosis and impaired skin barrier associated with eczema may allow more sensitization to allergens through the skin. Dermatologists can help to guide families to an understanding of eczema, stressing skin directed therapy and relating to them the information on how early feeding may prevent food allergies from developing.”

The recommendations

The first of the three guidelines focuses on infants with severe eczema, egg allergy or both and are, therefore, believed to be at high risk of peanut allergy. To reduce the risk of developing peanut allergy, health care providers should recommend that parents feed these infants peanut-containing foods as early as ages four to six months. Dermatologists and other providers might elect to perform tests to help determine how to safely introduce peanuts into infants’ diets, according to guideline one.

The second guideline recommends that infants with mild or moderate eczema can reduce their risk for peanut allergy by having peanuts introduced into their diets at about six months of age. And for infants without eczema or food allergies, parents can freely introduce peanut-containing foods in infants’ diets.

Parents should feed infants other solid foods before peanut-containing foods in all cases, according to the guidelines.

The National Institutes of Health (NIH) sponsored the expert panel representing 26 professional organizations, advocacy groups and federal agencies to develop the Addendum Guidelines. The panel referred to results from the landmark Learning Early About Peanut Allergy (LEAP) study, published February 2015 in the New England Journal of Medicine, which showed infants with severe eczema, egg allergy or both who regularly consumed peanut-containing foods in infancy through five years of age were 81 percent less likely to develop peanut allergy than infants who avoided exposure to peanuts in their diets.

“The population at highest risk is children in the first year of life with severe atopic dermatitis, a population cared for by many dermatologists, as well as those with egg allergy. Early evaluation (with serum IgE screening) or referral to allergy (specifically for skin testing for peanut) is important to allow this group of patients to benefit from the tolerance that can be developed with early feeding,” Dr. Eichenfield says.

Next: Putting the guidelines to practice

Putting the guidelines to practice

Peter Lio, M.D.The guidelines signal a change of practice. The recommendations are to identify children in the first year of life with severe atopic dermatitis or egg allergy and to get them evaluated, so that these children can get early peanut feeding, according to Dr. Eichenfield.

Dr. Eichenfield says that while children with mild to moderate eczema may be introduced to peanuts at six months of age or older, without any specific allergy evaluation, the introduction should generally be with dilute peanut butter. Peanuts can be dangerous, as they can be aspirated, he says.

It’s important, according to Dr. Eichenfield, that dermatologists understand the change in practice. They should discuss with their families with infants and young children with eczema that early feeding can prevent peanut allergy.

As for who should be considered as having severe eczema, Dr. Eichenfield says the expert panel used the definition: “Severe eczema is defined as persistent or frequently recurring eczema with typical morphology and distribution assessed as severe by a health care provider and requiring frequent need for prescription-strength topical corticosteroids, calcineurin inhibitors or other anti-inflammatory agents despite appropriate use of emollients.”

In essence, he says, infants with atopic dermatitis that are judged by the dermatologist to be severe and need frequent prescription-based treatments are the targeted patients to get evaluated.

“It should be stressed that the guidelines do not suggest general food allergy testing for common foods, recognizing that both skin testing and serum IgE testing has many false positive tests, and that food avoidance based on these tests is not a very successful strategy unless children have clinical reactions to specific foods,” Dr. Eichenfield says. “The guidelines are specific in recommending evaluation for specific IgE for peanut by blood test as a screen, which the dermatologist can do if she/he desires to, or the dermatologist can refer the child for skin prick testing for peanut.”

For young children with mild-to-moderate atopic dermatitis, dermatologists can mention that the new recommendations are for early peanut feeding, and refer parents to their pediatricians, online, or, perhaps, make a handout for the families with guidelines’ information, Dr. Eichenfield says.

Too soon?

Peter Lio, M.D., assistant professor of clinical dermatology and pediatrics, Northwestern University Feinberg School of Medicine, Chicago, and director of the Chicago Integrative Eczema Center, notes the Addendum Guidelines are really based on one study.

“One-albeit, excellent--study from 2015 called the Learning Early About Peanut Allergy (LEAP) study, a randomized trial of early allergen introduction as a preventive strategy. Of note, this study was not placebo-controlled, was at only one site in the UK, and, while large for this type of study, only involved 640 children,” Dr. Lio says.

While Dr. Lio says the study’s results were impressive, it may be premature to make such a bold statement based on one study.

“We are frequently cautioned against this in medicine, and it certainly seems possible that this will not be true--or ‘as true,’ perhaps--for all populations. That said, I think it reasonable and is likely to be the correct way forward; I just wish we had a few other corroborating studies,” Dr. Lio says.

Dr. Lio points out that there is no standardized way to delineate "severe" eczema from "moderate" eczema; yet, this is an important distinction for these guidelines because severe eczema warrants “evaluation with peanut- specific IgE and/or skin prick test,” while moderate disease would warrant introducing peanut-containing foods without testing, he says.

“This is very tough because what we as dermatologists would call ‘severe’ might be considerably different than how pediatricians define it, possibly resulting in much more allergy testing than is warranted,” he says. “For me, this is exciting because it really does seem to be a breakthrough in understanding, and we truly need this advancement. It is also a little bit scary, because I see myself referring an incredible number of patients to allergists for testing now, as I am worried that my definition of moderate may be someone else's definition of severe, and I fear recommending peanut-containing foods in those who may already be allergic.”

Resources

The Addendum Guidelines were published January 5 in the Journal of Allergy and Clinical Immunology and will also be published in the Annals of Allergy, Asthma and Immunology; Journal of Pediatric Nursing; Pediatric Dermatology; World Allergy Organization Journal; and Allergy, Asthma and Clinical Immunology.

The NIAID food allergy guidelines webpage offers a

and a

. The Addendum Guidelines also will be posted there soon, according to an NIH press release.

Disclosures: Drs. Lio and Eichenfield report no relevant conflicts.