In January, the National Institute of Allergy and Infectious Diseases (NIAID) published an addendum to 2010 guidelines for the diagnosis and management of food allergy in the United States. The addendum is specific to U.S. guidelines for preventing peanut allergy.
The update came on the heels of the February 2015 New England Journal of Medicine article that outlined the results of the Learning Early About Peanut Allergy (LEAP) trial. That trial was based on a prior observation that the prevalence of peanut allergy was 10 times higher among Jewish children in the United Kingdom compared with Israeli children of similar ancestry.
In Israel, peanut-containing foods are introduced in the diet when infants are approximately seven months of age and consumed in substantial amounts. In the United Kingdom, children typically do not consume any peanut-containing foods during their first year of life. In the LEAP trial, 640 children between the ages of four and 11 months with severe eczema, egg allergy or both, were randomized to consume or avoid peanut-containing foods until five years of age to determine the prevalence of peanut allergy. "Researchers found that regular consumption of peanut-containing foods beginning early in life reduced the risk of developing peanut allergy by 81 percent," the report states.
"Based on those findings, the addendum provides guidelines to pediatricians and to parents for early introduction of peanut-containing food to infants with peanut allergy," says Carol Smith, MD, of Birmingham Allergy & Asthma Specialists. "Early introduction of peanut can prevent peanut allergy in many infants."
In the first guideline, the expert panel recommends that infants with severe eczema, egg allergy or both be introduced to age-appropriate peanut-containing food as early as four to six months of age to reduce the risk of peanut allergy. Other solid foods should be introduced first to show that the infant is developmentally ready. The panel also recommends evaluation with peanut sIgE and skin prick testing to determine if the peanut should be introduced. "This guideline also instructs parents to check with their infant's healthcare provider before introducing peanut-containing foods," Smith says.
Guideline two suggests that infants with mild to moderate eczema or any food allergy have age-appropriate peanut-containing foods freely introduced in the diet, together with other solid foods and in accordance with family preferences and cultural practices. "The child's healthcare provider can advise parents of the severity of the child's eczema, at which time they can determine whether they should introduce peanut-containing foods at home," Smith says.
The third guideline suggests that infants without eczema or any food allergy have age-appropriate peanut-containing foods freely introduced in the diet, together with other solid foods and in accordance with family preferences and cultural practices.
"These guidelines definitely give us promise," Smith says. "We now have evidence that children develop allergies early in life. If we can identify those high-risk infants and introduce peanut before they develop an allergy, we hope that they can maintain their tolerance for life. We can induce tolerance through exposure, but they must continue the exposure to sustain tolerance to the allergen."
Smith says that additional studies are under way - LEAP-On which demonstrated the durability of oral tolerance to peanut achieved in the LEAP trial, and the Inquiring About Tolerance study which assessed the potential benefits of early introduction of six allergenic foods in a non-high risk cohort. "People are still looking at issues such as how long can tolerance be maintained and can we do this with other allergenic foods such as eggs, milk, soy and seafood," Smith says. "Questions are still out there, but the findings seem promising. The key is to get the children tested early."