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AAP: Early Peanut Introduction Cuts Later Risk of Peanut Allergy

Evidence indicates early introduction of infant-safe peanuts reduces the risk of developing peanut allergies, according to a clinical report from the American Academy of Pediatrics (AAP).

This is an update to the 2008 AAP report, which found “insufficient data to support a protective effect of any dietary intervention for the development of atopic disease,” reported Frank Greer, MD, FAAP, of the AAP Committee on Nutrition, Section on Allergy and Immunology, and the University of Wisconsin-Madison, and colleagues.

This report also enforces the 2017 recommendation from the National Institute of Allergy and Infectious Diseases (NIAID) which stated peanuts could be introduced as early as 4 to 6 months for infants with severe eczema and/or egg allergy, the authors wrote in Pediatrics.

For infants with mild or moderate eczema, peanuts can be introduced as early as 6 months, and for infants with no history of eczema or food allergy, peanuts can be introduced after 6 months at the family’s discretion, they noted.

“Although atopic diseases have a clear genetic basis, environmental factors, including early infant nutrition, have an important influence on their development,” Greer and colleagues wrote. “Thus, for pediatric health care providers, there is great interest in early nutritional strategies that may ameliorate or prevent this disease.”

Peanut allergies are rising in prevalence with roughly 1.2 million U.S. children and teens affected as of last year. The AAP endorsed the NIAID-sponsored guidelines shortly after they were published in 2017, and is now updating their clinical guidance with this report.

Guidelines regarding earlier introduction of peanuts were primarily based on the results of the Learning Early About Peanut Allergy (LEAP) trial, in which introducing peanuts as early as 4 months reduced the number of peanut allergies by about 86% in a sample of over 500 infants, Greer and colleagues noted. The same reduction was not seen with egg allergies, and thus the evidence to support the early introduction of eggs is “less clear.”

“There were signs as far back as [the early 2000s] that we were going the wrong way in not introducing foods sooner rather than later, but we didn’t really have a randomized control trial to support it,” Greer told MedPage Today. “This trial is about the strongest trial you’ll get for showing you can prevent peanut allergies by introducing them early.”

New Evidence on Role of Breastfeeding, Formula

Although the primary update in this clinical report focused on childhood allergies, there was new evidence regarding the role of breastfeeding and hydrolyzed formulas in the development of atopic disease in children.

The report found evidence that breastfeeding infants for a longer period of time was protective against asthma after 5 years, whereas in 2008 the evidence that breastfeeding was protective was “not convincing.”

Along those lines, any breastfeeding beyond 3 to 4 months was also protective against wheezing in the first 2 years of an infant’s life, Greer and colleagues noted. This differed from the 2008 report where only exclusive breastfeeding was protective against wheezing.

While the 2008 report found “moderate evidence” that hydrolyzed formulas delayed or prevented atopic dermatitis in infants not exclusively breastfed for the first few months, this report found a “lack of evidence” to support using hydrolyzed formula, even for children at a high risk for allergic disease.

However, many of the conclusions in the 2008 report remained unchanged, including:

  • Breastfeeding for the first 3 to 4 months decreased the incidence of eczema within the infant’s first 2 years
  • No long-term advantages resulted from breastfeeding beyond 3 to 4 months in terms of atopic disease
  • No conclusions were made regarding the role breastfeeding plays in the onset of food allergies

Also unchanged was a lack of evidence indicating the introduction of peanuts, eggs, fish, or other allergenic foods after 4 to 6 months prevents atopic disease, according to Greer and colleagues.

Finally, the report found no evidence to support restricting maternal diets during pregnancy or breastfeeding to prevent the development of allergies.

Greer and colleagues noted this report does not address guidelines for children who have already developed atopic disease; instead it is intended to describe ways to “prevent or delay atopic disease through early dietary intervention.” The data regarding the use of prebiotics, probiotics, vitamin D, and long-chain polyunsaturated fatty acids to prevent atopic disease was also limited and was thus not included in this report either.

Greer disclosed no conflicts of interest.

A co-author received royalties from UpToDate and Johns Hopkins University Press and his institution received grants and honoraria from HAL Allergy Group, Food Allergy Research and Education, the Immune Tolerance Network, the National Institute of Allergy and Infectious Diseases, and the American Academy of Allergy, Asthma, and Immunology.