More Support for Early Peanut Intro to Reduce Allergy Risk

Wide adoption of infant feeding guidelines calling for peanut introduction during the first year of life in Australia prompted a significant decline in child peanut allergies in that country, researchers reported.

In 2016, guidelines in Australia were changed to recommend the introduction of potentially allergic foods such as peanut butter, cooked eggs, dairy, and wheat before a baby’s first birthday, regardless of food allergy risk.

As a result, peanut introduction during infancy increased three-fold, with polling conducted after the change showing close to 90% of infants in a Melbourne study exposed to peanuts in their first year of life compared with just under 30% in the years prior to the guideline change.

Now, Victoria Soriano, of Murdoch Children’s Research Institute in Melbourne, who led that 2019 study, presented the new peanut allergy prevalence data during the virtual annual meeting of the American Academy of Allergy Asthma & Immunology.

Modeling designed to compare the prevalence of peanut allergy before and after the guideline change showed a 16% decline in peanut allergy prevalence, with the adjusted prevalence in 2018-2019 being 2.6%, compared with 3.1% in 2007-2011.

Soriano told MedPage Today that if the shift in feeding practices had not occurred, peanut allergy prevalence in Australia would likely have increased during the past few years due to lifestyle changes and migration factors that occurred among the population.

She said the shift in infant feeding practices occurred quickly in Australia, largely due to a massive public education campaign and a program providing near universal child and family health nursing services from birth to school entry.

As part of the program, caregivers meet with the specialty nurses at set times until the children reach school age to address key developmental issues.

“The nurses follow up with parents, providing advice about what is needed during the first year of life,” Soriano said. “One thing they really stress is food introduction.”

In the U.S., the diagnosis of pediatric food allergies almost doubled since the late 1990s, and the prevalence of reported peanut allergies has almost tripled among children and teens.

Estimates suggest that around 1.2 million children in the U.S., or 2.2% of the non-adult population, have peanut allergies.

Within the last few years, the American Academy of Pediatrics revised its own guidelines for introduction of allergic foods, abandoning an earlier recommendation to delay introduction of peanuts in high-risk babies. The shift in policy was based on findings from the landmark LEAP trial, which showed early introduction of peanuts to be protective against peanut allergies.

AAP guidelines now recommend that high-risk infants (i.e., those with severe eczema and/or egg allergy) be introduced to peanuts between the ages of 4 and 6 months under a physician’s guidance, with peanut introduction recommended at 6 months for moderate-risk infants (i.e., those with mild to moderate asthma).

Testing prior to peanut introduction — such as specific immunoglobulin E measurement, skin-prick test, and oral food challenges — is also recommended for high-risk infants when appropriate, the guidelines advise.

Edwin Kim, MD, medical director of the University of North Carolina at Chapel Hill Allergy & Immunology Clinic, who was not involved with the study, said the dramatic change in infant feeding practices seen in Australia has not occurred in the U.S.

“No one doubts the data that earlier introduction makes a difference for peanut allergy and probably most food allergies,” he told MedPage Today. “But the U.S. rollout of this has been very different than in Australia, where there was a national effort to get the message to parents. We really haven’t seen that here.”

Another difference, Soriano noted, is that the Australian guidelines do not differentiate between infants at low and high risk, and do not call for testing prior to peanut introduction and initial feeding under a doctor’s supervision for high-risk infants.

“We have specific guidelines for introducing allergic foods, but our guidelines don’t distinguish between risk categories,” and the early feeding strategy has proven safe even in high-risk infants, she said. “We are confident that this shift toward earlier introduction is being done safely.”

Her team’s study included a population of 1,933 infants age 12 months whose caregivers were surveyed between 2018 and 2019, compared with a sample of 5,276 infants recruited 10 years earlier (2007-2011). The same sample frame and methodology was used for the pre- and post-guideline change surveys.

Questionnaires included demographic and infant feeding data, infants underwent skin prick tests and food challenges if sensitized, and direct standardization and marginal effects modeling were used to compare peanut allergy prevalence between the cohorts, adjusted for food allergy risk factors.

The adjusted peanut allergy prevalence in 2018-2019 was 2.6% (95% CI 1.9%-4.0%) compared with 3.1% (2.6%-3.6%) in 2007-2011. Adjustment for eczema did not significantly change this prevalence (2.7%; 95% CI 2.1%-3.2%), Soriano reported.

In the latter survey, 77.7% (95% CI 75.7%-79.5%) of infants consumed peanut before age 12 months, including 2.6% who were peanut allergic, compared with 4.8% of those who avoided peanuts until after age 12 months.