The American Academy of Pediatrics (AAP) has issued interim guidance, in conjunction with 10 other medical organizations, supporting early rather than delayed peanut introduction during the period of complementary food introduction in infants. This new brief communication is designed to aid in the decision-making process for clinicians regarding the potential benefits and risks associated with early peanut introduction.
Present guidelines indicate that the introduction of highly allergenic foods like peanut need not be delayed past 4 or 6 months of life, but do not actively recommend introduction of peanut between 4–6 months of age in high-risk infants. As well, some guidelines recommend a consultation with a clinical expert for certain infants considered at high risk for allergic disease before peanut introduction. This interim guidance follows a recent study (LEAP trial) in which peanut introduction between 4–11 months in infants at high risk of peanut allergy led to an 11–25% absolute reduction in allergy risk and a relative risk reduction of up to 80%.
Based on this new data, the following interim guidance is suggested for clinicians:
- There is now scientific evidence (Level 1 evidence from a randomized controlled trial) that healthcare providers should recommend introducing peanut-containing products into the diets of ‘‘high-risk” infants early on in life (between 4–11 months of age) in countries where peanut allergy is prevalent because delaying the introduction of peanut can be associated with an increased risk of peanut allergy.
- Infants with early-onset atopic disease, such as severe eczema, or egg allergy in the first 4–6 months of life might benefit from evaluation by an allergist or physician trained in management of allergic diseases in this age group to diagnose any food allergy and assist in implementing these suggestions regarding the appropriateness of early peanut introduction. Evaluation of such patients might consist of performing peanut skin testing, in-office observed peanut ingestion, or both, as deemed appropriate after discussion with the family. The clinician can perform an observed peanut challenge for those with evidence of a positive peanut skin test response to determine whether they are clinically reactive before initiating at-home peanut introduction. Both strategies were used in the LEAP study protocol.
- Adherence in the LEAP trial was excellent (92%), with infants randomized to consume peanut ingesting a median of 7.7g of peanut protein (interquartile range, 6.7–8.8g) per week during the first two years of the trial compared with a median of 0g in the avoidance group.
- Although the outcome of the LEAP regimen was excellent, the study does not address use of alternative doses of peanut protein, minimal length of treatment necessary to induce the tolerogenic effect, or potential risks of premature discontinuation or sporadic feeding of peanut.