February/March 2017

Peanut Power: New Guidelines Encourage Early Introduction of Peanuts Into Diets

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Parents have feared peanut-containing foods for many years and excluded them from their infants’ diets, but new guidelines say it’s time to make friends once again with our favorite lowly legume. Yes, it’s true — peanuts are not nuts, after all. Now that we’ve completely turned your world upside down, here’s the science behind the latest recommendations.

Jonathan Spergel, MD, PhD, Allergy Section chief at Children’s Hospital of Philadelphia and professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, participated on the expert panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) that issued the guidelines to prevent peanut allergy. Studies show the number of children living with peanut allergy tripled between 1997 and 2008, according to the national organization Food Allergy Research & Education. Peanuts, out of all food allergies, most often cause the reactions that lead to fatal food anaphylaxis, so people living with peanut allergy must be vigilant about ingredient labels on the foods they eat.

However, scientific evidence gathered through observational studies over the last decade has shown that early exposure to peanuts actually makes you less likely to have allergy, Dr. Spergel said. A large-scale randomized trial of introducing peanuts early into the diet called Learning Early About Peanut Allergy (LEAP) gave scientists even more food for thought. Results from LEAP reported in 2015 showed that regular consumption of a peanut-containing snack begun in early infancy and continued until age 5 reduced the rate of peanut allergy in at-risk infants by 80 percent compared to non-peanut-consumers.

Professor Gideon Lack at Kings College London got the idea to conduct the LEAP study based on an observation that a Jewish population in England who weren’t fed peanut products during infancy had a very high rate of food allergy compared to a Jewish population in Israel who used a popular teething biscuit made with peanut butter and had a very low rate of food allergy. He wondered if the Israeli babies’ early exposure to peanuts was training their immune systems not to overreact. The research, which was published in The New England Journal of Medicine, helped to spur the fundamental change in the latest peanut allergy prevention guidelines.

“Early is better,” Dr. Spergel said, summing up the new peanut paradigm. “Avoiding things probably leads to more allergy. The big challenge is that there is a food allergy phobia we will need to help parents get over so that they will let their kids eat foods with peanuts.”

The recommendations are tailored to three levels of infants’ risk for developing peanut allergy: high risk (infants who have severe eczema, egg allergy, or both); moderate risk (infants who have mild or moderate eczema); and low risk (infants who do not have eczema or any food allergy).

  • High-risk group: Screen first. The expert panel suggests that parents and caregivers meet with their child’s pediatrician, family practice physician, or allergist to decide if a skin test or blood test is needed to determine if and how peanut can be safely introduced into the diet as early as 4 to 6 months of age.
  • Moderate-risk group: Give it a try on your own. The expert panel recognizes that some caregivers may prefer to consult with their pediatrician, physician, or allergist, but it recommends that infants in this category can have age-appropriate peanut-containing food introduced around 6 months of age at home without an in-office evaluation.
  • Low-risk group: No worries, eat and enjoy. The expert panel suggests that infants without eczema or any food allergy should have age-appropriate peanut-containing foods freely introduced in the diet.

Parents should remember two other important peanut pointers: All babies should try other solid foods before peanut-containing ones. And infants and small children should never be given whole peanuts due to the risk of choking.

While these new guidelines apply to peanut allergy, Dr. Spergel suggested that the next big research question will be to figure out if other foods, such as milk and eggs, that are known to trigger allergic responses also can be introduced early into babies’ diets. And since, the LEAP study was performed with 600 children from England, the study needs to be replicated to demonstrate that the findings are translatable to a broader population.

One of the practical issues that the guidelines took under consideration, Dr. Spergel noted, is that some communities have a shortage of allergy specialists, which is partly why it was important for the expert panel to limit the allergy screening recommendation to those infants with the highest risk.

“These guidelines were written not only for the U.S. but worldwide, and for most of the rest of the world, even with just the high-risk group, there aren’t enough allergists to do the testing,” Dr. Spergel said. “Getting all those patients in early, hopefully within the first eight months of life, is a challenge.”

The expert panel was comprised of specialists from a variety of clinical, scientific, and public health arenas who used a literature review of food allergy prevention research and their own expert opinions to prepare the guidelines. They appear in the Journal of Allergy and Clinical Immunology, and resources including a summary for clinicians and a summary for parents and caregivers are available on the NIAID website.

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