January 5, 2017

expert reaction to new US guidelines for the prevention of peanut allergy in the United States, published by the National Institute of Allergy and Infectious Diseases

The National Institute of Allergy and Infectious Diseases (NIAID) has published new guidelines for the prevention of peanut allergy in the United States, in the Annals of Allergy, Asthma, and Immunology.

Dr George Du Toit, Consultant in Paediatric Allergy, Guys’ and St Thomas’ Hospital, and Reader in Paediatric Allergy, King’s College London, said:

“It is exciting and rewarding to note the change in the US guidelines which are aimed at the prevention of peanut allergy.  The change comes about due to the LEAP study findings; the LEAP Study was published in 2015 in the New England Journal of Medicine.  The LEAP study findings demonstrate a significant reduction in the prevalence of peanut allergy at age 5 years in high-risk infants who were randomised to peanut consumption as compared with those that avoided peanut.

“These new guidelines, designed for healthcare professionals but with direct practicability for parents of low risk infants, are largely based on the LEAP findings and represent expert consensus.  The LEAP study methodologies have been adapted in these guidelines for use in daily allergy practice.  These guidelines cover practice in the USA but are based on the findings of the LEAP study which was undertaken in the UK at Guy’s and St Thomas’ Trust and King’s College London.  Guidelines in the UK and Europe are currently under review.

“These guidelines also offer several peanut-containing recipes as well as helpful methods to introduce age-appropriate peanut-containing foods to infants who have already eaten other solid foods.  Of note, whole peanuts should be avoided due to the risk of choking.  There are however important provisos included in the guidelines i.e. peanut consumption is not recommended for ‘higher risk’ infants prior to an allergy assessment; an infant at high risk of developing peanut allergy is one with severe eczema and/or egg allergy.

“For high risk infants, the guidelines recommend the introduction of peanut-containing foods as early as 4-6 months if solid foods have already been tolerated and after determining that it is safe to do so i.e. after a clinical assessment and with allergy (skin testing or blood IgE antibody) tests.  With allergy test results available, algorithms are then provided in order that health care professionals safely select and discuss with families the available management options.  High risk infants with low-positive tests i.e. peanut sensitised, can have peanut introduced in an appropriate medical setting.  For infants with a high likelihood of allergy i.e. with a large allergy test, the guidelines recommend that an allergy specialist may decide not to supervise introduction and recommend avoidance, or proceed with a peanut challenge after explaining the risks and benefits to the parents.  The guidelines recommend that moderate risk children – those with mild to moderate eczema who have already started solid foods – do not need an evaluation.  These infants can have peanut-containing foods introduced at home by their parents starting around six months of age.  Parents should however consult with their primary health care provider if they have concerns about this approach.  Low risk children (the majority of the population) with no eczema or egg allergy can be introduced to peanut-containing foods according to the family’s preference, at around 6 months.”

Prof. Anthony Frew, Professor of Allergy & Respiratory Medicine, Royal Sussex County Hospital, said:

“These new US guidelines reflect a landmark British study (New England Journal of Medicine 2016; 374:1435-1443) which showed that introducing peanuts into the diet at an early age dramatically reduces the risk of children becoming allergic to peanuts.  Apart from infants with severe eczema and/or egg allergy, peanut-containing foods (not whole peanuts) should be introduced into the diet around the age of 4-6 months if the child has already had other solid foods.  Avoiding peanuts at this age makes it much more likely that kids will become allergic as they get older.  Parents whose babies have severe eczema or egg allergy should get their peanut allergy status checked out before starting peanuts, but in most cases it will still be possible to give peanuts and take advantage of the protective effects of early introduction of peanuts.

“This approach is already being used in the UK and it is encouraging to see the US experts endorsing the work done in London and adopting it in their official guidance.  Previous UK advice to avoid early introduction of peanuts was based on guesswork.  The British researchers who did the work on which the new guidelines are based noted that children in Israel who were given peanuts as a weaning food had much less nut allergy than those in London who were avoiding peanuts. So they did a formal trial which has confirmed that it is not only safe to introduce peanuts early, but it is actually helpful to do this.”

Prof. Alan Boobis, Professor of Biochemical Pharmacology at Imperial College London, said:

“The toxicological and nutritional implications of the research that forms the basis of these recommendations has been thoroughly reviewed by the UK Committee on the Toxicity of Chemicals in Food, Consumer Products and the Environment and the Scientific Advisory Committee on Nutrition, respectively.  The findings, together with those of even more recent research*, provide further evidence that the previous view that delaying the introduction of allergenic foods decreases the risk of food allergy is incorrect and that if anything, the exclusion or delayed introduction of specific allergenic foods may increase the risk of allergy to the same foods, including peanut.

“However, the implications of these findings, with the possible introduction of solid food prior to 6 months, are complex. Hence, the two committees are currently working together to consider all of the various aspects involved, before finalising their advice to the Department of Health on the overall implications of these recent findings for the infant diet. It is expected that the report will be available in the first half of the year.  In the meantime, parents should follow the advice of the NHS at

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/solid-foods-weaning.aspx”

* AMA. 2016;316(11):1181-1192. doi:10.1001/jama.2016.12623

Michael Walker, member of the European Academy of Allergy and Clinical Immunology said:

“These are cautious, sound guidelines aimed to assist health care professionals in the USA to advise parents on prevention of peanut allergy. The guidelines are based on sound medical research carried out in the UK. For infants with severe eczema or egg allergy or both, and thus most at risk, the guidelines suggest clinical tests before a decision to introduce peanut-containing foods. Infants at less risk, e.g. mild eczema, or no eczema, can receive peanut-containing food from about 6 months, subject to family preferences and cultural norms. This is sensible advice that I am sure UK authorities will wish to think about.

“UK parents should consult their GP, bringing attention to the AAAI guidelines if necessary, before attempting peanut allergy prevention in their infant themselves.”

Prof. Alastair Sutcliffe, Professor of Paediatrics, UCL said:

“Since 1945, if one reads the figures, the importation of peanuts into the UK has gone up year on year, every year. This is one of a number of factors as to why peanut allergy has risen as more of the population have been exposed to them. But peanuts are an excellent healthful food for those non allergic. Due to the potentially catastrophic but rare deaths due to severe peanut allergy there has been immense public concern regarding nut allergies, especially amongst parents and their affected children.

“One advance is the availability of adrenaline auto injectors which have undoubtedly helped on some occasions where a severe anaphylaxis has taken place and one was available, but at significant expense.

“LEAP is a series of world class studies led by Gideon Lask and colleagues. What they have shown and in fact reversed conventional wisdom is if peanuts are introduced very early in the infant’s nutrition the risk of developing the allergy is substantially reduced. This is in a sense the opposite of previous practice where such nuts were thought to be best avoided, despite the fact that nut allergies are rare in Mediterranean countries.

“So the USA leads, as is often the case, where others follow and as a practicing paediatrician I welcome this new guidance.”

* ‘2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States’ is published on the National Institute of Allergy and Infectious Diseases website at: https://www.niaid.nih.gov/diseases-conditions/guidelines-clinicians-and-patients-food-allergy

^ǂ ‘Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases – sponsored expert panel’ by Alkis Togias et al. was published in the Annals of Allergy, Asthma, and Immunology on Thursday 5 January 2017. 

Declared interests

Prof. Alan Boobis: “I currently chair the Committee on Toxicity (COT).  I am also involved with the International Life Sciences Institute, an organisation that provides a precompetitive setting for public-private partnership to address issues of common concern in a number of areas, including nutrition.”

Michael Walker: “Through ‘Michael Walker Consulting Ltd’  I act on a consultancy basis as the Referee Analyst in the BIS funded Government Chemist Programme in LGC where I also manage analytical allergen detection research, https://www.gov.uk/government/organisations/government-chemist I was facilitator for the Safefood publically funded Food Allergy & Food Intolerance Network 2011 – 2015 under contract to LGC, http://safefoodallergy.ning.com/  I have a chemico-legal practice mainly in the Northern Ireland court system, see https://uk.linkedin.com/in/michaelwalkerconsultingltd  for further details of my current and previous roles. I am Chair of FSA in NI Strategic Food Surveillance Committee. Michael Walker Consulting Ltd is a corporate member of Anaphylaxis Campaign, Michael Walker is a member of the European Academy of Allergy & Clinical Immunology.”

Prof. Alastair Sutcliffe: “No conflicts of interest.”

None others received.