Ask the Allergist: What Parents Need to Know About Peanut Allergy Guidelines
Q: The National Institute of Allergy and Infectious Diseases (NIAID) releases peanut allergy prevention guidelines earlier this year. What do parents need to know before introducing peanut to infants?
Matthew Greenhawt, MD: If you look at the history of peanut allergy, for a period of time the guidelines said at-risk infants and young children should avoid peanut early in life. Now, we have research – specifically the LEAP and EAT studies – that shows giving peanut-containing products early within a specific time frame is associated with a much better outcome in terms of reducing risk of developing a peanut allergy.
The take-home message is this: Primary care physicians and allergists now encourage parents to include peanut in their infant’s diet. It should not be the first solid food given – that should remain a grain cereal, fruit or vegetable so the child can get used to the taste, texture and skill of eating solid foods. But once the child has tolerated a few solid foods, it is time to incorporate peanut.
I was part of the NIAID-sponsored expert panel charged with developing and translating the revised guidelines into practice. The best part about the revised guidelines is the potential to prevent tens of thousands of peanut allergy cases each year, which would be fantastic.
Q: How do you determine when to introduce peanut?
Dr. Greenhawt: The guidelines recommend the following:
- Infants with severe eczema, egg allergy or both are at high risk for peanut allergy and should be given peanut-containing foods starting as early as between 4-6 months of age to reduce the risk of developing peanut allergy. The infants should first see a board-certified allergist for peanut allergy testing to determine if peanut can be safely introduced. For some infants, it may be recommended the introduction of peanut be done in an allergist’s office.
- Infants with mild or moderate eczema should have peanut-containing foods introduced into their diets around 6 months of age to reduce the risk of developing peanut allergy. These children do not need to first see a specialist and can have peanut-containing foods introduced at home once they are tolerating a few solid foods.
- Infants without any eczema symptoms or egg allergy can have peanut-containing foods freely introduced into their diets together with other solid foods, in accordance with family preferences and cultural practice. This would also typically be around 6 months of life, once the children are tolerating a few solid foods. These children also do not need to first see a specialist and can have peanut-containing foods introduced at home.
Q: What types of peanut-containing foods should be given to infants?
Dr. Greenhawt: Certainly not whole peanuts – these are choking hazards until about age 4. You can use peanut butter that’s thinned with breast milk, formula or hot water. You can use Bamba, a commercial peanut-containing puff. The guidelines offer several suggestions, including a peanut soup using ground peanut.
Introducing peanut is not something you should do on a day where your child has a little cold, or a cough – you really want the child in good health, so that any allergy symptoms are not affected by the ingestion of peanut. And you should do this early in the day – not right before bed.
The guidelines recommend 2 grams of peanut given three times per week, but if you don’t give exactly that amount, or if it’s not three times per week, or if the child doesn’t like it one day, don’t worry. The exact timing and quantity of how often you give peanut is not as critical as being patient and persistent in trying to incorporate peanut-containing foods into the diet regularly.
Matthew Greenhawt, MD, FACAAI, is a board-certified allergist and immunologist and assistant professor of pediatric allergy at Children’s Hospital Colorado. He is chair of the Food Allergy Committee for the American College of Allergy, Asthma & Immunology (ACAAI).
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