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OtherPractice

Benefits of early peanut introduction

Danielle Perry, Adrienne J. Lindblad, Bonnieca Islam and Christina Korownyk
Canadian Family Physician March 2018, 64 (3) 201;
Danielle Perry
Knowledge Translation Expert at the University of Alberta in Edmonton.
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Adrienne J. Lindblad
Knowledge Translation and Evidence Coordinator for the Alberta College of Family Physicians and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.
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Bonnieca Islam
Assistant Professor in the Division of General and Community Pediatrics in the Faculty of Medicine and Dentistry at the University of Alberta.
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Christina Korownyk
Associate Professor in the Department of Family Medicine at the University of Alberta.
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Clinical question

Does early peanut introduction in infancy influence the development of peanut allergy?

Bottom line

Early peanut introduction reduces the risk of peanut allergy in high-risk infants from 17.2% to 3.2% at 5 years. Normal-risk infants might also benefit. As 9% of high-risk infants were excluded owing to a positive skin prick test (SPT) result, it might be reasonable to investigate those at highest risk before exposure.

Evidence

  • An RCT randomized high-risk infants (severe eczema, egg allergy, or both) aged 4 to 11 months (N = 640) to peanut consumption (6 g peanut/week) or avoidance.1

    • -At 5 years, there were positive oral food challenge results for peanut in 3.2% of the consumption versus 17.2% of the avoidance group (number needed to treat of 8).

    • -Harms included 7 of 319 infants reacting to a baseline food challenge in the consumption group (6 required antihistamines, 1 oral steroids). At 5 years, 1 child in the avoidance group required epinephrine after the oral food challenge.

    • -Limitations included no placebo group and infants were excluded if their SPT results were greater than 4 mm (9% of infants).

  • Another RCT randomized normal-risk breastfed infants (N = 1303) aged 3 months to early introduction of 6 allergens (eg, 2 g peanut/week) or avoidance of allergenic foods before 6 months.2

    • -At 1 to 3 years of age, there was no significant difference in positive oral food challenge results for peanuts (1.2% in early group vs 2.5% in avoidance group).

    • -Limitations included a complex protocol that led to statistically significant differences in adherence (avoidance, 93%; early introduction, 43%), and exclusion of infants with peanut sensitization (SPT results > 0 mm).

  • An observational study followed newborns (N = 2124) to examine food introduction timing and sensitization.3 Peanut avoidance during the first year increased risk of sensitization (SPT results > 2 mm) (odds ratio of 1.76; 95% CI 1.07 to 3.01).

    • -Limitations included potential recall bias, and confirmatory oral food challenges were not done.

Context

  • The early exposure hypothesis came from the 10-fold lower risk of peanut allergy among Israeli children compared with UK children despite greater intake of peanuts during infancy (7.1 g/month vs 0 g/month).4

  • A large cohort study (N = 10 907) suggested lower odds of peanut allergy in offspring of nonallergic mothers with increased peanut consumption during pregnancy of 5 times per week or more versus less than once per month (odds ratio of 0.31; 95% CI 0.13 to 0.75).5

Implementation

Infants with severe eczema or egg allergy are at highest risk, requiring allergy testing preferably by SPT before peanut consumption.6 Peanut-specific blood immunoglobulin (Ig) E can also be measured, but anything above a level of 0.1 kUA/L does not rule out allergy. About 21% of infants with an IgE level below 0.35 kUA/L (generally considered negative) will have a positive oral food challenge result.7 Infants with mild or moderate eczema or those without eczema or other food allergies do not require further evaluation.6 Blood IgE testing for multiple foods is not recommended owing to false-positive results. Guidelines and recipes for introducing peanuts are available.6

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2018 à la page e106.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
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    2. Roberts G,
    3. Sayre PH,
    4. Bahnson HT,
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    6. Santos AF,
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    . Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015;372(9):803-13. Erratum in: N Engl J Med 2016;375(4):398.
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    1. Perkin MR,
    2. Logan K,
    3. Tseng A,
    4. Raji B,
    5. Ayis S,
    6. Peacock J,
    7. et al
    . Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med 2016;374(18):1733-43.
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    1. Tran MM,
    2. Lefebvre DL,
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    . Timing of food introduction and development of food sensitization in a prospective birth cohort. Pediatr Allergy Immunol 2017;28(5):471-7.
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    1. Du Toit G,
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    5. Maleki SJ,
    6. Fisher HR,
    7. et al
    . Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122(5):984-91.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Frazier AL,
    2. Camargo CA Jr.,
    3. Malspeis S,
    4. Willett WC,
    5. Young MC
    . Prospective study of peripregnancy consumption of peanuts or tree nuts by mothers and the risk of peanut or tree nut allergy in their offspring. JAMA Pediatr 2014;168(2):156-62.
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    1. Togias A,
    2. Cooper SF,
    3. Acebal ML,
    4. Assa’ad A,
    5. Baker JR Jr.,
    6. Beck LA,
    7. et al
    . 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. Ann Allergy Asthma Immunol 2017;118(2):166-73.e7.
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  7. 7.↵
    1. Koplin JJ,
    2. Peters RL,
    3. Dharmage SC,
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    5. Tang MLK,
    6. Ponsonby AL,
    7. et al
    . Understanding the feasibility and implications of implementing early peanut introduction for prevention of peanut allergy. J Allergy Clin Immunol 2016;138(4):1131-141.e2.
    OpenUrl
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Canadian Family Physician: 64 (3)
Canadian Family Physician
Vol. 64, Issue 3
1 Mar 2018
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Benefits of early peanut introduction
Danielle Perry, Adrienne J. Lindblad, Bonnieca Islam, Christina Korownyk
Canadian Family Physician Mar 2018, 64 (3) 201;

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Danielle Perry, Adrienne J. Lindblad, Bonnieca Islam, Christina Korownyk
Canadian Family Physician Mar 2018, 64 (3) 201;
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