BOSTON -- Successful implementation of new guidelines on introducing peanuts into an infant's diet will require increased education and awareness, experts said here.
But a number of barriers among clinicians and caregivers still exist to the uptake of these guidelines, they noted in a plenary session at the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting.
In January 2017, a National Institute of Allergy and Infectious Diseases (NIAID) panel released new guidelines stratifying infants into risk categories for introduction to peanuts, in part based on severity of eczema and presence of egg allergy. These were based on results of the 2015 LEAP trial, which found that early introduction of peanuts was safe for most infants.
David Stukus, MD, of Nationwide Children's Hospital in Columbus, Ohio, discussed the importance of "physician buy-in" for these new guidelines to work, and the fact that many physicians may remain skeptical and anxious about them.
Safety is a prime concern, specifically the threat of anaphylaxis, according to Stukus. He pointed out that in the LEAP study, there was no significant difference in serious adverse events between the consumption group and the avoidance group. His own research included a review of 119 infants in his allergy clinic, ages ≤12 months, who had a skin prick on the day of evaluation and severe eczema or egg allergy, classifying classify them as high-risk. Stukus said he found only one case of anaphylaxis, which was in the group with a 3- to 7-mm wheal following skin prick testing.
He also cited prior research from the , which found that of 598 peanut challenges in infants at age 1 year, only two had anaphylaxis.
Ruchi Gupta, MD, of Ann & Robert H. Lurie Children's Hospital in Chicago, pointed out that pediatricians are also simply not administering these tests. A preliminary survey showed that a little under two-thirds of pediatricians they do not counsel parents on introduction of peanut into infant diets, and almost 60% didn't feel confident doing so.
"I keep hearing 'It was just one study [LEAP],' so people are a little cautious when it comes to changes in the guidelines," she said. "They're not being trained and they're not feeling confident and definitely not in the interpretation of diagnostic tests."
Other barriers cited by pediatricians include lack of resources and time to go through the new guidelines. Gupta said getting through them took "a good solid 5 to 6 minutes, but you only have about 10 minutes with patients. For busy pediatricians, it's hard."
Another barrier was ability to assess what would be considered "severe eczema." While Gupta said a clinician can use subjective symptoms to aid in their diagnosis, no existing apps seemed to be "workable" for pediatricians.
"We need to try to figure out something simple to help pediatricians assess the severity of eczema," she said.
Stukus cited prior research that found most parents were not introducing peanuts into their child's diet until they were a 1- to 2-years-old, so "there's a culture we're going to need to change," he said.
He added that while clinician buy-in is important, they did not anticipate how difficult it might be to get buy-in from caregivers, especially parents who already had a child with a peanut allergy. "[Caregivers] said 'You told us not to give them peanuts -- are you saying you could've prevented this all along?'"
Suggesting possible solutions, Stukus said that some parents take their younger child on a "peanut play date" so they can introduce peanuts to the child outside of the household where the older sibling has an allergy.
Gupta said one way to distribute the new guidelines is to include information about introduction to peanuts along with the handouts parents receive on how you introduce solid foods into an infant's diet.
Of course, more data and research are needed, Stukus noted. He said that the ACAAI/American Academy of Allergy, Asthma & Immunology is considering an early peanut introduction registry to help with these efforts.
"Implementation will not be one-size-fits-all," he said.
Primary Source
American College of Allergy, Asthma and Immunology
Stukus DR "Implementation 101: Convincing wary caregivers, colleagues and staff of why early introduction works" ACAAI 2017.
Secondary Source
American College of Allergy, Asthma and Immunology
Gupta R "How to work with primary care providers to identify high-risk children for referral" ACAAI 2017.