The importance of early peanut ingestion in the prevention of peanut allergy

ABSTRACT

Introduction: Peanut allergy appears to have increased in prevalence, is often severe and is typically life-long. Therefore, reducing its incidence through a primary prevention strategy is a priority. Guidelines on peanut introduction have evolved with time and given evidence of peanut allergy risk reduction with early infant ingestion exposure, the current US advice promotes early introduction for infants, particularly targeting those at highest risk.

Areas covered: This article describes the evolution of peanut introduction guidelines in infants in the US, as shaped by key research over the last 20–30 years and culminates in the landmark LEAP study. It also compares and contrasts current iterations of peanut introduction guidelines in infants globally. Finally, the early successes and barriers of implementation of early peanut introduction guidelines are discussed. We included literature from original articles, reviews, and consensus guidelines found in database searches through December 2018.

Expert commentary: LEAP guideline implementation has proven to be successful, in the study setting, in decreasing the incidence of peanut allergy. However, its implementation in the community has been met with obstacles including low awareness among stakeholders, and access to testing when needed.

KEYWORDS:

• Peanut
• prevention
• food allergy
• peanut allergy
• guidelines

Article highlights

• The approach to food allergy prevention, specifically for peanut, has significantly changed over the past two decades from advice to delay introduction for 3 years, to deliberate early and frequent feedings of peanut in high-risk infants as early as 4–6 months of age to prevent peanut allergy.

• The LEAP study demonstrated that 4–11 month-old infants with egg allergy and/or severe eczema, had reduced risk of peanut allergy when fed peanut early and consistently until the age of 5 yrs. The tolerance to peanut persisted when peanut was subsequently removed from the diet for a year.

• The remarkable success of the LEAP study leads to new consensus guidelines for peanut allergy prevention published by NIAID and adopted by the American Academy of Pediatrics in 2017. The guidelines essentially mimic the LEAP study approach for infants at high risk for peanut allergy and also include guidance on early introduction for those not at high risk.

• While many clinicians and parents have embraced the guidelines, there are many barriers to implementation that are yet to be adequately addressed, and long term outcomes of applying the Guidelines in the community are needed.

• International guidelines have some differences in recommendations regarding timing of peanut introduction, the need for pre-testing for sensitization, and whether and how to stratify risks.

Declaration of interest

S Sicherer receives grant support to his institutions from the National Institute of Allergy and Infectious Diseases (NIAID), Food Allergy Research and Education and HAL Allergy; royalties from UpToDate and Johns Hopkins University Press; honorarium from the American Academy of Allergy, Asthma and Immunology for his role as Deputy Editor of the Journal of Allergy and Clinical Immunology; and has served on the NIAID expert panel for peanut allergy prevention guidelines. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.