About-turn on peanut exposure

The change in recommendations around infant peanut exposure has been vindicated

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This year’s decision to recommend early exposure to egg and peanuts for Australian infants has been vindicated by a meta-analysis published in JAMA.

For decades parents had been advised to avoid feeding infants peanuts or egg early in life to avoid allergies.

But a growing body of evidence showed that exposure after four months of age actually protected against allergies, prompting the Australasian Society of Clinical Immunology and Allergy (ASCIA) to issue updated guidelines in March.

Now a systematic review of 146 studies lends further support to these changes.

The review found that introducing egg to children at four to six months was associated with a lower incidence of egg allergy.

Similarly, introducing peanuts to infants between four and 11 months reduced the rate of peanut allergies.

The evidence for these effects was of “moderate-certainty” and the size of the reductions was significant, the authors said.

Early exposure could prevent 24 cases of egg allergy in a population of 1000, while 18 cases of peanut allergy in every 1000 people could be avoided, the study found.

These figures depended on egg allergies having a 5.4% prevalence and peanut allergies a 2.5% prevalence in the population.

“These data conflict with previous recommendations to delay the introduction of allergenic foods to the infant diet and suggest that current guidelines that do not advise early introduction of allergenic foods may need to be revised,” the authors said.

Speaking with TMR, Professor Dianne Campbell, chair of allergy and clinical immunology at The Children’s Hospital Westmead, said early introduction of allergens should now be considered the norm for the majority of infants.

“But there will be circumstances – like if you happen to already have a peanut-allergic child in the household or if the child already has food allergy or already has very bad eczema”, where parents shouldn’t introduce the foods without medical advice, she said.

While infants at high risk of food allergies were the most likely to benefit from early exposure, some of them would require a supervised food challenge or screening test before peanuts or egg were introduced.

“But for most other children, including [children with] mild or moderate eczema, there is no recommendation for any specific screening.”

The current “common sense” guidelines suggested that parents started by giving babies a small amount of cooked egg or peanut butter just under the lip, said Professor Campbell.

If all was well, parents could then give babies normal portions two or three times a week, said Professor Campbell.

“We are not suggesting they have two teaspoons on the first day,” she added. “It’s just like you would cautiously introduce many other foods really.”

Introducing one food at a time would help identify an allergy should it occur.

ASCIA is currently in the process of developing a detailed set of guidelines for GPs and general pediatricians, which will provide further information about screening of high-risk infants.

JAMA 2016, 20 September