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New landmark guidelines for prevention of peanut allergy have been released

Two years ago, Dr. Michael Keiley reviewed a recent landmark study (Learning Early about Peanut (LEAP) Study) which suggested that peanut allergy can be prevented through introduction of peanut-containing foods beginning at 4-6 months of age in high-risk infants. (please see post from Feb. 2015). Prompted by these findings, and in collaboration with 25 professional organizations, federal agencies and patient advocacy groups, recommendations have been added to the National Institute of Allergy and Infectious Diseases (NIAID) food allergy guidelines to specifically address prevention of peanut allergy.

Briefly, the NIAID “Expert Panel” (EP) has added three addendums to the guidelines that address introduction of peanut (see Table 1). The three separate recommendations are to address different groups of infants that have a different risk for peanut allergy.

The first addendum guideline is for infants with severe eczema, egg allergy or both. For this group the EP recommends evaluation for peanut introduction as early as 4-6 months of age. Early introduction is to reduce the risk of developing peanut allergy (Other solid foods should be introduced before peanut containing foods). The EP recommends that these infants be evaluated for peanut allergy to determine whether or not peanut should be introduced. This can be done with a blood test, skin test or both. Figure 1 shows the recommended actions based on the testing results. We should emphasize that in this high risk group, you and your clinician may want to consult with an allergy specialist to determine how to proceed.

The second guideline addendum suggests that infants with mild-to-moderate eczema should have cautious introduction of age-appropriate peanut-containing food around 6 months of age. (Other solid foods should be introduced before peanut containing foods). While this introduction can be done at home, we would recommend you discuss it with your primary care clinician. He/she may recommend an in-office supervised feeding, evaluation, or both.

The third guideline addendum is for infants without eczema or any food allergy. The EP recommends age-appropriate peanut-containing foods can be freely introduced with other solid foods, in accordance with family preferences and cultural practices. However, the EP makes the point that early peanut introduction would probably be more beneficial than later introduction in these lower risk infants.

The participants in the LEAP Study ingested approximately 6 g of peanut butter per week in 3 separate meals. This would be 2 teaspoons of peanut butter 3 times per week.

Caution: Be aware of choking risks. The EP recommends that “whole nuts should not be given to children less than 5 years of age” and that undiluted “peanut butter directly from a spoon or in lumps/gallops should not be given to children less than 4 years of age.” For low risk infants receiving peanut butter at home for the first time, the EP recommends diluting 2 teaspoons of peanut butter with an equal volume of hot water, or pureed tolerated fruit/vegetables. A small part of the peanut serving should be introduced initially on the tip of a spoon, and 10 minutes later, if there is no allergic reaction, the remainder can be given at the infant’s usual eating speed. There should be a 2 hour observation period afterwards. If your child has severe eczema, egg allergy or both do not introduce peanut containing foods without having the child evaluated. If your child has had any previous reaction to peanut, do not offer additional peanut containing foods without having the patient evaluated. When in doubt, talk to your primary care clinician first!

peanutTable

 

peanutGraphic

 
References:
1. Du Toit, G. et. al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl. J. Med 2015;372:803-13.
2. Togias, A. 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. Journal of Allergy and Clinical Immunology. Downloaded from jacionline.org on February 28, 2017.

Intermittent Use of Inhaled Steroids May Prevent Asthma Exacerbations in Preschoolers

Many young people are prone to developing intermittent wheezing, usually with viral respiratory infections that can be potentially severe. This is an important issue this time of year when respiratory viruses become more common.

Various strategies have been used to prevent these episodes, including treating the child with inhaled steroids or the asthma pill Singulair year round. Another strategy is to start the inhaled steroid the moment the patient comes down with a cold and treating for about 7 to 10 days.

There was a recent study in the medical journal Pediatrics that compared these different strategies. They found that all three strategies are about equally effective in reducing significant asthma exacerbations. These treatments all decrease the likelihood of a bad exacerbation by about 30-40%.

It is important to recognize that recurrent wheezing, which may be able to be treated with just "as needed" inhaled steroids, is a different type of asthma from "persistent asthma." Persistent asthma is when the patient has asthma symptoms such as wheezing, chest tightness, shortness of breath, and coughing on a regular basis, usually more than twice a week. This type of asthma almost always requires daily therapy to prevent symptoms and complications.

Another important concept relating to recurrent wheezing is that if patients do not respond to the three strategies described above, they often will do very well by receiving a daily preventive treatment with a "combination inhaler." Combination inhalers contain both an inhaled steroid, as well as a second ingredient called a long-acting bronchodilator. If your child has either symptoms of recurrent wheezing or more persistent asthma, we can discuss the best treatment strategies for your individual case.

Azithromycin May Improve Childhood Wheezing Episodes

Acute wheezing episodes are common in preschool children. Up to 14-26% of preschoolers have recurrent wheezing in the first 6 years. These episodes result in unscheduled visits to clinician offices, urgent care centers, and emergency room departments, and place significant stress on families. New treatment approaches that would lessen the intensity of these episodes would be extremely beneficial. There is recent exciting evidence that the antibiotic azithromycin may improve these wheezing episodes.

There is also clearly a rationale for the use of antibiotics like a azithromycin for the prevention of wheezing episodes. Research shows that viral infections, especially rhinovirus infections, cause many of these episodes, but there is also evidence that bacteria may be involved. Macrolide antibiotics such as azithromycin are known to have both antimicrobial , as well as anti-inflammatory effects.

The results of the CARE Network’s Azithromycin for Preventing the Development of Upper Respiratory Tract Illness Into Lower Respiratory Tract Symptoms in children study (also called the APRIL study) was recently published. 607 children, aged 12 through 71 months with histories of recurrent, severe lower respiratory tract infections with minimal symptoms in between infections/exacerbations, were randomly assigned to receive azithromycin (12 mg/kg per day for 5 days) or placebo early in the course of a respiratory tract illness that the parents /guardians defined as a child’s usual starting point before development of a severe lower respiratory tract infection. The primary outcome variable was the number of treated respiratory tract infections not progressing to a severe lower respiratory tract infection. The main finding is that the azithromycin–treated children experienced a significant lower risk of progressing to a severe lower respiratory tract infection than the placebo–treated children (p=0.04).
A recent study from Denmark shows similar findings. Dr. Jacob Stokholm, and his colleagues conducted a randomized, double–blind, placebo–controlled trial from the Copenhagen Prospective Studies on Asthma in Childhood 2010 cohort. 158 children aged 1-3 years of age with recurrent asthma–like symptoms were randomized to receive azithromycin (10 mg/kg x3 days), or placebo, early in the course of an episode of troublesome lung symptoms lasting at least 3 days. The main finding was that the symptom duration was shortened by 63% in the azithromycin-treated group (p<0.0001).

The authors from the first study suggest that clinicians may consider a trial of azithromycin in children with recurrent intermittent wheeze early during the course of acute episodes, and if effective, to consider repeating such therapy with subsequent illnesses. This may make more sense in children with multiple frequent episodes.

More studies are certainly needed to define how to translate these findings into clinical care. Concerns regarding the development of antibiotic resistance, as well as potential deleterious alterations in bowel flora must also be taken into consideration.

  1. Barcharier, L. et. al. Early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses. A randomized clinical trial. JAMA 2015:314:2034-2044
  2. Cohen, Robyn et. al. Individual benefit versus societal effect of antibiotic prescribing for preschool children with recurrent wheeze. JAMA 2015:314:2027-9.
    3. Stokholm, J. et. al. Azithromycin for episodes with asthma–like symptoms in young children aged 1-3 years: A randomized, double –blind, placebo–controlled trial. Lancet Respiratory Medicine 2016; 4: 19–26.

A New Landmark Study Shows That Early Peanut Introduction Lessens Allergy Risk

Peanut allergy is a severe, potentially life-threatening condition that develops early life and is rarely outgrown. It imposes a significant psychological, as well as economic burden on the family. Its prevalence has quadrupled in the past 13 years. An exciting new study entitled Learning Early About Peanut (LEAP), recently appeared in the New England Journal of Medicine. This study from the United Kingdom shows that early consumption of peanut may dramatically reduce the risk of developing peanut allergy.

In this study, 640 infants, 4-11 months of age and at high risk of peanut allergy (because they had severe eczema, and/or egg allergy), were randomly assigned to consume or avoid peanuts until 5 years of age when their peanut allergy status was determined based on a peanut challenge in a medical environment. The infants had previously passed a peanut challenge in a medical environment with no reaction at the beginning of the study. One group of infants had a negative skin test to peanut, and the other had a borderline test with a wheal (bump) 1-4 mm in diameter. The main finding of the study was that the incidence of peanut allergy was dramatically reduced in the peanut consumption group compared to those who had avoided peanut. In the infants with the negative initial skin test results, the prevalence of peanut allergy at 5 years of age was 13.7% in the avoidance group, and 1.9% in the consumption group. In the group with a borderline allergy skin test reaction, the prevalence of peanut allergy to 5 years of age was 35.3% in the avoidance group, and 10.6% in the consumption group.

The main message of this study was that early introduction of peanut protein may prevent peanut allergy. This represents a dramatic shift in thinking from the past. In 2000, there was a recommendation from the American Academy of Pediatrics to wait until 3 years of age to give peanut products, with the thought that the avoidance might prevent peanut allergy. In 2009, this recommendation was retracted. At this time, there is no official recommendation about when to introduce peanut. However, based on the initial recommendations from the year 2000, later introduction of peanut has become a common practice.

In summary, this is a landmark study that will dramatically change clinical practice, and hopefully help reduce the epidemic of peanut allergy. According to the authors of an accompanying editorial in the same issue of the New England Journal of Medicine, “… the results of this trial are so compelling, and the problem of increasing prevalence of peanut allergy so alarming, new guidelines should be forthcoming very soon.” If you have any questions about how to proceed in light of this new study, please contact one of the providers.

References

  1. Du Toit, D. et. al. Randomized trial of peanut consumption in infants at risk for peanut allergy. The New England Journal of Medicine. Downloaded from nejm.org on February 24, 2015.
  2. Gruchalla, R. et. al. Preventing peanut allergy through early consumption-Ready for prime time? Downloaded from nejm.org on February 24, 2015.