Tools for Practice


#197 Early Peanuts for Little Peanuts: The not-so-paltry benefits


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

BOTTOM LINE
Early peanut introduction reduces the risk of developing peanut allergy in high-risk infants from 17% to 3% at five years. Normal risk infants may also benefit. Since 9% of high-risk infants were excluded due to a positive baseline skin prick test (SPT), it may be reasonable to investigate those at highest risk prior to exposure. 


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EVIDENCE
  • Randomized Controlled Trials: 
    • 640 high-risk infants (severe eczema, egg allergy, or both) aged 4-11 months, randomized to consumption (6 g peanuts/week) or avoidance.1 At five years:  
      • Positive oral food challenge to peanuts: 3.2% consumption versus 17.2% avoidance, Number Needed to Treat=8.  
      • Harms: Consumption group underwent baseline food challenge, 7/319 infants reacted, (six required antihistamine, one oral steroids). At five years, one child in avoidance group required epinephrine following oral food challenge. 
      • Limitations: No placebo, infants excluded if SPT >4 mm (9% of infants). 
    • Normal-risk, breastfed infants (n=1,303) aged three months randomized to early introduction of six allergens (example 2 g peanuts/week) or avoidance of allergenic foods before six months.2 
      • At 1-3 years of age, no significant difference in positive oral food challenge: 
        •  Peanuts: 1.2% early versus 2.5% avoidance. 
      • Limitations: Complex protocol led to significant difference in adherence (43% early versus 93% avoidance); excluded infants with peanut sensitization (SPT >0 mm). 
  • Observational study: 
    • Newborns (n=2,124) followed to examine food introduction timing and sensitization.3 Peanut avoidance during first year increased risk for: 
      • Peanut sensitization (SPT >2 mm): Odds Ratio 1.76 (1.07-3.01). 
      • Limitations: Potential recall bias, confirmatory oral food challenges not done.
Context: 
  • Early exposure hypothesis came from the 10x lower risk of peanut allergy among Israeli compared to UK children. Israeli children had greater intake of peanuts during infancy (7.1 g/month versus 0 g/month).4 
  • Large cohort study (10,907 participants) suggested a lower risk of peanut allergy in offspring of non-allergenic mothers who had increased peanut consumption during pregnancy, ≥5 times per weeks versus <1 per month, Odds Ratio 0.31 (0.13-0.75).5 
  • Guidelines recommend not restricting maternal diet or delaying food allergen introduction in high-risk infants.6,7 
October 16, 2017

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Author(s):

  • Christina Korownyk MD CCFP
  • Danielle Perry RN

1. Du Toit G, Roberts G, Sayre PH, et al. N Engl J Med. 2015; 372(9):803-13.

2. Perkin MR, Logan K, Tseng A, et al. N Engl J Med. 2016; 374(18):1733-43.

3. Tran MM, Lefebvre DL, Dai D, et al. Pediatr Allergy Immunol. 2017; 28(5):471-7.

4. Du Toit G, Zadik-Mnuhin G, Amir T, et al. J Allergy Clin Immunol. 2008; 122(5):984-91.

5. Frazier AL, Camargo CJ, Malspeis S, et al. JAMA Pediatr. 2014; 168(2):156-62.

6. Fleischer D, Sicherer S, Greenhawt M, et al. Pediatr Dermatol. 2016; 33(1):103-6.

7. Chan E, Cummings C. Paediatr Child Health. 2013; 18(10):545-54.

Authors do not have any conflicts of interest to declare.