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


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


BOTTOM LINE
RÉSULTAT FINAL
Early peanut introduction reduces the risk of developing peanut allergy in high-risk infants from 17% to 3% at five yearsNormal 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
DONNÉES PROBANTES
  • 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 challenge7/319 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 (9of 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. 
      • LimitationsComplex 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). 
      • LimitationsPotential recall biasconfirmatory 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 


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Author(s)
Auteur(s)
  • Danielle Perry RN
  • Christina Korownyk MD CCFP

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.