Should we give peanuts to infants?

A new study suggests that giving infants peanuts might reduce their rate of peanut allergy.

This is important because peanut allergy is a difficult problem to manage.

The problem, though, is that news organizations are implying that we’ve found a cure for the high rate of peanut allergy by giving all infants peanuts.  But the study was performed only on infants known to be at high risk, not all healthy infants.

Here’s a statement from the AAP:

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Study: Feeding peanut to high-risk infants may reduce allergy rate

by Scott H. Sicherer, M.D., FAAP

The early introduction of peanut among infants with high-risk atopic disease is a promising approach to prevent the development of peanut allergy, according to a study released in the New England Journal of Medicine on Feb. 23 (www.nejm.org/doi/full/10.1056/NEJMoa1414850).

The Learning Early About Peanut Allergy (LEAP) study randomized 640 infants ages 4 months up to 11 months of age to eat peanut consistently until 5 years of age or to avoid peanut. Families randomized to introduce peanut were instructed to give a soft peanut snack of a smooth peanut butter spread (not whole peanuts or peanut butter, which are potential choking hazards) at least three times per week. The study only included infants at high risk of peanut allergy, having severe eczema, egg allergy or both. All potential participants were allergy tested using skin prick tests, and those with larger test results were excluded from the study, assuming likely peanut allergy.

The first feeding of peanut was under direct medical supervision using a slower graded feeding for infants with positive tests.

Results following supervised feeding at 5 years of age showed that the rate of peanut allergy was 17% in those avoiding peanut compared to 3% in those who ate peanut. Among infants entering the study with negative allergy tests, there was an 86% reduction and for those with small positive allergy tests, there was a 70% reduction in peanut allergy in the group randomized to eat peanut compared to avoidance.

The remarkable reduction in peanut allergy reported by the study suggests that this approach can significantly reduce the rate of peanut allergy in this high-risk group. Various professional organizations, including the Academy, are working on recommendations that follow from these results.

To safely recapitulate the approach used in the study, infants at high risk of peanut allergy could be skin tested; feedings medically supervised as necessary; and for those for whom peanut was tolerated, families instructed on safe approaches to routinely incorporate peanut into the diet. Issues regarding avoidance of peanut for allergic family members would need to be addressed.

There remain several unknowns. The effect of introducing but not routinely incorporating peanut into the diet or ingesting amounts different from those used in the study remain unexplored. Additionally, it is not known if a period of abstinence from peanut would leave some children apt to react to peanut on re-exposure. This latter concern is under evaluation in the LEAP study population by having those on peanut avoid it and then undergo another medically supervised feeding. The results are forthcoming.

In addition, the study did not address healthy infants. The Academy, in a clinical report released in 2008 (Pediatrics. 2008;121:183-191), noted that there was no convincing evidence that delaying introduction of allergenic foods, including those containing peanut protein, has a protective effect on the development of atopic disease. There are no studies to support a specific ideal age of introduction of peanut for healthy children. Furthermore, peanuts and many peanut products are potential choking hazards for very young infants.

A study comparing the dietary approach of Jewish children in Israel to those in the U.K., the latter having a 10-fold higher rate of peanut allergy at school age, noted that U.K. infants generally were not ingesting peanut products. In contrast, for the Israeli children, peanut protein usually in soft snack foods was introduced into the diet at around 7 months of age. Additionally, the median monthly peanut consumption at ages 8-14 months was approximately the equivalent of 2 tablespoons of peanut butter for Israeli children compared to none in those in the U.K.

Although specific studies are lacking, the results of the LEAP study, prior observations and AAP guidance all support the notion that introduction of peanut in the infant diet need not be delayed. It is not envisioned that peanut should become a “first food” for infants. Rather, it could be incorporated into the diets of healthy infants who have tolerated other first foods without difficulty and are developmentally ready to ingest peanut-based foods without choking.

Dr. Sicherer is immediate past chair of the AAP Section on Allergy and Immunology Executive Committee.