Guidelines for the prevention of peanut allergy in the United States: From development to prospective outcomes

Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy

BACKGROUND

Whether to screen high-risk groups before early peanut introduction is controversial.

OBJECTIVE

We sought to determine the risk of peanut allergy (PA) before peanut introduction for infants with (1) moderate-severe eczema, (2) another food allergy (FA), and/or (3) a first-degree relative with peanut allergy (FH).

METHODS

Infants aged 4 to 11 months with no history of peanut ingestion, testing, or reaction and at least 1 of the above risk factors received peanut skin prick test and, depending on skin prick test wheal size, oral food challenge or observed feeding.

RESULTS

A total of 321 subjects completed the enrollment visit (median age, 7.2 months; 58% males); 78 had eczema only, 11 FA only, 107 FH only, and 125 had multiple risk factors. Overall, 18% of 195 with eczema, 19% of 59 with FA, and 4% of 201 with FH had PA. Only 1% of 115 with FH and no eczema had PA. Among those with eczema, older age (odds ratio [OR], 1.3; 95% CI, 1.04-1.68 per month), higher SCORing Atopic Dermatitis score (OR, 1.19; 95% CI, 1.06-1.34 per 5 points), black (OR, 5.79; 95% CI, 1.92-17.4 compared with white), or Asian race (OR, 6.98; 95% CI, 1.92-25.44) and suspected or diagnosed other FA (OR, 3.98; 95% CI, 1.62-9.80) were associated with PA.

CONCLUSIONS

PA is common in infants with moderate-severe eczema, whereas FH without eczema is not a major risk factor, suggesting screening only in those with significant eczema. Even within the first year of life, introduction at later ages is associated with a higher risk of PA among those with eczema, supporting introduction of peanut as early as possible.

How to prevent food allergy during infancy: what has changed since 2013?

PURPOSE OF REVIEW

The purpose of this review is to summarize recent studies and emerging consensus guidelines regarding food allergy prevention in infants of the past 5 years.

RECENT FINDINGS

Prior to 2013, the general consensus regarding prevention of food allergy in infants was to recommend delayed introduction or complete avoidance of commonly allergenic foods, such as milk, egg and peanut. However, in the past 5 years, several landmark studies have been conducted, particularly with peanut. The results of these studies have led to a paradigm shift from recommending delayed introduction to early introduction and frequent feeding of highly allergenic foods such as peanut, with hopes of achieving primary and secondary prevention of food allergy in infants.

SUMMARY

Recent clinical trials have demonstrated that early introduction and frequent feeding, rather than delayed introduction or complete avoidance, of commonly allergenic foods plays a critical role in preventing food allergy in infants. More studies are required to risk-stratify infants by personal and family atopic history to tailor guidelines for groups with inherently different risks. The universal acceptance of the guidelines and their application outcome are still to be determined.