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Roberts G, Bahnson HT, Du Toit G, O'Rourke C, Sever ML, Brittain E, Plaut M, Lack G. Defining the window of opportunity and target populations to prevent peanut allergy. J Allergy Clin Immunol 2023; 151:1329-1336. [PMID: 36521802 PMCID: PMC10689252 DOI: 10.1016/j.jaci.2022.09.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Peanut allergy affects 1% to 2% of European children. Early introduction of peanut into the diet reduces allergy in high-risk infants. OBJECTIVE We aimed to determine the optimal target populations and timing of introduction of peanut products to prevent peanut allergy in the general population. METHODS Data from the Enquiring About Tolerance (EAT; n = 1303; normal risk; 3-year follow-up; ISRCTN14254740) and Learning Early About Peanut Allergy study (LEAP; n = 640; high risk; 5-year follow-up; NCT00329784) randomized controlled trials plus the Peanut Allergy Sensitization (PAS; n = 194; low and very high risk; 5-year follow-up) observational study were used to model the intervention in a general population. Peanut allergy was defined by blinded peanut challenge or diagnostic skin prick test result. RESULTS Targeting only the highest-risk infants with severe eczema reduced the population disease burden by only 4.6%. Greatest reductions in peanut allergy were seen when the intervention was targeted only to the larger but lower-risk groups. A 77% reduction in peanut allergy was estimated when peanut was introduced to the diet of all infants, at 4 months with eczema, and at 6 months without eczema. The estimated reduction in peanut allergy diminished with every month of delayed introduction. If introduction was delayed to 12 months, peanut allergy was only reduced by 33%. CONCLUSIONS The preventive benefit of early introduction of peanut products into the diet decreases as age at introduction increases. In countries where peanut allergy is a public health concern, health care professionals should help parents introduce peanut products into their infants' diet at 4 to 6 months of life.
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Affiliation(s)
- Graham Roberts
- University of Southampton and Southampton NIHR Biomedical Research Centre, Southampton, and the David Hide Centre, Isle of Wight, United Kingdom
| | - Henry T Bahnson
- Benaroya Research Institute and the Immune Tolerance Network, Seattle, Wash
| | - George Du Toit
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College, and the Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Colin O'Rourke
- Benaroya Research Institute and the Immune Tolerance Network, Seattle, Wash
| | - Michelle L Sever
- Rho Federal Systems Division, Durham, and PPD Government and Public Health Services, Wilmington, NC
| | - Erica Brittain
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Gideon Lack
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College, and the Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
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Logan K, Bahnson HT, Ylescupidez A, Beyer K, Bellach J, Campbell DE, Craven J, Du Toit G, Clare Mills EN, Perkin MR, Roberts G, van Ree R, Lack G. Early introduction of peanut reduces peanut allergy across risk groups in pooled and causal inference analyses. Allergy 2022; 78:1307-1318. [PMID: 36435990 DOI: 10.1111/all.15597] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Learning Early About Peanut allergy (LEAP) study has shown the effectiveness of early peanut introduction in prevention of peanut allergy (PA). In the Enquiring About Tolerance (EAT) study, a statistically significant reduction in PA was present only in per-protocol (PP) analyses, which can be subject to bias. OBJECTIVE The aim of this study was to combine individual-level data from the LEAP and EAT trials and provide robust evidence on the bias-corrected, causal effect of early peanut introduction. METHOD As part of the European Union-funded iFAAM project, this pooled analysis of individual pediatric patient data combines and compares effectiveness and efficacy estimates of oral tolerance induction among different risk strata and analysis methods. RESULTS An intention-to-treat (ITT) analysis of pooled data showed a 75% reduction in PA (p < .0001) among children randomized to consume peanut from early infancy. A protective effect was present across all eczema severity groups, irrespective of enrollment sensitization to peanut, and across different ethnicities. Earlier age of introduction was associated with improved effectiveness of the intervention. In the pooled PP analysis, peanut consumption reduced the risk of PA by 98% (p < .0001). A causal inference analysis confirmed the strong PP effect (89% average treatment effect relative risk reduction p < .0001). A multivariable causal inference analysis approach estimated a large (100%) reduction in PA in children without eczema (p = .004). CONCLUSION We demonstrate a significant reduction in PA with early peanut introduction in a large group of pooled, randomized participants. This significant reduction was demonstrated across all risk subgroups, including children with no eczema. Furthermore, our results point to increased efficacy of the intervention with earlier age of introduction.
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Affiliation(s)
- Kirsty Logan
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Henry T Bahnson
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Washington, USA
| | - Alyssa Ylescupidez
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Washington, USA
| | | | | | - Dianne E Campbell
- Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Joanna Craven
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - George Du Toit
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - E N Clare Mills
- School of Biological Sciences, Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, Manchester Institute of Biotechnology, University of Manchester, Manchester, UK
| | - Michael R Perkin
- The Population Health Research Institute, St George's University of London, London, UK
| | - Graham Roberts
- University of Southampton and Southampton NIHR Biomedical Research Centre, Southampton, UK
| | - Ronald van Ree
- Departments of Experimental Immunology and of Otorhinolaryngology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Gideon Lack
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
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Abrams EM, Shaker M, Greenhawt M, Mack DP. International Peanut Allergy Prevention, 6 Years After the Learning Early About Peanut Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:71-77. [PMID: 34311123 DOI: 10.1016/j.jaip.2021.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/26/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
Six years ago, the Learning Early About Peanut (LEAP) trial findings helped fundamentally shift the paradigm of peanut allergy prevention. Although the results of LEAP are well accepted, policy-makers, caregivers, and clinicians struggle with how best to implement and apply the study's key findings in clinical practice. Differences in guidelines highlight issues related to peanut allergy prevention implementation, including caregiver acceptability, cost, fidelity, feasibility, appropriateness, and adoption. The goals of this rostrum are to review how the LEAP study has informed international peanut allergy prevention policy, as well as to review the strengths and ongoing controversies in peanut allergy prevention implementation.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth, Hanover, NH
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Halton Pediatric Allergy, Burlington, Ontario, Canada
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Keet C, Pistiner M, Plesa M, Szelag D, Shreffler W, Wood R, Dunlop J, Peng R, Dantzer J, Togias A. Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy. J Allergy Clin Immunol 2021; 147:984-991.e5. [PMID: 33483153 PMCID: PMC8462937 DOI: 10.1016/j.jaci.2020.11.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Corinne Keet
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
| | - Michael Pistiner
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Mihaela Plesa
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Daria Szelag
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Wayne Shreffler
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Robert Wood
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Joan Dunlop
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Roger Peng
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Jennifer Dantzer
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Alkis Togias
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Sicherer SH, Wood RA, Perry TT, Jones SM, Leung DYM, Henning AK, Dawson P, Burks AW, Lindblad R, Sampson HA. Clinical factors associated with peanut allergy in a high-risk infant cohort. Allergy 2019; 74:2199-2211. [PMID: 31120555 PMCID: PMC6817376 DOI: 10.1111/all.13920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/23/2019] [Accepted: 04/27/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Prognostication of peanut allergy (PNA) is relevant for early interventions. We aimed to determine baseline parameters associated with the development of PNA in 3- to 15-month-olds with likely egg and/or milk allergy, and/or moderate to severe atopic dermatitis (AD) and a positive egg/milk skin prick test (SPT), but no known PNA. METHODS The primary endpoint was PNA [confirmed/convincing diagnosis or last classified as serologic PNA (<2 years, ≥5 kUA/L, otherwise ≥14 kUA/L, peanut IgE)] among 511 participants (median follow-up, 7.3 years). Associations were explored with univariate logistic regression; factors with P < 0.15 were analyzed by stepwise multiple logistic regression, using data stratified by PNA status and randomly assigned to development and validation datasets. RESULTS 205/511 (40.1%) had PNA. Univariate factors associated with PNA (P < 0.01) included increased AD severity, larger egg and peanut SPT, greater egg, milk, peanut, Ara h1-h3 IgE, higher peanut IgG and IgG4, and increased pregnancy peanut consumption. P-values were between 0.01 and 0.05 for younger age, non-white race, lack of breastfeeding, and increased lactation peanut consumption. Using a development dataset, the multivariate model identified younger age at enrollment, greater peanut and Ara h2 IgE, and lack of breastfeeding as prognosticators. The final model predicted 79% in the development and 75% in the validation dataset (AUC = 0.83 for both). Models using stricter or less strict PNA criteria both found Ara h2 as predictive. CONCLUSIONS Key factors associated with PNA in this high-risk population included lack of breastfeeding, age, and greater Ara h2 and peanut-specific IgE, which can be used to prognosticate outcomes.
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Affiliation(s)
- Scott H. Sicherer
- Department of Pediatrics, Icahn School of Medicine at Mount
Sinai, New York, NY
| | - Robert A. Wood
- Department of Pediatrics, Johns Hopkins University School
of Medicine, Baltimore, MD
| | - Tamara T. Perry
- Department of Pediatrics, University of Arkansas for
Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
| | - Stacie M. Jones
- Department of Pediatrics, University of Arkansas for
Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
| | | | | | | | - A. Wesley Burks
- Department of Pediatrics, University of North Carolina,
Chapel Hill, NC
| | | | - Hugh A. Sampson
- Department of Pediatrics, Icahn School of Medicine at Mount
Sinai, New York, NY
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Castenmiller J, de Henauw S, Hirsch-Ernst KI, Kearney J, Knutsen HK, Maciuk A, Mangelsdorf I, McArdle HJ, Naska A, Pelaez C, Pentieva K, Siani A, Thies F, Tsabouri S, Vinceti M, Bresson JL, Fewtrell M, Kersting M, Przyrembel H, Dumas C, Titz A, Turck D. Appropriate age range for introduction of complementary feeding into an infant's diet. EFSA J 2019; 17:e05780. [PMID: 32626427 PMCID: PMC7009265 DOI: 10.2903/j.efsa.2019.5780] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.
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Satitsuksanoa P, Jansen K, Głobińska A, van de Veen W, Akdis M. Regulatory Immune Mechanisms in Tolerance to Food Allergy. Front Immunol 2018; 9:2939. [PMID: 30619299 PMCID: PMC6299021 DOI: 10.3389/fimmu.2018.02939] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022] Open
Abstract
Oral tolerance can develop after frequent exposure to food allergens. Upon ingestion, food is digested into small protein fragments in the gastrointestinal tract. Small food particles are later absorbed into the human body. Interestingly, some of these ingested food proteins can cause allergic immune responses, which can lead to food allergy. So far it has not been completely elucidated how these proteins become immunogenic and cause food allergies. In contrast, oral tolerance helps to prevent the pathologic reactions against different types of food antigens from animal or plant origin. Tolerance to food is mainly acquired by dendritic cells, epithelial cells in the gut, and the gut microbiome. A subset of CD103+ DCs is capable of inducing T regulatory cells (Treg cells) that express anti-inflammatory cytokines. Anergic T cells also contribute to oral tolerance, by reducing the number of effector cells. Similar to Treg cells, B regulatory cells (Breg cells) suppress effector T cells and contribute to the immune tolerance to food allergens. Furthermore, the human microbiome is an essential mediator in the induction of oral tolerance or food allergy. In this review, we outline the current understanding of regulatory immune mechanisms in oral tolerance. The biological changes reflecting early consequences of immune stimulation with food allergens should provide useful information for the development of novel therapeutic treatments.
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