Children’s Health

The recommendations regarding when peanuts should be introduced into children's diet have recently changed. No surprise then that some people are still confused about this subject and are asking for more information. So, when is the best time to introduce peanuts into a child's diet? According to the American Academy of Pediatrics and the National Institute of Allergy and Infectious diseases, it is good to start giving peanuts to infants before six months of age. This measure is likely to decrease the incidence of peanuts allergy the most in infants who are at higher risk for this condition. Finally, it is essential to emphasize that the initiation of peanuts in your child's diet should always be discussed with your pediatrician or family practitioner before putting it into action. In the article, I will give you background information about peanut allergy, explain why the dietary guidelines regarding that protein changed, and provide you with evidence for that change. Then, finely, I will tell you what actions doctors may need to take depending on the levels of risk your baby has for peanut allergy. Breast feeding is believed to provide some protection from allergies. You can also read my article about other benefits of breastmilk. Peanut allergy - general information Different sources estimate that between 1% and 2% of children suffer from peanut allergies. In addition, the highest incidence is observed in developed countries such as the USA, Australia, and Canada. Peanut allergy symptoms may be severe, and the condition is usually lifelong. The strongest risk factors for the development of this allergy are severe atopic dermatitis and egg allergy. Also, the timing of the first consumption or exposure to peanuts may play a significant role. The latter we will discuss in more detail below. Most pathological reactions to peanuts are mediated by "allergenic Immunoglobulins (IgE)." The milder symptoms may be limited locally to the mouth or throat. The systemic response may involve skin swelling and rash. Some individuals will develop severe and life-threatening allergic reactions known under the medical term "anaphylactic reactions." That severe systemic reaction may include difficulty in breathing, extremely low blood pressure, systemic rashes, and gastrointestinal symptoms. There is evidence that many individuals who developed life-threatening reactions, had milder responses to peanuts earlier. Therefore, having a history of milder reactions to peanuts does not exclude the possibility of anaphylaxis later on in life. Treatment of peanuts allergy includes avoiding this allergen (peanut protein), appropriate medical treatment of allergic reactions, carrying Epi-pen, and potentially oral desensitization therapy to increase tolerance to peanuts. I will not expand on those therapies as I want to focus here on the importance of the early introduction of peanuts in the diet to prevent peanut allergy altogether. History of peanut dietary guidelines Ever since peanut allergy was recognized as a serious medical condition, doctors have thought about ways to prevent it or lessen its severity. Historically, one of the recommendations to achieve that goal was a suggestion to delay the introduction of peanuts into children's diet until three years of age. But unfortunately, this solution was not based on any factual data but was only a proliferated opinion by so-called experts. With time we gathered some evidence that earlier introduction of peanuts to the diet (at 4-6 months of age) may actually decrease the incidence of this condition. After careful analysis of scientific evidence, two American organizations (the American Academy of Pediatrics - AAP and the National Institute of Allergy and Infectious Diseases - Link Here) announced the new recommendations. The updated guidelines say that children at risk will benefit from introducing peanuts into their diet at or before six months of age. Additionally, this dietary intervention must be implemented safely (see below for suggested protocols for medical professionals). What was the evidence for changing peanut dietary recommendations? There are two landmark studies published recently on this subject. The first one was published in the New England Journal of Medicine in 2015. Its title is: "Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy." The scientists studied a population of 640 infants with a history of severe eczema, egg allergy, or both. You may ask why children in the study had to have a history of these two conditions? It is easier to study something in people if the population under observation is likely to develop a condition in high numbers. That way, one needs fewer subjects in the study to prove the clinical and statistical differences to prove the researchers' hypothesis. Since children who have severe eczema or egg allergies are more likely to develop peanut allergies, it is logical and more practical to use such children in a research trial. The children aged 4 months to 11 months were assigned randomly (by chance) into two study groups. One group was advised to avoid peanuts in their diet until 60 months of age. And another group included children who were supposed to regularly consume peanuts or their equivalents. Significantly, each group was subdivided into smaller subgroups based on their initial sensitivity to peanuts as measured by their response to the peanut skin-prick test. The outcome of interest to the scientists was the proportion of children with peanut allergy in each group and, of course, comparisons between the two groups (no exposure group versus consumption of peanuts group). In the end, the evaluation for the presence of peanut allergy was conducted by performing an oral food challenge. The results were staggering: 13.7% of children had peanut allergy in the avoidance group versus only 1.9% of children had that allergy in the consumption group. It means an 86% reduction in the frequency of peanut allergy in this studied population of children. The same positive effects of early peanut introduction were observed in the population with positive skin prick allergic tests at the beginning of the study. In that subgroup, 35% of the children in the avoidance group developed a peanut allergy, and 10% of children developed allergies in the consumption group. So again, the early consumption of peanuts resulted in a 70% risk reduction for the allergy. The second study I want to present to you was a follow-up study conducted on the same population of children that I have just described above. The researchers wanted to see what happens to the positive effect of early peanut introduction in children's diet if they stop consuming peanuts for the subsequent 12 months. Therefore, researchers collected results at around 72 months of life (as you may remember initial study got completed at 60 months). The results were published again in the New England Journal of Medicine, but one year later, in April 2016. The scientific article was titled: "Effect of Avoidance on Peanut Allergy after Early Peanut Consumption." The study concluded that 12 month period of subsequent peanut avoidance was not associated with an increase in the prevalence of peanut allergies. Therefore, we can consider this positive effect of peanut exposure early in life as somewhat durable. But, of course, it would be premature to speculate how long it would last if an individual completely stopped consuming peanuts. Fortunately, such a situation would be unlikely as peanuts are widely present in our lives. Moreover, their small particles are found in many food products, whether wontedly or not. The lesson for you should not be to start giving peanuts to your child on your own. You need to know how to do it safely, and you need to find out from your medical provider if your child needs an evaluation first. Additionally, caution is warranted because peanuts and peanut butter may create a choking hazard for your infant. You have to learn how to implement this diet recommendation without harming your little one. Responsible way of introducing peanuts into your child's diet Before you start giving peanuts to your child, please consult your doctor. Each child will have individual circumstances, and it is impossible to analyze them here. The protocol presented below is a simplified version of how most doctors would do this dietary introduction. Still, there are additional modifications that may be needed for each child. In general, we can divide all children we want to give peanuts into three groups: Low-risk infants - those children do not have any history of eczema or food allergyAt-Risk infants - those children have a history of mild or moderate eczemaHigh-Risk infants - who have a history of severe eczema or egg allergy Most infants (about 85%) belong to the low-risk group. If these children are already tolerating solid foods, the family may introduce age-appropriate peanut-containing food at home at six months or later, without additional evaluation for an allergy. About 12%-13% of infants will qualify as "at-risk children" (they have mild eczema or egg allergy). Usually, after reassuring parents that their infant has "only" mild eczema or food allergy, the introduction of peanuts may also take place at home. However, for some parents who are very anxious about this, medical providers can offer to supervise that first oral feeding in their office. The appropriate age would also be at around six months or later. Only less than 2% of all children are in the high-risk group (history of severe eczema or allergy). For this group, a special evaluation before peanut introduction is indicated, and it should occur early. To achieve the most significant effect in preventing peanut allergy in this group, starting peanuts as early as 4 months is recommended. Most general practitioners will refer such children to an allergist for an evaluation. An allergist will likely perform skin prick testing for peanut allergy with or without an additional blood test measuring specific IgE. Depending on the results of skin prick testing, three recommendations are possible: Home dietary introduction if all results are negative or extremely mildSupervised in the clinic dietary introduction - in cases of mild to moderate reactions after skin prick testAvoidance of peanuts in cases where severe allergy to peanuts is detected What issues should parents discuss with their doctors regarding these recommendations? The recommendation is to provide 6-7 grams of peanut protein per week divided into three or more servings. However, peanuts are also a choking hazard, and it may be challenging to do it safely. Some countries have special preparations (Bamba in Israel). In the USA, people can dilute peanut butter with warm water or milk to achieve the proper texture. The other way to accomplish that is to create a paste by grinding peanuts in a blender with an adequate amount of water or milk or mixing the ground peanuts with yogurt. We can also mix peanut flour with yogurt or applesauce. Defining what constitutes mild or moderate eczema versus severe eczema may be challenging or subjective. Therefore, an evidence-based approach to this subject is needed. Of course, doctors should also be mindful of parental anxiety levels and adjust their approach to that. In cases of disagreement, doctors can offer to perform the first oral feeding with peanuts-containing products in their clinic. Suppose a child resides in a small city or rural area. In that case, access to specialized evaluations by an allergist may be difficult. The option of doing only an IgE testing and offering clinic supervised first oral feeding may need to be considered so early introduction of peanuts is not delayed for too long. Again, these difficult decisions will depend on many other factors. The early introduction of peanuts contradicts WHO guidelines to breastfeed infants for the first six months exclusively. There is no current study comparing the introduction of peanuts at 4 months of age versus at 6 months. On the other hand, it is believed that an earlier introduction will have a better preventive effect. This issue should be resolved by having honest discussions about facts and beliefs between parents and their pediatrician or allergist. We can always modify our approach based on priorities and expected outcomes for each family. Disclaimer: This article is only for general information purposes. It should not be viewed as any medical advice. There is always a chance that information here may be inaccurate. It would be best if you always discussed all health-related matters with your doctor before making any decisions that may affect yours or your family members' health.