New Guidelines: Early Introduction of Peanut to Prevent Peanut Allergy
Jan 05, 2017
Why the New Recommendations?
Prior recommendations for parents and pediatricians were to avoid introduction of peanut until after 3 years of age. However, cumulative evidence has demonstrated that early feeding is associated with less peanut allergy. In 2015, strong evidence emerged from the LEAP (Learning Early about Peanut Allergy) study that early introduction prevents the development of peanut allergy in many children. Because of the LEAP and a few additional studies, an expert panel of physicians, scientists, and public health experts have created new guidelines for early introduction of peanut to infants.
New Guidelines: When and How to Introduce
Given the large potential beneficial impact on a population level, the new guidelines recommend that age appropriate peanut-containing foods be introduced to all infants prior to 11 months of age, and ideally closer to 6 months of age. For full background information and specific details, please read the guideline document. The information contained here will serve as an introduction to new concepts and a general guide.
Beginning around 4 months of age, infants will need to be stratified according to risk of developing peanut allergy prior to introduction and will fall into 4 groups:
Severe eczema, egg allergy or both
Mild to moderate eczema
No eczema or any food allergy
No/mild eczema and no food allergy but a family history of peanut allergy in 1st degree relative
Group 1: Severe eczema, egg allergy or both
This group is at highest risk to develop peanut allergy and would benefit most from early introduction
These infants should all be evaluated for peanut sensitization (by skin prick or blood IgE test) prior to introduction
Depending upon the test results, it may be best to introduce in the doctor’s office first
Group 2: Mild to moderate eczema
These infants do not require peanut IgE testing prior to introduction
It is recommended that these infants be introduced to age appropriate peanut containing foods as early as 4 to 6 months of age
Infants should already be eating other solid foods to demonstrate developmental readiness to incorporate peanut containing foods into their diet
It is recognized that some caregivers and health care providers may desire an in office supervised feeding and/or evaluation prior to introduction
Group 3: No history of eczema or food allergy
These infants do not require peanut IgE testing prior to introduction
It is recommended that these infants be introduced to age appropriate peanut containing foods as early as 4 to 6 months of age
These infants do not require a supervised feeding in the doctor’s office
Group 4: No/mild history of eczema or food allergy but a family history of peanut allergy
Data regarding this group are very limited
Due to potential benefit, it is recommended that these infants have age appropriate peanut containing foods introduced into their diets around 4-6 months of age
However, due to a lack of studies in this cohort, evaluation and method of introduction can be left to the discretion of parent and health care provider preference
How Much Peanut Do Infants Need to Eat?
LEAP criteria fed infants 2 grams of peanut 3 times a week
It remains unknown whether lesser amounts or less frequent feedings will offer the same benefit in prevention of peanut allergy
Once peanut is successfully introduced into the infants diet, it should continue to be regularly consumed indefinitely (unless concerns for a new onset allergic reaction arise)
The total amount of peanut protein to be consumed per week should be 6 to 7 grams over 3 or more feedings
What Type of Peanut Containing Foods Should be Given?
The developmental readiness of the infant must always be taken into account prior to introduction of any peanut containing foods and they should be eating other solid foods prior to introducing peanut
Whole or divided peanuts should never be given to an infant due to risk for choking
There are several sources that can be used to offer 2 grams of peanut protein per feeding:
Peanut containing puffs or sticks:
21 sticks = ~2 g of peanut protein
Infants < 7 months of age: soften with 4-6 teaspoons of water
Older infants can eat unmodified but can also soften, if desired
Thinned smooth peanut butter:
Measure 2 teaspoons of peanut butter and slowly add 2-3 teaspoons hot water
Stir until dissolved and well blended
Let cool
Increase water amount if necessary or add to previously tolerated infant cereal to achieve consistency comfortable for the infant
Smooth peanut butter puree:
Measure 2 teaspoons peanut butter
Add 2-3 tablespoons of pureed tolerated fruit or vegetables to peanut butter
Volume of puree can be adjusted to achieve desired consistency
Peanut flour and peanut butter powder:
Measure 1 teaspoon of either produce (both interchangeable)
Add 2 tablespoons of pureed tolerated fruit or vegetable to flour or powder
Volume of puree can be adjusted to achieve desired consistency
Important Points for Consideration
These guidelines only apply to infants who have not ingested peanut or experienced any reaction to peanut
If an infant is already consuming peanut containing foods without problems, then they are not allergic and should continue to consume regularly as outlined above – they do not require any evaluation or testing
If symptoms suggestive of an allergic reaction have previously occurred (hives, swelling, anaphylaxis) after ingestion of peanut, then that infant should be properly evaluated for suspected peanut allergy prior to introduction. This should occur in a timely fashion as risk of developing peanut allergy increase with age.
If infants develop concerning symptoms after introduction of peanut, then parents should contact their health care provider for additional evaluation of possible peanut allergy.
These guidelines address prevention of peanut allergy and do not apply to anyone with known or existing peanut allergy. These should not be confused with treatment recommendations or any form of immunotherapy.
For more information about Nationwide Children's Hospital's Allergy and Immunology Department, click here.
David Stukus, MD, is an associate professor of pediatrics in the Section of Allergy and Immunology at Nationwide Children’s Hospital. Dr. Dave, as his patients call him, is passionate about increasing awareness for allergies and asthma.
All Topics
Browse by Author
About this Blog
Pediatric News You Can Use From America’s Largest Pediatric Hospital and Research Center
700 Children’s® features the most current pediatric health care information and research from our pediatric experts – physicians and specialists who have seen it all. Many of them are parents and bring a special understanding to what our patients and families experience. If you have a child – or care for a child – 700 Children’s was created especially for you.