New Guidelines: Early Introduction of Peanut to Prevent Peanut Allergy

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:

1. Severe eczema, egg allergy or both
2. Mild to moderate eczema
3. No eczema or any food allergy
4. No/mild eczema and no food allergy but a family history of peanut allergy in 1^st 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.