by Michael Jordan, MD, MS-HQSM, CPE, FAAP
Medical Director Rochester Regional Health
Chief Pediatrician, Newark Wayne Community Hospital
On my recent Southwest Airlines flight the stewardess announced that she would not be distributing peanuts during that flight because one of the passengers had reported a peanut allergy. This may seem like an overly cautious decision but it is actually a wise move on the part of the airline.
Peanut allergy is the most common form of food allergy and the leading cause of death from a food product in United States. In addition, the prevalence of peanut allergies appears to be increasing. Patients with peanut allergy are at risk for a life-threatening condition called Anaphylaxis. This event can come on quite suddenly after exposure to an allergen. The symptoms of Anaphylaxis are sudden development of lip or tongue swelling, shortness of breath, wheezing, difficulty breathing and often giant hives. The reaction can occur within 5 minutes of the exposure and without medical intervention can result in sudden death. Indeed, approximately 200 people per year die in the United States from peanut allergy. All patients with peanut or tree nut allergy should have an emergency action plan and have ready access to injectable adrenaline, usually as prescribed as an EpiPen auto injector. The EpiPen injection will bring short term benefit, but all who have a reaction must go directly to the nearest emergency room for continued treatment with IV steroids and often additional doses of adrenaline to maintain a safe and open airway.
Recent scientific research has shown peanut allergy can be prevented with changes in the usual infant diet. A clinical trial was published called the Learning Early About Peanut allergy - the LEAP study - which found early introduction of peanut protein in infants who were at risk for developing food allergies resulted in an 81% reduction in their rate of peanut allergy compared to comparable high risk control group who followed the usual feeding recommendations limiting peanut containing food until after a year of age.
An 80% reduction in peanut allergy would be a really big deal considering more than a million Americans have peanut or tree nut allergy. Based on the amazing results of this well designed study the nutritional guidelines for introducing peanut-containing foods in infancy have been revised.
The new guidelines consider three groups of infants selected by their predicted risk for allergy; those at high risk, those at moderate risk and those at low risk.
High Risk: Those infants with severe eczema or egg allergy. We know that children who have eczema or egg allergy have a much higher risk of developing peanut allergy. It is in this group of infants where the early introduction of peanut protein may be most beneficial. It is also in this group that the early introduction of peanut-containing foods may be the most risky. If your child has severe eczema and egg allergy before introducing peanut protein it is a good idea to check a blood test for IgE antibody, if that test is positive, the infant should be referred to allergist for skin prick testing (SPT) to determine the level of risk. In those babies who are in this high risk group their first taste of peanut containing foods is may be best done in the doctor’s office and as early as age 4 months. If that first introduction shows no reactions these infants should then be fed at least three servings of peanut containing protein per week. The best way to do this is to simply mix about a teaspoon of peanut butter into the infant cereal or fruit and to blend it carefully to avoid any choking risk.
Moderate or Low risk: Infants with mild or moderate eczema. For those infants and toddlers with moderate or low risk (whose skin rash Eczema is controlled with occasional creams or those without Eczema), may also benefit from early peanut introduction as a preventive step. In these children peanut containing foods may be introduced at the usual time of strained food introduction and served 3-4 times per week and well blended into the other pureed solids such as infant cereal, fruit and vegetables.
Although we have now begun to recommend introducing peanut butter early in life to infants parents and caregivers should never give whole nuts or peanuts to young children because of the risk of choking.
It is a hopeful expectation that by following these new guidelines, we may prevent many future cases of this very serious and lifelong allergy.
For further reading on this subject, visit www.niaid.nih.gov.
