Infants at risk of food allergy might benefit from early introduction of peanut
by Scott H. Sicherer, M.D., FAAP
The Academy and nine other medical professional organizations have
endorsed Consensus Communication
on Early Peanut Introduction and
the Prevention of Peanut Allergy in High-Risk Infants
early. Among infants entering the study with negative
allergy tests, there was an 86% reduction in peanut
allergy in those randomized to eat peanut compared
to avoidance; for those with small positive allergy tests,
there was a 70% reduction.
ally, the communication acknowledges that it focuses
on prevention of peanut allergy in infants at high risk.
Forthcoming expert guidance from the National Institute of Allergy and Infectious Diseases will address
generalizing this approach to other circumstances.
(bit.ly/earlynut2015). This document, posted online
June 19 by the Journal of Allergy and Clinical Immunology, provides guidance regarding early peanut introduction based on the results of the Learning Early About
Peanut (LEAP) study.
The study, published in the New
England Journal of Medicine in February, suggested early introduction of
peanut among infants with high-risk
atopic disease could be a promising approach to prevent development of peanut allergy (www.nejm.org/
The randomized trial enrolled 640 infants between 4
and 11 months of age with severe eczema, egg allergy or
both. The study enrollment procedures included skin
testing to peanut, and infants with large skin tests were
excluded with the assumption that they likely already
were allergic. Infants enrolled and randomized to ingest
peanut did so initially under physician supervision,
with a graded feeding for those with positive tests (
overall, seven of 319 reacted at the baseline feeding). Those
who tolerated the early introduction were instructed to
ingest 6 grams of peanut protein per week.
The guidance essentially suggests recapitulating the
study approach. It suggests that infants in the first four
to six months of life with early onset atopic disease, such
as severe eczema or egg allergy, might benefit from evaluation by an allergist or physician trained in the management of allergic disease to diagnose any food allergy
and assist in implementing the introduction of peanut early. The evaluation
could consist of performing peanut allergy skin tests, in-office observed peanut ingestion or both, as appropriate.
The consensus communication reviews the selection
criteria, procedures and the feeding schedule used in the
LEAP study. The guidance suggests that the clinician can
perform an observed peanut food challenge for infants
with a positive peanut skin test prior to home introduction. Also noted is that serum testing for peanut-specific
immunoglobulin E (IgE) antibody, if performed instead
of skin testing, could result in considerably higher rates
of identified sensitization, which could lead to numerous
unnecessary physician-supervised graded food challenges.
Studies suggest that peanut allergy has increased worldwide, having tripled in U.S. children. The LEAP trial
provides clear evidence that peanut avoidance is associated with allergy in high-risk children. Such children are
precisely those for whom physicians previously may have
suggested prolonged avoidance. This guidance, therefore,
emphasizes an opportunity to intervene and significantly reduce risks. It also indirectly substantiates information provided in a 2008 AAP clinical report (Pediatrics.
org/content/121/1/183.full), that there is no current
convincing evidence that delaying solid food introduction, including allergens such as fish, egg and foods with
peanut protein, beyond 4-6 months has a significant protective effect on the development of atopic disease.
The need for a change in culture of early feeding
practices with regard to allergy is clearly at hand.
Additionally, the guidance is sensitive to the notion
that peanuts and peanut butter are choking hazards,
and provides suggestions for safe forms.
Pediatricians are well-positioned to give families current advice regarding the lack of need for restricting allergens for healthy infants and the updated information
regarding addressing introduction of peanut for infants
who are at risk based on early onset atopic disease.
Based on the results of medically supervised feeding
of peanut at 5 years of age, the study found that the
rate of peanut allergy was 17% in those randomized to
avoid peanut compared to 3% in those who ate peanut
The communication notes several limitations in
translating the study results to practice. For example,
there are no data to address alternate doses of peanut,
the ideal or necessary length of time of “treatment,”
risks of sporadic feeding or discontinuation. Addition-
Dr. Sicherer is immediate past chair of
the AAP Section on Allergy and Immunology Executive Committee and one of
the authors of the endorsed document.
AAP has long history of supporting children of gay, lesbian parents
by Lynn Hunt, M.D., FAAP
Similarly, marriage allows for economic and legal protections for families.”
The U.S. Supreme Court’s ruling recognizing
same-gender marriage in all 50 states was another
milestone in the Academy’s years-long advocacy for
children with gay or lesbian parents.
James E. Crawford-Jakubiak, M.D., FAAP, authored
multiple resolutions at the 2004-’07 Annual Leadership
Forums calling for AAP support of marriage equality and
other protections for children with same-gender parents.
Dr. Crawford-Jakubiak said. “The Academy’s support
of marriage equality does just that for children with
AAP efforts in support of marriage equality and other protections for children with same-gender parents
have included policy statements, amicus briefs filed in
cases before the U.S. Supreme Court, resolutions voted
on at the Annual Leadership Forum and establishment
of the Provisional Section on Lesbian, Gay, Bisexual
and Transgender (LGBT) Health and Wellness.
“The Annual Leadership Forum allows members to
speak directly to national leadership about what the priorities of the membership are,” Dr. Crawford-Jakubiak
said. “It’s clear that the voices of the membership were
heard by the national leadership about this issue.”
Over the past decade, the Academy also has filed
several amicus briefs in cases before the U.S. Circuit
Courts of Appeals as well as the U.S. Supreme Court
challenging the constitutionality of the Defense of
Marriage Act. The amicus briefs focused on the need
for equal protection under the law for all families. In
addition, numerous AAP chapters have been involved
in this issue in various capacities.
“This has always been about the needs of children,”
said Ellen C. Perrin, M.D., FAAP, author of the 2002
AAP technical report on co-parent or second-parent
adoption by same-sex parents from the AAP Committee on the Psychosocial Aspects of Child and Family
Health (http://bit.ly/1MI2qNJ). “The ability of gay or
lesbian parents to legally adopt a child ensures that both
parents can be involved in health care decision-making, have rights to visit their child in the hospital, and
that the child will not be moved out of the family if
the legally adopting parent becomes disabled or dies.
Following the 2004 Annual Leadership Forum, the
AAP Board of Directors requested an analysis of the
effects of amendments that prohibit same-gender civil marriages, civil unions and domestic partnerships
on the legal, financial, emotional and psychological
health and well-being of children. The AAP Division
of State Government Affairs worked with several AAP
committees and staff to write “The Effects of Marriage, Civil Union and Domestic Partnership Laws on
the Health and Well-being of Children” published in
the July 2006 issue of Pediatrics, http://pediatrics.aap
The Academy’s advocacy and policy efforts continued
with expansion of the co-parent adoption statement to
address the benefits to children of marriage equality
for gay and lesbian couples. Many pediatricians were
involved in developing, reviewing and promoting the
policy statement (http://bit.ly/1SCjDfj) and technical
report (http://bit.ly/1IU6VnC) co-authored by Benjamin S. Siegel, M.D., FAAP, and Dr. Perrin. Both
documents were published shortly before the U.S.
Supreme Court heard arguments on the Defense of
Marriage Act in 2013.
“I sincerely believe that these efforts helped to educate all pediatricians and the general public on what
we know about the needs of children whose parents
are gay or lesbian,” Dr. Siegel said.
The AAP Provisional Section on Lesbian, Gay, Bisexual
and Transgender Health and Wellness education program
“Caring for Children of Gay and Lesbian Parents” will be
held from 8 a.m. to noon Oct. 26 at the 2015 AAP National
Conference & Exhibition in Washington, D.C.
More than 25 years of research show children raised
by same-gender parents do as well as those raised by heterosexual parents, according to the analysis, and there is
no relationship between parents’ sexual orientation and
a child’s emotional, psychosocial and behavioral adjustment. The analysis concluded that the rights, benefits
and protections of civil marriage can further strengthen
families with one or more gay parents.
“The Academy has always been clear that it advocates
for the health and welfare of all children in all families,”
Dr. Hunt is chair of the AAP Provisional
Section on Lesbian, Gay, Bisexual and
Transgender Health and Wellness Executive Committee.