tion group (p<0.001; 86.1% relative risk reduction).
Among those in the SPT positive group, the prevalence
of peanut allergy was 35.3% in the avoidance group
and 10.6% in the consumption group (p=0.004; 70%
relative risk reduction).
New recommendations based on risk
Three new guidelines in the addendum characterize
infants based on clinical features reflecting the risk of
having or developing peanut allergy and provide recommendations accordingly.
Guideline #1 recommends that the highest risk infants — those with severe eczema and/or egg allergy (see
box at right) — be introduced to peanut as early as 4-6
months of age, following successful feeding of other solid
food(s) to ensure the infant is developmentally ready.
Allergy testing is strongly advised prior to peanut
introduction for this group. The preferred test is the
SPT, but the guideline also allows for blood testing for
peanut-specific IgE (sIgE), which is more widely available (see figure below). Allergy tests for multiple foods
are not recommended because of their poor positive
The guideline also recommends home or physician-su-pervised feeding or exclusion of peanut based on the test
results. If a blood test is used to screen and is positive to
peanut (sIgE ≥ 0.35 kUA/L), referral to a specialist with
training and experience to perform and interpret the
peanut SPT and to safely perform medically supervised
feeding tests is advised. The guideline discusses the manner of peanut introduction according to the test results,
whether at home or under physician supervision.
Additionally, the amount to feed weekly is discussed.
Based on what was done in the LEAP study, 6-7 grams
of peanut protein is given over three or more feedings
per week. The LEAP study had infants eat this amount
to age 5 years. In studies following up on the LEAP
trial, this approach resulted in durable protection, was
safe, did not affect duration or frequency of breastfeed-
ing, and did not influence growth or nutrition.
Guideline #2 suggests that infants with mild to
moderate eczema, a group also at increased risk of pea-
nut allergy, should be introduced to peanut “around 6
months of age, in accordance with family preferences
and cultural practices, to reduce the risk of peanut aller-
gy.” These infants may have peanut introduced at home
following successful ingestion of other solid food(s)
without an in-office evaluation, although an evaluation
can be considered.
Guideline #3 addresses infants without eczema or
food allergy who are not at increased risk, suggesting
that peanut be introduced “freely” into the diet together with other solid foods and in accordance with family
preferences and cultural practices.
Purposeful early feeding of peanut is a reversal from
the 2000 AAP recommendations that suggested high-
risk infants avoid peanut to age 3 years. The avoid-
ance advice was rescinded in the 2008 AAP clinical
report Effects of Early Nutritional Interventions on the
Development of Atopic Disease in Infants and Children:
The Role of Maternal Dietary Restriction, Breastfeeding,
Timing of Introduction of Complementary Foods, and
Hydrolyzed Formulas (Pediatrics. 2008;121:183-191;
http://bit.ly/2hDuw1f ), which concluded: “Although
solid foods should not be introduced before 4 to 6
months of age, there is no current convincing evidence
that delaying their introduction beyond this period has
a significant protective effect ...”
The new guidelines go further by promoting early
ingestion for the highest risk infants. Evaluation and
peanut introduction for this highest risk group at 4-6
months is conveniently timed with routine pediatric
health care office visits, allowing for identification of
infants at risk and discussion of the approach. Addition-
ally, it is less likely for younger infants to have positive
allergy tests to peanut. However, the guideline empha-
sizes that if the 4- to 6-month time period is missed for
any reason, peanut should be introduced to infants older
than 6 months as they also are anticipated to benefit (the
LEAP study included infants 4 up to 11 months of age).
The addendum guidelines represent an update to
the 2010 comprehensive food allergy guidelines published by a National Institute of Allergy and Infectious
Diseases (NIAID)-sponsored expert panel (http://bit.
ly/2g TLoSF). They reflect the work of a coordinating
committee and expert panel representing 26 professional organizations, including the Academy, advocacy
groups and federal agencies, which evaluated a literature review prepared by the NIAID.
Dr. Sicherer represented the Academy on
the guideline coordinating committee and
was a member of the expert panel. He is
past chair of the AAP Section on Allergy
and Immunology Executive Committee.
Definitions in the
Severe eczema is defined as persistent or frequently
recurring eczema with typical morphology and distribution, assessed as severe by a health care provider
and requiring frequent need for prescription-strength
topical corticosteroids, calcineurin inhibitors or other
anti-inflammatory agents despite appropriate use of
Egg allergy is defined as a history of an allergic reaction to egg and a skin prick test wheal diameter of
≥ 3 millimeters with egg white extract or a positive oral
egg food challenge.
To minimize a delay in peanut introduction for children who may test negative, testing for peanut-specific IgE may be the preferred initial approach in certain health care settings. Food allergen panel testing or the addition of sIgE
testing for foods other than peanut is not recommended due to poor positive predictive value.
skin prick test
*** oral food challenge
Recommended approaches for evaluation of children with severe eczema and/or egg allergy before peanut introduction