by Scott H. Sicherer, M.D., FAAP
Following are answers to some common questions regarding how to implement recommendations in the AAP-endorsed report on the prevention
of peanut allergy.
The report, Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Report
of the National Institute of Allergy and Infectious
Diseases-Sponsored Expert Panel ( http://dx.doi.
early introduction of infant-safe forms of peanut
according to an initial risk assessment, which may
include allergy testing. The recommendations are
based heavily on the Learning Early About Peanut
(LEAP) study (Du Toit G, et al. N Engl J Med.
The table on page 16 summarizes the three risk
categories and approaches described in the report.
The rationale for the approaches, choice of testing
and infant-safe forms of peanut are discussed in
In Guideline #1, “high risk” is described as having persistent or frequently recurring eczema requiring
frequent prescription-strength anti-in-flammatory medications despite appropriate use
of emollients and/or egg allergy. Why this definition rather than family history or other risks?
This definition and its associated recommended
actions approximate the entry criteria and approach
used in the LEAP study, which randomized infants
4-11 months of age with negative or small positive
peanut skin prick tests for peanut avoidance vs.
early introduction. The approach proved to be safe,
by Steven A. Abrams, M.D., FAAP
One of the most common questions
parents ask pediatricians is how much
100% fruit juice they should give their
children. A new AAP policy recommends
some children should be consuming less
juice than previously advised.
An AAP policy statement published
in 2001 and reaffirmed in 2006 recommended no juice for children younger
than 6 months of age, 4-6 ounces daily
for children ages 1-6 years and 8-12
ounces for children 7 and older. Since
then, however, considerable concern
has been expressed about increasing
obesity rates and risks for dental caries.
Lower daily intakes
The Academy’s new policy Fruit
Juice in Infants, Children and Adolescents: Current Recommendations
builds on the original but considers
the evidence released since then. The new advice
indicates that fruit juice should not be provided to
children younger than 1 year of age unless there is
a strong clinical basis for it in the management of
constipation. For older children, maximum daily
intakes of 100% juice products should be 4 ounces
for children ages 1-3 years, 4-6 ounces for children
ages 4-6 years and 8 ounces for those 7 and older.
The policy, from the AAP Section on Gastroenterology, Hepatology and Nutrition and the
Committee on Nutrition, is available at https://
doi.org/10.1542/peds.2017-0967 and is published
in the June issue of Pediatrics.
Importance of whole fruits, other advice
Further recommendations emphasize the importance of fresh fruit in children’s diets. Fruit generally
contains additional fiber compared to juices. Consistent with recent AAP recommendations, water
Pediatricians and the Law
Set up procedures
to ensure lab results
don’t fall through the cracks
by Susan M. Scott, M.D., J.D., FAAP
The following is an actual malpractice case.
After an uncomplicated pregnancy, a woman in her
late 30s gave birth to a son at 9 p.m. State-mandated
newborn screening specimen collection was performed
at 1 a.m. Infant’s phenylalanine level was 4.1 mg/dL.
The state required that newborn screening tests (NST)
be completed as close to discharge as practical. Baby
and mother were discharged at 48 hours after birth; the
NST was not repeated.
Over the ensuing months, the mother noticed something was wrong with her son and expressed those concerns to the pediatrician. Until age 5, numerous doctors
saw the patient for various health-related issues, some
of which involved him being developmentally delayed.
It wasn’t until the child was 6 years old that a pediatric
neurologist ordered additional labs including phenylketonuria (PKU), which proved the patient suffered
from PKU deficiency.
The plaintiff sued the birth hospital and pediatric
clinic alleging that:
• the hospital was negligent in diagnosis for draw-
ing blood for specimen collection at 4 hours of
age and not recollecting the specimen closer to the
• the pediatric clinic was negligent for failing to re-
view the results of the NST; and
• the pediatrician ignored the parents’ repeated con-
cerns regarding their son’s developmental delays,
failed to refer the patient to a specialist and failed to
order the metabolic testing that would have shown
This case clearly demonstrates how problems with
lab tests such as NST can lead to devastating patient
outcomes and serious malpractice claims.
Tracking test results vital
It has been reported that 70% of diagnoses are made
using laboratory results.
The most frequent basis for medical malpractice
litigation in pediatric claims is “failure to diagnose.”
Many failures or delays in diagnosis can be directly
tied to a patient’s lab or test results being lost, unread
www.aapnews.org Volume 38 • Number 6 • June 2017
See Fruit juice, page 4
See Peanut allergy, page 16
See Law, page 18
In this issue
New code update
Answers to common questions about the new health risk assessment
codes released Jan. 1. Page 30
A candid look at AAP presidential candidates
Get a glimpse into their lives, passions and reasons why they want to
lead the Academy. Pages 14-15
Focus on Subspecialties
Weighing in on fruit juice:
AAP now says no juice before age 1
Focus on Subspecialties
How to implement new peanut
allergy prevention guidelines