Peanut allergy prevention: A mother’s perspective

A recent review by Chua et al1Chua G.T. Greenhawt M. Shaker M. Soller L. Abrams E.M. Cameron S.B. et al.The case for prompt salvage infant peanut oral immunotherapy following failed primary prevention.J Allergy Clin Immunol Pract. 2022; 10: 2561-2569Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar highlights the benefits of oral immunotherapy (OIT) for infants who fail primary prevention. In 2015, the Learning Early About Peanut Allergy (LEAP) study revolutionized recommendations for peanut ingestion in early life.2Du Toit G. Roberts G. Sayre P.H. Bahnson H.T. Radulovic S. Santos A.F. et al.Randomized trial of peanut consumption in infants at risk for peanut allergy.N Engl J Med. 2015; 372: 803-813Crossref PubMed Scopus (1375) Google Scholar Infants 4 to 11 months of age were advised to ingest 2 g of peanut protein (PP) 3 times weekly with Bamba puffs (Osem Food Industries, Shohan, Israel).2Du Toit G. Roberts G. Sayre P.H. Bahnson H.T. Radulovic S. Santos A.F. et al.Randomized trial of peanut consumption in infants at risk for peanut allergy.N Engl J Med. 2015; 372: 803-813Crossref PubMed Scopus (1375) Google Scholar Early introduction followed by regular ingestion significantly lowered the likelihood of peanut allergy in later childhood.2Du Toit G. Roberts G. Sayre P.H. Bahnson H.T. Radulovic S. Santos A.F. et al.Randomized trial of peanut consumption in infants at risk for peanut allergy.N Engl J Med. 2015; 372: 803-813Crossref PubMed Scopus (1375) Google Scholar Following this study, the 2017 National Institute of Allergy and Infectious Diseases (NIAID) addendum guidelines advised the introduction of peanut as early as 4 to 6 months of age.3Togias A. Cooper S.F. Acebal M.L. Assa'ad A. Baker Jr., J.R. Beck L.A. et al.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.J Allergy Clin Immunol. 2017; 139: 29-44Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar Peanut feeding guidelines provided recipes containing either 2 teaspoons of peanut butter (PB) or 21 Bamba (each 2 g of PP), and full portions were encouraged.3Togias A. Cooper S.F. Acebal M.L. Assa'ad A. Baker Jr., J.R. Beck L.A. et al.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.J Allergy Clin Immunol. 2017; 139: 29-44Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar Although more flexible infant feeding guidelines were updated in 2021, parents were still encouraged to offer 1 to 2 g of PP with PB or peanut flour at least once weekly.4Fleischer D.M. Chan E.S. Venter C. Spergel J.M. Abrams E.M. Stukus D. et al.A consensus approach to the primary prevention of food allergy through nutrition: guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology.J Allergy Clin Immunol Pract. 2021; 9: 22-43.e4Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar This PP dose remains well above the average eliciting dose in peanut allergy.5Purington N. Chinthrajah R.S. Long A. Sindher S. Andorf S. O'Laughlin K. et al.Eliciting dose and safety outcomes from a large dataset of standardized multiple food challenges.Front Immunol. 2018; 9: 2057Crossref PubMed Scopus (32) Google Scholar Infant feeding guidelines may not be congruent with the actual LEAP methodology. In the treatment arm, infants were advised to ingest 6 g of PP weekly. However, compliance was defined as consumption of only 3 g of PP weekly, and this was required for only 50% of the weeks enrolled in the study. Infants needed to ingest 2 g of PP only once in the first and second years of life.2Du Toit G. Roberts G. Sayre P.H. Bahnson H.T. Radulovic S. Santos A.F. et al.Randomized trial of peanut consumption in infants at risk for peanut allergy.N Engl J Med. 2015; 372: 803-813Crossref PubMed Scopus (1375) Google Scholar With this flexible definition of compliance, infants may have diverged significantly from the recommended early doses of PP. Current guidelines may set unrealistic targets for what early doses of PP are necessary to prevent peanut allergy in infancy and could paradoxically raise the risk of allergy through a domino effect. With large early doses, the risk of a dose-dependent reaction may increase, which in turn may result in avoidance during a critical window of life for active intervention. Chua et al1Chua G.T. Greenhawt M. Shaker M. Soller L. Abrams E.M. Cameron S.B. et al.The case for prompt salvage infant peanut oral immunotherapy following failed primary prevention.J Allergy Clin Immunol Pract. 2022; 10: 2561-2569Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar highlight that despite early introduction, peanut allergy among 12-month-olds has not decreased in some studies.6Soriano V.X. Peters R.L. Ponsonby A.L. Dharmage S.C. Perrett K.P. Field M.J. et al.Earlier ingestion of peanut after changes to infant feeding guidelines: the EarlyNuts study.J Allergy Clin Immunol. 2019; 144: 1327-1335.e5Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,7Mullins R.J. Dear K.B.G. Tang M.L.K. Changes in Australian food anaphylaxis admission rates following introduction of updated allergy prevention guidelines.J Allergy Clin Immunol. 2022; 150: 140-145.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Although Chua et al1Chua G.T. Greenhawt M. Shaker M. Soller L. Abrams E.M. Cameron S.B. et al.The case for prompt salvage infant peanut oral immunotherapy following failed primary prevention.J Allergy Clin Immunol Pract. 2022; 10: 2561-2569Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar defined the problem, they did not hypothesize why LEAP is falling short in a real-world setting. Infant feeding guidelines could be partially culpable. Both the 2017 NIAID and 2021 feeding guidelines encourage doses of PP for young infants that do not necessarily reflect the actual LEAP methodology. Early infant feeding behavior is often exploratory, starting with tiny bites of solid food such as Bamba. From a mother’s perspective, babies naturally eat much smaller doses of PP when ingesting Bamba relative to PB. As the infant’s eating skills progress, they gradually consume higher doses of PP in Bamba over time. PB is starkly different. It is easy to give high doses of PP quickly at very young ages. Why does the mother’s perspective matter? Well, we feed infants constantly. Smaller doses of PP for early ingestions may be more congruent with peanut allergy prevention, akin to the gradual approach of OIT and thus provide an opportunity for inadvertent desensitization in infants who develop early IgE sensitization. Starting low and going slow may also enhance parental comfort with home introductions and thus increase adherence to primary prevention. It is time for a change. The Case for Prompt Salvage Infant Peanut Oral Immunotherapy Following Failed Primary PreventionThe Journal of Allergy and Clinical Immunology: In PracticeVol. 10Issue 10PreviewRecent guideline recommendations have shifted from recommending prolonged avoidance of allergenic foods in the first 3 years of life to a primary prevention approach involving the deliberate early introduction to infants at risk of developing food allergy. Despite this, some infants, especially those with severe eczema who are at highest risk for developing peanut allergy, fail to receive the preventative benefits of early peanut introduction due to hesitancy and other factors. Difficulty adhering to regular ingestion after introduction further reduces the effectiveness of primary prevention. Full-Text PDF Reply to “Peanut allergy prevention: A mother’s perspective”The Journal of Allergy and Clinical Immunology: In PracticeVol. 11Issue 5PreviewWe appreciate the correspondence from Wangberg1 and her interest in our rostrum on management options for failed primary peanut allergy prevention. Our rostrum article discussed the rationale, latest evidence, and the benefits and risks of prompt infant oral immunotherapy (OIT) as a salvage for infants who fail primary food allergy prevention.2 Full-Text PDF