New Guidelines Help Pediatricians and Parents Introduce Peanuts

Recently, the American Academy of Pediatrics (AAP) endorsed a recommendation on the introduction of foods containing peanuts to “high-risk” infants between ages 4 and 11 months.  The interim guidelines come as a result of the findings of the LEAP (Learning Early About Peanut Allergy) study that were released earlier this year.

Dr. JJ Levenstein

Dr. JJ Levenstein

In this Q&A, Dr. JJ Levenstein, MD, FAAP, pediatrician and president and co-founder of MD Moms ? and chair of the National Peanut Board’s Food Allergy Education Advisory Council ?  shares perspective on the new guidelines and how parents and healthcare providers can work together to apply  the findings.

Dr. JJ, we’ve heard a lot the past few months about LEAP.  Why has it been such a game changer when it comes to food allergy?

According to AAP, “The interim guidance summarizes the evidence that finds early peanut introduction is safe and effective in infants at high risk of peanut allergy.”

The study was conducted in the UK in order to learn whether the early introduction of peanut into the diets of high-risk infants (with eczema, egg allergy, or both, and whose skin prick tests showed tiny or no responses) ? compared with a matched group who waited to eat peanut until age 5 years ? would result in less peanut allergy in the exposed group.  The results of the study, published in the New England Journal of Medicine in February 2015, were stunning.  17 percent of the children in the avoidance group developed peanut allergy when they underwent a food challenge, as opposed to 3.2 percent in the peanut consumption group ? a relative risk reduction of 80 percent.

You can find more information about LEAP in this previous blog post.

What have AAP and other groups done as a result of the LEAP findings?

Traditionally, Western cultures like the US and UK, had advocated the delayed introduction of high risk foods, including peanut, in children, especially those considered to be at greater risk.  Rather than see a fall in food allergy rates, we saw a disturbing rise, shooting a hole in the traditional approach. Given that approximately 2 percent of school aged children in the US, the UK, and other developed countries suffer from peanut allergies, our knowledge and paradigm about prevention has taken a radical and important turn.

As a result, multiple disciplines in medicine and public health worldwide have gathered to thoughtfully develop some new guidelines, which currently are interim, but give health practitioners a consistent approach.

What exactly are the new guidelines?
  • Health care providers should recommend parents introduce peanut-containing products into the diets of high-risk infants early on in life (between 4-11 months of age) in countries where peanut allergy is prevalent.
  • Infants with early-onset atopic disease, such as severe eczema, or egg allergy in the first 4-6 months of life might benefit from evaluation by an allergist or physician trained in the management of allergic diseases in this age group. It can then be determined whether it is appropriate to begin the introduction of peanut into the baby’s diet after the baby has had either skin prick testing or a directly observed food challenge eating peanut protein.  Direct observation in the office by a trained physician would determine if a baby is clinically reactive before initiating at-home peanut introduction.
  • What we currently know is that an at-risk baby should eat peanut protein at least 3 times weekly, consuming at least 6 gm of peanut protein per week.
Why are these guidelines just interim at this point?

The LEAP-ON study, now in progress, will ultimately give us guidance to the minimum duration of peanut exposure that achieves allergy risk reduction, as well as whether tolerance (the ability to be allergy–free) can be achieved after peanut exposure, even if peanuts are not eaten regularly.  These guidelines will likely morph and become much more precise as further studies contribute to our knowledge.  But for now, we have enough guidelines to address our babies at risk.

What does all of this mean to a parent who is trying to decide what action to take?

The presumption, first, is that for babies who appear to have little risk, there is no harm in giving peanut protein early.  Although healthy low-risk children were not included in the study, we can extrapolate that some of them may ultimately develop peanut allergy as well. For those babies at high risk, we will be preventing many from life-long, life threatening peanut allergies at a time when food allergy is a huge concern.  LEAP now opens the door to inspire other science which hopefully will give us insight into other allergens like milk, wheat, soy, etc. Our hope is that, in a decade or two, we will have so many solid, good answers and a much better understanding of food allergy prevention.

What are some good ways to introduce peanut products to infants?

We don’t recommend giving a child under 4 years of age whole peanuts because of the risk of choking.  But there are still a number of great options at a parent’s disposal.  Here are just a few:

  • Mix 1 teaspoon of smooth peanut butter with breast milk or formula, or with mashed or pureed foods.
  • You can give a weaning snack called “Bamba.”   With older children it literally melts in the mouth. For babies it can be softened with an ounce of water, formula or breast milk, or with mashed or pureed fruits or vegetables. About 21 sticks (2/3 of a 1 ounce package) is the “dose.”
  • Use peanut butter to make a soup, or a sauce for ground up protein (such as chicken).  And peanut power – which is now commonly found on supermarket shelves, can be incorporated into baked goods.
  • Mix finely ground peanuts into yogurt.

Here are some recipes for introduction of peanuts into an infant/toddler’s diet.

Parents and caregivers who have questions about their child’s risk should discuss early feeding with their pediatrician for guidance. For more information on introducing foods to infants and management of peanut allergies, visit

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