In February, the results of a landmark study showing up to an 86% reduction in peanut allergies was released, making headlines worldwide. The study, led by Gideon Lack of Kings College, London, UK, followed 640 children who were at high risk for developing peanut allergies because they had been diagnosed with egg allergy or had moderate to severe eczema. After skin testing and oral food challenges, the children, between 4 and 11 months of age, were randomized to either eat peanut protein or avoid peanut protein and were followed for five years.
In an editorial accompanying the study results, Rebecca S. Gruchalla, M.D., Ph.D and Hugh A. Sampson, M.D. wrote, “…we believe that because the results of this trial are so compelling, and the problem of the increasing prevalence of peanut allergy so alarming, new guidelines should be forthcoming soon.”
I caught up with Dr. Lack to get some additional thoughts on the study and its implications, as well as future considerations:
SCC: The results of the LEAP (Learning Early About Peanut allergy) study are groundbreaking and challenge long-held convictions about avoidance as a way to prevent food allergy. Do you find that there are still researchers or physicians who are hesitant to recommend feeding infants potential allergens, especially peanuts? If so, how can these individuals be persuaded to do so?
Dr. Lack: This will require a change in mindset amongst both physicians and parents. Although the efficacy and safety of the data is convincing there is still a persistent belief that eating peanuts and other allergens early in infancy will lead to eczema and other allergic diseases. In fact, it is the reverse and it is the children with eczema who are most at risk for developing peanut and other food allergies. I believe it will take considerable education and transmission of the message through different healthcare professionals before there is a generalized acceptance to introduce peanut early into the diet in countries where peanut allergy is a problem.
SCC: Since the LEAP study was released, some have called for new guidelines for infant feeding. Do you have any idea what those new guidelines might include?
Dr. Lack: It is too early to say what form new guidelines will take. I imagine that active introduction of peanut products will be encouraged in infant’s diet but whether or not this will be confined to a high risk group, whether infants will first need to be evaluated, and what the recommended age of introduction will be, all remain to be determined. It will be critical that all the major specialty groups and stakeholders come together to produce a set of guidelines that are both clinically sound and pragmatic.
SCC: Do you think that is a necessary step for every child with eczema or a family history of allergy? Many Americans do not have easy access to an allergist and reports suggest there aren’t enough allergists to meet the demand for such a recommendation.
Dr. Lack: At the moment I am advocating that all babies with moderate to severe eczema or egg allergy have skin prick testing prior to 1st introduction of peanuts.
SCC: Since we know peanuts are a choking hazard for very young children, people often ask me how to introduce peanut protein to their children. In what form were the infants in the study fed peanut protein?
Dr. Lack: Clearly early consumption of peanuts needs to occur in a safe manner. Peanut was never the first solid introduced into the infants diet but was only introduced once the infant had been accustomed to eating solids over at least a week. Whole peanuts were not given because of the risk of choking. The Israeli snack Bamba (a common puffed corn and peanut food) was commonly used. Peanut butter mixed with fruits in a purée was frequently eaten. Some babies had peanut soup.
Clearly this study has provided great information regarding the development of peanut allergies and the potential for prevention. Questions still remain and future studies will need to be conducted. Dr. Lack was careful to state that the results of the LEAP study answered some questions about those children at high risk for developing peanut allergies. He has an ongoing study called EAT (Enquiring About Tolerance) that will help answer the question about whether or not the results are the same for children without risk factors and whether the findings will apply to other allergenic foods.
At present, guidelines from the American Academy of Pediatrics and American Academy of Allergy, Asthma and Immunology state that research does not support withholding potential allergens past 4-6 months as a means to prevent peanut allergy. Thus introduction of peanuts (in a safe form like thinned peanut butter) into an infant’s diet is consistent with these guidelines.
On June 1st, a consensus statement was released on behalf of the American Academy of Asthma Allergy and Immunology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, and a host of other international professional organizations to provide interim guidance for introducing peanuts to high-risk infants. Based on the LEAP study and other scientific evidence, the consensus is that, “healthcare providers should recommend introducing peanut-containing products into the diet of “high-risk” infants early on in life (between 4 – 11 months of age) in countries where peanut allergy is prevalent, since delaying the introduction of peanut may be associated with an increased risk of developing peanut allergy.”
Infants who already have allergic disease (such as severe eczema or egg allergy in the first 4-6 months) may benefit from an evaluation and food allergy diagnosis, as well as assistance with implementing these recommendations. Parents and caregivers who have questions about their child’s risk should discuss early feeding with their pediatrician for guidance.