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Peanut Allergies and Infants

Current Canadian guidelines recommend introducing solid foods, including peanut products, to infants at about six months of age when they are showing signs of readiness. The Learning Early About Peanut Allergy (LEAP) study was a randomized trial that used early allergen introduction as a strategy to prevent peanut allergies. The results of the study showed that early introduction of peanut products to infants at high risk of allergy was safe and led to an 81% percent relative reduction in the development of peanut allergy. This is significant as approximately two percent of Canadian children report an allergy to peanuts.

As a result of the LEAP study, the National Institute of Allergy and Infectious Diseases (NIAID) released new recommendations about the optimal time to introduce peanut products to high risk infants. These recommendations have been endorsed by the Canadian Society of Allergy and Clinical Immunology and Food Allergy Canada. In January 2019, the Canadian Pediatric Society released a Practice Point with similar recommendations.

 

Summary of Guidelines

The guidelines for introducing peanut products to infants depends on their risk of peanut allergy. Infants are divided into three groups based on their risk of peanut allergy. Infants in the LEAP study ate two grams of peanut protein, three times per week. It is not known whether the same reduction in peanut allergy will occur with a lower quantity or frequency of consumption of peanut products.

Infants at high risk of peanut allergy

Infants with a history of severe eczema and/or an egg allergy are considered at high risk for the development of peanut allergy. The guidelines recommend that these infants are introduced to age-appropriate peanut products at six months of age, but no earlier than four, to reduce the risk of peanut allergy. The infant should first be introduced to other solid foods to determine developmental readiness. Healthcare providers should strongly consider that these infants are first tested with peanut specific immunoglobin E (peanut sIgE), skin prick testing (SPT) or both to determine if peanut products should be introduced and, if so, the method of introduction (i.e. in office oral challenge or introduction at home). A referral to a pediatric allergy specialist should be considered if available in a timely manner. Testing of other potential food allergies is not recommended due to the risk of false positives.

Infants at moderate risk of peanut allergy

Infants with mild to moderate eczema are considered at moderate risk of peanut allergy. These infants should be introduced to age-appropriate peanut products at about six months of age at home. Other solid foods should be introduced first to determine developmental readiness. Once introduced, peanut products should be offered regularly to help reduce risk of peanut allergy.

Infants at low risk of peanut allergy

Infants with no eczema and no history of food allergy are considered at low risk of peanut allergy. These infants may have age-appropriate peanut products introduced freely in the diet with other solid foods from about six months.

Introduction of peanut products to infants with no eczema or food allergies, but with a positive family history of peanut allergy was not addressed by the LEAP study. These infants should be introduced to age-appropriate peanut products in accordance with Canadian recommendations at approximately six months of age. Once introduced, peanut products should be offered regularly to reduce the risk of peanut allergy. Care should be taken to avoid cross-contamination and risk of reaction for the family member with a peanut allergy.

How can families safely introduce peanut products

Generally, it is safe for most infants to be introduced to peanut products by about six months of age when they are showing signs of readiness.

  • Healthcare providers should counsel parents/caregivers to monitor infants for allergic reactions. The signs and symptoms of allergic reactions, including rash, vomiting, diarrhea, or breathing problems, should be reviewed. Parents/caregivers should be encouraged to seek medical attention with concerns about a possible food allergy.
 
  • Infants should be introduced to high allergen foods when they are feeling well. Symptoms of other illnesses, like a cold, may be mistaken for possible allergic reactions.
  • Infants should be first introduced to peanut products at home. At least one parent/caregiver should remain with the infant during the feeding and after to monitor the infant for signs of an allergic reaction.
  • Age-appropriate peanut-containing foods include: smooth peanut butter thinned with hot water; smooth peanut butter added to cereals, pastas, eggs, yogurts and fruit/vegetable purées, foods containing peanut flour.

Conclusion

The key message from the NIAID and CPS guidelines is to introduce age-appropriate peanut products to infants early, about six months of age, and to continue to offer them a few times a week to maintain tolerance. Infants at high risk of peanut allergy are recommended to receive peanut allergen testing and potentially have their first introduction to peanut products under physician supervision at six months, but not before four months. The majority of infants can be safely introduced to peanut products at home. Other Canadian recommendations, including waiting two days between introducing high allergen foods, monitoring for allergic reactions and then including those foods regularly in the diet, are still applicable to help reduce the risk of food allergies.

 
Date of creation: January 2, 2018
Last modified on: July 25, 2019

References

1Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. (2015, January 19). Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months. Retrieved from
https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months/6-24-months.html
2Togias A et al. (2017). 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. Journal of Allergy and Clinical Immunology. 139(1):29-44.
3Soller L et al. (2012). Overall prevalence of self-reported food allergy in Canada. Journal of Allergy and Clinical Immunology. 130(4): 986-988.
4Canadian Pediatric Society. (2019) Practice Point – Timing of introduction of allergenic solids for infants at high risk. Retrieved from
https://www.cps.ca/en/documents/position/allergenic-solids