WASHINGTON — Most babies should start eating peanut-containing foods well before their first birthday, say guidelines released Thursday that aim to protect high-risk tots and other youngsters, too, from developing the dangerous food allergy.
The new guidelines from the National Institutes of Health mark a shift in dietary advice, based on landmark research that found early exposure dramatically lowers a baby's chances of becoming allergic.
The recommendations spell out exactly how to introduce infants to peanut-based foods and when — for some, as early as 4 to 6 months of age — depending on whether they're at high, moderate or low risk of developing one of the most troublesome food allergies.
"We're on the cusp of hopefully being able to prevent a large number of cases of peanut allergy," said Dr. Matthew Greenhawt of the American College of Allergy, Asthma and Immunology, a member of the NIH-appointed panel that wrote the guidelines.
Babies at high risk — because they have a severe form of the skin rash eczema or egg allergies — need a check-up before any peanut exposure, and might get their first taste in the doctor's office.
For other tots, most parents can start adding peanut-containing foods to the diet much like they already introduced oatmeal or mushed peas.
No, babies don't get whole peanuts or a big glob of peanut butter — those are choking hazards. Instead, the guidelines include options like watered-down peanut butter or easy-to-gum peanut-flavored "puff" snacks.
"It's an important step forward," said Dr. Anthony Fauci, director of NIH's National Institute of Allergy and Infectious Diseases, which appointed experts to turn the research findings into user-friendly guidelines. "When you do desensitize them from an early age, you have a very positive effect."
Peanut allergy is a growing problem, affecting about 2 percent of U.S. children who must avoid the wide array of peanut-containing foods or risk severe, even life-threatening, reactions.
For years, pediatricians advised avoiding peanuts until age 3 for children thought to be at risk. But the delay didn't help, and that recommendation was dropped in 2008 — although parent wariness of peanuts persists.
"It's old news, wrong old news, to wait," said Dr. Scott Sicherer, who represented the American Academy of Pediatrics on the guidelines panel.
Thursday's guidelines make that clear, urging parents and doctors to proactively introduce peanut-based foods early.
"Just because your uncle, aunt and sibling have an allergy, that's even more reason to give your baby the food now" — even if they're already older than 6 months, added Sicherer, a pediatric allergist at Mount Sinai Hospital in New York.
In Columbus, Ohio, one doctor told Carrie Stevenson to avoid peanuts after her daughter was diagnosed with egg allergy. Then Stevenson found an allergy specialist who insisted that was the wrong advice — and offered baby Estelle a taste test of peanut butter in his office when she was 7 months old.
"I was really nervous," Stevenson recalled, unsure which doctor to believe. But, "we didn't want her to have any more allergies."
Now 18 months old, Estelle has eaten peanut butter or peanut-flavored puffs at least three times a week since then and so far seems healthy. Stevenson, pregnant again, plans early exposure for her next child, too.
The guidelines recommend:
—All babies should try other solid foods before peanut-containing ones, to be sure they're developmentally ready.
—High-risk babies should have peanut-containing foods introduced as early as 4 to 6 months after a check-up to tell if they should have the first taste in the doctor's office, or if it's OK to try at home with a parent watching for any reactions.
—Moderate-risk babies have milder eczema, typically treated with over-the-counter creams. They should start peanut-based foods around 6 months, at home.
—Most babies are low-risk, and parents can introduce peanut-based foods along with other solids, usually around 6 months.
—Building tolerance requires making peanut-based foods part of the regular diet, about three times a week.
What's the evidence? First, researchers noticed a tenfold higher rate of peanut allergy among Jewish children in Britain, who aren't fed peanut products during infancy, compared to those in Israel where peanut-based foods are common starting around age 7 months.
Then in 2015, an NIH-funded study of 600 babies put that theory to the test, assigning them either to avoid or regularly eat age-appropriate peanut products. By age 5, only 2 percent of peanut eaters — and 11 percent of those at highest risk — had become allergic. Among peanut avoiders, 14 percent had become allergic, and 35 percent of those at highest risk.
Whether the dietary change will spur a drop in U.S. peanut allergies depends on how many parents heed the new advice — and if a parent seems skeptical, the guidelines urge doctors to follow up.
|Justin Sullivan/Getty Images|
New NIH guidelines on infants and peanuts may contradict everything you’ve heard before
When my husband and I had our first child seven years ago, the prevailing wisdom was that babies at risk of allergies should avoid peanuts or peanut products until age 3 or older. The idea behind this restriction — which was based on American Academy of Pediatrics (AAP) guidelines released in 2000 — was that feeding peanuts too early to little ones might risk severe, possibly life-threatening allergic reactions.
Over the years that thinking has done a 180. Now, scientists believe the exact opposite: Giving your baby peanuts earlier rather than later might prevent them from developing an allergy.
While many doctors and medical groups have come out over the past year to endorse this view, there has been a lot of confusion about which kids could benefit from early exposure, the optimal timing of the exposure, and how exactly one should feed peanuts (which, after all, are a choking hazard in their raw form) to babies.
On Thursday, the National Institute of Allergy and Infectious Diseases released formal, detailed guidelines for pediatricians and allergists.
The document, published in six medical journals, includes three separate sets of recommendations based on the level of risk an infant has for developing a peanut allergy. Those at highest risk are defined as babies with severe eczema — a skin condition where patches of skin become inflamed, itchy, red and cracked — or egg allergy or both. Those in the middle group have mild-to-moderate eczema. And those in the lowest-risk group have no eczema or food allergies.
The guidelines come at a terrifying time for new parents in terms of allergies. The number of American children with nut allergies has quadrupled in the past 13 years, and peanut allergies are now estimated to affect 2 percent of them. Most schools now ban foods with peanuts, and manufacturers are required to label whether food contains peanuts or was manufactured in a facility that processes them. The soaring price of EpiPens, which are used to treat a severe allergic reaction and retail for up to $650 for a two-pack, has become a hot political topic.
Anthony S. Fauci, NIAID director, said in an interview that the new thinking on peanut exposure grew out of observations of Israeli children in Israel versus Israeli children in Britain. In the former, he said, parents as part of their culture often give various types of peanut preparations such as paste or nuggets in the very earliest days of a child's life. Scientists noted that the incidence of peanut allergies in Israeli children in Israel is lower than in Israeli children in Britain and wondered whether the two things could be related.
“They thought that perhaps we should try the counterintuitive approach of feeding peanuts to babies early on rather than withholding them in order to protect them,” Fauci explained.
That theory was put to a test in the much-praised Learning Early About Peanut Allergy (LEAP) study, a randomized trial led by Gideon Lack of King's College London involving 640 infants considered at high risk of developing peanut allergies. The results, published in 2015 in the New England Journal of Medicine, showed that children at high risk who regularly consumed peanuts as infants had an 81 percent lower chance of developing a peanut allergy by age 5.
Fauci called the results “very striking” and estimated that the new guidelines could prevent thousands of children from developing peanut allergies.
“If you can get anywhere close to an 81 percent decrease that we saw in the original study, we're talking about saving thousands and thousands of kids from peanut allergies,” he said.
Similar studies are being conducted on early exposure to tree nuts and eggs, but results probably won't be available for a few more years.
Matthew Greenhawt, a physician at Children's Hospital Colorado who is chair of the food allergy committee of the American College of Allergy, Asthma and Immunology, explained that the new guidelines are closely tied to eczema because it is an obvious external measure that has been linked to food allergies going back to the 1900s. While no one has been able to definitively explain why these conditions appear together so often, children with eczema produce a lot of immunoglobulin E antibodies, which play a role in food allergies, hay fever and asthma.
He said that children with severe eczema are probably already in the care of a doctor for the condition so they should be easy to identify, noting that “severe eczema is not a kid with a little arm or cheek rash. These are kids with a decent percentage of their bodies covered despite good moisturizing, bathing and increasing topical prescriptions.”
Those children at highest risk should be exposed to peanuts earliest — at 4 to 6 months — and be referred to a specialist who might perform a blood or skin test before deciding how to handle their first exposure to peanuts. Some may decide that with low readings, the child could be given peanuts at home, while others may suggest giving a child peanuts for the first time in a doctor's office anyway. Those precautionary measures reflect the tricky nature of diagnosing a peanut allergy. Many people can test positive for allergies through a skin test or a blood test but may tolerate the food just fine. The opposite, while less common — that you can have a low reaction to a blood or skin test but still have a severe allergic reaction — also can be true.
Those in the middle group should be fed peanuts when they are about 6 months old. This can be done at home. Those at lowest risk can have them at any time, also at home, but can typically start when they are about 6 months old, as well.
“For these kids, we are not considering peanut as different than any other type of food,” Greenhawt said.
The NIH guidelines also contain some common-sense advice such as reminding parents that all infants first progress to solid foods such as pureed vegetables and cracker puffs on their regular schedule before being exposed to peanuts. The guidelines also provide step-by-step instructions along with “recipes” for home exposure to peanuts. They remind parents to feed their infant peanuts for the first time only when he/she is healthy (with no vomiting, diarrhea or other signs of illness), at a time when at least one adult can focus all of his/her attention on the infant for at least two hours to watch for signs of a reaction, and to not give whole nuts or a huge spoonful of peanut butter to an infant to avoid choking. A child's pediatrician should go over the signs of an allergic reaction, but they could include things like a hivelike rash, vomiting, coughing, wheezing or a child otherwise looking lethargic or ill.
Greenhawt also emphasized that the guidelines are simply recommendations and that “your child dictates when they are ready for some foods.” The same could be said of exposing kids to broccoli or fish.
“As a parent, I know the child has a mind of their own. They will eat what they want to and will spit out what they don’t want,” he said. “It's always a challenge to give them new foods. You have to be persistent and creative.”
Here's how to feed your infant, from the guidelines:
1. Prepare a full portion of a peanut-containing food such as peanut butter dissolved or thinned with water, peanut butter, peanut flour or powder mixed with a fruit or vegetable puree or several pieces of Bamba, a puffed maize snack with peanuts, which can be softened with water or not depending on the child's age or preferences.
2. Offer your infant a small part of the peanut serving on the tip of a spoon.
3. Wait 10 minutes.
4. If there is no allergic reaction after this small taste, then slowly give the remainder.
And here is the passage containing infant-friendly peanut recipes:
Group 1: At highest risk, with severe eczema, egg allergy or both
Strongly consider evaluation by blood test, skin prick test or oral food challenge. Based on test
results, introduce peanut-containing foods at 4 to 6 months.
Group 2: Moderate risk, with mild-to-moderate eczema.
Introduce peanut-containing foods around 6 months.
Group 3: Less risk, with no eczema or any food allergy
Introduce peanut-containing foods at an appropriate age and in accordance with family preferences and cultural practices.
New NIH Guidelines on Infant Exposure to Peanuts Upend Years of Parental Paranoia
In recent years, a child’s first peanut exposure has turned into a major milestone, the cause of much parental fretting and planning. I remember reading on one parenting forum that I should feed my daughter her first smear of Skippy in a car parked outside a hospital emergency room, just in case. For many years, medical experts advised parents to wait until high-risk children were at least three years old to even try giving them peanuts.
New guidelines from federal health authorities are completely upending that wait-and-fear approach. On Thursday, the National Institutes of Health announced that parents should feed babies their first foods containing peanuts when they are as young as four months old—which is the earliest that they should be eating any solid foods at all. Children who are at the highest risk of developing a peanut allergy because they have severe eczema or an egg allergy should try peanuts in that early window. Children with moderate eczema can wait until around six months, while children without any risk factors can have peanuts “freely introduced into their diets” once they’ve adjusted to other solid foods. “There is this magic window of opportunity, where you can introduce peanut-containing foods,” David Stukus, a pediatric allergist who coauthored the new guidelines, told Stat News. When “we introduce peanut-containing foods early, the immune system can get used to it.” Up is down, down is up, peanut products are for babies.
The old conventional wisdom did not come out of nowhere. Nut allergies can be deadly, prompting reactions including severe tongue and throat swelling that block the airway. They are also on the rise. The prevalence of peanut allergies in children more than tripled between 1997 and 2010, rising from .4 percent to 1.4 percent according to one study; the peanut allergy rate in adults barely changed over the same period. Some schools now ban peanut products outright, and many food labels now state not just whether they contain nuts, but whether they were prepared in the vicinity of nuts. Severe reactions can occur the very first time a child is exposed to a peanut product, so you can understand how some parents find themselves idling outside the E.R. with a toddler and a jar of Jif.
Expert advice on children and peanut exposure has effectively reversed within just a few years. As recently as 2000, the American Academy of Pediatrics issued a recommendation that high-risk infants should not be fed peanuts and tree nuts until age three. The same recommendation suggested some women whose infants were considered at risk of developing an allergy should avoid eating peanuts if they were breastfeeding, and that some women should even avoid peanuts during pregnancy. The assumption was that avoiding exposure to potential allergens would help a child’s gastrointestinal and immune systems mature until he was old enough to handle it.
Alas, the research didn’t bear out the intuitive notion that avoiding allergens leads to avoiding allergies. Over the last several years, several major studies have made clear that early exposure was actually good for children at risk of developing food allergies. As Melinda Wenner Moyer summed it up in Slate almost two years ago in a helpful piece that collected much of the relevant recent research, “Scientists now believe that exposing the gastrointestinal system to an allergen early in life is unlikely to cause an allergy. It probably does the opposite.”
There are important caveats to the new recommendations. Children with severe risks, or who have an older sibling with a serious peanut allergy, should see an allergist first. Parents should still keep a close eye on how children react to their first exposure. And don’t feed infants whole peanuts or even big spoonfuls of peanut butter, which remain a choking hazard. When conventional wisdom flies out the window this dramatically, it’s worth restating the obvious. But the big takeaway from today’s announcement isn’t fear, but freedom. As it goes with peanuts, so it goes with parenting and life in general: An overabundance of caution doesn’t always make us safer.