Data indicate that peanut allergy is a growing epidemic, with a current prevalence of 2.2%, up from 0.8% in the early 2000s. Evidence suggests that parent and pediatric clinician concerns have grown in step with prevalence, as about one in 13 US children are now affected by food allergy. Of these, peanut allergy is the most common.
The groundbreaking Learning Early About Peanut (LEAP) study answered the question of why there has been a large increase in peanut allergy cases and whether it can be prevented from developing, while also providing evidence supporting the introduction of peanut in infants prior to their first birthday. In response, the National Institute for Allergy and Infectious Disease (NIAID) published the 2017 Addendum Guidelines for the Prevention of Peanut Allergy (PPA guidelines). The PPA guidelines provide pediatric clinicians with instructions for evaluating infants for peanut allergy, triaging them into risk categories, recommending whether to introduce peanuts, and guiding clinicians to counsel parents on peanut introduction.
Disseminating the PPA Guidelines to pediatric clinicians—with instructions contrary to the previous AAP recommendation of peanut avoidance—and facilitating adherence with the guidelines have proven difficult. Compounding the challenge, clinicians currently are often managing heavy patient loads in busy practices with limited patient time during 4 and 6 month well visits.
A previously successful method for facilitating clinician guideline adherence is through clinical decision support (CDS) tools embedded in the electronic health record (EHR). Using this method, Ruchi S. Gupta, MD, MPH, and colleagues developed the Intervention to Reduce Early (Peanut) Allergy in Children (iREACH), a pediatric clinician training module and set of EHR-based CDS tools. Embedded within 4 and 6 month well visits, the tools include:
1) An order set for peanut–specific immunoglobulin (sIgE) testing or allergy referral for infants at high risk of peanut allergy.
2) A reminder to evaluate infant peanut allergy risk.
3) A prompt indicating peanut product introduction counseling.
4) An instructional handout for clinicians to provide parents and caregivers.
5) A best-practice advisory alert for infants with documented eczema or egg allergy.
For a paper published in JAMA Pediatrics, Lucy A. Bilaver, PhD, and colleagues conducted a pilot study to examine the effectiveness of the iREACH intervention. The intervention was implemented in one practice, while a second practice received no training modules or EHR modifications. Data was collected from 151 infants from the intervention practice and a random sample of 312 from the control practice (Table). The criteria for pediatric clinician adherence to the PPA guidelines was met if peanut introduction was documented in the EHR for those infants considered low-moderate risk for peanut allergy or sIgE testing and/or allergy referrals for those considered high-risk. Criteria for partial adherence was met if the parent or caregiver instructional handout was distributed to families of the low-moderate risk infants, even if recommendation of peanut introduction was not noted in the EHR.
Results from the iREACH pilot study indicated a significant difference between the iREACH intervention group and controls among low-moderate risk infants (Table). In the iREACH intervention group, pediatric clinicians were adherent to the PPA guidelines with 52.4% of infants seen; the control clinicians were adherent with only 14.1% of infants. Pediatric clinicians were partially adherent in 93.0% of infants seen in the iREACH practice. For infants at high risk for peanut allergy, results were inconclusive, as the sample size was too small for statistical significance.
Results from the iREACH pilot study suggest that a CDS tool may improve clinician adherence, but a more comprehensive study is needed. Thus, Dr. Gupta and team have begun a randomized control trial in more than 30 pediatric clinics to investigate the effectiveness of the iREACH intervention of increasing pediatric clinician adherence to the PPA guidelines and reducing the incidence of peanut allergy in children by age 2.5.