By Shereen Lehman

(Reuters Health) – Primary care physicians and pediatricians may not be following current guidelines that recommend introducing puréed peanuts to allergy-prone babies before the age of 6 months, a Canadian study suggests.

In a survey of pediatricians, family doctors and allergy specialists, the majority of pediatricians and family doctors recommended introducing allergenic foods between 6 months and 1 year of age. Most allergists correctly said milk, egg and puréed peanuts or peanut powder should be introduced between the ages of 4 and 6 months.

Emerging evidence that early peanut ingestion can help prevent peanut allergy in high-risk children has resulted in changing guidelines, said lead study author Dr. Elissa Abrams, a pediatric allergist at the University of Manitoba in Winnipeg.

“We felt it was important to identify what knowledge gaps existed, if any, among both primary care physicians and allergists with respect to guidelines about allergy prevention in infancy,” Abrams said in an email.

The researchers sent a survey to members of the Canadian Pediatric Society, the Canadian Society of Allergy and Clinical Immunology and a wide sample of Canadian family physicians. The survey asked about the doctor’s approach to managing infants at high risk for food allergies.

Eighty allergists, 170 pediatricians and 206 family practice physicians responded.

“Some primary care physicians are still recommending delaying introduction of allergenic solids, which was an interesting finding as the guidelines support earlier introduction of these foods to prevent food allergy, especially in children with a family history of allergies,” Abrams said.

Infants with known egg allergy or severe eczema are also considered to be at high risk of other food allergies, the study team writes in The Journal of Allergy and Clinical Immunology: In Practice. After being evaluated by a physician, these kids should be introduced to peanut between 4 and 6 months of age.

In the survey, allergists were almost 10 times more likely than pediatricians and family practitioners to recommend allergy testing before introducing peanuts to infants with severe eczema. Only 17 percent of allergists, 8 percent of pediatricians and 10 percent of family practitioners routinely recommended peanut allergy testing in infants with egg allergies, however.

Almost all allergists considered infants with severe eczema or egg allergy as being high risk. Most family practitioners and pediatricians defined high risk as having siblings or parents with peanut allergy.

“American Academy of Pediatrics and the Canadian Pediatric Society guidelines have defined an infant at risk of food allergy as having one or more immediate family members with an allergic condition such as food allergy, allergic rhinitis (hayfever), asthma, or eczema,” Abrams said.

The National Institute of Allergy and Infectious Diseases addendum guideline on peanut allergy prevention more recently defined an infant at risk of peanut allergy specifically as having either severe eczema and/or egg allergy. It’s likely that risk is a gradient, and perhaps some infants – such as those with severe eczema – are at higher risk than others, Abrams noted.

The researchers also found that allergists tended to recommend at least three feedings of peanuts each week, while the other practitioners didn’t offer any advice on how often peanuts should be fed after they’re introduced.

“I think this was a much-needed study to give an idea of how the guidelines are being implemented clinically,” said Dr. Rita Kachru, an allergist at the David Geffen School of Medicine at the University of California, Los Angeles who wasn’t involved in the study.

The results underline the need for better dissemination of data to all groups, she said.

“The recommendations in the U.S. are that infants at the highest risk for development of food allergy (severe eczema and/or egg allergy) be introduced to peanut as early as 4-6 months after allergy testing either by serology (specific IgE) or skin testing,” Kachru said in an email.

“If the testing is negative, introduction of food is implemented; if the testing is done by pediatrician/FP and is positive, the recommendation is a referral to an allergist for possible further testing/oral challenge.”

SOURCE: The Journal of Allergy and Clinical Immunology: In Practice, online August 13, 2018.