Further efforts needed to reduce implementation and adherence barriers

While most pediatricians are familiar with the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States, most have not fully embraced them in their practice.

According to a study/survey of pediatricians, 64% of those familiar with the guidelines have partially implemented them, while just 29% have fully implemented those guidelines,

The results of the study, led by Ruchi S. Gupta, MD, MPH, Center for Food Allergy & Asthma Research, Northwestern University Feinberg School of Medicine, suggest that efforts are needed to reduce the barriers to guideline implementation and adherence in order to reduce the incidence of peanut allergies in infants.

The study was published in JAMA Network Open.

Food allergies affect about 8% of children in the United States, and that number is increasing. The most common pediatric food allergy is peanut allergy (2.2% of children), which many children do not outgrow and can result in severe reactions.

Results from the Learning Early About Peanut Allergy randomized clinical trial showed that when infants between the ages of 4 and 11 months who are at high risk for developing peanut allergies are introduced to peanuts it reduces peanut allergy prevalence by 81% by the time those children reach 5 years of age. Consequently, the Addendum Guidelines for the Prevention of Peanut Allergy in the United States were published in 2017, with these recommendations:

  • Infants with severe eczema and/or egg allergy should undergo evaluation for allergic sensitization to peanuts through specific immunoglobulin E test and/or skin prick testing and, if necessary, an oral food challenge, with peanut products introduced into the diet as early as 4 to 6 months of age depending on the results.
  • Infants with mild to moderate eczema should begin peanut consumption around age 6 months.
  • Infants with no eczema or food allergy may consume peanuts when age appropriate, in accordance with family preference and cultural practices.

Gupta and colleagues pointed out that previous studies have shown that pediatricians have been slow to implement and adhere to these guidelines. Therefore, in this study their objective was to measure rates of guideline awareness and implementation and identify those barriers to successful implementation.

From June1, 2018-Dec. 1, 2018, 1,781 pediatricians in the American Academy of Pediatrics vendor database responded to an electronic survey consisting of 29 questions. Among these respondents, the vast majority (93.4%) were aware of the guidelines, and most reported they were somewhat or very familiar with their content.

However, of those aware of the guidelines, only 28.9% reported fully implementing them, while 64.3% reported partial implementation. And, when presented with three clinical scenarios that would demonstrate correct guideline implementation, only 40.6% of participants were able to give answers consistent with the guidelines for infants in all three (high, moderate, and low) risk categories.

The most common barriers to implementation included parental concerns about potential allergic reactions (36.6%), uncertainly in understanding and correctly applying the guidelines (33.2%), uncertainty about correctly conducting in-office feeding of peanuts (32.4%), lack of clinic time (28.7%), newness of the guidelines (25.5%), and parental concerns about blood draws (20.1%).

More than 2/3 of the respondents (68.4%) acknowledged the need for more guideline training.

Gupta and colleagues suggested that more research is needed into the kinds of training and practice aids that will increase implementation, and that future revisions to the guidelines should be considered “to improve their penetrability.”

In a commentary accompanying the study, Marcus Shaker, MD, MSc, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Elissa M. Abrams, MD, University of Manitoba, and Matthew Greenhawt, MD, MBA, MSc, University of Colorado School of Medicine suggested that implementation of these guidelines should involve “a contextual family preference–sensitive discussion.”

Shaker and his colleagues wrote that a screening approach to the introduction of peanuts is not cost-effective and, as demonstrated in the study by Gupta and colleagues, “appears to have low acceptance among clinicians and caregivers.” They also pointed out that while the evidence for early peanut introduction is of high certainty, “the evidence supporting screening is not.”

Furthermore, they noted that the United States is the only country that recommends universal peanut screening for high-risk infants, and that while countries like Canada, the U.K, Australia, and New Zealand encourage the introduction of peanuts in infants without screening, no fatalities have been reported in the literature from an infant eating a peanut the first time.

“As clinicians, we must help families find the balance between the risks and benefits of peanut introduction during infancy,” wrote Shaker and his colleagues. “In some circumstances, family preferences may lean toward screening, presumptive peanut allergy diagnosis, or a supervised oral food challenge. However, our recommendations must be contextual and tailored to each patient and family so that we can provide the right care at the right time.”

  1. While the vast majority pediatricians are aware of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States, most have not fully implemented them.

  2. The study authors suggest that efforts are needed to reduce the barriers to guideline implementation and adherence in order to reduce the incidence of peanut allergies in infants.

Michael Bassett, Contributing Writer, BreakingMED™

Gupta reported receiving grants from the National Institute of Health (NIH) during the conduct of the study and from Stanford Sean N. Parker Center for Allergy Research, UnitedHealth Group, Thermo Fisher Scientific, Genentech, and the National Confectioners Association as well as personal fees from Before Brands, Kaléo Inc, Genentech, Institute for Clinical and Economic Review, Food Allergy Research & Education, Aimmune Therapeutics, and DBV Technologies outside the submitted work.

Abrams reported serving on the Healthcare Advisory Board of Food Allergy Canada during the conduct of the study.

Greenhawt reported receiving grants from the Agency for Healthcare Quality and Research as well as personal fees from Intrommune, Aimmune, DBV Technologies, Thermo Fisher, Nutricia, Kaleo, Sanofi/Genzyme, Nestle, Genentech, AllerGenis, Aquestive, Allergy Therapeutics, Prota, Monsanto, Merck, GlaxoSmithKline, Aravax, and American College of Allergy Asthma and Immunology outside the submitted work.

Cat ID: 99

Topic ID: 80,99,730,99,138,192,925