Parents, Providers Still Not Following Guidelines for Early Peanut Introduction

LOUISVILLE, Ky. -- NIH guidelines call for introducing babies to peanut products at around age 6 months to reduce allergy risk, but most U.S. parents said they waited much longer to introduce peanuts to their child's diet, according to a nationally representative survey.

Only about one in 20 caregiver responders said they introduced peanuts before age 6 months, with 44% stating that their children still had not had peanuts introduced to their diets by age 12 months, reported Ruchi Gupta, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago.

And among caregivers of high-risk babies with eczema, just 6% said they had introduced peanuts by age 6 months while 51.7% had done so by age 12 months, she said in a presentation at the American College of Allergy, Asthma & Immunology (ACAAI) annual meeting.

The survey results show that uptake of the early feeding recommendation from the National Institute for Allergy and Infectious Disease and ACAAI, remains low among caregivers and pediatricians, who may still be confused about when babies should be introduced to certain foods.

Gupta noted that allergists had a much greater knowledge of the latest recommendations calling for early feeding, but even they expressed some confusion and a desire for more training on how to best follow the guidelines. Her group reported similar results at the 2021 ACAAI meeting.

She noted that prior to the publication of the groundbreaking 2015 LEAP study, which showed early peanut introduction was tied with a >80% reduction in peanut allergies in high-risk children, parents of high-risk children were told to practice avoidance, and not introduce potentially allergic foods.

Recommendations for early feeding of high-risk infants soon followed publication of LEAP, and they have now been extended to all infants. A 2020 consensus guidelines from ACAAI and others extend the early feeding recommendation to include eggs, as well as peanuts. Specifically, the guidelines state that "To prevent peanut and/or egg allergy, both peanut and egg should be introduced around 6 months of life, but not before 4 months. Screening before introduction is not required, but may be preferred by some families. Other allergens should be introduced around this time as well. Upon introducing complementary foods, infants should be fed a diverse diet, because this may help foster prevention of food allergy."

For the current study, 1,895 general practice pediatricians in the U.S. answered the survey. Around 28% said they always followed the guidelines when advising caregivers, while 64% said they used only parts of the guidelines in their recommendations.

In terms of barriers, parental concerns about early feeding of potentially allergic foods was the main obstacle to early infant feeding, cited by 36% of the responding pediatricians. A third cited lack of understanding about how to best implement the guidelines, while a third cited lack of clinic time. One in four pediatricians cited the newness of the 2020 guidelines as a barrier. Just over two-thirds (68%) said they needed more training to best implement the guidelines.

Gupta reported that lack of time was the "number one thing pediatricians mentioned" as a barrier. She added that, in her own clinic, advising parents has been a challenge because of the time it takes to educate them about early feeding, and how to best introduce potentially allergic foods to their infants' diets.

"We have to tell them how much to give, how often, and what [allergic reactions] to look for, and that conversation takes time," she said. Gupta noted that the optimal time to have the conversation is at the 4- or 6-month well-child visit, but that can be difficult.

"There are a hundred things that need to be talked about -- [infant] development, feeding, sleeping. There is a lot going on at these visits," she said.

Gupta said a persistent misperception about food introduction among parents and pediatricians is that caregivers should introduce new foods separately, with a 3-5 day-interval before introducing the next new food. But that practice decreases the amount of food diversity during the important 4- to 6-month food introduction period, potentially increasing the risk for developing food allergies.

She also noted that almost half of the pediatricians surveyed said they were still recommending that exclusively breast-fed babies delay food feedings until age 6 months. Many said they still recommend waiting longer to introduce peanut, or other potentially allergic foods, to high-risk infants than to infants with average risk.

Gupta stressed that that is "the opposite of what they should be telling parents. [Babies] with risk factors for food allergies should be starting these foods earlier and getting more of these foods in their diets, but we are actually doing the opposite."

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