Some parents, doctors confounded by reversal of advice on peanut allergies

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PITTSBURGH — As a nurse, Amber Williams was well aware of the medical recommendations for starting her daughter on solid foods. She waited until Sienna turned 1 to give her milk, and was planning to wait until age 2 to introduce eggs and age 3 for peanuts.

But when Sienna was about 20 months old, her godmother gave her a bite of a peanut granola bar while babysitting. Welts broke out on her skin. Her blood pressure crashed. By the time she arrived at Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center in an ambulance, her throat was so swollen that a tube couldn't fit inside.

"I still have the book that I followed to a 'T,'"said Williams. "I did exactly what the American Academy of Pediatrics told me to."

A study released recently casts doubt on the advice once given to parents of children like Sienna, now 8, to delay introducing peanuts well into toddlerhood.

The study, conducted in the United Kingdom and published in the New England Journal of Medicine, followed 640 children deemed high-risk for developing peanut allergies. One group was given peanut products between 4 months and 11 months old, and continued to eat them three or more times per week. The other group wasn't given peanuts at all.

By the time the children were 5 years old, 3.2 percent of those who had eaten peanuts from an early age developed an allergy, versus 17.2 percent of those who had not.

The study, known as the Learning Early about Peanut Allergy (LEAP) trial, has been highly anticipated. "It's a study we've all known about for the last five years and we've been eager to see the results," said Todd Green, an allergist and immunologist at Children's Hospital of Pittsburgh. "The results were what people were expecting but even more of a dramatic effect than people thought. "

Allison Freeman, an allergist with the Allegheny Health Network, was in the audience at the American Academy of Allergy, Asthma and Immunology conference in Houston recently where the study was presented. "When it was announced, there was not an empty seat," she said. "People were lining the aisles."

The conclusions drawn from the study — that introducing peanuts early can actually help prevent allergies — are completely contrary to the theories espoused by doctors, including Dr. Freeman, in the 1990s and early 2000s.

"We went crazy 20 years ago telling parents to avoid feeding these allergenic foods to their newborns — moms even went to the extent of avoiding it during pregnancy and breastfeeding," she said. "I have a lot of personal guilt. I had it all wrong, this is my mea culpa."

At the time, she said, doctors were looking for answers not necessarily to the problem of peanut allergies but to rising asthma rates, a condition often associated with peanut allergies. On the theory that children would better be able to handle peanuts if their immune systems and gut were given more time to mature, they urged parents to wait before feeding them the legumes. The AAP formally recommended in 2000 that parents wait until children turn 3 to first try peanuts.

But since that time, the number of peanut allergies has risen sharply. One study found that the rate of peanut allergies in the U.S. has more than quadrupled, jumping from 0.4 percent in 1997 to more than 2 percent in 2010.

"It has become a societal problem," said Dr. Freeman. "These families can't go to a restaurant, can't go to a birthday party, can't trust the school system."

The prevalence isn't hard to spot: Day-care centers are regularly peanut free, for example, and some local elementary schools ban all snacks in the classroom that aren't pre-packaged. The popular line of American Girl dolls sells, for $28, an "allergy-free lunch," complete with berry smoothie, medical bracelet and toy allergy syringe.

"It affects almost every decision we make about where he goes in the world," said Jodi Hirsh, whose 6-year-old son Simon broke out in hives and starting coughing and grabbing his throat after eating a small bit of his first peanut butter sandwich when he was about 18 months old. "We think about, will there be food there, will there be an adult there who could administer a shot (that would administer epinephrine, the drug that treats severe allergic reactions)? In terms of everyday life, what if he's at a playground where someone was eating a peanut butter sandwich very messily and he puts his hand down?"

When Simon's 3½-year-old sister, Ruby, was tested for a peanut allergy at age 2 and came up borderline, doctors advised her family to hold off on giving them to her. At this point in her life, she's never had a peanut, though Hirsh called last week after hearing about the study to make an allergist appointment for her.

"If a study comes out and says, if you had just done 'X' that wouldn't have happened, it can be frustrating; I followed the medical guidelines," she said. "I have great respect for the field of medicine, but allergic medicine has been incredibly frustrating. There's no consistent advice."

Inconsistencies between how countries deal with peanut introduction actually spurred the idea for the study. During a talk in Israel about 15 years ago, study co-author Gideon Lack asked a room of doctors to raise their hands if they had treated a patient with a peanut allergy. Less than a handful of hands went up, whereas when he asked that question of doctors in England nearly every hand did.

He theorized that the difference might be due to the popularity of a puffed peanut snack, called Bamba, commonly given to infants in Israel, vs. the practice in the United Kingdom to delay the introduction of peanuts past a child's first birthday.

In a 2008 study, he found that the risk of developing a peanut allergy was 10 times as high for Jewish children in the U.K. versus children in Israel with a similar genetic history.

Also in 2008, the AAP backed off of its earlier recommendations, saying that there was no evidence that delaying the introduction of allergenic foods made allergies worse, though there was also no evidence that introducing them earlier prevented allergies.

The current advice from allergists is likely to change based on the results of the LEAP study.

"It's a little bit dangerous to make big changes based on one study but this was a very well-designed study and it was pretty dramatic," said Dr. Green at Children's. He believes an official position statement from the AAP or a similar group will likely come soon on the issue, and said he would change his advice to patients accordingly.

Dr. Freeman at AHN isn't waiting that long. She is urging parents with infants who are high-risk for a peanut allergy — those with severe eczema, other food allergies or siblings with allergies — to make appointments as soon as possible to figure out whether it is possible for them to safely introduce peanuts.

The LEAP study gave initial skin tests to its participants. Those with a minor reaction to the test were still given peanuts under supervision in a doctor's office. In that group specifically, 10.6 percent who were given peanuts had developed an allergy by age 5, vs. 35.3 percent in the group that did not consume peanuts.

For infants with no risk factors for peanut allergies, Dr. Freeman recommends trying peanuts and other allergens early in the process of introducing solid foods. After a baby can tolerate traditional baby foods like a vegetable or cereal, she recommends the parents try egg yolk, then egg white, then dairy and then peanut products (not the actual peanuts because they could be a choking hazard for a child that young).

"If the baby has very bad skin, get in and talk to an allergist by 4 or 5 months of age," she said. "Up until this point we probably wouldn't have seen the child until they were 1. I'd rather see a lot of babies and do a little testing now and prevent the allergies rather than treating them later."

Believing that some pediatricians are regularly passing on outdated information on delaying peanut consumption, Dr. Freeman is planning to reach out directly to obstetricians, asking them to share the new data with their pregnant patients.

Dr. Green cautioned that even though the results of the study were strong, they were not 100 percent. Even among participants with no initial reaction to the skin test, 1.9 percent who ate peanuts went on to develop an allergy.

The study also does not provide any good news for children like Sienna who already have a peanut allergy. Only about 20 percent of children diagnosed with a peanut allergy eventually outgrow it.

Since her diagnosis, Sienna has been rushed to the hospital twice — once while drinking from a cup at a restaurant that used peanut oil and another time after eating Chex Mix at a friend's house. Sienna has a hot pink purse in which she carries EpiPens at all times and has never eaten food from a bakery. Grocery shopping takes about two hours, said Williams, because she checks every label.

"It makes me wonder if we had started peanuts when we did solid food, we wouldn't be in the situation we're in," said Williams. "By the time she had it, her body was like, 'What the heck is that?'"

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