Should we be giving infants foods containing peanuts?

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Dear Parents,

For the longest time the theory was as follows:

Introducing foods that are more frequently associated with allergy  to a young child when the gastrointestinal wall is more permeable to allergens was likely to sensitize a child to have allergies in later life.

The theory seems to make perfect sense ; however in our day and age of evidence based medicine, sometimes our theories are turned upside down. More recent studies have shown no benefit in many cases of allergy avoidance, and the newly publishes LEAP ("Learning Early About Peanut Allergy") study has in fact  suggested that introducing young children to peanuts may in fact  decrease the later prevalence of peanut allergy in older children. 

In recent years peanut allergy has increased worldwide and has in fact tripled in the United States. In Israel, where 90 % of the population buys BAMBA, a peanut containing snack on a regular basis, there is a much lower incidence of peanut allergy.

Dr. Gideon Lack, a professor of pediatric allergy at King’s College London, led an international team of researchers in a groundbreaking study based on the idea that Israeli children have lower rates of peanut allergy compared to Jewish children of similar ancestry residing in the United Kingdom.The study tested the hypothesis that the very low rates of peanut allergy in Israeli children were a result of high levels of peanut consumption beginning in infancy.

Children high risk for developing peanut allergy who were given peanut containing foods for 3 years in childhood had a lower incidence of peanut allergy at 5 years of age,  as opposed to the control group  who obstained from exposure to peanut containing products.

Findings from the LEAP study were published in "The New England Journal" February 2015, and in the "Pediatrics" Journal last month, September 2015. The Academy of Pediatrics has endorsed their findings.

How does this translate into our practice.
Many feel that given the potential benefit, all infants, regardless of risk level, should have peanut introduced early into the diet.
It has also been suggested that atopic infants (those with moderate to severe eczema or allergy to eggs) should consider to be tested by an allergist using skin prick testing to see if they have already developed severe peanut allergy; in which case peanuts should be strictly avoided. If the results demonstrate no allergy, then peanut containing foods should be introduced and continued at 2 grams three times a week for the next 3 years. If the testing demonstrates only mild allergy, peanut contaning food products should  be introduced, but only under the direct supervision of a physician. 

In truth some questions still remain:

Does this tolerance remain after the 3 year period even when peanuts are not continually given?

Does this tolerance only develop when peanut is given 3 times a week continually  as was done in the study?

If peanuts are taken only intermittently, would these children be at higher risk for severe allergy?

Does living in a nut free environment negatively affect peanut tolerance in those without significant or severe allergy?

Can these findings be extrapolated to all allergens as well?

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Howard Nass MD FAAP and staff