Early peanut introduction gaining traction among US parents, but more work needed

In 2017, the National Institutes of Health (NIH) announced a dramatic reversal in its approach to peanut-allergy prevention, recommending parents expose their infants as young as four months old to peanuts to prevent peanut allergy.

In the five years since, early introduction to peanuts has been gaining traction among U.S. parents and caregivers, but more work must be done to communicate the guidelines more broadly, especially to those with less access to health-related information, reports a new study from Northwestern University and the Ann & Robert H. Lurie Children's Hospital of Chicago. Among all surveyed parents and caregivers in the U.S., 13% of parents said they're aware of the guidelines and 48% believed feeding peanuts early prevented peanut allergy, despite knowing about the guidelines or not.

"There was general awareness of 'If I give these foods early, it will help,' even if families didn't know it came from the NIH guidelines," said Dr. Waheeda Samady, associate professor of pediatrics at Northwestern University Feinberg School of Medicine and director of clinical research at Northwestern's Center for Food Allergy and Asthma Research. "There's still a lot of room for growth in terms of educating families and clinicians about these guidelines."

The study found that having a pediatrician who recommended early peanut introduction was the strongest factor in whether a parent or caregiver was aware of the guidelines.

"This study is taking a look at something still so new to health systems in the U.S.," said senior author Dr. Ruchi Gupta, director for the Center for Food Allergy and Asthma Research, professor of pediatrics and a pediatrician at Lurie Children's Hospital. "As a pediatrician, I'm sensitive to the fact that there is a lot to juggle during a four- or six-month appointment. We need to find ways to support pediatricians in their workflows to incorporate the prevention guidelines."

The study is the first nationwide survey to examine the impact and implementation of the guidelines since their release five years ago. It will be published July 21 in Pediatrics.

The authors said the findings provide an understanding of where American parents land on peanut feeding and where the gaps are. This includes:

• Access to care barriers and systemic racism, which makes this information less known to non-white, less-educated and lower-income parents
• Supporting primary care providers to provide this information in a timely way
• Public health messaging about reactions to peanuts, since this was the main fear reported in the survey

A closer look at the findings:

The 13% of parents and caregivers who said they were aware of the 2017 guidelines reported being white, between the ages of 30 and 44, educated and high income, or cared for a child with food allergy or eczema, the study found.

The scientists asked survey respondents if they exposed their children to peanuts 1) before seven months (around four to six months old) and 2) after seven months (between seven months and a year old). Seventeen percent of all parents first offered peanut-containing foods before the age of seven months and 42% did so between the age of seven and 12 months, the study found. Peanut introduction occurred earlier among guideline-aware parents/caregivers, with 31% offering it before seven months.

Fear of reaction was No. 1 reason for delayed introduction

Thirty-three percent of those who delayed peanut introduction reported a fear of reaction to peanuts as the most common reason. However, the percentage of actual reported reactions of infants and children during peanut introduction were only 1.4%.

"Previous studies have found that, on average, infant reactions are much milder than older kids' reactions," Samady said. "Based on this, I would say you should be more concerned about your older child, not your five-month-old. Statistically, reactions are much milder younger in life."

The study found reactions that did occur were mostly dermatological (e.g., a rash) or gastroenterological (e.g., vomiting).

"The perception among U.S. parents/caregivers about how common reactions are in children is much higher than the reality," Samady said.

Broad dissemination of information, resources to integrate are key

There must be a multifold approach to reaching all U.S. parents and caregivers, Samady said.

"We have to get to all the pediatricians, not just those who work in academic or affluent areas," Samady said. "But we need to think outside that box as well." The information should be shared at community centers, daycares and supplemental nutrition programs for WIC clinics (women, infants and children), Samady said.

Other Northwestern co-authors include Christopher Warren, Lucy Bilaver, Justin Zaslavsky and Jialing Jiang.