Key Points for Practice
• Food containing peanuts should be introduced into the diet of infants four to six months of age who have severe eczema and/or egg allergy.
• Peanut-specific immunoglobulin E should be measured or a skin prick test performed before introducing peanuts in high-risk groups.
• If an infant has mild to moderate eczema, foods with peanuts can be given at approximately six months of age.
From the AFP Editors
Allergy to peanuts presents early and remains throughout life for most patients. It is the leading cause of death in the United States associated with anaphylaxis caused by food.
Because of a lack of evidence, the first guideline on food allergies published in 2010 by the National Institute of Allergy and Infectious Diseases (NIAID) did not provide recommendations on preventing peanut allergy. However, data have emerged indicating that peanut allergy can be prevented by introducing foods containing peanuts early to infants. For this reason, the NIAID has provided addendum guidelines, which include recommendations based on this new evidence.
Food containing peanuts should be introduced into the diet of infants four to six months of age who have severe eczema, egg allergy, or both. Before doing so, peanut-specific immunoglobulin E (IgE) should be measured or a skin prick test performed. When diagnosing an allergy via peanut-specific IgE, it should be noted that there is a strong negative predictive value for a level less than 0.35 kUA per L, making this test beneficial over skin prick testing in certain situations (e.g., family medicine and pediatric offices) to avoid unneeded subspecialist referral or to shorten the delay in introducing peanuts into the patient's diet. In infants whose IgE level is less than 0.35 kUA per L, the risk of experiencing a reaction is low; therefore, peanuts can be introduced at home or an office setting, depending on the preferences of the patient's parents or health care professional. Patients with a peanut-specific IgE level of at least 0.35 kUA per L should receive subspecialist referral, and skin prick testing should be considered.corrected
If skin prick testing with peanut extract results in a wheal of up to 2 mm greater than saline placebo, the risk of an allergy is low, and peanuts can be introduced at home or in the office setting, again based on the preferences of the patient's parents and physician. If a wheal of 3 to 7 mm develops, the risk of allergy is moderate to high, and supervised feedings in an office setting or referral for an oral food challenge is recommended. If these infants do not have a reaction during the supervised feeding or food challenge, peanuts can be introduced. If a wheal of at least 8 mm is produced, the infant is likely to have an allergy and should remain in the care of a subspecialist for assessment and monitoring.
If an infant has mild to moderate eczema, foods with peanuts can be added to his or her diet at home at approximately six months of age. Supervision in an office setting is not necessary, but it can be considered based on the preferences of the patient's parents or physician. Foods containing peanuts can be introduced with other age-appropriate solid foods to infants without eczema or other food allergies.
Guideline source: National Institute of Allergy and Infectious Diseases
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? No
Published source:Ann Allergy Asthma Immunol. February 2017;118(2):166–173.e7
LISA HAUK, AFP Senior Associate Editor