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New Peanut Allergy Protocols

On Jan. 5, an expert panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), issued new clinical guidelines regarding the prevention of peanut allergies in children. The guidelines are based on groundbreaking studies conducted in recent years.

The panel issued three separate recommendations determined by the level of risk babies have for developing a peanut allergy.

In this segment, Dr. Avraham (Avi) Beigelman, MD, a Washington University allergy, immunology and pulmonary medicine specialist at St. Louis Children’s Hospital discusses these new guidelines for children with peanut allergies and when a pediatrician should refer to a specialist.
New Peanut Allergy Protocols
Featured Speaker:
Avraham (Avi) Beigelman, MD
Avraham (Avi) Beigelman, MD, is a Washington University allergy, immunology and pulmonary medicine specialist at St. Louis Children’s Hospital.

Learn more about Avraham (Avi) Beigelman, MD

Melanie Cole (Host): Recently, an expert panel sponsored by the National Institutes of Allergy and Infectious Diseases, part of the National Institutes of Health, issued new clinical guidelines regarding the prevention of peanut allergy in children. The guidelines are based on groundbreaking studies conducted in recent years. My guest today is Dr. Avraham Beigelman. He’s a Washington University Allergy, Immunology, and Pulmonary Medicine specialist at Saint Louis Children’s Hospital. Welcome to the show, Dr. Beigelman. First, let’s describe the peanut allergy and really how it is identified.

Dr. Avraham Beigelman (Guest): Good morning, everyone, and thanks for having me. Peanut allergy, like any other food allergy, usually will be diagnosed once the child has an adverse reaction to the food. The most common adverse reaction are skin symptoms, which could be rash, hives, but as any other food allergy, some of the reactions are severe and may cause anaphylaxis. Anaphylaxis is what we call a reaction which involves more than one system in our body. This could be hives and vomiting -- sometimes in the most severe cases a drop in the blood pressure and, obviously, some of the reactions could be very severe – could be life-threatening. And it’s not really different between peanuts and other food allergies, but the focus, today is peanuts just because of the new guidelines for food allergy -- or peanut allergy prevention.

Melanie: So there was an article recently published in the physician newsletter discussing the new NIH guidelines recommending the early introduction of peanut-based foods, Dr. Beigelman, and the new clinical guidelines regarding the prevention of peanut allergies in children. Speak about those new recommendations for a bit.

Dr. Beigelman: Yes, absolutely, and basically these new recommendations are a total change in the way that we understand a peanut allergy and most probably other food allergies. Just as a reminder, the guidelines were totally different 17 years ago. In the year 2000, the official guidelines from the American Academy of Pediatrics and the European Society were to postpone the introduction of peanuts and other allergenic foods like eggs and tree nuts for babies that are at high risk to develop those food allergies. The idea was – people believed if we postpone it, we might be able to prevent food allergy. We know today that it was totally wrong and actually, the evidence to come out even ten years ago -- because the guidelines were changed in 2006 – the official guidelines from the American Academy of Pediatrics was you don’t need to postpone the feeding. You can start solid foods, even for high-risk infants, at the age of 4 to 6 months in addition to breastfeeding, but it was not an official recommendation that you have to do it and this is the major change in the current guidelines.

The major change today is not that you can do it, but you should do it. If I’m a physician and one of my patients is a baby that is in high-risk to develop peanut allergy, usually based on the existence of eczema, the guidelines suggest that I should actively recommend to the family to eat peanut products. I think that’s the major change in the current guidelines from the previous version that came out in 2006.

I want to emphasize two very important issues regarding early introduction of peanuts. We will never, never give whole peanuts or any other tree nuts to babies because of the risk of choking. We need to adjust the food to the age of the child, and the months we are speaking about early introduction of peanut products in young babies, usually, we will recommend introducing smooth peanut butter that is dissolved in something. It could be a little bit of water; it could be the baby’s formula, breast milk, apple sauce, something because we’re really nervous about the risk of choking.

This is one thing, and the other thing that I want to emphasize that we are dealing with the early introduction of peanuts and most probably it’s true for all other foods, but it’s not instead of breastfeeding. We’re still advocating for breastfeeding, but then, in addition, by the age of four months, we can start to introduce all other foods. Those are the major changes in these new guidelines that came from the National Institute of Health.

Melanie: If eczema is present, is peanut testing before introduction required for these infants?

Dr. Beigelman: That’s a great question. The problem is that eczema is a very common disease. The guidelines divide the recommendation based on the severity of the eczema. For patients with mild eczema or mild-to-moderate eczema, and they define it as eczema that does not require treatment with prescription medication. A little bit of moisturizer is fine; over-the-counter topical steroid is fine. This level of eczema you don’t want to do any prior testing, any prior evaluation.

There is one group of patients, which is a very limited group of patients – those are the patients with severe eczema that require treatment with prescription medications for the eczema. The guidelines suggest that these babies should be evaluated for an allergy before we introduce the peanuts. We evaluate these babies in our clinic, and we will perform skin testing. Based on the results, we will decide if we should tell the family just introduce the peanut product – peanut butter at home, or sometimes we will just feed the babies with the peanut butter at the clinic to be sure that they are not already allergic, but they want to emphasize those are the minority of the population of babies because severe eczema is not so common. For most of the babies at the age of 4 to 6 months, they can be fed with peanut products at home, again, with the acknowledgment that we need to adjust the food to the age of the child to avoid choking, but most of them do not need to be evaluated. Those with severe eczema, they should be evaluated by an allergist before.

Melanie: In the presence of existing peanut allergy, which so many children do have at this time, what would you tell other pediatricians about managing that child and possible treatments that are out there right now?

Dr. Beigelman: Right now, we are limited to the treatments that are available for the general population on to the regular – that are available as the main practice. There are protocols that are in research right now, and I’m pretty sure that in not too many years from now we will be able to actively treat these babies. There are two main pathways; one is the oral desensitization protocol. They are done, right now, as a research protocol in multiple institutions. The fine details of this protocol still need to be defined because they are still associated with a higher prevalence of adverse reaction. They are not ready for prime time yet, but I am optimistic.

The other area of research is the peanut patch. There is a company that is based in Europe that developed a patch which contains a small amount of peanut allergen, and now they’ve expanded to other foods. They are applied to the skin for weeks and months, and the initial results are actually encouraging and again, it’s not ready for prime time yet. It’s still under research, but I’m really optimistic that in a few years we will be able to actively treat these children and not just recommend them to avoid, which is basically what we are doing right now.

Melanie: So wrap it up for us, Dr. Beigelman, for other pediatricians and what you would like them to know about these new recommendations. What would you like to tell them about when to refer and what you would like them to know?

Dr. Beigelman: I think the main change is the concept. It’s very clear that early introduction of foods is beneficial. It’s proven in more than one study for peanuts. It has been proven for eggs, and most probably it’s true for other foods, so I think it’s safe to recommend to introduce all types of food from the age of 4 to 6 months. Of course, we will do it one at a time. We will tailor the foods to the age of the child and his or her capacity to eat the foods and avoid other risks of choking, but it’s very clear that early introduction is beneficial and specifically for peanuts is the issue of whether the child is at high-risk to develop a peanut allergy. For the kids that are at the highest risk to develop the allergy based on the coexistence of severe eczema or other food allergies like egg allergy, it would be better if they will be evaluated first by an allergist. For all other children, it would be safe to recommend them to start to eat peanut butter dissolved in some carrier at home by the age of 4 to 6 months, and again, it’s not instead of breastfeeding, it’s in addition to breastfeeding in order to prevent a peanut allergy and other food allergies.

Melanie: And tell us about your team, why is Saint Louis Children’s Hospital so great to work with?

Dr. Beigelman: We have a very large division and a very large team of allergists and nurses that can take care and support this population. We have 6 allergists in our division, multiple nurses. We are working very closely with Saint Louis Children’s Hospital dieticians, and we are ready and happy to take care of all the children, and of course, it’s the first time we can do something actively to prevent peanut allergy and prevent other food allergies.

Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds, with Saint Louis Children’s Hospital. For more information about resources available at Saint Louis Children’s Hospital, you can go to, that’s This is Melanie Cole. Thanks, so much, for listening.