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Two-Thirds of Doctors Don't Follow Peanut Allergy Guidelines

child eating peanut butter sandwich

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Key Takeaways

  • A new survey of U.S. pediatricians showed most knew about peanut allergy guidelines, but only 29 percent were fully implementing them.
  • The biggest factor as to why allergy assessment may not be done is not enough office visit time.
  • Not all children should be given peanuts, especially those with eczema, as well as siblings who have a diagnosed allergy.

In 2017, the National Institute of Allergy and Infectious Diseases updated its clinical guidelines, which had been in place since 2010, for the diagnosis and management of peanut allergies, particularly for infants and young children.

Although previous guidance had called for avoiding peanuts and any foods containing them until later in childhood, the 2017 update noted there wasn't enough evidence to warrant that approach. Instead, it called for pediatricians to assess risk and introduce peanuts into the diet at 4 to 6 months of age.

Survey results just published in JAMA Network Open finds that the prevailing response among U.S. clinicians has been lackluster.

The survey asked 1,781 pediatricians if they were aware of the guideline change, and if they were implementing it. Awareness was high, at 93%, but that doesn't mean adherence was similar. In fact, of that group, only 29% were fully implementing the guidelines, while 64% reported partially implementing them.

"We have strong evidence demonstrating that avoidance of peanuts is linked with food allergy development, whereas early introduction, along with ongoing inclusion in the diet, is an effective prevention strategy for many infants," says David Stukus, MD, specialist in allergy and immunology in Columbus, Ohio, and advisor to the Asthma & Allergy Foundation of America. "That said, I'm not surprised by these recent findings, and it echoes what I've seen as well."

The prevalence of peanut allergies is on the rise, and while pediatricians are certainly not the cause of this, it's possible they may need to play a larger role in educating parents on the best ways to help prevent peanut allergies in their children.

Why They Skip It

Even with compelling evidence that avoidance of peanut allergies posing a potential risk, there are many reasons why pediatricians might be aware of these guidelines and choose not to follow them, Stukus says.

Although some may be hesitant due to past experience with negative peanut reactions in infants—which Stukus says can create bias and a higher degree of caution—the majority simply don't have time during the appointment to cover food allergies, as well as everything else that needs to be discussed during an infant wellness visit.

David Stukus, MD

Pediatricians have so much to cover with every family in the middle of a very busy office visit. It is nearly impossible for them to discuss all recommendations based on age-related well visit concerns, provide anticipatory guidance, and answer all parental questions.

— David Stukus, MD

Often, doctors may find it challenging to even remember or address feeding recommendations, so the the current findings reflect limitations with time rather than conscious pushback about following the guidelines.

Not every baby would benefit from peanut introduction, however. The guidelines state that caution should be used for children who have:

  • Severe eczema
  • Egg allergy
  • Parents or siblings with peanut allergies

Peanut Allergy Testing

Even though a conversation about peanut allergies doesn't take much office time, the actual protocol of assessing risk in an infant is another story. As the 2017 guidelines describe, it can involve:

  • Skin prick testing or blood testing, also called slgE tests
  • Availability of rescue medication if needed
  • Having four different peanut preparations on hand
  • Giving one dose of a preparation to an infant, then waiting for reactivity for 15 to 20 minutes
  • If no symptoms appear, dose 2 is given, for another 15 to 20 minutes
  • This is repeated for dose 3, 4, and 5

If all the instructions are followed, risk assessment would be at least two hours, and would involve a fairly high degree of observation for any allergic reactions.

Also, not every pediatrician has access to a peanut slgE test, adds Mitchell Grayson, MD, advisor to the Asthma and Allergy Foundation of America and specialist in pediatric allergy, asthma and immunology at Nationwide Children's Hospital.

"There may well be a fraction of providers who are simply trying to 'play it safe' and therefore, not introducing the peanuts per the guidelines."

What This Means For You

If you'd like to do allergy testing for your infant, it's helpful to try and schedule a separate, longer appointment for that with your pediatrician, or to ask for referral to an allergy specialist who would have access to a peanut slgE test and experience with this type of protocol. That's often easier than trying to fit allergy testing into an infant wellness visit.

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  1. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139(1):29-44.

  2. Gupta RS, Bilaver LA, Johnson JL, et al. Assessment of pediatrician awareness and implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States. JAMA Netw Open. 2020;3(7):e2010511. doi:10.1001/jamanetworkopen.2020.10511

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