Implementation of Early Peanut Introduction Guidelines Among Pediatricians

Abstract

RATIONALE: To evaluate the safety of sublingual immunotherapy (SLIT) for peanut allergy using commercially prepared peanut cream. METHODS: We enrolled children aged <15 years who were diagnosed with peanut allergy by an open oral food challenge (OFC) and who agreed to undergo peanut SLIT. Doses of peanut protein from commercially prepared peanut cream were gradually increased from 13.8 mg/day to 4600 mg/day over the study period. We evaluated adverse events during SLIT and changes in maximum tolerated OFC doses from initiation to 12 months. RESULTS: Ten patients with a median age of 5.6 years (range: 5-13 years) were included in our study. One patient withdrew from the study; however, this was not due to an adverse event. Regarding adverse events, symptoms involving the oral cavity occurred in 7/10 cases (156/2045 dose times, 7.6%), and mild systemic symptoms occurred on an average at 0.1 times/case/year. The median maximum tolerated OFC dose increased significantly from 0.3 g (range: 0.1-0.5 g) to 0.4 g (range: 0.1-3.0) over 12 months (p50.034). In addition, the skin prick test wheal size decreased significantly from 1062.4 to 7.361.7 mm over 12 months (p50.006). Conversely, median peanut-specific IgE levels were not significantly different at 12 months (13.6 UA/ml) compared to baseline (13.5 UA/mL) (p50.43). CONCLUSIONS: SLIT using commercially prepared peanut cream resulted in only a few, mild adverse reactions and may increase tolerance to peanuts. Further studies are needed to evaluate the effectiveness of peanut SLIT.

Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States

“…More recent studies involving medical record review of infants at the 4 to 6–month well-child visits have also suggested low rates of guideline adherence. 11 , 16 In a review of 312 infant well-child visits in a Chicago clinic, pediatricians were fully adherent to the guidelines for only 14% of infants, regardless of risk level. 11 Tapke et al 16 indicated that early peanut introduction was discussed in 3.3% of the 4 to 6–month well-child visits of infants with high risk.…”

“… 11 , 16 In a review of 312 infant well-child visits in a Chicago clinic, pediatricians were fully adherent to the guidelines for only 14% of infants, regardless of risk level. 11 Tapke et al 16 indicated that early peanut introduction was discussed in 3.3% of the 4 to 6–month well-child visits of infants with high risk. These data raise the possibility that despite their knowledge of and willingness to adhere to the guidelines, pediatricians may encounter practical obstacles that decrease implementation rates.…”

“…In the Hoffman et al survey of pediatricians at an academic medical center, 11% of respondents achieved high rates of adherence; however, this study was conducted soon after the publication of the guidelines. More recent studies involving medical record review of infants at the 4 to 6–month well-child visits have also suggested low rates of guideline adherence . In a review of 312 infant well-child visits in a Chicago clinic, pediatricians were fully adherent to the guidelines for only 14% of infants, regardless of risk level .…”

User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study

“…Despite the new guidelines, the rates of early peanut introduction remain low [20][21][22][23]. The recommendation for testing high-risk infants prior to early introduction created confusion [21,24], high cost [25], and logistical challenges [21,24,25].…”