Overview

Definition:
-The early introduction of peanut-containing foods to infants, particularly those considered high-risk for developing peanut allergy, aims to induce tolerance and prevent sensitization
-This strategy is largely informed by the landmark Learning Early About Peanut allergy (LEAP) study.
Epidemiology:
-Peanut allergy is a significant and increasing public health concern, affecting approximately 1-2% of children in Westernized countries
-High-risk infants, defined by severe eczema, existing egg allergy, or both, have a substantially higher risk (up to 80%) of developing peanut allergy compared to the general infant population.
Clinical Significance:
-Uncontrolled peanut allergy can lead to severe, life-threatening anaphylactic reactions
-Early, evidence-based introduction strategies can significantly reduce the incidence of peanut allergy, mitigating long-term health burdens and improving quality of life for affected children and their families
-This is a crucial topic for pediatricians preparing for DNB and NEET SS examinations.

Risk Stratification

High Risk Infants:
-Infants with severe eczema, egg allergy, or both are considered high-risk
-These infants may benefit most from early introduction and require careful evaluation.
Moderate Risk Infants:
-Infants with mild to moderate eczema are considered moderate risk
-Introduction strategies for this group may also be beneficial.
Low Risk Infants:
-Infants without eczema or other food allergies are considered low risk
-Current guidelines recommend introduction around 6 months of age, alongside other solids.

Diagnostic Approach

History Taking:
-Detailed history of eczema severity, previous allergic reactions, family history of allergies (especially peanut allergy), and maternal diet during pregnancy and lactation are crucial
-Assess for existing food allergies.
Physical Examination:
-Thorough assessment for eczema severity, including atopic dermatitis classification
-Check for signs of other allergic conditions like rhinoconjunctivitis or asthma.
Allergy Testing:
-For high-risk infants, consideration of peanut-specific IgE testing or skin prick testing (SPT) may guide the timing and approach to introduction
-A positive test warrants discussion with an allergist and careful supervised introduction
-However, a negative test does not preclude allergy.
Referral Consideration: High-risk infants with severe eczema or positive allergy tests should ideally be evaluated by an allergist or pediatrician experienced in food allergy management before commencing peanut introduction.

Management Strategies

For High Risk Infants:
-The LEAP study demonstrated that early introduction (between 4-6 months of age) of peanut protein in high-risk infants, following allergy testing and physician consultation, significantly reduced the incidence of peanut allergy
-Introduction should be supervised by a healthcare professional, with immediate access to emergency care
-Peanut protein can be introduced in forms like smooth peanut butter or peanut puffs, avoiding whole nuts due to choking hazard.
For Moderate Risk Infants:
-For infants with mild to moderate eczema, early introduction around 6 months of age, along with other complementary foods, is generally recommended
-If there is concern, consultation with a pediatrician is advised
-Avoidance is no longer the recommended strategy.
For Low Risk Infants:
-Introduction of peanut products should occur around 6 months of age, once other solid foods have been successfully introduced
-There is no need for prior allergy testing in this group
-Smooth peanut butter mixed with breast milk, formula, or pureed food is a safe option
-Avoid whole peanuts due to choking risk.
Introduction Method:
-Start with small amounts of thoroughly cooked or processed peanut protein
-Observe for any allergic reaction for 2 hours after the first introduction
-Gradually increase the amount if no reaction occurs
-Continue regular consumption (e.g., 3 times per week) to maintain tolerance.

Monitoring And Follow Up

Immediate Monitoring: Observe infants for at least two hours after the initial introduction for signs of allergic reaction, such as rash, hives, vomiting, diarrhea, difficulty breathing, or swelling.
Ongoing Monitoring:
-Continue to offer peanut products regularly (at least 3 times per week) to maintain tolerance
-Monitor for any delayed reactions or development of new symptoms over time.
Allergy Signs:
-Educate parents on recognizing symptoms of anaphylaxis and the importance of immediate medical attention
-This includes angioedema, urticaria, bronchospasm, stridor, hypotension, and gastrointestinal distress.
Follow Up Appointments:
-Regular pediatric follow-up is essential
-Discuss any concerns regarding food introduction and allergy development
-Further allergy testing may be indicated if symptoms arise.

Complications

Allergic Reactions:
-The primary complication is an allergic reaction, ranging from mild symptoms like hives to severe anaphylaxis
-Early identification and prompt management are critical.
Anaphylaxis:
-A life-threatening systemic reaction characterized by airway compromise, circulatory collapse, and/or gastrointestinal or skin symptoms
-Prompt administration of epinephrine is the mainstay of treatment.
Choking Hazard:
-Whole peanuts and chunky peanut butter pose a significant choking hazard for infants and young children
-Use age-appropriate, smooth, and diluted forms.
Delayed Reactions:
-While most reactions occur within minutes to hours, delayed reactions can also occur
-Parents should remain vigilant.

Key Points

Exam Focus:
-LEAP study findings on early peanut introduction significantly reduce allergy incidence in high-risk infants
-DNB/NEET SS will test understanding of risk stratification, timing, and safe introduction methods
-Differentiate management for high, moderate, and low-risk infants
-Anaphylaxis management is critical.
Clinical Pearls:
-For high-risk infants, consider IgE/SPT testing prior to supervised introduction
-ALWAYS supervise the first introduction and observe for 2 hours
-Emphasize smooth peanut butter or puffs, never whole nuts
-Regular, consistent exposure is key to maintaining tolerance
-Educate parents thoroughly on reaction signs and management.
Common Mistakes: Delaying introduction in high-risk infants (which increases risk), recommending avoidance strategies, using whole peanuts or unsafe forms, failing to supervise initial introduction, and not emphasizing consistent, regular consumption to maintain tolerance.