Nieman: Fear wins out over facts on early exposure to peanuts

I have always been intrigued by guidelines. Guidelines are generated by experts who know substantially more than their target audience and these experts’ sincere motives are to change the behaviour of both doctors and their patients.

In 2000, the American Academy of Pediatrics infant feeding guidelines recommended delaying the introduction of peanuts until three years of age.

As expected, with more knowledge generated by research, guidelines are often revised. The issue of when children should first be exposed to peanuts was revised in 2008 and again in 2017. However the more guidelines are revised, the more confusing things may become.

The matter of preventing peanut allergies serves as a telling example of the gap between guidelines and the reality of behaviours which are slow to change.

A particular study, known as the Learning About Peanut Allergy trial (LEAP), reported an 81 per cent reduction in peanut allergy among high-risk infants when peanut products were introduced between four and 11 months of age.

The LEAP study led to the 2017 recommendations to doctors and parents that peanut exposure should not be delayed, but be done before one year of age, in some cases as early as four months of age.

However, six years later, we are learning that only 31 per cent of parents in North America are willing to feed peanut products to their infants at six months of age. A great number of primary care doctors still tell parents to delay the introduction of peanut products until a patient enters toddlerhood.?

In other parts of the world, such as Australia, the rate of early peanut introduction is significantly higher. The EarlyNuts study done Down Under showed that the rate of early introduction in the Australian population increased from 24 per cent to 88 per cent. Researchers feel that a more robust national campaign and high access to pediatric care may explain such a vast difference in adopting the most recent guidelines.

At the most recent annual meeting of the AAP, a number of presentations were given on the matter of preventing peanut allergies via the early introduction of peanut products. Other than the LEAP study, additional data are confirming significant reductions in peanut allergies as a result of early exposure. And yet, parental hesitancy and doctors not adhering to guidelines, even six years after the guidelines were first released, remain a dilemma to the experts who wish their expertise made a difference to patients.

In a recent report published in the journal Pediatrics, we learn that 25 to 30 per cent of primary caregivers still counsel to delay the introduction past age one. In other studies, it appears that only 29 per cent of doctors are implementing the guidelines.?

In a study conducted at the Northwestern University Feinberg School of Medicine in Chicago, only 1.4 per cent of infants exposed early to peanuts experienced a reaction; and the reaction was mild. This finding was consistent with other similar studies.?

To me, the biggest lesson, regarding guidelines to prevent peanut allergies, is the power of emotion. Fear always will be one of the most powerful emotions to navigate. In the case of peanut allergies, fear indeed determines outcome. When there is a battle between fear and facts, fear often wins – for now at least.

The good news is that as researchers continue to collect data, it appears that even though parents fear the early introduction of peanuts to infants, slowly but surely more and more parents are at least open to change as long as they are properly guided by their primary care doctors or nurse clinicians.

Raising awareness, educating both parents and doctors and knowing that beliefs often take a long time to change may be the path forward. What worked in Australia may not work in North America, but the consensus at the AAP meeting in Washington, D.C., recently was that the discrepancy between perceived risk and true risk needs to be addressed with more effort and more wisdom to reduce the incidence of peanut allergies.

Providing parents merely with handouts is not enough. On this important topic, more time spent in education and explaining seems to be required.

For parents interested in more information about the timing of early peanut exposure, this resource is very helpful: https://foodallergycanada.ca/wp-content/uploads/FAQs-for-early-infant-feeding-guidelines.pdf

Dr. Nieman is a community-based pediatrician and the author of Sustained: A Life Rewritten After Sudden Misfortune, published in November 2023. For more information, visit www.drnieman.com