ASCIA Guide for introduction of peanut to infants with severe eczema and/or food allergy

This guide provides options and information for health professionals about introducing peanut to infants with severe eczema and/or existing food allergy. These infants are considered to have an increased risk of developing peanut allergy.

ASCIA HP Guide for introduction of peanut to infants with severe eczema and/or food allergy240.50 KB

Why should this guide be followed?

Recently published studies (1,2) have shown that the introduction of peanut to infants with severe eczema and/or egg allergy before 12 months can reduce the risk of these infants developing peanut allergy by around 80%.

For all infants, including those with severe eczema and/or existing food allergy, peanut and other solid foods should be introduced around 6 months (not before 4 months) and in the first 12 months, when developmentally ready, as recommended in the ASCIA guidelines for infant feeding and allergy prevention.

If possible, it is preferable for mothers to continue breastfeeding whilst introducing solid foods to infants, as there is some (weak) evidence that this may reduce the risk of allergies developing. There are many other health benefits of continued breastfeeding.

ASCIA guidelines for infant feeding and allergy prevention are available open access on the ASCIA website: www.allergy.org.au/hp/papers/infant-feeding-and-allergy-prevention

Suggested procedure for introduction of peanut before 12 months (not before 4 months)
when the infant is developmentally ready for solid food - under medical supervision (e.g. in GP rooms) or at home

• Rub a small amount of smooth peanut butter/paste on the inside of the infant's lip (not on their skin).
• If there is no allergic reaction after a few minutes, feed the infant ¼ teaspoon of smooth peanut butter/paste (as a spread or mixed into other food that the infant is already eating or mixed with a few drops of warm water) and observe for 30 minutes.
• If there is no allergic reaction, give ½ teaspoon of smooth peanut butter/paste and observe for a further 30 minutes.
• If there is no allergic reaction, parents should continue to include peanut in their infant’s diet in gradually increasing amounts at least weekly, as it is important to continue to feed peanut to the infant as a part of a varied diet.
• If there is an allergic reaction at any step, stop feeding peanut to the infant and seek medical advice (if at home).
• An allergic reaction should be treated by following the ASCIA Action plan: www.allergy.org.au/hp/ascia-plans-action-and-treatment 
  - Mild or moderate allergic reactions (swelling of the lips, eyes or face, urticaria or vomiting) can be treated using non-sedating antihistamines such as cetirizine, loratadine or desloratidine. To avoid confusion with the symptoms of anaphylaxis, sedating antihistamines should not be used to treat allergic reactions.
  - If there are symptoms of anaphylaxis (difficult/noisy breathing, pale and floppy, swollen tongue) treat with adrenaline and call an ambulance immediately.
• If an infant has an allergic reaction they may be referred to a clinical immunology/allergy specialist for further investigations: www.allergy.org.au/patients/locate-a-specialist

Further Information

• Some infants will develop peanut allergy despite following ASCIA guidelines.
• Whilst severe allergic reactions have been reported, to date there have been no case reports of fatality to peanut ingestion in infants under 12 months of age.
• Some infants can have an allergic reaction on the first (or subsequent) oral feeding of peanut, as they may already be sensitised to peanut prior to any known oral exposure before 12 months of age.
• Never smear or rub food on infant skin, especially if they have eczema, as this will not help to identify possible food allergies. This could also sensitise the infant, who may then develop an allergy to that food.
• Screening programs for infants with severe eczema and/or egg allergy prior to introduction of peanut have been proposed in the US NIAID Guidelines (4). However, there is insufficient evidence to support a population based screening approach in Australia and New Zealand. There are concerns that allergy tests are not suitable for screening and referrals may delay peanut introduction to high risk infants (5).
• ASCIA guidelines for infant feeding and allergy prevention are available open access on the ASCIA website www.allergy.org.au/hp/papers/infant-feeding-and-allergy-prevention 
• ASCIA information for parents about how to introduce solid foods is available open access on the ASCIA website www.allergy.org.au/patients/allergy-prevention 
• ASCIA information about eczema is available open access on the ASCIA website www.allergy.org.au/patients/skin-allergy 

References

1. Du Toit G et al. Effect of avoidance on peanut allergy after early peanut consumption. N Engl J Med. 2016. DOI: 10.1056/NEJMoa1514209
2. Du Toit G et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015 Feb 26;372(9):803-13
3. Perkin MR et al. Randomised trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016. DOI: 10.1056/NEJMoa1514210
4. Togias A et al Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases (NIAID) sponsored expert panel. WAO J 2017 10(1):1
   www.ncbi.nlm.nih.gov/pmc/articles/PMC5217343/ 
5. Turner PJ, Campbell DE. Implementing primary prevention for peanut allergy at a population level. JAMA 2017 Feb 13. www.jamanetwork.com/journals/jama/fullarticle/2603418 

© ASCIA 2017

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand

Website: www.allergy.org.au
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Disclaimer

This document has been reviewed by ASCIA members and represents available published literature at the time of review. The content is not intended to replace professional medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner. Development of this document is not funded by any commercial sources and is not influenced by commercial organisations.

Content updated 2017