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Introduction of peanut products urged at earlier age

After decades of caution, new guidelines may decrease peanut allergies

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Surprising new guidelines that urge an earlier introduction of peanut products to babies may well change the progression of allergic reactions in children.

The guidelines — the result of work by a U.S. allergy panel with its sole Canadian representative, Vancouver's Dr. Edmond Chan — now suggest introducing peanut-based products between four and six months of age, not after age three as was previously recommended.

This latest study, which not only underscores a North American fear of peanut allergies in children and an ensuing deadly anaphylaxis that can result, is partly a result of research in other cultures in which peanuts are routinely introduced early in life.

"The hesitation, or fear of introduction is prevalent in North America," said Chan by phone from Vancouver where the guidelines were announced Jan. 5. Chan is director of the Allergy Clinic at BC Children's Hospital, head of the Division of Allergy and Immunology and clinical professor in UBC's Department of Pediatrics.

"What that study showed is that countries like Israel — which is not fearful of introducing peanuts — have been doing it for decades and they have proven that it can be done very safely."

For children whose families have a history of severe eczema and egg allergies, the usual recommendation was to avoid specific foods until the child was older. The reasoning was that babies and toddlers have immature guts that inhibit proper digestion of the food proteins, and the delay allowed the child's immune system to mature.

"In 2000, there was an official recommendation to delay peanuts until three years of age," said Chan. "And in the ensuing years, there was a tripling of the rate of peanut allergies."

For Whistler's Michelle Williamson, there was no family history of food allergies, but when daughter Mardi was born with eczema and food allergies, the family got its introduction to allergies the hard way.

"Mardi had a rough start, she struggled to gain weight. She was unwell all the time, she had eczema and I realized that she couldn't tolerate breast milk because everything I was eating, she was allergic to," said Williamson. "We couldn't find formulas because she was allergic to dairy and soy, and it was kind of touch and go for the first five months of her life until we connected with Dr. Chan."

Once a proper formula was sorted out — a U.K. amino-acid based mixture that cost $1,500 a month — Mardi gained weight and, as her mom said, "turned a corner."

Mardi, now 11, is trace anaphylactic to peanuts and carries an Epi pen with her at all times. The first time she had to use it, she was in a situation without her parents.

"It was a relief for us to know she had the calmness and the wherewithal to realize (a reaction) was happening and to give herself the Epi pen," said Williamson. "Mardi knows she can't eat a thing unless she has the pen with her and we have been preparing her for that moment when she might need to use it herself."

There are more cases of peanut allergy in North America compared to other countries. For example, Chan mentioned the early introduction of peanut products to babies in Israel, where a popular puffed-corn snack called Bamba is a staple.

"That snack is given in the first year of life when solids are started. The thinking was that early introduction was better, and ultimately, it set up the framework for doing this randomized clinical trial, which took five years' duration and was published in 2015," he said.

"They looked at 640 infants and they followed the exact same instance over five years — half of them were getting peanut early, half of them not getting peanut. Children who received peanut early had an over 80-per-cent reduction in peanut allergy."

Chan said one study from the U.S. revealed only about 15 per cent of parents were introducing peanut product to babies before one year of age. The peanut paranoia is typical in both the U.S. and Canada.

"It's just on everyone's radar to avoid peanuts in certain ways. The more fearful we have become of peanut, and the more we go out of our way to avoid it, it comes back to bite us and results in even more peanut allergy. There's this great irony at play here with this whole issue. It's going to take some time to change that," he said.

For families with a history of severe eczema and egg allergy, it is recommended that children be tested before the introduction of peanut. "For the small minority that need to be tested, the end goal should be peanut introduced in physician's office," he said.

Williamson is encouraged by the findings and was on hand with Chan at the announcement of the guidelines in Vancouver last week.

"This could be like a window of early exposure that can help protect children," she said. "This is very exciting news. We definitely need to get the word out there so people are aware this is the best chance they can give their kids to prevent these allergies from manifesting."

Although there is only a 20-per-cent chance that allergies are outgrown, Williamson said this research may mean the difference between an allergy and anaphylaxis, the reaction that, if not treated, can be fatal.

"With Mardi's history of eczema and egg allergy, we would have needed to do an in-office test, but at that point in time maybe it was mild and wasn't anaphylactic. Maybe Mardi would not have become anaphylactic with peanut. Maybe that could have been avoided. I wish I knew."

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