Early introduction of highly allergenic foods is now encouraged once complementary feeding is well established; however, peanut protein introduction causes anxiety for many parents. The pediatrician plays a critical role by providing family-friendly advice, reliable resources, and acknowledging concerns. Careful explanation of the high-risk groups and a reminder that the majority of patients are actually low risk is critical to easing anxiety and promoting introduction. It is helpful to remind parents that in the early introduction studies, systemic allergic reactions were rare and the majority were relatively mild and did not require epinephrine.
In “Infant Peanut Introduction Simplified,” the authors explain that peanuts can be introduced without any testing for the majority of infants. However, parental anxiety can lead to a delay in introduction. In that case, performing a supervised introduction in the office is often helpful. If a provider is uncomfortable, timely referral to an allergist can be considered. For the high-risk group, testing should be performed. Parents need to be educated regarding age-appropriate introduction strategies and the importance of maintaining peanut in the diet three times weekly. This recommendation is taken from the LEAP study protocol and while we do not know if this is the best way to proceed, or the only effective way, benefit was demonstrated in this high-risk population. In the author’s experience, inconsistency has occasionally led to allergy development in this high-risk population.
Another concern for parents is how to proceed if an older child (typically younger than 5 years of age) has peanut allergy and the family has not had peanut protein in the home. This ultimately comes down to family preference. Helpful strategies include feeding peanut protein when the sibling is out of the house or having a defined location to eat peanut, for example, only in the highchair. In addition, it is essential to remember that whole nuts and even large clumps of nut butters are choking hazards. Providing resources for peanut preparation is critical.
Through education for pediatricians and family-centered counselling, early peanut introduction can be accomplished in a cost-effective manner that helps families feel empowered to help avoid this often life-long allergy. For those families that have a child with peanut allergy, it is important to remind caregivers that they did not “cause” their child’s allergy by something they did or did not do; allergy results from a complex interplay of genetics and the environment and there is much more to learn.