Earlier Ingestion of Peanut After Changes to Infant Feeding Guidelines: The EarlyNuts Study

In 2016, Australian feeding guidelines were updated to recommend early introduction of peanut (PN) and egg without screening high-risk infants beforehand. The aim of this study was to assess the consequences of that change on the rate of early introduction and the prevalence of PN and egg allergy as compared with the HealthNuts study (J Allergy Clin Immunol 2014;133(2):476-484).

This was a population-based, cross-sectional, observational study. The first 860 infants (11–15 months) who agreed to participate were recruited from immunization sessions in Melbourne.

Feeding practices were compared with those identified after 2008 when Australian guidelines removed recommendations to avoid early introduction of allergenic foods.

PN introduction was earlier than in the previous study (P < .0001) with a median age of 6 months (interquartile range [IQR] 6–8 months) and with 88.6% introduction (95% confidence interval [CI]: 86.1% to 90.7%) by 12 months as compared with 28.4% (95% CI 27.2% to 29.7%) previously. Early PN introduction was similar in the high-risk subgroup (atopic dermatitis diagnosed before 6 months old and requiring topical steroids) as compared with the low-risk population (83.5% vs 89.6%). Parents reported reaction to PN within one hour of ingestion more often than in the HealthNuts study (4.0% vs 2.4%, P = .054). Of those 25 infants, 12 tried repeat feedings and 5 tolerated PN.

The median age of egg introduction was also 6 months (IQR 6–8 months) with 95.5% (95% CI 93.7% to 96.8%) by 12 months. Egg introduction was also earlier (P < .0001) than in the HealthNuts study but the change was less than seen so for PN. By 12 months, 97.6% (95% CI 96.2% to 98.6%) had eaten eggs as compared with 95.7% (95% CI 95.1% to 96.3%) in HealthNuts. However, the shift was toward introduction at 6 months (57.9% vs. 25.0%).

Australian feeding guideline changes in 2016 were associated with a shift toward earlier introduction of PN and egg. Without pre-screening, high-risk infants were also given the foods earlier than previously.

In 2008, the AAP Section on Allergy and Immunology also removed its recommendation to delay introduction of allergenic foods. It was not until the LEAP study [New Eng J Med 2015;372(9):803–813] was published that guidelines worldwide were updated to actively recommend early introduction. My observations were similar to the results of this study. That is, before the LEAP study, many infants had not been offered PN before 1 year. Now, the majority have been, and for most of those who have not, the reason is usually because of a family history of PN allergy and/or parental anxiety over trying.

As references cited in this article note, the potential health care costs of screening high-risk infants for PN allergy before introduction are staggering, raising the question as to what we should do. My opinion is nothing more than that, but I believe it needs to be an individualized decision. Better to screen those who are hesitant to introduce PN than to delay introduction and increase the risk of subsequent allergy.

Finally, what about foods for which we have no data? I can only say we have no reason to not offer them in age-appropriate forms if tolerated. Increased dietary diversity may also increase diversity of the gut microbiome and potentially have other health benefits.