Peanuts: Start early to prevent allergy

mom-and-baby

GRAND RAPIDS, Mich (WOTV) – At 10 months old, Lucas Suescun loves his peanut butter. His mom gives it to him on bread cut into small pieces, and he munches it right down.

Wait. Feeding peanut butter to a baby? That’s right—doctor’s orders.

The doctor is Nicholas Hartog, MD, a specialist in pediatric and adult allergy and immunology. He and his colleague, Theodore Kelbel, MD, also an allergy and immunology specialist, have just opened the Pediatric Allergy and Immunology Clinic at the Helen DeVos Children’s Hospital Outpatient Center at 35 Michigan Street.

Drs. Kelbel and Hartog designed the clinic around the best research and practices. In immunology, their work involves diagnosing and treating children with rare immune system abnormalities that disrupt the body’s ability to fight off infections.

On the allergy side, it includes the therapeutic introduction of highly allergenic foods to prevent allergies.

A fundamental shift

For parents who were raising babies in the early 2000s, the notion of feeding peanuts and other highly allergenic foods to infants is startling. Back then, pediatricians advised parents to delay introducing peanut butter until kids were 2 or 3 years old. Doctors hoped withholding certain foods could help prevent life-threatening allergies.

Today, thanks to the groundbreaking LEAP study, the advice is almost the opposite: Give babies a variety of foods—even allergenic ingredients—early and often.

“We found it was a huge mistake to suggest delaying introduction (of peanuts),” Dr. Hartog said.

Delayed introduction actually increases food allergy, Dr. Kelbel added.

Researchers made these discoveries after watching food allergy rates climb year after year with no signs of slowing. Peanut allergies were especially troubling, with numbers tripling between 1997 and 2008 for children in the United States.

The LEAP study showed that peanut allergy is preventable in high-risk infants. And the way to prevent it is to begin feeding peanut products to these babies long before their first birthdays.

“The results were really compelling: an 80 percent food allergy reduction in those who ate peanut versus those who didn’t,” Dr. Kelbel said.

Getting an early start—even as early as 4 months of age—is the most important thing.

“The earlier we start, the better,” Dr. Hartog said. “Once we get over a year, the chance that they’ve developed a peanut allergy is much higher. It really is a race against the clock in these high-risk kids.”

This need for speed is why the new children’s hospital allergy clinic has a fast-track policy for high-risk children.

“If a parent or the referring physician deems that a patient is an urgent referral, we’ll get them in within the week,” Dr. Kelbel said. The same is true for immunodeficiency patients.

Baby Lucas is a good example of an urgent referral. From early on, he’d displayed one of the telltale signs of a child at high risk for food allergies: severe eczema.

His parents worried about whether he might have allergies to peanuts and other foods.

Then, one day at daycare, Lucas was given scrambled eggs for lunch. In the afternoon his mother, Johanna Zea-Hernandez, MD, called the daycare center to check on him.

“They told me, ‘Oh, good that you called. We were going to call you because he just woke up from his nap and he’s all red and itchy,’” she said.

Suspecting this was a reaction to the egg, she talked to her colleague, Dr. Hartog.

Dr. Zea-Hernandez, a pediatric pulmonologist, works in the Helen DeVos Children’s Hospital Pediatric Pulmonology Clinic, which collaborates closely with the Pediatric Allergy and Immunology Clinic.

Dr. Hartog told her that egg allergy and severe eczema are the two major risk factors for peanut allergy. Children who have either of those two factors are 25 to 30 times more likely to develop a peanut allergy than kids who don’t, he said.

Because Lucas was still under a year old, he was a perfect candidate for the early introduction of peanut products as therapy to prevent the development of a peanut allergy.

Oral food challenge

Dr. Zea-Hernandez called the scheduling center and requested a fast-track appointment with Dr. Hartog. Two days later, Lucas was in the clinic getting a skin test to screen for both egg and peanut allergies.

Though he tested positive for egg allergy, he was negative for peanut allergy.

That meant it was safe to conduct what allergists call an oral food challenge using peanuts—feeding a tiny amount of the food to see whether the child reacts; then, if there’s no reaction, feeding increasing amounts over the next hour or two, watching closely until it’s safe to say the patient has tolerated the food.

“If the reaction is positive, we say you’re allergic and need to avoid the food,” Dr. Hartog said. Doctors and dietitians can then counsel the family on how to read food labels, how to stay safe and how to use an EpiPen.

“If it’s negative, then we say you’re not allergic to peanut yet,” he said. “But if you avoid eating peanut, you’re still at high risk for developing an allergy later on. We say you should be eating about 2 grams of peanut three to four times a week,” for the long term.

With Lucas, the outcome of the food challenge went just as his mom had hoped.

First he tried a little peanut butter on bread—while his mom held her breath. He didn’t react. Soon she gave him more, and again he didn’t react.

Relieved, his mom now has the confidence to make peanut products a regular part of his diet.

“I’m supposed to feed it three times a week, but since he likes it, I do it more often than that,” she said.

Sometimes she gives him peanut butter on bread, sometimes peanut powder stirred into yogurt. She also tried a puffed peanut snack, but Lucas didn’t care for it.

Lucas is one of the lucky ones. His peanut therapy started early enough to prevent an allergy.

“The goal is really prevention, which we’ve realized is something we can do,” Dr. Hartog said. “This is the area where we’ll probably have the biggest impact.”

Research on the treatment of established allergies is less promising, he said.

Early and often

The LEAP study looked strictly at the early introduction of peanuts with high-risk children. Now a related trial, the EAT study, is testing the early introduction of six highly allergenic foods with low-risk kids.

Results to date have encouraged Drs. Kelbel and Hartog to tell parents of low-risk infants—those without eczema or previous food allergies—to get an early start in feeding their babies a variety of foods.

“For the general population, introduce all foods, including things that are traditionally allergenic,” Dr. Kelbel said. “Be sure to serve tolerated items regularly. This can start as early as 4 months.”

There’s no evidence that early introduction of any food would be harmful for the general population. The doctors also pointed out that the early introduction of foods has no impact on breastfeeding duration or infant growth.

But why does this practice work? Why would early exposure to foods prevent allergies?

The doctors gave this explanation: The route through which you’re exposed to a food protein drives how your body’s immune system sees it. If you’re introduced to a food protein by eating it, the immune system of the gut tells your body that this is a food. But if you’re first exposed via the skin, your gut may not recognize it as safe for consumption and you’ll be more likely to develop an allergy to it.

With roughly 8 percent of the nation’s children living with food allergies—two to three kids per classroom—Drs. Hartog and Kelbel are eager to see the allergy rate taper off.

Lucas’ mom has hope that it will.

“Speaking as a mother, not as a doctor, I think that this place is amazing,” Dr. Zea-Hernandez said of the clinic and its results.

If you have an infant at high risk for food allergies, or if your child is struggling with allergies, asthma or immune system issues, ask your primary care physician for a referral to the Helen DeVos Children’s Hospital Pediatric Allergy and Immunology Clinic or call 616.267.8150.

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