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Severity of Peanut Allergy and the Unmet Gaps in Care: A Call to Action
Jay A. Lieberman, MD
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Severity of Peanut Allergy and the Unmet Gaps in Care: A Call to Action

Jay A. Lieberman, MD
According to the guidelines, if peanut is introduced into the diet of children with severe eczema, egg allergy, or both, the total amount of peanut protein ingested per week should be approximately 6 to 7 grams over 3 or more feedings.41 This recommendation is based on data from the LEAP trial where, at evaluations conducted at age 12 and 30 months, 75% of children in the peanut consumption cohort reported eating at least this amount of peanut protein per week according to analysis of their food diary for the 3 days before evaluation.38 The guidelines recommend that if, after 1 week or more of consuming peanut, the child displays mild allergic symptoms within 2 hours of peanut ingestion, the healthcare provider should be contacted for further evaluation.41

Gaps in Care

The new 2017 NIAID guidelines represent a paradigm shift in current thinking on the prevention of food allergies. This has led to an educational gap for providers, as well as parents and caregivers, because many parents are understandably hesitant to introduce peanuts early to infants, especially those considered high-risk. A recent survey study conducted by Greenhawt and colleagues found that just 31% of new and expecting caregivers with infants younger than 1 year expressed willingness to implement early peanut introduction before or around age 6 months, although 40% expressed willingness to introduce peanut after age 11 months. The study also found that 56.8% of these caregivers were unwilling to allow an in-office oral peanut challenge before age 11 months.42 Therefore, a significant gap exists in understanding that must be addressed before broad-based implementation of the guidelines can be implemented.

Another area of controversy involves the role of screening younger siblings of children with peanut allergy. The NIAID guidelines do not directly identify this group as a population requiring allergy testing before peanut introduction. Many families are hesitant with early introduction because they are concerned that the development of peanut allergy may have a genetic cause, although this has not been proven.43 Families should be encouraged to discuss their concerns with providers and to introduce younger siblings to peanuts at around age 6 months with evaluation if necessary.43

Finally, the recommendations surrounding peanut exposure in schools are areas of significant debate and variability throughout the country. As of 2017, 49 of 50 states had enacted some sort of law requiring schools to stock epinephrine (with most laws providing for an option to stock epinephrine versus a mandate to stock epinephrine), but fewer than 25% of states have any formal food allergy management guidelines.44 There are no state guidelines or allergy professional societies that advocate for allergen bans as an effective strategy to accommodate students with peanut allergy, although this is a popular strategy adopted by many caregivers and advocates.44 Results of a recent study of school nurses in Massachusetts showed that there was no association between “nut-free” schools and a decrease in epinephrine use, although a significant reduction in epinephrine use was found in schools with nut-free tables.45 Therefore, this important issue is still being debated at community, state, and national levels.


Peanut allergy is one of the most common food allergies in children and can be life-changing for patients and their families to manage. It is critical to recognize and differentiate true food allergies from other conditions and to appropriately introduce peanut-containing foods to infants, especially those at high risk for development of allergy. As the understanding of this food allergy evolves, educating parents and caregivers is essential to ensure that new guidelines are being implemented effectively.

Author affiliation: Associate Professor, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN.
Funding source: This activity is supported by an independent educational grant from Aimmune Therapeutics.
Author disclosure: Dr Lieberman has the following relevant financial relationships with commercial interests to disclose:
CONSULTANT–Aimmune Therapeutics, DBV Technologies.
Authorship information: Concept and design, acquisition of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content.
Address correspondence to:
Medical writing and editorial support provided by: Mona Shah, PharmD.
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