Infectious Disease

13.3% of caregivers aware of guidelines for early peanut introduction


Samady reports receiving institutional research funding from Food Allergy Research & Education and NIH. Please see the study for all other authors’ relevant financial disclosures.


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Key takeaways:

  • Caregivers who were white, aged 30 to 44 years, were educated and had income more than $60,000 were more likely to be aware of the guidelines.
  • Only 1.4% reported an allergic reaction with the first feeding.

The percentage of parents and other caregivers who know they should introduce peanuts into their infants’ diets to prevent allergy is improving, but disparities between populations exist, according to a study published in Pediatrics.

Public health campaigns targeting families and primary care providers may improve these disparities, Waheeda Samady, MD, MSCI, associate professor, Center for Food Allergy and Asthma Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, and colleagues wrote.

Counseling from a primary care provider was the most common facilitator for introduction to peanuts before age 7 months, whereas fear of reactions was the most common reason why parents and caregivers delayed introduction beyond age 7 months. Image: Adobe Stock

In 2017, National Institute of Allergy and Infectious Diseases’ Guidelines for the Prevention of Peanut Allergy recommended introducing peanut into the diets of high-risk infants between age 4 and 6 months.

“They were a major change from recommendations provided previously,” Samady told Healio. “Therefore, we felt it was imperative to identify where American caregivers and parents were at, and who was and was not getting this information so that we can make targeted interventions to further prevent peanut allergy.”

Study design, results

The researchers conducted their national survey between Jan. 21, 2021, and Feb. 15, 2021, among 3,062 parents and caregivers of children aged 7 months to 3.5 years, all of whom would have been born after the NIAID guidelines were published.

Waheeda Samady

The survey found that 13.3% of parents and caregivers were aware of the guidelines. Those who were white, aged 30 to 44 years, had a bachelor’s degree or higher and/or reported an annual income of more than $60,000 were most likely to be aware of the guidelines (P < .001).

The parents and caregivers who reported awareness also were more likely to have a personal history of atopy, particularly mothers with food allergy (P = .004) or eczema (P < .001) and fathers with eczema (P = .01). Those who were aware were more likely to have an index child with an atopic condition as well (P < .05).

Also, the survey found that 47% believed that early introduction of peanuts prevented peanut allergy, but 33.5% said they “don’t know.” The cohort included 49.8% who believed that feeding infants other foods such as milk and egg during their first year decreased the risk for allergies to those foods as well.

“I think it was interesting to see that the general concept of early introduction was acceptable to parents as a belief, but that so few recognized that there were national guidelines around peanut allergy prevention,” Samady said.

Among the parents and caregivers who were aware of the guidelines, 76.5% believed peanut consumption prevented food allergy and 77% believed that feeding their infants other foods prevented food allergy (P < .001).

Among the full survey population, 7.9% said it was safe to feed infants peanut before age 7 months, 24.4% said it was safe between age 7 and 9 months, and 22.7% said it was safe between age 10 and 12 months, with similar results among those whose child had eczema.

The parents and caregivers who were aware of the guidelines, however, included 18.2% who said peanut introduction was safe before age 6 months and 37.2% who said it was safe between age 7 and 9 months (P < .001).

“Often times, guidelines will be shared, and then that will have an effect on the general population’s belief about the effectiveness of a public health recommendation,” Samady said. “Here, it seems like there is already acceptance before awareness.”

The full survey population included 47.1% who said they worried about food allergies as they prepared to feed their infant, with 35% saying they were most concerned about peanut allergy. The parents and caregivers who were aware of the guidelines were more worried about food allergies (51.6%; P<.001), but not specifically about peanut allergy.

Further, 96.4% of the full cohort said they did not have any difficulties in feeding their infants peanuts, with 70% saying they felt informed or very informed about peanut introduction.

Whereas 57.8% of the full cohort said their primary care provider discussed peanut introduction with them, 73.9% said this discussion occurred when their infant was aged 6 months or older.

Additionally, 5% of those whose primary care providers discussed early introduction said they were advised to begin feeding their infant peanut at age 4 months, 18.6% were told to begin at age 6 months, 15.9% between age 7 and 11 months, 27% at age 1 year and 10.8% at age 2 years.

Peanut introductions included 17.2% who began before age 7 months, 11.8% between age 7 and 8 months, and 29.9% between age 9 and 12 months, with 77.3% typically feeding less than 2 teaspoons of peanut product per feeding during the first month of introduction. Also, 3.4% reporting daily feeding and 24.2% reporting feeding a few times a week.

Percentages of parents and caregivers who introduced peanut by age 6 months increased with birth year, beginning with 12% among those infants born in 2017, 15% among those born in 2018, 20% among those born in 2019, and 25% among those born in 2020 (P < .001).

Also, 31% of the parents and caregivers who were aware of the guidelines and 17.2% of those who were not aware introduced peanuts into their infants’ diets before age 7 months or younger (P < .001), including 34.5% reporting multiple feedings a week and 8.4% reporting daily feedings (P < .001).

Parents and caregivers waited until their infants were older than 7 months because they were afraid of reactions (32.5%) or believed that earlier introduction was not important (31.7%).

The parents and caregivers who waited until their infant was aged 12 months did so because they did not believe that early introduction was important (32%), they were afraid of a reaction (29%) or because their primary care provider advised them to do so (26%).

Across the whole cohort, 1.4% reported an allergic reaction to peanut during initial introduction, with 12.9% of these reactions occurring when the infant was aged younger than 6 months, 37.6% when the infant was aged 7 to 11 months and 49.5% when the infant was aged older than 1 year.

Symptoms among infants younger than age 1 year primarily were dermatologic, including 56.2% with hives, 45.6% with rash, 42.6% with itching, 32.1% with swelling and 28.8% with flushing, and gastrointestinal, including 28.4% with vomiting or heaving, 28.6% with diarrhea and 27.7% with stomach pain.

Finally, the parents and caregivers whose primary care providers recommended introduction before age 6 months were significantly more likely to do so (OR = 16.09; 95% CI, 11.61-22.31) and significantly less likely (OR = 0.5 95% CI, 0.02-0.1) to wait until age 1 year.

Conclusions, next steps

Considering the differences in introduction based on race, income and education level, the researchers said access to medical care and information was disproportionate in the United States. They called for a public health campaign that would partner with community organizations to overcome barriers and increase awareness among parents and caregivers.

The researchers also recognized the need to educate and support primary care providers who care for infants in improving early peanut introduction, noting that approximately a quarter of them instructed families to delay introduction until after age 1 year. Handouts and tools designed to improve guideline implementation may help, the researchers said.

Meanwhile, Samady advised physicians to keep things simple and not over-medicalize something that can be a natural part of the infant’s diet.

“When we act like early peanut introduction is a medical intervention, I think that naturally makes families anxious and worried,” she said.

“But if we talk about it more in regards of general diet diversity, and that nuts can be a healthy part of the diet and that early exposure to them allows for the child to develop tolerance, it’s more of a feeding recommendation than a medical intervention, and that’s really how we should go about it,” she said.

Physicians also should give families that are hesitant about these introductions “a lot of information about exactly how to go about it and what to do, and really identify what their worries and concerns are and help them feel supported,” Samady said.

Research is continuing as well, with semi-structured interviews to further understand some of the nuances in the data found in these surveys to develop tools that support and educate families about early peanut introduction and general diet diversity.

“We also have a lot of ongoing studies in pediatric clinics supporting pediatricians as well as studies understanding the real-world barriers and successes of trying to introduce multiple allergens in a child’s diet early as a way to prevent multiple food allergies,” Samady said.



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