Infectious Disease

Caregiver, physician awareness of peanut introduction guidelines remains low



Healio Interviews

Nolte reports employment as science director of Ready. Set. Food!


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Key takeaways:

  • A third of caregivers did not know early introduction could prevent peanut allergy.
  • Only 1.4% of early introductions resulted in an allergic reaction.
  • Pediatricians are looking for training and support tools.

NIAID updated guidelines for introducing peanuts to infants to prevent allergy in 2017, but most caregivers and even many primary care providers including pediatricians are still not implementing these recommendations.

Published in Pediatrics, the study from the Center for Food Allergy and Asthma Research found that only 13.3% of caregivers were aware of the guidelines, which recommend introduction between age 4 and 6 months.

Also, 57.8% of caregivers said their primary care provider discussed peanut introduction with them, but 73.9% said this discussion occurred when their infant was aged 6 months or older.

Healio spoke with Erika D. Nolte, PhD, science director of Ready. Set. Food!, to find out more about the implications of this gap between recommendations and practice.

Healio: Do you think these findings are surprising or significant?

Nolte: These findings provide evidence of what many working in food allergy prevention have thought might be true for a while. When parents know more about early allergen introduction — for example, they know about medical guidelines for introduction — they are more likely to introduce peanuts to their babies in that golden window of age 4 to 6 months.

This study shows that there is a long way to go in making sure every parent has the knowledge to effectively prevent food allergies in their babies. More than one-third of parents surveyed did not know that early introduction of peanuts could prevent a peanut allergy, which makes their children vulnerable.

The authors also found that parents who identified as white and who had higher incomes and higher levels of education were more likely to be guideline aware. One of the major issues in preventing food allergies right now is thinking about equity and how we can ensure that all parents have access to this information. Other studies have shown that Black children are at greater risk for food allergies and that Black parents are less likely to introduce allergens early. We need to be thinking about strategies that are community-centered to improve access for these families.

It is significant that in 2021, several years after new guidance came out, only 17.2% of parents introduced peanuts before age 7 months. We will need to see significant improvement in that number if we want to see an impact on overall peanut allergies in the U.S.

The data support the idea that pediatricians are an integral part of the puzzle in getting more parents to introduce allergens to their babies. The authors found that when pediatricians recommended allergen introduction before age 6 months, parents were much more likely to feed their infants peanuts before age 6 months and less likely to delay until after age 12 months. This is an important finding because it reinforces the idea that pediatricians are really going to be the gateway to parental action.

However, in this group, most of the parents said that their pediatrician didn’t talk about early allergen introduction until after their baby was aged older than 6 months, and a small minority said their pediatrician still encouraged delayed introduction. We need better strategies to help pediatricians get evidence-based information to their patients at the right time — ideally before their babies are aged 4 months.

Healio: Do these findings reflect your own experience?

Nolte: About a third of parents didn’t introduce peanuts before age 7 months because they were afraid of an allergic reaction, which seems in line with what has been previously published and what I hear frequently from parents and clinicians. This seems to be one of the most critical information gaps identified because allergic reactions are more rare in babies introduced to potential allergens early, and when they happen, infants tend to have very mild food reactions. That doesn’t mean severe reactions are impossible, but they are definitely not as common as many parents fear. Only 1.4% of parents in the study reported a peanut reaction during early introduction, which seems similar to what I see in my work. Early introduction of peanuts works and is safe.

Healio: How can we support pediatricians in discussing peanut introduction with the families they treat?

Nolte: Previous studies have shown that pediatricians are looking for additional training and increased support tools. Well baby visits are already extremely busy, so automated and built-in tools will help keep early introduction at the forefront of pediatricians’ minds. And, when it is possible to automate providing information directly to parents in those settings, we should be doing that as well.

Healio: Is there anything else we can do to encourage families to introduce peanuts into their infants’ diets?

Nolte: I think this study shows convincingly that the best thing we can do to encourage families to introduce peanuts is to continue educating them on the importance of preventing food allergies and introduction by age 6 months. There is also more to be done to help parents understand that allergic reactions during infancy are rare, and severe reactions are vanishingly rare. When we can empower parents with the knowledge of how to improve the lives of their babies and help them feel secure in acting, I think we will see a big change in rates of introduction.

Healio: What should the next step be in this study?

Nolte: For me, the next step would be to consider that third of parents who do not know that early introduction can prevent food allergies, that pediatrician encouragement drives introduction, and that most parents did not hear about introduction from their pediatrician until after age 6 months and develop and test interventions. We should be working to implement more educational programs and then testing to see if they can improve rates of introduction.


For more information:

Erika D. Nolte, PhD, can be reached at


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