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Early Intervention

New guidelines on peanut introduction could prevent children’s allergies 

by DANA KELLY

A simple snack has developed a terrifying reputation.

The peanut is no longer a regular staple of a child’s lunch because many classrooms have become “no-nut zones.” For those who are allergic, that fear is warranted: there’s a very real potential of a life-threatening reaction. In the general population, however, the overall risk is low, particularly in infants who have never tried a peanut before.

Food allergies in Canada are on the rise. Genetics can play a role, but one theory suggests that increasingly clean, sanitized environments are also to blame. Our immune systems are exposed to fewer germs than ever and, as a result, may be identifying certain foods as harmful to our bodies.

Peanut allergies are among the most common food allergies in Canada, affecting about two in every 100 children in the country. For any new parent, those numbers can be worrisome. Many are unsure when to introduce potentially allergenic foods, such as peanuts, milk, eggs, wheat and soya into their infant’s diet.

When it comes to peanuts, Vancouver-based pediatric allergist Dr. Edmond Chan, director of the Allergy Clinic at BC Children’s Hospital, says children should start eating them as early, and as often, as possible.

“There is no benefit to delaying the introduction of allergenic foods, like peanuts, beyond six months of life, and delaying appears to increase the risk of food allergy,” says Dr. Chan. “Waiting until 10 or 11 months may be too long, as the risk of peanut allergy already having developed rises by [that age].”

This advice is especially important for infants considered at high risk of developing food allergies. They include infants with severe eczema, existing food allergies and/or a first-degree family history (in parents or siblings) of an allergic condition such as asthma, eczema and hay fever. Once introduced, peanuts should be eaten regularly — ideally several times a week — to allow the child to build up immune tolerance.

A randomized controlled clinical trial of peanut consumption in high-risk infants, conducted by the Immune Tolerance Network in 2015, echoes this advice. The Learning Early About Peanut Allergy (LEAP) trial studied 640 children between the ages of four and 11 months over a five-year period. It found 17 per cent of the children who avoided peanut developed an allergy by the time they reached the age of five, compared to just three per cent who were regularly exposed to the food.

About a year before the LEAP study was published the Canadian Paediatric Society, recognizing that more research was needed, updated its guidelines on the introduction of specific foods to prevent allergies. New mothers are advised to not restrict their diets during pregnancy or lactation, and to breastfeed exclusively for at least the first six months of their infants’ life. If necessary, parents can supplement nursing with some hydrolyzed cow’s milk-based formula. The guidelines also instruct families to not delay the introduction of allergenic foods such as peanut, egg, or fish beyond six months, and recommend eating them several times a week afterward, keeping in mind that a soft mashed form works best to avoid choking. 

In mid-2015, major professional allergy organizations around the world, including the Canadian Society of Allergy and Clinical Immunology represented by Dr. Chan, published a “Consensus Communication” that advised parents to introduce peanut-containing products into infants’ diets between the ages of four and 11 months. The LEAP study chose a frequency of about two teaspoons of peanut butter three times a week. If parents are afraid to introduce peanuts into their babies’ diets on their own, Dr. Chan suggests the presence of a pediatric allergist. The National Institute of Allergy and Infectious Disease in the US has convened an expert panel (with Dr. Chan representing Canada) to write guidelines on which infants might benefit the most from introduction with a specialist like a pediatric allergist, versus introduction at home.  These guidelines will be published this year.  

Dr. Chan supports these recent recommendations because of the high success rate in countries like Israel. “To date, no infant younger than 12 months has died from first ingestion of peanut protein,” he says. “Countries like Israel have been introducing peanut in infancy for decades without problems, and Israel has hardly any peanut allergy.”


NAVIGATING ALLERGY CARE

Imagine being Allyson and David Prescesky on that one day in March 2012, as they sat at BC Children’s Hospital watching their two little boys break out with severe allergic reactions.

The couple had waited for a full year to combine their sons – Carson, then seven years old, and Rylan, five – into one appointment for the big series of tests. In one session, BC Children’s Hospital caregivers applied nearly 30 tests on the boys, and stood by with antihistamines and topical creams, noting their reactions.

It was messy.

“They were both in tears,” says Allyson from her home in Victoria. “It was really uncomfortable when they got the reactions, even when they gave them antihistamines and applied cream, it was very hard to watch.”

Three years later, Allyson and Dave are able to laugh about that ordeal. And the whole family came away from it armed with knowledge, new expectations and confidence in the future.

“It was nerve-wracking, because we didn’t know what to expect,” Allyson says.

The Prescesky boys are just two of the 300,000 Canadian children under 18 years who have food allergies, and among the one in 50 children in the country who must cope with nut allergies. About 30 per cent of these children, like the Presceskys, come from outside the Greater Vancouver area. The family’s visits will be among the nearly 2,000 annual visits to the Allergy Clinic at BC Children’s Hospital; there, they’ll get specialized care and treatment and learn new coping skills.

“We were grateful we were going to get some answers, so we know what to stay away from and having those answers to explain to people.”

Explaining to people: there lies one of the prickliest parts of caring for a child with allergies, Allyson says. Both Carson and Rylan suffered their first allergic attacks in the presence of their parents. But what happens when they’re with their grandparents? At school? With friends on playdates or at birthday parties? The dreaded “what if” weighs on every parent’s mind when their allergic child is in another’s care.

Getting solid answers from caregivers at BC Children’s offered hope and validation that Dave and Allyson were doing right by their kids. In their engagement with friends, family and social activities, the parents set themselves to new standards of caution and care. Thanks to their diligence, Allyson and Dave’s friends, teachers and family know how to react if and when the boys suffer an allergic reaction.

“BC Children’s provided us with invaluable information that helped us develop a plan for how we are going to deal with this throughout their lives,” Allyson says.


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