New Guidelines for Early Peanut Introduction to Prevent a Peanut Allergy

Freedom Allergy, New Infant Peanut Guidelines, Pediatric Allergist, Peachtree City, Marietta, Georgia

 

On Thursday, January 5, 2017, the National Institute of Allergy and Infections Diseases released formal and detailed guidelines about the early introduction of peanuts to infants in order to proactively prevent the development of a peanut allergy.  This announcement is a complete reversal from past advice of peanut avoidance for high risk infants until 3 years old.  The American Academy of Pediatrics endorses these guidelines and encourages parents to begin feeding their infants peanuts early.

The new guidelines is a result of the Learning Early About Peanut Allergy (LEAP) study that was published in 2015 in the New England Journal of Medicine.  The study divided over 600 high-risk children between the ages of 4 and 11 months old into two groups, and followed them until age 5.  The participants had to have severe eczema, an egg allergy, or both, with a negative or positive peanut skin prick test less than 4 mm in diameter.  The first group avoided peanuts.  The second group consumed peanut-containing snacks at least three times a week.  Of the children who avoided peanut, 17% developed the allergy by age 5.  Of the children who consumed peanut, only 3% developed a peanut allergy.  The result was definitive and confirms that early introduction of peanut to an infant is highly effective in preventing a peanut allergy from developing.

The new released guidelines are categorized into three groups:

  • High Risk:  infants with severe eczema, egg allergy, or both
  • Guidance:  introduce peanut as early as 4-6 months
  • How/Where:  allergy testing with an allergist is strongly advised, with peanut introduction under physician supervision (see chart below)

 

  • Moderate Risk:  infants with mild to moderate eczema
  • Guidance:  introduce peanut around 6 months
  • How/Where:  peanut introduction can be at home, although testing and physician-supervised feeding may be conducted at the request of the parent

 

  • Low Risk:  no eczema, no food allergies, and no family history of allergies
  • Guidance:  introduce peanut at any time
  • How/Where:  peanut introduction at home

The NIH guidelines also advise parents to feed their infant peanuts for the first time only when he/she is healthy, and to ensure observation of the infant for at least two hours after peanut consumption to watch for signs of a reaction.  Signs of an allergic reaction may include:  hives, vomiting, coughing, wheezing, swelling (face, lip, or tongue), change in skin color, or lethargy.  In addition, recipe options are provided for the safe feeding of peanuts to infants, such as mixing peanut butter with warm water to thin it out, mixing peanut powder into baby food, or using Bamba peanut puff snacks.  It is also recommended to feed peanut-containing food at least three times a week.

Parents who have an high-risk infant (having either eczema, an egg allergy, or both) should contact an allergist before introducing peanut at home.  A parent who is concerned or nervous about introducing peanut to their infant may also contact an allergist for supervised feeding in the office.  A skin prick test or blood test may be conducted to assess the risk of peanut introduction to the child (see chart below).  Based on the results, an in-office introduction may be performed at the office under the supervision of the doctor, or it may be advised that the infant is allergic and should not be fed peanut.

 

SPT = skin prick test OFC = oral food challenge

SPT = skin prick test
OFC = oral food challenge

http://www.annallergy.org/article/S1081-1206(16)31164-4/fulltext#appsec5

Addendum Guideline 1, Figure 1.

 

 

 

References:

Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel

http://www.annallergy.org/article/S1081-1206(16)31164-4/fulltext#appsec5

Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy (LEAP study)

http://www.nejm.org/doi/full/10.1056/NEJMoa1414850#t=article

LEAP website

http://www.leapstudy.com/leap-study-results#.WHHBBLGZNWc

New guidelines detail use of ‘infant-safe’ peanut to prevent allergy

http://www.aappublications.org/news/2017/01/05/PeanutAllergy010517

 

Starting Young – Breckan’s OIT Journey

Pediatric Allergist, Peachtree City, Fayetteville, Marietta, Georgia, Peanut Oral Immunotherapy

Starting Young – Breckan’s OIT Journey

Written by Deborah C.

At just over a year old we did what most parents do – give their child peanut butter for the first time.  His older brother isn’t allergic and we had no reason to think he would be.  Breckan’s first two small bites were uneventful and I thought we were in the clear.  I made him a peanut butter and honey sandwich and he LOVED it!!  Fifteen minutes later that sandwich would lead to the most terrifying trip to the ER to date.  My little boy looked as though he had been attacked by a swarm of bees from head-to-toe and was screaming to breathe.  That pivotal day is ingrained forever in my mind, and from that point onward I searched for any sign of hope or treatment for his anaphylactic food allergy.

When Breckan was 18 months old, I came across a Facebook group where someone mentioned Oral Immunotherapy (OIT).  I honed in on it immediately.  It just made sense, and I knew it was the treatment best suited for Breckan’s deadly allergy.  I hit the jackpot, because at the same time I learned of OIT, I heard there was a doctor opening up a private practice in the Atlanta area and I tracked him down and called him immediately.  It sounds cliche, but when Dr. Agrawal picked up the phone he changed our family’s life forever!  We watched Breckan’s peanut IgE numbers with hope over the next year, but when they shot up and his skin test exploded at 2.5 years old we decided to start OIT asap under the direction of Dr. Agrawal.

Breckan began his OIT journey on October 5, 2015 at 2 yrs, 9 months old.  Personally, I find beginning OIT at a young age provides so many benefits!  Some of these being little or zero anxiety, being completed before starting kindergarten, earlier protection, and at this age such a young child really hasn’t had to feel much, if any, exclusion due to their allergy.  Many parents who are interested in starting their child younger ask “what about communicating symptoms?”  I can assure anyone that communication is both verbal and non-verbal.  Your child doesn’t have to speak every word perfectly and know a vast vocabulary to complete OIT.  You are watching and observing (more like hawk-eyeing) and you will know if there are any symptoms or reactions.  Without a doubt, you will know.  A parent knows their child better than anyone and even the slightest change in expression can tell you if something is “off.”  We had zero issues with communicating symptoms throughout our experience and we did have a handful of them along the way, but nothing that couldn’t be worked through and overcome.  I also found that starting young made it easier to control and shape that this is just how things are now.  Period.  Meaning when it comes to dosing and then the observation period after for Breckan, I just made it into “this is what we do and this is just part of life.”  He is one of the most stubborn kids I have met, but by treating this as “peanut medicine” to him it was that – medicine – he ate a meal, he took his medicine, and he knew that meant “calm play” after.  Anyone who knows Breckan knows that calm and him do not go hand-in-hand.  Active is an understatement.  However, I think the term “rest period” with OIT is mis-labeled.  Kids do not have to sit still and not move!  They can do so many things!!  MagnaTiles, Legos, color, paint, use their imaginations to build cities or anything for that matter, play with dinosaurs or their favorite current toy, Star Wars themed toys, and the list goes on and on for all the things Breckan could do during his calm play time.  That list doesn’t even include video games or apps on his tablet which we’d sometimes do too.  We even dosed during vacations, like on our family winter ski vacation which was very active.  Breakfast, dose, calm play in condo, drive to mountain, and by the time he was skiing we were good to go!  OIT adapts to your life and you adapt to OIT.

Even being young, it amazed me throughout this process how much Breckan just “got it.”  One example was back in February 2016, in an instance that reminded me why we were doing this.  We had picked up Panda Express (not for the kids), and to our surprise, Breckan wanted to try the entree.  At this point he wasn’t “cleared” to eat any cross-contaminated food yet.  We obviously didn’t get any items that contained peanuts, but there was still too much of a risk for him to eat it when it’s a place that serves peanuts like that.  We hadn’t brought that food into our house at all in a couple years, but we felt ok doing it now with where he was at with OIT.  Unfortunately, we had to explain to him that he couldn’t try the entree.  I wasn’t expecting his reaction or I would have never brought it home.  He got teary-eyed and very upset that he wasn’t allowed to try it because of his allergy.  He kept saying, “but I take my peanut medicine” through a quivering lower lip.  My heart just broke for him.  I explained that this is why we are doing it, that this is why he is eating more and more peanuts and when he can eat even more, which will be soon, that he’ll be able to try new foods like this.  He understood, smiled, and was happy then and said, “I want to see Dr. Agrawal tomorrow.”  It probably seems so small to so many, but the exclusion to things like this and gaining freedom to have choices are some of the reasons we went through OIT.

On August 16, 2016, Breckan completed OIT and is now in maintenance!  Dr. Agrawal has given him the gift of protection and life insurance in its truest form.  I never thought this was possible when my head was swirling after that fateful ER trip 2.5 years ago.  Our lives were changed forever that day after being sealed with an anaphylactic peanut allergy diagnosis, but because of OIT we are able to give him the most “normal” life possible without the usual limitations of a deadly allergy.  He will never know what an allergy table is like at school, he’ll be able to eat the same birthday cake with all the other kids at parties, he can try new restaurants and new foods (and without having to investigate them first), we don’t have to worry about all the food recalls that are totally out of our control, we have no worries about mistakes made at the hands of others in food service industries, no more reading labels with a magnifying glass, he won’t have to leave a playground because a kid comes with a peanut butter sandwich and I can see it on their fingers as it smears everywhere, he’ll be able to go to overnight camps and field trips without his mom hovering over him (or maybe I still will)…and the list goes on and on.  It is really the simple day-to-day things that mean so much and one of the reasons we did OIT!  The biggest reason is accidental exposure and preventing a possible life-ending anaphylactic reaction… I would do anything to protect him to the best of my ability from that, but I also want him to be able to live the fullest life possible and thanks to Dr. Agrawal, his staff, and OIT, he can do just that!

If you’d like to read more about our OIT journey, please refer to our blog, “conquering peanut: Breckan’s OIT journey”  at http://coxfamilyconquers.blogspot.com

 

First peanut OIT dose!

First peanut OIT dose!

Eating peanut M&M’s with Nurse Danielle!

My Peanut OIT Experience – From Kaitlyn

Pediatric Allergist, Peachtree City, Fayetteville, Marietta, Georgia, Oral Immunotherapy

IMG_6582

My Peanut OIT Experience

– written by Kaitlyn L.

When I first started OIT I was 9. I didn’t really understand how severe my allergy was. All I really knew was that if i came in contact with a peanut I would die in a few seconds. We used to go to Helen in our camper and they had a little shop that served boiled peanuts. I could smell them before I saw them, that’s how allergic I was. When Dr. Agrawal first tested me he told my mom my allergy was really ‘’off the charts’’.

The night before I started OIT I didn’t exactly sleep at all. I was up all night with my stomach killing me. We had to start at the hospital in case something went wrong. Dr. Agrawal told my mom to pack lots of entertainment because it would take all day. The day before I cried all day because I was so scared. I didn’t get that they were trying to get me to eat something they told me not to even get near it my entire life. And now they were telling me to eat it, I didn’t get it. And thats where it all started.

First Day of OIT

First Day of OIT

When we got to the hospital I just about squeezed Mr. Bunny’s arm off I was so nervous. I was shaking like crazy. We went back to the room and when Dr. Argawal brought in the first dose I start crying like crazy. When I finally calmed down I took the first bit of peanut solution. I hated the flavor. I had to eat a meal before I came even though I wasn’t hungry. Most people who start OIT make it a lot further than I did. When we got back from the hospital my sister ‘’Kember’’ and grandmother ‘’Nan Nan’’ greeted me with flowers and balloons. After the hugs I went straight to bed. I was super tired.

Every morning at breakfast we talk about the day’s schedule and decide what time is best to take my dose. We choose a time based on my schedule that will give me 2 hours to rest. If I have softball that night, then I usually take it before school at breakfast. But during the summer I can take it later or during lunch since it is so hot outside. I have to eat a big meal before I take my dose and then I take my pills. These pills make sure I don’t get sick. I eat the peanut(s) and drink lots of water so my throat doesn’t get tingly. Then I usually draw or watch t.v. and rest until my two hour rest period is over. I do this every single day. It kind of gets old.  Every two weeks I updose to a higher level of peanuts at Dr. Agrawal’s office. Before every updose, my sister, my mom and me always estimate how much peanut I will go to at the appointment. Both, Ms. Danielle and Ms. Carla are super sweet.

First Cupcake from a Bakery

First Cupcake from a Bakery

It is really cool now, but when I started it didn’t seem very important. But now it’s changed everything. My school experience, my food experience, it’s even made me and my family closer. I’ve almost made it to maintenance which is super exciting for me and my family. Because I was off the charts when I started but now I’m eating 4 peanuts! And, I get it is SUPER scary when you start. But it gets a lot better. I’m now allowed to eat at bakeries, candy stores, and many more things I can’t even count that I could NEVER do before. Thanks so much Dr. Argawal! He is the very best and sweetest allergist there is. He has inspired me to become an allergist when I grow up.

From Peanut Particles to Actual Peanuts

Pediatric Allergist, Peachtree City, Fayetteville, Marietta, Georgia

Kaitlyn picture

From Peanut Particles to Actual Peanuts, 

Our Family’s Peanut OIT Journey with Dr. Agrawal

written by Jennifer L.

Kaitlyn has a life-threatening peanut allergy that truly dictates every aspect of her daily life.  Her allergy is so severe, that she will go into anaphylactic shock if she ingests even the smallest particle of a peanut.  This includes ingesting any product that has been produced at a facility that also produces peanut products, being touched by someone who has recently eaten a peanut, and even airborne particles such as those recirculated in a commercial airplane.  Daily life is hard, and arguably harder on a such a young girl of 11.

Kaitlyn has many limitations but is overcoming them with dignity and strength.  She is taking action to change the way she lives her life.  In March of 2015, Kaitlyn started peanut oral immunotherapy (OIT) treatment with Dr. Agrawal in hopes that it will desensitize her immune system and potentially save her life.

OIT is a journey, it isn’t quick or easy. Kaitlyn had to put all of her fears aside and ingest the very food that she has been warned about her entire life. She was terrified at first and then slowly warmed to the idea of going in for the initial appointment. Dr. Agrawal was fabulous with her and very understanding of her fears.

We moved forward with scheduling our initial appointment to begin OIT. Other than the nerves, it was relatively easy. We were armed with entertainment and foods to help coat her stomach. She didn’t make it to the highest dose that day because she was having hives, stomach pain and strange bumps on her tongue that came up after the third of fourth dose. We went home with her liquid dose and started the life changing process of OIT dosing once a day every day with a two hour rest period to ensure her body doesn’t fight peanut. Kaitlyn had a lot of nerves for months but she continued to take her dose.

We slowly continued to increase until September when everything came crashing down. Kaitlyn got sick and had horrible stomach pain, we decreased her dose more and more and she still had reactions so we finally had to stop. Kaitlyn felt horrible for weeks. After endless blood work, ultrasounds, and doctor appointments with Dr. Agrawal and our pediatrician they concluded that she had a stomach virus that was further irritated by her peanut dose and possibly a stomach ulcer. Our family was crushed to stop OIT but assured by Dr. Agrawal that we would begin again when she was feeling better.

We did start OIT again but had to go back to a much lower dose. Kaitlyn was beyond terrified and highly discouraged by starting the process over. Dr. Agrawal made several attempts to encourage her and get her to take her dose. It was agonizing to start over the process that we had worked so hard to get through. As of June 2016, Kaitlyn has successfully increased to 4000mg (roughly 4 whole peanuts). It’s absolutely amazing the freedom for her and our family to eat at restaurants we’ve never had the luxury of eating at, or consuming foods that we never dreamed of, and to relax just a little while she is at school or a playdate. Our goal is 6-7 peanuts to secure her safety.

Every little girl has big dreams.  Kaitlyn’s big dreams are ones that may seem small to the average kid; to fly on an airplane, to be able to eat a cookie cake with her friends, to be able to attend sleepovers, and to not have her Mom hover so closely.  The risk of contamination was too great for her to enjoy birthday cake, cookies, or most any food that her parents couldn’t verify were 100% safe.  Being left out of social functions and school parties has taken its toll on Kaitlyn emotionally.  Kaitlyn’s big dreams are to “fly to Paris,” to eat at the Great American Cookie Company and to one day become an allergist! And, thanks to Dr. Agrawal and OIT her dreams are now becoming reality!

We keep a blog about our OIT journey {kknaughtynuts.blogspot.com} where we share all of the trials and triumphs so feel free to read more details of Kaitlyn’s inspiring OIT journey.

A Family’s Journey from India to Pursue Food Allergy Treatment

Pediatric Allergist, Peachtree City, Fayetteville, Marietta, Georgia

DSC04543

It has been difficult for the Kumar family raising a daughter with food allergies in India where food allergies are not common or accepted.  When Laxmi was five months old, her parents discovered she was allergic to certain foods when her face swelled up, when she developed hives, and when she projectile vomited her baby cereal.  After testing, they uncovered the extent of her food allergies: she was allergic to milk, egg, wheat, peanuts, and all tree nuts.  Any exposure to those foods would result in an allergic reaction.  It was difficult to manage all the allergies in a country where food allergies are not prevalent.  As a result, Laxmi’s mom chose to stop pursuing her PhD in Biotechnology to stay home and care for her daughter.  She decided to homeschool her daughter and make each meal from scratch.

However, Mr. and Mrs. Kumar were intent on finding treatments or possible food allergy cures for their daughter.  Through online allergy support groups, Mrs. Kumar discovered Oral Immunotherapy (OIT), a treatment that desensitizes the body to a food allergen by daily ingestion of the food in increasing amounts.  After thorough research, they believed this treatment was the path they felt was the safest and most effective way to tackle Laxmi’s allergies to help her live a life without the restrictions of food allergies.

Unfortunately for the Kumar family, OIT is not offered in India.  Therefore, after much consideration and planning over five years, they decided to travel to the United States to pursue OIT.  Out of the 60 OIT allergists available in the United States, they chose Dr. Agrawal at Freedom Allergy in Peachtree City, Georgia to be their OIT allergist.  They researched and interviewed various other allergists, and felt that he was the best doctor for them due to his patient nature, knowledge, availability, and concern for all his patients.  With careful planning, they have moved to Georgia to pursue OIT treatment for 3 months.  Their goal is to return to the U.S. several times over the course of the next year to complete OIT for all of Laxmi’s allergens, and for her to be able to live a freer and safer life.

Laxmi is a courageous girl as she is dosing daily with her known allergens.  She is currently consuming a total of 0.24 ml of milk every day, an amount that could have caused anaphylaxis in the past.  When asked what she most looks forward to eating, she says she wants to eat ice cream, cakes, and chocolates, just like any regular kid.

This family made the move to a different country, to an unfamiliar city, with no friends or family nearby, to secure a better life for their daughter.  They chose the best doctor for their child, and they are excited for the future.

** names have been changed for the privacy of the family

Infants with Food Allergies

Pediatric Allergist, Peachtree City, Fayetteville, Marietta, Georgia

little toddler smiles over her messy mouth and bowl

The new guidance for food introduction to babies is to start feeding them foods as young as 4 months old.  The new guidance stems from the Learning Early About Peanut Allergy (LEAP) study that was published in The New England Journal of Medicine in February 2015.  Rather than avoid highly allergenic foods during the first few years of a child’s life, it is important to introduce it as early as possible for the child’s body to recognize it as a food, and not an allergen.

At Freedom Allergy, we specialize in the prevention, diagnosis, treatment, and management of pediatric food allergies.  Every child is unique, and we treat each patient as an individual.

We encourage you to schedule an appointment with us if:

  • if you are pregnant, and want to receive guidance on ways to possibly prevent a food allergy from developing in your unborn child
  • you are unsure how to introduce foods to an infant in the same household of a sibling with food allergies
  • there is a concern that your child may be allergic to a food,
  • your child is allergic to a food, and you are interested in oral immunotherapy (OIT), a food desensitization treatment that will allow your child protection from accidental ingestion or cross contamination of his/her allergen

We will review you and your child’s overall health history, family genetic risk factors, and perform and evaluate skin and blood tests, if necessary.  We will then come up with a plan to help your family navigate through the prevention or management of food allergies.

Back to School Allergy and Asthma Tips

Pediatric Allergist, Peachtree City, Fayetteville, Georgia

ACAAI Back to School Tips

With the new school year now underway, you may consider these back-to-school allergy and asthma tips from the American College of Allergy, Asthma and Immunology. These simple tools can help set up you and your child for success in this exciting new school year!

Teacher Teacher – While your child’s teacher is the first line of defense at school in helping reduce sniffing, wheezing and sneezing, the right systems must be established at home before they get on the bus. If your child takes an allergy or asthma medication, make sure they take them at home, and that good avoidance measures are set up to keep their triggers under control. If your child’s teacher knows your child’s triggers, she may be able to help them steer clear in the classroom as well.

Too cool for school? Nah. – Discuss how to handle emergencies with the school principal and school nurse. Since 2010, all 50 states have laws protecting students’ rights to carry and use asthma and anaphylaxis medications at school. Children who are at risk for a life-threatening allergic reaction (anaphylaxis) from certain foods or insect stings should have epinephrine auto-injectors immediately available for treatment.  Be sure your child and school staff know how to use emergency medications. Continue reading

Blood Tests – False Positive?

Freedom Allergy, Allergy Doctor, Atlanta, Georgia

False Positive Food Allergies

While many medical offices use blood tests to evaluate allergies, board certified allergists rely on skin prick testing, which offers a more appropriate reflection of true allergies. Blood tests frequently show “false positive” results, and provide evidence of an allergy that is not accurate. Many times, families come to our office with blood results from another doctor’s office showing a food allergy, when they have never actually had an allergic reaction to that food. If you have a question of blood results, it would be best to discuss the findings with an allergist, to make sure you move forward with the best plan for your allergies. After all, why eliminate a food from your diet, when you are not actually allergic to that food?

Read more, from the American College of Allergy, Asthma and ImmunologyContinue reading

Fall Allergies Are Upon Us

Allergy and Asthma Doctor, Atlanta, Georgia  

Freedom Allergy, Fall Allergies Ragweed, Atlanta, Georgia

Autumn is rapidly approaching. As backpacks fill with homework, football games kick off, and the Georgia heat simmers down, many know ragweed season also lurks around the corner. Ragweed grows most predominantly in the southern, northeastern and midwestern United States, and thrives in warm, humid environments. According to the Asthma and Allergy Foundation of America, 75% of people who are allergic to pollen-producing plants also suffer ragweed allergies. Ragweed emits a particularly large amount of pollen – up to 1 billion pollen grains per plant – and the pollen can extend up to two miles into the atmosphere. Ten to twenty percent of Americans suffer ragweed allergy flare-ups near the end of the summer, usually peaking around early September, and these flare-ups can lead to asthma exacerbations, headaches, and chronic sinusitis. With fall allergy season already upon us, do not wait to schedule an appointment with your board certified allergist, who can help keep your allergies and asthma under control.

Read more about ragweed allergies here.

Resources:

Costa S. Are Your Allergies Ready for a Relocation? U.S. News & World Report.  Aug 2014. http://health.usnews.com/health-news/health-wellness/articles/2015/08/14/are-your-allergies-ready-for-a-relocation.

Pongdee T. Ragweed Plants Packed with Pollen. American Academy of Allergy Asthma and Immunology. Aug 2011. http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Libraries/EL-ragweed-patient.pdf.

Back to School with Food Allergies

Pediatric Food Allergy Doctor, Peachtree City, Fayetteville, Georgia

Back to School

School is right around the corner, and along with the excitement of new clothes, bright supplies, and fresh possibilities, your child may also have a few butterflies in the stomach. For a parent of a child with a severe food allergy, you may have some butterflies of your own. Many parents worry their child will accidentally eat a food they’re allergic to while at school, and suffer a severe reaction. Setting your child up at school with an epinephrine auto-injector (EAI) is important, but this also requires staff and personnel who can recognize an anaphylactic reaction and can correctly use the EAI.

Children need help from adults in managing their food allergies. One survey out of Mississippi schools revealed 97% had at least one child with a food allergy, but only 30% had action plans for these students. Schools were more likely to have action plans when the school nurse had received appropriate information from a physician. If you need refreshing on how to use your EAI, or would like assistance in educating personnel at your child’s school on recognizing and treating anaphylaxis, call our office today. Anaphylaxis action plans can also be written by physicians and distributed in daycares and schools.

Reference: O’Keefe AW, De Schryver S, Mill J, et al. Diagnosis and Management of Food Allergies: New and Emerging Options: A Systematic Review. Journal of Asthma and Allergy. 2014;7:141-164.