Since 2017, the National Institutes of Allergy and Infectious Diseases has recommended the early introduction of peanut foods to help prevent peanut allergies. Pediatricians can play an integral part in helping parents understand and implement early introduction accurately and in a timely manner. Dr. JJ Levenstein is the chair of the National Peanut Board’s Food Allergy Education Advisory Council, a multidisciplinary group of professionals with interest in the management of food allergies. Registered dietitian and food allergy expert Sherry Coleman Collins asked Dr. JJ to share her perspective on how infant feeding has changed and the role of the pediatrician in helping parents get up to speed on their approach to feeding their babies. As part of our ongoing investment in helping promote the early introduction of peanut foods to help prevent peanut allergies, the National Peanut Board has created a new resources page just for pediatricians and health professionals: https://preventpeanutallergies.org/pediatrician-resources/.
SCC: You’ve had a long career in pediatrics. Can you briefly speak to some of the changes you have seen in early feeding recommendations for infants over the last decade or two?
Dr. JJ: When I started taking care of children in the early 1980’s, introducing complementary foods was routine at 4 months of age. It was common practice to give some babies cereal in their bottles as a mode of thickening their milk to reduce “spittiness.” Juice was a commonly offered and marketed beverage for infants, and of course, infant formula use was widespread. Breastfeeding support in the hospital/newborn nursery was a rarity, and baby food, unless fresh, was served from jars in a variety of hues. Grandparents used to “sneak” bites of taboo food into their grandchildren’s mouths when parents weren’t looking (and as I think back, perhaps that was a good thing) and babies ate from bowls, spoons, and with their own hands.
As we entered 2000, more and more of the benefits of breastfeeding started to emerge in scientific publications and were endorsed enthusiastically by pediatric stakeholders. As a result, feeding complementary foods was discouraged before 6 months so that babies could reap the benefits of exclusive breast feeding. Infant formula companies’ swag bags were ousted from baby friendly hospitals, and lactation consultancies popped up nationally. With many women returning to work, some companies created pump-friendly environments or better yet, added in house day care so mothers could continue to successfully nurse. We’ve made inroads to eliminating juice as a dietary necessity, improving dental health and hopefully keeping rising BMIs and future obesity at bay. The American Academy of Pediatrician’s recommendation in 2000 to delay the introduction of “highly allergenic” foods was, unfortunately, based on a tiny study, and over the ensuing 10-15 years, we saw food allergies rise in prevalence and severity – exactly the opposite of the guideline’s goals.
Food allergies have risen to a level of urgency in the scientific community, and as a result, guidelines have recommended that withholding any food in the first year of life does not prevent food allergies. And because of the results of the LEAP study, evidence supports early introduction of peanut as a means to help prevent peanut allergies, especially in high risk children.
SCC: The new guidelines now recommend early introduction starting as early as 4-6 months and recently the AAP released their own paper in support of early introduction, but not everyone is onboard yet. What would you say to a pediatrician who is skeptical about the latest recommendations?
Dr. JJ: I’ve always followed the good science and been a student of medical history as well. When I speak to my peers (I am in my 60’s), I remind them that our generation has very few food allergies. Why? [One reason is likely] because in the 40’s and 50’s our parents fed us everything – early and often. We also benefited from fewer C-sections, less antibiotics, more dirt exposure and likely a healthier biome. I encourage pediatricians and clinicians to read the LEAP study in its entirety, and the follow-up studies that support early introduction. I remind them that pendulums swing when it comes to many of our recommendations and reinforce that delaying the introduction of allergens resulted in nothing but harm to many children. I acknowledge, openly, that clinicians must remain humble, and be willing to bite the bullet of change if it benefits our kids – that’s our common goal.
SCC: Research shows that parents rely on their pediatrician to give them the best advice for infant and child care, including feeding. How can pediatricians help their patients overcome barriers (particularly fear) to the early introduction of peanut foods?
Dr. JJ: Pediatricians should encourage parents to discuss their fears, stories they may have read or heard about, and then discuss the evidence in a way parents can understand. If you are confident in the science, that confidence will come through as you navigate the guidelines. Remind parents that they are not alone on this journey and that you will support them. Providing parent-friendly handouts, posting signs encouraging parents to ask about the new guidelines, and mobilizing your local allergists for support are good strategies. Remind parents that peanut foods are affordable, nutrient-dense and healthy. Emphasize that, although it might be scary to think about giving peanut foods early, the potential of preventing peanut allergy could yield a life-long benefit.
SCC: What resources do you recommend to your colleagues and other healthcare professionals who want to learn more about this issue?
Dr. JJ: I encourage clinicians to read the LEAP Study, the NIAID guidelines and Addenda; AAAAI and AAP. In addition, CME resources like Medscape have excellent articles and supporting materials to deepen knowledge. PreventPeanutAllergies.org has lots of resources for clinicians to share with their patients and families including handouts in English and Spanish, office posters and videos that can be downloaded and used without cost.
SCC: Is there anything else you think pediatricians should know about this issue?
Dr. JJ: Read and embrace the science. Dig deeper if you have to. Then approach your patients with confidence. KNOWING (through evidence) is much more powerful than THINKING (via anecdote). Change is scary, exciting, humbling and ultimately, beneficial when backed up with good evidence.