Early Food Introduction Guidelines and Reduction in Food Allergy

Source: Gabryszewski SJ, Dudley J, Faerber JA, et al. Guidelines for early food introduction and patterns of food allergy. Pediatrics. 2025;156(5):e2024070516; doi: 10.1542/peds.2024-070516.Investigators from Children’s Hospital of Philadelphia conducted a retrospective cohort study to evaluate changes in rates of peanut immunoglobulin E-mediated food allergy (IgE-FA) or any IgE-FA in young children following guidelines recommending early peanut introduction. For the study, they reviewed the American Academy of Pediatrics Comparative Effectiveness Research through Collaborative Electronic Reporting (CER2) database that includes data on children seen in primary care practices in the US. Study participants were children with =1 visit to 48 practices participating in CER2 with a minimum of 2 years of observation. Based on the release of guidelines recommending early peanut introduction in 2015 and addendum guidelines in 2017, 3 cohorts of study patients were developed. The pre-guidelines cohort included children who entered the study between September 2012 and August 2014, the post-guidelines cohort entered between September 2015 and August 2017, and the addendum cohort included those entering the study from February 2017 to January 2019. The occurrence of IgE-FA in participants was determined using ICD-9 and ICD-10 codes, along with a prescription for an epinephrine autoinjector. The specific cause of IgE-FA was recorded (eg, peanuts, eggs). The 2-year cumulative incidence of peanut IgE-FA and any IgE-FA among children in the pre- and post-guideline cohorts was compared using Cox regression, after adjusting for confounders. Following the initial 2-year period, the 1-year cumulative incidence of IgE-FA was compared among those in the pre-guidelines and addendum cohorts.A total of 38,594, 46,680, and 39,594 patients, respectively, were included in the pre-guidelines, post-guidelines, and addendum cohorts. In the 2-year cumulative incidence analysis, the mean age of children in the pre-guidelines cohort was 1.2 years and 0.9 years for those in the post-guidelines cohort. The 2-year cumulative incidence of peanut IgE-FA decreased from 0.92% in the pre-guidelines cohort to 0.67% post-guidelines (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55, 0.77). There also was a significant decrease in the 2-year cumulative incidence of any IgE-FA (1.98% vs 1.23%; HR, 0.69; 95% CI, 0.61, 0.78). In the pre-guidelines cohort, peanut allergy was the most commonly diagnosed IgE-FA, with egg allergy second. However, in children enrolled post-guidelines, egg allergy was the most common IgE-FA. Among patients included in the 1-year observation period, there was a stepwise decrease in peanut IgE-FA cumulative incidence between those in the pre-guidelines, post-guidelines, and addendum cohorts (0.79%, 0.53%, and 0.45%, respectively), and any IgE-FA (1.46%, 1.02%, and 0.93%, respectively). The cumulative incidence of peanut IgE-FA and any IgE-FA were significantly lower among patients in the addendum cohorts than in those enrolled in the pre-guidelines period (HR, 0.55; 95% CI, 0.46, 0.66 and HR, 0.63; 95% CI, 0.55, 0.72, respectively).The authors conclude that guidelines recommending early introduction of peanuts were associated with decreased rates of peanut IgE-FA and any IgE-FA in young children.Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The current study highlights the importance of data-driven policy guidelines. In 2000, the American Academy of Pediatrics (AAP) recommended delaying the introduction of peanuts until the age of 3 years for high-risk children.1 This decision was affirmed by similar bodies in Europe. However, the data behind that recommendation were sparse.1 In 2017, the AAP changed course, suggesting that high-risk and moderate-risk children could ingest peanuts after food allergy testing.2 In 2021, incorporating broad population studies, the AAP recommended the introduction of allergenic foods such as peanuts and eggs as early as 4–6 months, a complete turnaround from the restrictive recommendations of 2020.3 (See AAP Grand Rounds. 2022;48[4]:39.)4This consensus opinion from 2020 has had far-reaching impact. By 2022, only 17% of parents, 29% of pediatricians, and 65% of allergists had adopted the updated 2017 and 2021 guidelines.5,6 Despite the slow update of the latest recommendations, the current authors demonstrate the real-world impact with 3 large cohorts: There was a 45% reduction in all IgE-FA after the implementation of liberalized dietary recommendations.Early introduction of allergenic foods makes sense physiologically. When allergenic proteins are introduced in the gut between the ages of 4–6 months, the response within the gut-associated lymphoid tissue elicits a protective response from regulatory T-cells, rather than an allergic response of IgE.7 IgE sensitization of allergenic proteins most often occurs through protein exposure of disrupted skin, such as with eczema.7There has been a reduction of both peanut and any IgE-FA since the implementation of liberalized food introduction guidelines.