Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States.

Importance: The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States recommend that pediatricians assess infant peanut allergy risk and introduce peanut in the diet at age 4 to 6 months. Early introduction has the potential to prevent peanut allergy development. Objectives: To measure the rates of guideline awareness and implementation and to identify barriers to and factors associated with implementation among US pediatricians. Design, Setting, and Participants: This population-based study survey used a 29-item electronic survey instrument that was administered to pediatricians practicing across the United States from June 1, 2018, to December 1, 2018. Invitations to complete a survey were emailed to all pediatricians in the American Academy of Pediatrics vendor database. Eligible participants were nonretired US-based pediatricians providing general care to infants aged 12 months or younger. Main Outcomes and Measures: The primary outcome was the prevalence of guideline implementation, which was measured by 1 survey item about awareness followed by a second item about implementation. Secondary outcomes included identification of guidelines-focused services provided by pediatricians, knowledge of the guidelines (measured with 3 clinical scenarios), barriers to guideline implementation, need for training, and facilitators of guideline implementation. Results: A total of 1781 pediatricians were eligible to participate and completed the entire survey. Most respondents self-identified as white (1287 [72.5%]) and female (1210 [67.4%]) individuals. Overall, 1725 (93.4%; 95% CI, 92.2%-94.5%) pediatricians reported being aware of the guidelines. Of those pediatricians who had knowledge of the guidelines, 497 (28.9%; 95% CI, 26.8%-31.1%) reported full implementation and 1105 (64.3%; 95% CI, 62.0%-66.6%) reported partial implementation. Common barriers to implementation included parental concerns about allergic reactions (reported by 575 respondents [36.6%; 95% CI, 34.3%-39.1%]), uncertainty in understanding and correctly applying the guidelines (reported by 521 respondents [33.2%; 95% CI, 30.9%-35.6%]), and conducting in-office supervised feedings (reported by 509 respondents [32.4%; 95% CI, 30.1%-34.8%]). Many pediatricians (1175 [68.4%; 95% CI, 66.1%-70.5%]) reported a need for further training on the guidelines. Conclusions and Relevance: This survey found that most pediatrician respondents appeared to know of the 2017 guidelines, but less than one-third of respondents reported full implementation. Results of this study may inform future efforts to eliminate barriers to guideline implementation and adherence, thereby reducing the incidence of peanut allergy in infants.

Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early Peanut Introduction.

Importance: Early peanut introduction reduces the risk of developing peanut allergy, especially in high-risk infants. Current US recommendations endorse screening but are not cost-effective relative to other international strategies. Objective: To identify scenarios in which current early peanut introduction guidelines would be cost-effective. Design, Setting, and Participants: This simulation/cohort economic evaluation used microsimulations and cohort analyses in a Markov model to evaluate the cost-effectiveness of early peanut introduction with and without peanut skin prick test (SPT) screening in high-risk infants during an 80-year horizon from a societal perspective. Data were analyzed from April to May 2019. Exposures: High-risk infants with early-onset eczema and/or egg allergy underwent early peanut introduction with and without peanut SPT screening (100 000 infants per treatment strategy) using a dichotomous 8-mm SPT cutoff value (stipulated in the current US guideline). Main Outcomes and Measures: Cost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy. Results: In the simulated cohort of 200 000 infants and using the base case during the model horizon, a no-screening approach had lower mean (SD) costs ($13 449 [$38 163] vs $15 279 [$38 995]) and higher mean (SD) gain in QALYs (29.25 [3.28] vs 29.23 [3.30]) vs screening but resulted in more allergic reactions (mean [SD], 1.07 [3.15] vs 1.01 [3.02]), severe allergic reactions (mean [SD], 0.53 [1.66] vs 0.52 [1.62]), and anaphylaxis involving cardiorespiratory compromise (mean [SD], 0.50 [1.59] vs 0.49 [1.47]) per individual. In deterministic SPT sensitivity analyses at base-case sensitivity and specificity rates, screening could be cost-effective at a high disutility rate (the negative effect of a food allergic reaction) (76-148 days of life traded) for an at-home vs in-clinic reaction in combination with high baseline peanut allergy prevalence among infants at high risk for peanut allergy and not yet exposed to peanuts. If an equivalent rate and disutility of accidental and index anaphylaxis was assumed and the 8-mm SPT cutoff had 0.85 sensitivity and 0.98 specificity, screening was cost-effective at a peanut allergy prevalence of 36%. Conclusions and Relevance: The results of this study suggest that the current screening approach to early peanut introduction could be cost-effective at a particular health utility for an in-clinic reaction, SPT sensitivity and specificity, and high baseline peanut allergy prevalence among high-risk infants. However, such conditions are unlikely to be plausible to realistically achieve. Further research is needed to define the health state utility associated with reaction location.

Allergenicity assessment on thermally processed peanut influenced by extraction and assessment methods.

The effect of processing on allergenicity of peanut, a major allergic food remains uncertainty. To discover the influence of thermal processing, extraction and assessment methods on potential allergenicity, protein was extracted by three methods or digested in the form of defatted peanut powder (DPP). The components of extracted allergens were analyzed using electrophoresis and mass spectrometry; the advanced structures (the secondary structure and the tertiary structure) were characterized through spectroscopies; the potential allergenicities were assessed by enzyme linked immunosorbent assay (ELISA), Biolayer interferometry (BLI) and KU812 cell degranulation assay. Results demonstrated that extraction influenced the allergenicity assessment significantly, and the assessment method was also important. The potential allergenicity of protein changed after processing, it increased after roasting, while decreased after boiling. Additionally, digested DPP combined with basophilic granulocyte degranulation model might be a good allergenicity assessment method.

Environmental exposure to peanut and the risk of an allergic reaction.

OBJECTIVE: To review the evidence of the risk of environmental exposure to peanut to a peanut allergic individual. DATA SOURCES AND STUDY SELECTION: A narrative review was performed using a PubMed search of relevant articles involving peanut environmental distribution, environmental peanut abatement, and public policy regarding peanut restriction. RESULTS: Data from 4 studies have shown that peanut butter vapors and smeared peanut butter on skin do not cause systemic reactions, that peanut can be abated from hands and surfaces using appropriate cleaning agents, and that shelled peanut dust does not become airborne. Studies have recently confirmed dose of 1.5 mg of peanut protein would be generally tolerated by approximately 95% of the peanut-allergic population based on objective symptoms in challenge-based studies, affirming earlier research. Restrictive policies that focus on bans (or restricted presence in certain areas) of peanuts or peanut-containing products in environments such as schools or on commercial aircraft are not backed by evidence that such measures work, which may raise an uncomfortable clash between accommodations that lack any medical evidence of necessity and a desire to provide measures that comfort our patients. CONCLUSION: There is little risk posed from non-oral exposure to peanut in the environment, from casual contact, proximity, or inhalation. If 5% of the population may tolerate a threshold of approximately 1.5 mg of peanut protein, this may help liberate behavior and situational-decision making regarding the necessity of certain avoidances and restrictions. Continued work is needed to dispel myths about the mechanisms of how peanut may induce an allergic reaction.

"To screen or not to screen": Comparing the health and economic benefits of early peanut introduction strategies in five countries.

BACKGROUND: Early peanut introduction (EPI) in the first year of life is associated with reduced risk of developing peanut allergy in children with either severe eczema and/or egg allergy. However, EPI recommendations differ among countries with formal guidelines. METHODS: Using simulation and Markov modeling over a 20-year horizon to attempt to explore optimal EPI strategies applied to the US population, we compared high-risk infant-specific IgE peanut screening (US/Canadian) with the Australiasian Society for Clinical Immunology and Allergy (Australia/New Zealand) (ASCIA) and the United Kingdom Department of Health (UKDOH)-published EPI approaches. RESULTS: Screening peanut skin testing of all children with early-onset eczema and/or egg allergy before in-office peanut introduction was dominated by a no screening approach, in terms of number of cases of peanut allergy prevented, quality-adjusted life years (QALY), and healthcare costs, although screening resulted in a slightly lower rate of allergic reactions to peanut per patient in high-risk children. Considering costs of peanut allergy in high-risk children, the per-patient cost of early introduction without screening over the model horizon was $6556.69 (95%CI, $6512.76-$6600.62), compared with a cost of $7576.32 (95%CI, $7531.38-$7621.26) for skin test screening prior to introduction. From a US societal perspective, screening prior to introduction cost $654 115 322 and resulted in 3208 additional peanut allergy diagnoses. Both screening and nonscreening approaches dominated deliberately delayed peanut introduction. CONCLUSIONS: A no-screening approach for EPI has superior health and economic benefits in terms of number of peanut allergy cases prevented, QALY, and total healthcare costs compared to screening and in-office peanut introduction.

Assessment of peanut allergen Ara h1 in processed foods using a SWCNTs-based nanobiosensor.

The goals of this research were to develop a rapid single-walled carbon nanotube (SWCNT)-based biosensor and to employ it to commercial food products for Ara h1 detection. The SWCNT-based biosensor was fabricated with SWCNTs immobilized with antibody (pAb) through hybridization of 1-pyrenebutanoic acid succinimidyl ester (1-PBASE) as a linker. The resistance difference (ΔR) was calculated by measuring linear sweep voltammetry (LSV) using a potentiostat. Resistance values increased as the concentration of Ara h1 increased over the range of 1 to 105 ng/L. The specific binding of anti-Ara h1 pAb to antigen including Ara h1 was confirmed by both indirect ELISA kit and biosensor assay. The biosensor was exposed to extracts prepared from commercial processed food containing peanuts, or no peanuts, and could successfully distinguish the peanut containing foods. In addition, the application of present biosensor approach documented the precise detection of Ara h1 concentrations in commercially available peanut containing foods.

BSACI guideline for the diagnosis and management of peanut and tree nut allergy.

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required.

Early introduction of peanuts.

Peanut allergy is the most common food allergy and the leading cause of anaphylaxis and death due to food allergy. Despite previous guidelines created by the American Academy of Pediatrics in 2003, peanut allergy has continued to significantly increase over the past decade. Therefore, further research has been done to help clinicians provide more evidence-based recommendations about the timing of introduction of peanuts. The LEAP study, published in February 2015, demonstrated the value of much earlier introduction of peanuts to nonallergic patients than previously suggested. These findings have altered current practice, and recommendations supported by the American Academy of Pediatrics now allow the introduction of peanuts as early as age 4 months to reduce the likelihood of developing peanut allergy.

Local versus offshore production of ready-to-use therapeutic foods and small quantity lipid-based nutrient supplements.

Manufacturers on four continents currently produce ready-to-use therapeutic foods (RUTF). Some produce locally, near their intended users, while others produce offshore and ship their product long distances. Small quantity lipid-based nutrient supplements (SQ-LNS) such as Nutriset's Enov'Nutributter are not yet in widespread production. There has been speculation whether RUTF and SQ-LNS should be produced primarily offshore, locally, or both. We analyzed The United Nations Children's Fund (UNICEF) Supply Division data, reviewed published literature, and interviewed local manufacturers to identify key benefits and challenges to local versus offshore manufacture of RUTF. Both prices and estimated costs for locally produced product have consistently been higher than offshore prices. Local manufacture faces challenges in taxation on imported ingredients, low factory utilization, high interest rates, long cash conversion cycle, and less convenient access to quality testing labs. Benefits to local economies are not likely to be significant. Although offshore manufacturers offer RUTF at lower cost, local production is getting closer to cost parity for RUTF. UNICEF, which buys the majority of RUTF globally, continues to support local production, and efforts are underway to narrow the cost gap further. Expansion of RUTF producers into the production of other ready-to-use foods, including SQ-LNS in order to reach a larger market and achieve a more sustainable scale, may further close the cost and price gap. Local production of both RUTF and SQ-LNS could be encouraged by a favorable tax environment, assistance in lending, consistent forecasts from buyers, investment in reliable input supply chains, and local laboratory testing.

When there is no school nurse--are teachers prepared for students with peanut allergies?

Peanut allergies account for the majority of severe food-related allergic reactions and affect 1% of Americans today. Therefore, food allergies among students are one of the most common healthcare conditions that must be addressed in the school setting. With the lack of full-time school nurses, teachers feel overwhelmed when the responsibility is placed upon them to care for these students. This article will discuss the prevalence of peanut allergies in schools and acknowledge the difficulties faced by teachers when dealing with a student with a peanut allergy. It is imperative that teachers receive a comprehensive educational program on peanut allergies when no school nurse is available. Ultimately, we want teachers and school staff responsible for student supervision to recognize quickly what symptoms might indicate anaphylaxis and know how and when to get help. This knowledge would increase their awareness of their own role in preventing allergy-related deaths.

Peanut allergen exposure through saliva: assessment and interventions to reduce exposure.

BACKGROUND: Exposure to food allergens through saliva (kissing, utensils) can cause local and systemic allergic reactions. OBJECTIVE: To determine the time course of peanut allergen (Ara h 1) persistence in saliva after ingestion of peanut butter and to evaluate mouth cleansing interventions to reduce salivary peanut allergen. METHODS: Thirty-eight individuals ingested 2 tablespoons of peanut butter, and saliva was collected at various time points. At another time, samples were collected after 5 interventions (brushing teeth, brushing and rinsing, rinsing, waiting then brushing, waiting then chewing gum). Detection of Ara h 1 was performed by a monoclonal-based ELISA (detection limit, 15-20 ng/mL). RESULTS: Salivary Ara h 1 varied considerably immediately after ingestion, but included levels expected to invoke reactions (as much as 40 microg/mL). Most (87%) subjects with detectable peanut after a meal had undetectable levels by 1 hour with no interventions. None had detectable levels several hours later after a peanut-free lunch. This result indicates (95% confidence) that 90% would have undetectable Ara h 1 in saliva under these circumstances. All of the interventions reduced salivary Ara h 1, in some cases by >95%, but Ara h 1 remained detectable in approximately 40% of samples (though typically below thresholds reported to induce reactions). CONCLUSION: Patients with peanut allergy require counseling regarding risks of kissing or sharing utensils, even if partners have brushed teeth or chewed gum. Advice to reduce risks, though not as ideal as total avoidance, includes waiting a few hours plus eating a peanut-free meal. CLINICAL IMPLICATIONS: Waiting several hours and ingesting a peanut-free meal were more effective at reducing salivary peanut protein concentration than simple, immediate interventions.

Governing peanuts: the regulation of the social bodies of children and the risks of food allergies.

This paper explores the way in which children with life-threatening food allergies, their parents and their public caregivers have increasingly been made subject to both projects of moral regulation and mechanism of governance aimed at the management of risk. We argue that new regulatory measures in Canada designed to significantly change the food consumption practices among children in elementary schools have three main consequences. First, they structure the relationship between ideologies of individualism and community so as to blur the distinction between the public and private dimensions of school life. Second, such efforts ensure that a discourse, formerly concerned with the problem of health promotion, has been supplanted by new sets of discourses styled by absent experts that focus on the management of risk. Third, such regulatory practices have a particular dual effect that is characteristic of liberal welfare governance. On the one hand, they encourage the individualized development of self-governing subjects, and on the other, they stimulate a heightened moral problematization of 'safe' eating habits within the environment of the elementary school.