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When to Introduce Peanuts to Kids: How to reduce food allergy risk

Who knew one little legume could cause so much trouble? The peanut has led schools in states from Alabama to Wisconsin to set up peanut-free tables in the cafeteria or ask parents to keep the PB&J at home, and a few months ago Air Canada refused to let a 19-year-old with a severe peanut allergy board a flight. Meanwhile, in Florida, some parents have recently been calling for a first-grader with life-threatening peanut allergies to be home-schooled rather than have their own kids forced to wash their hands and rinse out their mouths before entering the classroom.

Partly because the effects of a severe peanut allergy can be fatal if not treated immediately, many doctors advise waiting at least a year – sometimes up to three – before introducing peanut products to babies, and several parents said they automatically hewed to the recommendation. One New Jersey couple who absentmindedly fed their daughter peanut butter at 11 months found out early that she was allergic, after she broke out in hives – just the kind of story that feeds parental anxiety. “I am nervous about allergies and anaphylactic shock,” said another parent, the mother of a nearly 3-year-old boy and a 7-month-old girl. “I would rather listen to my doctor than take chances.”

But what if the doctors who recommend waiting, and the parents who avoid feeding peanut products to young children regardless of the doctors’ recommendations, are operating on the wrong premise? The idea of holding off on giving children potential allergens is based on the theory that doing so is liable to increase the chance that the child will develop an allergy to that food. But amid all the fears and cautionary advice, what many parents may not realize is that the National Institutes of Health and the American Academy of Pediatrics have both determined that there is no convincing medical evidence that actually backs up that hypothesis.

Moreover, the desire to play it safe might actually end up increasing the likelihood that children will ultimately develop a peanut allergy. A study published in the Journal of Allergy and Clinical Immunology in October 2008 comparing Israeli children with British ones found peanut allergy to be 10 times more prevalent among the British kids than in Israel, where babies are routinely given immensely popular peanut puffs called Bamba (or its generic imitators), which has the look and feel of Cheez Doodles but tastes like peanut butter. The study found that 69 percent of Israeli infants consume peanut products by the time they are nine months old, compared to just 10 percent of their British counterparts. (The participants in both groups were Jewish, to minimize any underlying genetic differences.) That finding is bolstered by a study published this May in Food Research International, which found that feeding peanuts to pregnant and nursing mice protected their offspring from sensitization to peanuts.

And in the United States, both the NIH and the AAP have determined that there is no reason to avoid delaying the introduction of any food beyond four to six months of age for any infants without a documented food allergy, even if they are at risk of developing one because a parent or sibling has an allergy. (Of course, no one is recommending feeding an infant actual peanuts, which pose a choking hazard.)

“There is no known benefit to avoiding potentially allergenic foods,” an expert panel sponsored by the NIH’s National Institute of Allergy and Infectious Diseases stated in guidelines released in December, specifically citing cow’s milk, eggs, peanuts, tree nuts, wheat, soy, fish, and crustacean shellfish. “[R]estricting developmentally appropriate solid food variety beyond age 6 months can lead to inadequate nutrient intake, growth deficits, and feeding problems.” The guidelines also say it is not recommended for pregnant or breastfeeding women to stay away from potential food allergens.

Dr. Jerry M. Shier, an allergist at the Asthma and Allergy Center in Maryland and an assistant clinical professor at George Washington University’s medical school, said that although he now tells parents they can introduce all solids after six months if the child is healthy, many people are reluctant to hear the message. “Many parents who have allergy themselves or who already have a child who is allergic are skeptical about the new recommendations and proceed to avoid,” he said. “It will take years for parents and physicians to embrace the new information.”

But while a fear of peanuts may be commonplace among American parents, it’s not like that everywhere in the world.

In Israel, where I live, doctors and parents tend to view children’s peanut consumption as about as much of a medical issue as their pureed carrot consumption, and there is virtually no allergy awareness. When I take my young daughters to the park, we’re likely to stumble across abandoned bits of Bamba on the bottom of the slide; the country’s main children’s hospital stocks Bamba in its vending machines, and my daughter’s previous day care center, near Tel Aviv, hands it out to the kids as an occasional treat. One of the teachers there was taken aback when she found out parents in the United States would be less than sanguine if they discovered their babies and toddlers were getting peanut products in day care. “What, they don’t eat Bamba over there?” she asked. “That’s really weird.”

“There has never been anything [in Israel] prohibiting parents from giving peanut snacks from a particular age,” said Dr. Yael Levy, the deputy head of the Kipper Institute of Immunology at Schneider Children’s Medical Center of Israel. “The advantage of this snack is that you can even put it into the mouths of babies who don’t have teeth, because it really melts,” she added. “The practice is to give it the first year – from six or seven months old – and there’s no danger in that.”

According to the theory that keeping kids and peanuts far away from each other is the best method of preventing allergy, Israel should be swarming with allergic kids, but it’s not, as seen in the study comparing British and Israeli children. The practical dilemma that poses – whether to welcome peanut products into your home or to treat them as radioactive – is precisely what Gideon Lack, one of the researchers who conducted the study, is attempting to resolve.

Lack is the principal investigator of the Learning Early About Peanut Allergy (LEAP) study, a British clinical research study that aims to discover whether avoiding or consuming peanut products in infancy is the best way to prevent peanut allergy. Of 640 infants at high risk of developing peanut allergy, the study randomly assigned half to avoid peanut-containing foods until age 3 and half to be fed an age-appropriate peanut snack three times a week. The study is expected to be completed in 2013.

But for now, at least, it doesn’t look like American infants are going to be gobbling goober snacks just like Israeli ones any time soon. While the researchers behind the Israel-U.K. comparison study conclude that recommendations to avoid peanut products “might be promoting the development of peanut allergy,” even they say doctors shouldn’t be advised to recommend early consumption until more conclusive results are in.

There are also cultural differences, with some studies noting that differences in peanut preparation could contribute to the varied rates of peanut allergy, given that most peanuts in the United States are dry-roasted, which may make them more allergenic than boiling. And the attitude issue shouldn’t be discounted either. In the allergy age, it can sometimes seem like even whispering the words “peanut snack” in the States might send someone into anaphylactic shock. Indeed, parents who already have a child with food allergies tend to be “so emotionally wrought,” said Dr. Chitra Dinakar, an allergist and a pediatrics professor at the University of Missouri-Kansas City, that they typically prefer conservative options no matter how slim the evidence that delaying the introduction of specific foods will make a difference.

Although Dinakar and other U.S. doctors are waiting for more definitive evidence before recommending that parents go out of their way to feed their infants potential allergens, parents should bear in mind that peanut products have been given a medical stamp of approval as soon as babies – even those with a family history (but not a personal history) of food allergy – start eating solids. And beyond that, as Shier, the Maryland allergist, put it: “Exposure may be good.”

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