New Research Shows Peanut Allergy May Be Prevented Early in Life

GoingNuts · February 27, 2015, 07:06:41 AM

Two Editorials. The first one had me seeing 10 different shades of red:

http://www.newsday.com/opinion/columnists/lane-filler/don-t-get-nutty-over-peanuts-lane-filler-1.9973081

I much prefer the second, from Snacking Safely:

http://snacksafely.com/2015/02/of-babies-peanuts-and-allergy-moms/

ajasfolks2 · February 27, 2015, 10:04:01 AM

Link to the DISCLOSURES form for the study:

http://www.nejm.org/doi/suppl/10.1056/NEJMoa1414850/suppl_file/nejmoa1414850_disclosures.pdf

guess · February 27, 2015, 11:54:16 AM

To more fully zero out my concerns about funding bias I would have preferred not so many of the co-authors operate on National Peanut Board money so I could dial down the skepticism, but to be fair this was solid work with plain design. It also helps answer the question why only peanut. Kicking the tires never reveals anything settling.

Or, non-specified 'support' as it was written. Non-financial support should have been disclosed as non-financial. Generic 'support' wasn't part of the definitions.

Linden · February 27, 2015, 12:21:27 PM

I keep thinking back to the scene in Good Will Hunting where Robin Williams just keeps repeating to Will,
"It's not your fault."

guess · February 27, 2015, 12:59:00 PM

The questions start getting uncomfortable when you match up ajas' recent post to NPB's internal concerns about promoting a marketing makeover for their industry due to peanut allergic children then this makes a splash with NPB money. Thankfully, disclosures make for better transparency. You can't buy better marketing turnaround than that. Mentally I'm playing with the vast majority of kids in the untreated group that just didn't sensitize despite a lack of OIT regimen. Also, what does this mean for allergens and anaphylaxis aside from peanut? I mean I get why peanut, NPB funds peanut allergy studies that would promote more peanut eating like dairy culture manufacturers fund the Australia probiotic OIT study.

I'm still left with what's moving forward in allergy and immunology? Anaphylaxis? Mechanisms? The segment that is always excluded -- are we still on a steady forced march towards marginalisation? It's like reading tea leaves where I need to start looking more towards Stanford with Dr. Nadeau out of self-preservation.

But that's why context is key: for what this identifies it shows positive results. With any such study it's the media translation that mangles it.

guess · February 27, 2015, 01:05:09 PM

Quote from: GoingNuts on February 27, 2015, 07:06:41 AM
Two Editorials. The first one had me seeing 10 different shades of red:

http://www.newsday.com/opinion/columnists/lane-filler/don-t-get-nutty-over-peanuts-lane-filler-1.9973081

I much prefer the second, from Snacking Safely:

http://snacksafely.com/2015/02/of-babies-peanuts-and-allergy-moms/

Hmm. The first one I blew off as a blowhard. Lane Miller probably has all sorts of problems with everything.

The second guy, while I appreciate his pep talk I'm not having an emotional roller coaster on this. We never avoided to begin with. I mean thanks, I'm cool though. There's also this other guy I live with that does just as much managing as I do.

guess · February 27, 2015, 02:02:03 PM

I dig this and thank them for taking the time to speak up. While I'm not blaming myself in the least what the two doctors are doing here is combatting overgeneralization.

http://community.kidswithfoodallergies.org/blog/new-peanut-allergy-study-does-not-say-parents-are-to-blame-1?nc=1

Tweetworthy.

GoingNuts · February 27, 2015, 10:11:50 PM

From Medscspe:

New Peanut Allergy Recommendation Debated
Kate Johnson
February 24, 2015

HOUSTON — Within hours of the release of the Learning Early About Peanut (LEAP) study results, experts were debating the logistics and magnitude of the changes recommended for the management of infants considered to be at high risk for peanut allergy.

Parents should not simply hear a "consume peanut" message, said James Baker, MD, chief executive officer of Food Allergy Research & Education. "We hope that parents understand this isn't something you do without consulting a physician and making absolutely sure the child is not allergic first," he said during a news conference here at the American Academy of Allergy, Asthma & Immunology 2015.

The finding that consumption, not avoidance, reduces the risk of developing peanut allergy by the age of 5 led the LEAP investigators to call for new guidelines to be drafted.

"Timing here is key; there's a narrow window of opportunity to intervene early," said LEAP investigator Gideon Lack, MB BCh, from King's College London and Guy's and St. Thomas' National Health Service Foundation Trust, United Kingdom.

All at-risk infants should receive skin-prick testing for peanut, the LEAP team suggests. Those with a negative test should proceed to normal peanut consumption. Those with a positive test should undergo an oral food challenge and, depending on the results, proceed to normal peanut consumption with careful supervision or avoidance.

When asked about the logistics of such an approach, Dr Lack acknowledged it will be a challenge.

"To actually put this into practice is really going to take a coordinated strategy between all the stakeholders, health professionals, and departments of health in different countries," Dr Lack told Medscape Medical News.

However, he said, the about-face on infant peanut consumption will likely be well received in the medical community.

"One of the things about coming out of medical school is that you realize the learning curve has just started. We have to re-educate ourselves all the time, and that's key. As we acquire more evidence, things change," he explained.

"We believe there's an urgent need for clinicians to be skilled in identifying the at-risk population," said LEAP investigator George Du Toit, MB BCh, from King's College London and Guy's and St. Thomas' NHS Foundation Trust.

Managing Risk

"This means a basic knowledge about atopic eczema, egg allergy, and milk allergy, which are all risk factors for peanut allergy, and then of course skin-prick testing, which in the LEAP study we found to be invaluable for dissecting risk categories," Dr Du Toit explained. "Worldwide, not all patients — in fact a real minority of allergic patients — have access to even those basic diagnostic skills."

On top of that, although infants in the LEAP cohort had only mild to moderate allergic reactions, and no hospitalizations or epinephrine were required, "clinicians need to be able to deal with young infants who have an allergic reaction," he said.

"If any high-risk challenges were to take place, they should only occur in experienced hands and in the appropriate setting with resuscitation skills and facilities," Dr Du Toit explained.

New guidelines are urgently needed to reflect these findings, said Daniel Rotrosen, MD, from the National Institute of Allergy and Infectious Diseases. However, "even with a landmark study like this, and obvious improvement, it's difficult to move to implementation," he explained.

Pediatricians, dermatologists, and family practitioners will be urged to work toward updating the guidelines. "I don't think it should become a turf issue," said Dr Lack. "What matters is expertise. It could be a pediatrician, a family doctor, or a dermatologist who assesses the child and does a skin-prick test. The important thing is training in these procedures, and recognition."

Matthew Greenhawt, MD, from the University of Michigan in Ann Arbor, said he has concerns about the sudden change suggested by LEAP investigators and other experts.

Leaping to Conclusions

Should policy be changed on the basis of one study, "even one study with truly remarkable results?" Dr Greenhawt asked.

"I'd love to see this replicated in the United States, and I'd love to know whether you need to do this for 5 years or 3 years or 12 months," he told Medscape Medical News.

This study was small, Dr Greenhawt pointed out. "You would never change cholesterol recommendations based on one study of 500 patients, and the suggestion being made is that we need to act on this now," he explained.

"I certainly understand the logic and I think we are on the right track, but are we putting the cart before the horse? If you're going to make a recommendation like that, there should be an infrastructure in place to handle the volume of patients that we're going to see," Dr Greenhawt warned.

Dr Baker recently served as senior vice president and global vaccine head at Merck Corporation. Dr Lack reports holding stock and stock options in DBV Technologies. Dr Du Toit and Dr Rotrosen have disclosed no relevant financial relationships. Dr Greenhawt has reported that he is a member of the Educational Advisory Council for the National Peanut Board and has served as a consultant for Deerfield Industries.

American Academy of Allergy, Asthma & Immunology (AAAAI) 2015. Presented February 23, 2015.

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Cite this article: New Peanut Allergy Recommendation Debated. Medscape. Feb 24, 2015.

Mezzo · February 28, 2015, 06:41:26 AM

The doctor who says you'd never change the way cholesterol is handled for everyone based on one small study - that makes a lot of sense. Are they sure they're ready to do something new to this many BABIES? Shouldn't someone replicate this?

GoingNuts · February 28, 2015, 07:49:14 AM

Good point Mezzo.

guess · February 28, 2015, 08:52:13 AM

QuotePediatricians, dermatologists, and family practitioners will be urged to work toward updating the guidelines. "I don't think it should become a turf issue," said Dr Lack. "What matters is expertise. It could be a pediatrician, a family doctor, or a dermatologist who assesses the child and does a skin-prick test. The important thing is training in these procedures, and recognition."

"This means a basic knowledge about atopic eczema, egg allergy, and milk allergy, which are all risk factors for peanut allergy, and then of course skin-prick testing, which in the LEAP study we found to be invaluable for dissecting risk categories," Dr Du Toit explained. "Worldwide, not all patients — in fact a real minority of allergic patients — have access to even those basic diagnostic skills."

On top of that, although infants in the LEAP cohort had only mild to moderate allergic reactions, and no hospitalizations or epinephrine were required, "clinicians need to be able to deal with young infants who have an allergic reaction," he said.

"If any high-risk challenges were to take place, they should only occur in experienced hands and in the appropriate setting with resuscitation skills and facilities," Dr Du Toit explained.

I believe he needs to read the recent paper on pediatricians' near complete lack of understanding allergens and anaphylaxis treatment. Also, recipe for clustermessup in the making. I disagree with the idea that it is a turf issues so much as a subject matter expertise related to a select few within the discipline itself.

Quote... the suggestion being made is that we need to act on this now

If you're going to make a recommendation like that, there should be an infrastructure in place to handle the volume of patients that we're going to see," Dr Greenhawt warned.

Yes, making economics and geography independent variables that threaten to stratify patient care levels not to mention regimen compliance.

This sort of begs the question though: Are many out there avoiding like the untreated cohort? When we speak of the theoretical window for the theoretical lowest risk for anaphylaxis but higher risk for sensitizing individuals are they really out there in large numbers? Keep in mind the vast majority in the strict avoidance group (no treatment) did not sensitize regardless, as a small number in the treatment group did.

Assuming in a non clinical setting it's neither regimen nor strict avoidance we could hypothesize a lower number than the untreated group for sensitization. The risk of neither treating or avoiding may yield a number not far away from treatment.

Also, I'd like to see a 5 year follow up of no regimen then test for sustained unresponsiveness. Did it hold? Or do longitudinal data of the treatment cohort trend similarly to standard OIT data once the regimen treatment has ended.

unrelated but saw this in post: Intranasal Flu Vaccine Appears Safe for Egg-Allergic Kids. need to find that.