Early Peanut Introduction Clinic (EPIC)
What is the Early Peanut Introduction Clinic?
It is a clinic for infants at high risk of peanut allergy that was created for the safe early introduction of peanut into the diet, with the goal of decreasing the likelihood that these infants will go on to develop peanut allergy. The clinic concept builds upon the findings of the recent well-publicized LEAP study and is consistent with the American Academy of Pediatrics and other prominent medical societies' joint statement on interim guidance for introduction of peanuts for high-risk infants.
What is the LEAP study?
LEAP (Learning Early About Peanut allergy) was a randomized controlled clinical trial designed and conducted by the Immune Tolerance Network (ITN) with funding from the National Institutes of Health (NIH) to determine the best strategy to prevent peanut allergy in young children. The incidence of peanut allergy has been rising despite previous recommendations for strict peanut avoidance in the first year of life. The LEAP study examined whether early introduction of peanut to the diet of high-risk infants may decrease the incidence of peanut allergy among those children. Over 600 children between 4 and 11 months of age at high risk for peanut allergy were randomized to either consume or avoid peanut until age 5 in order to compare the incidence of peanut allergy between the two groups. Children in the peanut consumption arm of the trial ate a peanut-containing snack-food at least three times each week, while children in the peanut avoidance arm did not ingest peanut-containing foods.
Of the children who avoided peanut, 17% developed peanut allergy by the age of 5 years. Only 3% of the children who were randomized to eating the peanut snack developed allergy by age 5. Therefore, in high-risk infants, sustained consumption of peanut beginning in the first 11 months of life was highly effective in preventing the development of peanut allergy.
The study demonstrated that consumption of a peanut-containing snack by infants who are at high-risk for developing peanut allergy prevents the subsequent development of allergy. The full text of the LEAP study can be found here: http://www.nejm.org/doi/full/10.1056/NEJMoa1414850.
What are the AAP (American Academy of Pediatrics) guidelines for early peanut introduction?
The AAP and numerous other prominent medical societies have released a consensus statement that recommends evaluation by an allergist and introduction of peanut-containing products early on in life to the diets of high-risk infants. The full text of the AAP interim guidance can be found here: http://pediatrics.aappublications.org/content/136/3/600.full.
Who is eligible for the EPIC clinic?
The LEAP study defined “high-risk” for peanut allergy as severe eczema and/or egg allergy. We will broaden this to include moderate eczema (atopic dermatitis), other food allergy (such as milk allergy), or strong family history of peanut allergy (sibling or parent with peanut allergy). Given that the goal of the clinic is early introduction of peanut in order to prevent peanut allergy, patients should be between the ages of 4 and 12 months at the time of their initial visit.
What is the process for the LEAP clinic?
At the initial visit, a thorough history will be taken and the child will have a physical examination. Allergy skin-prick testing will be performed to peanut and other common food allergens. Blood tests will also be ordered. Children with negative results (no evidence of peanut allergy yet) will be fed a small amount of peanut in clinic under Dr. Parrish's supervision to confirm that they can safely eat peanut. After this, they will include peanut in the child's diet on a regular basis at home. There will be periodic follow-up to ensure ongoing tolerance of peanut at home. Periodically allergy testing (skin and blood testing) will be done. Oral challenges will be done at less frequent intervals.
Any child who has strong evidence of peanut allergy by initial or subsequent testing or from a reaction to peanut ingestion will stop eating peanut and will be referred to our Food Allergy Clinic. Some children may have equivocal (intermediate) results on the initial testing. For these children, we will discuss the options for proceeding on an individual basis. This may include a graded oral challenge (eating increasing amounts of peanut in clinic) to distinguish between peanut sensitization (abnormal tests without allergy) and peanut allergy- this strategy was used in the LEAP study. Some parents may opt to forego such a challenge and proceed directly to referral to our Food Allergy Clinic.
What kind of peanut can infants eat?
The LEAP study used a snack food known as Bamba (https://en.wikipedia.org/wiki/Bamba_(snack)). Children who didn't like this food ate peanut butter instead. We will use these foods for our patients as well.
Who is Dr. Parrish?
Dr. Parrish is a clinical allergist and immunologist and board certified physician in both internal medicine and pediatrics. He was a part of the Medical Scholars program at the University of Wisconsin-Madison and received his medical degree from the University of Wisconsin School of Medicine and Public Health in 2007. He then completed his combined residency in internal medicine and pediatrics at the University of Southern California. Following residency, he served as Chief Resident in charge of education for the USC internal medicine program. After a year as an Assistant Clinical Professor of Medicine at USC he then completed his fellowship training in allergy and immunology, also at USC. He has recently transitioned to his current role as a clinical allergist and immunologist at Miller Children's Hospital and at Southern California Allergy, Asthma, & Pulmonary Specialists. Dr. Parrish has authored several peer reviewed abstracts and publications. He is excited about the opportunities TPIRC presents for clinical research and care for rare and orphan diseases.
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