Early Peanut Introduction Guidelines Linked to Drop in Food Allergy Rates

A new study detected reduced rates of peanut or other immunoglobulin E (IgE)-mediated food allergies in the period following the publication of early peanut introduction and addendum guidelines.1

“Our study is one of the first to detect a significant trend toward reduced IgE-FA diagnosis in the United States following the evidence-based paradigm shift toward early food introduction as a means of preventing food allergy,” wrote study investigator David A. Hill, PhD, MD, from the Children’s Hospital of Philadelphia, and colleagues.1

Following the LEAP trial, which showed early peanut introduction can protect high-risk infants from developing peanut allergies, several organizations issued guidelines recommending early introduction.2 The initial guideline, released in 2015, targeted high-risk infants with severe atopic dermatitis or an existing egg allergy. The 2017 addendum guidelines expanded recommendations to moderate-to-high-risk infants, using food allergy testing or stratification.

Both guidelines targeted screening—such as peanut-specific IgE or skin prick tests—but these can be costly limited, and prone to false positives, potentially delaying introduction. In response, a 2021 expert panel recommended introducing peanut and egg around 6 months regardless of atopic history or prior testing. Yet adoption has varied: surveys show only 29% of pediatricians and 65% of allergists fully implemented the 2017 guidelines, and just 17% of caregivers followed the 2021 guidance.3,4,5 This variation in practice underscores the importance of examining real-world food allergy trends.

In this new study, investigators sought to determine food allergy diagnosis patterns in children before and after the publication of early peanut introduction guidelines. The study examined a subset of Collaborative Electronic Reporting practices (September 1, 2012, to January 31, 2020), including 31 practices affiliated with an academic health system in the mid-Atlantic region and 17 independently owned private pediatric offices across the US.

The first analysis included 2 cohorts: pre-guidelines (n = 38,594; September 1, 2012 – October 31, 2014) and post-guidelines (n = 46,680; September 1, 2015 - August 31, 2017). A second analysis with a 1-year observation window included pre-guideline, post-initial guidelines, and post-addendum guidelines (n = 39,594; cohorts; February 1, 2017 - January 31, 2019) cohorts.1

In the 2-year observation analysis, mean ages were 1.2 and 0.9 years for the pre- and post-guidelines cohorts; in the 1-year observation, mean ages were 1.0, 0.9, and 0.8 years for the pre-guidelines, post-guidelines, and post-addendum guidelines cohorts, respectively.1

Following the introduction of the 2015 guidelines, cumulative incidences of IgE-mediated peanut allergy dropped significantly (0.67% vs 0.92%, 27.2% decrease; P <.0001), as did 1 or more IgE-mediated food allergies (1.23% vs 1.98%, 37.9% decrease; P <.0001) and 2 or more IgE-food allergies (0.56% vs 0.79%, 29.1% decrease; P <.0001).1

“Although significantly reduced, the percent reduction in peanut IgE-FA in our study was lower than that observed in the LEAP trial,” investigators wrote.1

Post-addendum analyses showed further declines: peanut IgE-FA (0.45% vs 0.79%, 43.0% decrease), 1 or more IgE-FAs (0.93% vs 1.46%, 28.6% decrease), and 2 or more IgE-FAs (0.40% vs 0.56%, 28.6% decrease; all P <.0001).1

An adjusted analysis detected significant reductions in the risk of diagnosis peanut IgE-food allergy in the pre- to post-guidelines period (hazard ratio [HR], 0.65; 95% CI, 0.55–0.77) and the pre-guidelines to post-addendum guideline periods (0.55; 95% CI, 0.46–0.66). Any IgE-mediated food allergy also declined (pre- to post-guidelines HR, 0.69; 95% CI, 0.61–0.78; pre- to post-addendum HR, 0.63; 95% CI, 0.55–0.72).1

An interrupted time series analysis found that peanut IgE-FA diagnoses at age 2 years showed a small, non-significant drop after guideline publication, while diagnoses of one or more IgE-mediated food allergies fell significantly across the entire post-guidelines period, rather than just after the initial or addendum guidelines (slope change, −0.027; 95% CI, −0.051 to −0.0029; P < .05).1

“The authors are to be commended for leveraging data from the AAP’s harmonized EHR database,” wrote Ruchi S. Gupta, MD, MPH, from the Center for Food Allergy & Asthma Research, Northwestern University Feinberg School of Medicine, and colleagues, in an accompanying commentary.6 “This resource represents a significant step forward in capturing real-time, practice-based trends in food allergy prevalence. However, caution is warranted in interpreting these findings. The data were collected from a subset of participating practice sites…and may not be fully representative of the broader US pediatric population. Future analyses should seek to validate these trends in larger, more diverse samples using expanded diagnostic criteria, such as food allergy testing and oral food challenges.”

References

1. Gabryszewski SJ, Dudley J, Faerber JA, et al. Guidelines for Early Food Introduction and Patterns of Food Allergy. Pediatrics. Published online October 20, 2025. doi:10.1542/peds.2024-070516

2. Du Toit G, Sayre PH, Roberts G, et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med. 2016;374(15):1435-1443. doi:10.1056/NEJMoa1514209

3. Gupta RS, Bilaver LA, Johnson JL, et al. Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States. JAMA Netw Open. 2020;3(7):e2010511. Published 2020 Jul 1. doi:10.1001/jamanetworkopen.2020.10511

4. Johnson JL, Gupta RS, Bilaver LA, et al. Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI. J Allergy Clin Immunol. 2020;146(4):875-883. doi:10.1016/j.jaci.2020.07.020

5. Venter C, Warren C, Samady W, et al. Food allergen introduction patterns in the first year of life: A US nationwide survey. Pediatr Allergy Immunol. 2022;33(12):e13896. doi:10.1111/pai.13896

6. Gupta RS, Bilaver LA, Togias A. Encouraging Trends in Peanut Allergy Prevention: Real-World Impact of Prevention Guidelines. Pediatrics. Published online October 20, 2025. doi:10.1542/peds.2025-072593