New Intervention Boosts Early Peanut Introduction to Prevent Peanut Allergy

A new cluster randomized trial showed that a multifaceted educational intervention to reduce early peanut allergy in children improved clinician guideline adherence.1

The 2017 US Addendum Guidelines for the Prevention of Peanut Allergy recommend early peanut introduction to infants as young as 4 to 6 months to prevent peanut allergy.2 A study had found that incorporating peanut products into the diet from infancy to age 5 years reduces the rate of peanut allergy in adolescence by 71%, despite a child avoiding peanuts for years.3

Few pediatricians adhere to the guidelines of early peanut introduction. A study in 2020 reported that among 93% clinicians who were aware of the 2017 US Addendum Guidelines, only 29% were fully implementing them, and 64% were partially implementing them.4 Barriers to implementing early peanut introduction included parental fears of allergic reactions, confusion about how to interpret and apply the guidelines, and challenges with conducting supervised feedings in the office. Pediatricians also noted a need for additional training on the guidelines.

Given the low rate of clinician adherence to the guidelines, investigators identified the need for an intervention to better equip pediatricians to implement early peanut introduction in infants.1 Study investigator Ruchi S. Gupta, MD, MPH, professor of pediatrics and medicine at Northwestern University Feinberg School of Medicine, and colleagues conducted the Intervention to Reduce Early Peanut Allergy in Children (iREACH) trial to evaluate whether an intervention could improve pediatricians’ adherence to the guidelines. The primary outcome was clinician adherence to the guidelines, as recorded in EHR data from infants’ 4- or 6-month well-child visits.

The study classified clinicians as adherent if they recommended early peanut introduction to low-risk infants (no/mild/ moderate eczema and no egg allergy).1 For high-risk patients, those with severe eczema or egg allergy, the team considered clinicians adherent if they ordered a peanut-specific immunoglobulin E test and counseled appropriately or referred to an allergist.

The intervention included clinician education, a clinical decision support tool embedded into electronic health record systems, and visual aids. The control arm did not receive the intervention. Involving 30 pediatric practices, investigators evaluated the adherence of 290 clinicians who collectively cared for 18,480 infants (9290 in the intervention group and 9190 in the control group).1

Clinicians had a high adherence to guidelines (83.7%) when treating low-risk infants (n = 18,182), compared with only 34.7% of clinicians in the control arm (odds ratio [OR], 14.6; 95% confidence interval [CI], 7.0-30.5; P < .001). The intervention resulted in smaller improvements in adherence among clinicians caring for high-risk infants. Compared with controls (10.4%), 26.8% clinicians adhered to guidelines when it came to high-risk infants (OR, 3.1; 95% CI, 1.1-8.8; P = .03)1

“A multifaceted educational intervention improved clinician guideline adherence,” investigators concluded.1 “Wide dissemination of the intervention and implementation of the guidelines could reduce the incidence of [peanut allergy].”

Food allergies are on the rise, with approximately 6.2 million children in the US having a peanut allergy.5 Experts believe that the dated practice of steering clear of peanuts during early childhood in the 1990s and early 2000s has contributed to this rise. In the early 2000s, guidelines lacking evidence recommended avoiding peanuts until 3 years old. It was not until the 2015 LEAP study confirmed that early introduction of allergens could reduce allergy development, leading the National Institute of Allergy and Infectious Diseases (NIAID) to issue new clinical guidelines in 2017 recommending the introduction of peanut-containing foods in infants aged 4 – 6 years.

Following the LEAP study and updated guidelines, this intervention could help more clinicians implement early peanut introduction and move away from previously recommended avoidance practices, particularly for low-risk infants.1

References

1. Gupta RS, Bilaver LA, Jiang J, et al. Pediatric Clinician Adherence to Peanut Allergy Prevention Guidelines: A Randomized Trial. Pediatrics. Published online October 6, 2025. doi:10.1542/peds.2025-071233

2. New Reasons, Resources Supporting Early Peanut Introduction. Aafp.org. Published 2017. Accessed October 9, 2025. https://www.aafp.org/about/sponsored-resources/national-peanut-board-introduction.html

3. Leifman L. Introducing peanut in infancy prevents peanut allergy into adolescence. National Institutes of Health (NIH). Published May 28, 2024. https://www.nih.gov/news-events/news-releases/introducing-peanut-infancy-prevents-peanut-allergy-into-adolescence

4. 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

5. Lieberman J, Sublett J, Ali Y, et al. INCREASED INCIDENCE AND PREVALENCE OF PEANUT ALLERGY IN CHILDREN AND ADOLESCENTS IN THE UNITED STATES. Annals of Allergy, Asthma & Immunology. 2018;121(5):S13. doi:https://doi.org/10.1016/j.anai.2018.09.039