New guidance on introducing allergenic foods: Implications for family medicine - October 31, 2019 Jennifer Gerdts, Executive Director, Food ...
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New guidance on introducing allergenic foods:
Implications for family medicine
October 31, 2019
Jennifer Gerdts, Executive Director, Food Allergy Canada
Dr. Elissa Abrams MD, FRCPC and Dr. Edmond Chan MD, FRCPC
Faculty/presenter disclosure • Faculty: Jennifer Gerdts • Relationships with financial sponsors: • Grants/Research Support: N/A • Speakers Bureau/Honoraria: N/A • Consulting Fees: N/A • Patents: N/A • Other: Employee of Food Allergy Canada
Learning objectives
By attending our session, you will be able to:
• Describe the evidence for early introduction of
allergenic foods
• Explain the implications of early introduction for
primary care
• Provide practical recommendations on introducing
food allergens
Food Allergy Canada
• Mission: Educate, support and
advocate
• Key focus: Providing the educational
foundation to help individuals with
food allergy manage their condition
• Our value: The national voice for
patient advocacy
Food allergy landscape in Canada
• 2.6 million Canadians
• 500,000 kids
• 50% of households impacted
• 1 allergist visit/year
• ED visits for anaphylaxis doubled in 7 years
• 170,000 allergy-related ED visits/year
• No cure, limited treatment options
A coordinated effort to address food allergy
Mission
To help Canadians with food
allergy live safely &
confidently, & advance the
prevention, diagnosis &
treatment of food allergy
FRAMEWORK OF PLAN
Prevention
Reducing incidence & risk of food allergy
• CPS/CSACI guidance
recommends early intro of
allergenic foods (4-6mths)
• Fundamental shift in approach
from previous guidance requiring
instrumental change in behaviour
to have impact
Evidence from research supports the prevention of food allergy
through early introduction of allergenic food – however, today families
are given inconsistent guidance from the health sector
Food allergy prevention:
Common questions from parents on early introduction
New guidance: Screening:
Will early intro prevent all babies Does my child need to see an
from developing food allergy? allergist or have testing done
before eating allergenic foods?
Why should I trust this will work?
Feeding: Reactions:
Is there a recommended order for What’s the risk of a severe allergic
introducing allergenic foods? reaction the first time a baby eats a
If my baby is tolerating an allergenic food?
food, how often should I feed it to Can I give a jr. dose of an
them? auto-injector to a 4-month-old?
NEW CPS GUIDANCE ON FOOD ALLERGY PREVENTION Elissa Abrams, MD, FRCPC Assistant Professor, Department of Pediatrics, Section of Allergy and Immunology, University of Manitoba Associate Member, Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia President, Allergy Section, Canadian Pediatric Society Vice Chair, Food Allergy/Anaphylaxis Section, Canadian Society of Allergy and Clinical Immunology
Faculty/Presenter Disclosure
■ Faculty: Dr. Elissa Abrams
■ Relationships with financial sponsors:
– Speakers Bureau/Honoraria: Novartis (Unrestricted educational grant,
moderator fees), AstraZeneca (moderator fees)Disclosure of Financial Support
■ Dr. Elissa Abrams has received financial support from Food Allergy Canada in the
form of an honorarium.
■ Potential for conflict(s) of interest:
– Dr. Elissa Abrams has received moderator fees from Novartis/AstraZeneca and an
unrestricted educational grant from Novartis.Goals of this Presentation
■ To provide a background to the new Canadian Pediatric Society
guidelines on Timing of Introduction of Allergenic Solids for Infants
at Risk
■ To discuss the current 2019 CPS Practice Point recommendationsWhat Contributes to the Development
of Food Allergy?
Lack G et al. J Allergy Clin Immunol. 2016;137:998-1010Dual Allergen Exposure Hypothesis
Lack G et al. J Allergy Clin Immunol. 2012;129:1187-97Early Egg Introduction
Koplin JJ, Osborne NJ, Wake M et al. J Allergy Clin Immunol 2010;126:807-13A “LEAP” forward
80% reduction in
peanut allergy in group
with early, regular
ingestion
■ Study of 640 infants
at high risk of
peanut allergy Peanut Allergy
■ Randomized to 40% 35%
early, regular peanut 35%
ingestion (4-11 30%
25%
months of age) or
20%
peanut avoidance 15% 13%
10%
(5 years of age) 10%
5% 2%
■ Outcome: Peanut 0%
allergy rates at 5 Skin test Skin test Skin test Skin test
years of age -ve -ve +ve +ve
Du Toit G et al. NEJM 2015; 137:803-812■ Moderate certainty
evidence from 5 trials
(1915 participants) that
early egg introduction at 4-6
months of age was
associated with reduced
egg allergy
■ Moderate certainty
evidence from 2 trials
(1550 participants) that
early peanut introduction at
4-11 months was
associated with reduced
peanut allergy
Ierodiakonou D, Garcia-Larsen V, Logan A et al. JAMA 2016;316:1181-92Timing of Allergenic Solids for Infants at High
Risk
▪ Definition of high risk: Infant
with allergies such as
eczema or an immediate
family history of atopy
Abrams EM et al. Paediatrics and Child Health 2019; 24: 56-7Timing of Allergenic Solids for Infants at High
Risk
▪ Introduce allergenic
solids “at around 6 but
not before 4 months of
age”
▪ Commonly allergic
foods:
▪ Milk, egg, nuts, wheat, fish,
soy
▪ Solid introduction
should be based on
developmental
readiness
Abrams EM et al. Paediatrics and Child Health 2019; 24: 56-7Timing of Allergenic Solids for Infants at High
Risk
▪ Once introduced keep it
in the diet a few times a
week
▪ Introduce one at a time
without unnecessary
delay between solids
▪ Breastfeeding should
continue with solid
introduction
Abrams EM et al. Paediatrics and Child Health 2019; 24: 56-7Timing of Allergenic Solids for Infants at High
Risk
▪ If infants are lower risk
wait until about 6
months for solids
Abrams EM et al. Paediatrics and Child Health 2019; 24: 56-7Should siblings of
■ In general, no
– A lot of risk is environmental
– Low specificity of allergy testing
– Risk of allergy with delayed ingestion
■ “A younger sibling with peanut allergy is not an absolute
indication for pre-emptive screening…However some
individualization is still required.”Practical Ways to Counsel Feeding
Allergic Solids
■ 2 tsp of smooth peanut butter and add 2-3 teaspoons of hot
water; stir until dissolved and well blended. Allow to cool. This
mixture can be offered alone, or added tolerated infant food
(cereal, pureed fruit)
■ For egg and other allergenic solids – a practical way is to puree
a boiled egg (can eat egg white and yolk) and mix it with a
tolerated infant food
■ It is not recommended to place the food on the skin first
■ Whole peanuts are a choking hazard and should not be offered
to children less than 4 years of age
■ In general, there are no ‘absolutes’ about how much to feed –
give an age appropriate dose and then keep feeding if it’s well
toleratedSoriano VX et al. J Allergy Clin Immunol 2019 [epub ahead of print]
PREVIEW OF WHAT’S TO COME…
Concluding Messages
■ If the infant has an immediate family member with
allergies or has eczema feed allergic foods (in
particular egg and peanut) at around 6 but not before
4 months of age
■ Once introduced feed it regularly (a few times a week)
■ Introduce one allergic food at a time without
unnecessary delay between foods
■ Foods should be age appropriate (to prevent choking)
■ Breastfeeding should be encouraged until 2 years or
beyond
■ If infant is low risk, introduce allergic foods at around
6 months of ageT312: New Guidance on Introducing Allergenic
Foods: Implications for family medicine
Edmond S. Chan, MD, FRCPC
Clinical Associate Professor, University of British Columbia, Canada
Head, Division of Allergy & Immunology, Department of Pediatrics
Oct 31, 2019 (10:00-11:00)
Family Medicine ForumFaculty/Presenter Disclosure
• Faculty: Dr. Edmond S. Chan
• Relationships with commercial interests:
– Grants/Research Support: DBV Technologies
– Speakers Bureau/Honoraria:
– Consulting Fees: Pfizer, Pediapharm, Leo Pharma, Kaleo
– Other:
• Relationships without commercial interest:
– Expert Panel for NIAID (National Institute of Allergy & Infectious Diseases), Early peanut
introduction addendum guidelines
– Committee for the American Gastroenterological Association & AAAAI/ACAAI Joint Task Force
guidelines, Management of Eosinophilic Esophagitis
– CSACI, AAAAI, AGA, CPS, Food Allergy Canada
– Research support from CIHR, AllerGen, and BCCH FoundationDisclosure of Financial Support • Dr. Edmond S. Chan has received financial support from Food Allergy Canada in the form of an honorarium.
Objective • Implement active conversations and anticipatory guidance with expecting parents for the following: 1. Which foods to introduce 2. Whether screening is mandatory 3. Amount and frequency once introduced
Which allergenic foods should be introduced
early?Poll #1 • You are seeing a 6 month old girl with moderate atopic dermatitis. Her 2 year old brother has anaphylactic wheat allergy and the mother has anaphylactic fish allergy. Which of the following “should” be given early? A) Wheat + Fish B) Peanut + Cooked egg C) Tree nuts D) Dairy E) All of the above
Togias A et al. J Allergy Clin Immunol. 2017 Jan;139(1):29-44.
ASCIA (2016, 2019)
• All infants should be given allergenic solid foods including
peanut butter, cooked egg, dairy and wheat products in the
first year of life. This includes infants at high risk of allergy.
• When introducing solid foods to your baby, include common
allergy causing foods by 12 months in an age appropriate form,
such as well cooked egg and smooth peanut butter/paste.
These foods include egg, peanut, cow’s milk (dairy), tree nuts,
soy, sesame, wheat, fish, and other seafood.
www.allergy.org.au/hp/papers/infant-feeding-and-allergy-prevention
www.allergy.org.au/patients/allergy-prevention/ascia-how-to-introduce-solid-foods-to-babiesBSACI (2018)
www.bsaci.org/about/early-feeding-guidance2019 CPS (Canadian Paediatric Society)
• For high-risk infants, and based on developmental readiness,
consider introducing common allergenic solids at around
6 months of age, but not before an infant is 4 months of age
Abrams EM et al. Paediatr Child Health. 2019 Feb;24(1):56-57Rationale for “all” allergenic solids early
• Impractical/unethical to conduct “LEAP (peanut) or PETIT
(cooked egg) clinical trials” for every allergenic food
• Ethics: would you in 2019 enroll your own child into a control group
that delays introduction of an allergenic food for several years?
• Removal of variability/confusion between guidelines in
different countries
• Permit uniformity in research for implementation strategies
• Stronger language implies active (“should”) rather than passive
(“do not delay”) messagingIs screening mandatory for certain infants?
Poll #2 • The parents of the 6 month old girl in Poll #1 recently gave dairy and it “made her eczema worse.” They gave peanut butter twice without problems, but on third exposure during a viral cold she had hives (onset after 4 hours.) Next step? A) Explore whether they feel comfortable re-trying at home B) Skin prick test cow’s milk and peanut C) Skin prick test cow’s milk, peanut, egg, fish, and wheat D) sIgE blood testing to cow’s milk and peanut E) Observed ingestion of cow’s milk and peanut on separate days
2017
ASCIA (2017)
• Screening programs for infants with severe eczema and/or egg
allergy prior to introduction of peanut have been proposed in
the US NIAID Guidelines. However, there is insufficient
evidence to support a population based screening approach in
Australia and New Zealand.
• There are concerns that allergy tests are not suitable for
screening and referrals may delay peanut introduction to high
risk infants.
www.allergy.org.au/hp/papers/ascia-guide-peanut-introductionBSACI (2018)
www.bsaci.org/about/early-feeding-guidanceCPS (Canadian Paediatric Society)
• 2013:
– Routine skin or specific IgE blood testing before a first ingestion is
discouraged due to the high risk of potentially confusing false-positive
results
• Will be updating the 2013 Position Statement soon…will have
updated messaging distinct from 2017 NIAID
Chan ES, Cummings C. Paediatr Child Health. 2013 Dec;18(10):545-54Proposal (E Chan): Base screening on hesitancy despite
education, e.g.) introducing tree nuts to peanut allergic infant
Discuss with parent: i) whether comfortable introducing TN’s (tree nuts) at home
ii) the potential for false positive results if do SPT/sIgE
Uncomfortable introducing at home
Comfortable introducing Observed ingestion of TN mix SPT
TN’s at home ASAP, eat without SPT (preferred)
regularly (e.g. several
times/week)
NegativeRationale for no mandatory screening • High risk of false positive skin or sIgE test results • Lack of availability of infant oral food challenges • Delayed introduction due to infants being on waiting lists for testing • Poor cost-effectiveness of mandatory screening • Medicalization of infant feeding Shaker M, Stukus D, Chan ES, Fleischer DM, Spergel JM, Greenhawt M. Allergy. 2018 Aug;73(8):1707-1714
What should be the amount and frequency
once introduced?Poll #3 • The parents of the 6 month old girl in Polls #1 & #2 remained hesitant to introduce wheat and fish, but were comfortable re- trying peanut at home, which was tolerated. What amount and frequency of non-choking peanut should they give? A) 2g peanut protein (e.g. 2 tsp peanut butter), 3 times per week B) 1g peanut protein (e.g. 1 tsp peanut butter), 2 times per week C) 1g peanut protein (e.g. 1 tsp peanut butter), daily D) 2g peanut protein (e.g. 2 tsp peanut butter), once a week E) Any of the above
NIAID (2017) • If the decision is made to introduce dietary peanut based on the recommendations of addendum guideline 1, the total amount of peanut protein to be regularly consumed per week should be approximately 6 to 7 g over 3 or more feedings – e.g.) 2 teaspoons of peanut butter, 3 times per week
ASCIA (2017, 2019)
• Introduce well cooked egg and smooth peanut butter/paste in
small amounts to start with, as you would with other foods
• If there is no allergic reaction, parents should continue to
include peanut in their infant’s diet in gradually increasing
amounts at least weekly, as it is important to continue to feed
peanut to the infant as a part of a varied diet.
www.allergy.org.au/hp/papers/ascia-guide-peanut-introduction
www.allergy.org.au/patients/allergy-prevention/ascia-how-to-introduce-solid-foods-to-babiesBSACI (2018)
• When the infant is ready, at around 6 months of age (but not
before 4 months), introduce complementary foods (solids) --‐
usually as pureed foods. Start by offering small amounts of
vegetables, fruit, starchy foods, protein. Never add salt or
sugar --‐ they don't need it.
• Continue to give the baby these foods regularly as part of
their usual diet, unless not tolerated – this may help reduce
the chance of their developing an allergy to that food later.
www.bsaci.org/about/early-feeding-guidance2019 CPS (Canadian Paediatric Society)
• The texture or size of any complementary food should be age-
appropriate to prevent choking.
• If an infant appears to be tolerating a common allergenic food,
advise parents to offer it a few times a week to maintain
tolerance
Abrams EM et al. Paediatr Child Health. 2019 Feb;24(1):56-57Rationale for age-appropriate amounts and at
least weekly
• Avoids medicalization
• Wide range of doses in RCT’s to date (e.g. PETIT vs LEAP)
• Mandating 2g protein 3 times a week for each food could be
unrealistic if introducing “all” allergenic foods early, “setting
them up for failure”
Greenhawt MJ, Fleischer DM, Atkins D, Chan ES. J Allergy Clin Immunol Pract. 2016 Mar-Apr;4(2):221-5SUMMARY of my “How to” list 1. “Should” introduce “all” allergenic foods early 2. Screening is not mandatory and has many pitfalls Only screen if hesitancy to introduce at home despite proper education 3. Eat in age appropriate amounts, several times/week or at least weekly
Acknowledgements • Everyone around the world who has contributed to this paradigm shift of early introduction, and its impact on advocacy • Special thank you to: – Elissa Abrams, MD – David Fleischer, MD – Matthew Greenhawt, MD
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