The management of food allergies has continued to evolve, with a renewed focus on ways to prevent the development of food allergies in children who are at high risk. The role of early exposure for the primary prevention of food allergies is widely accepted, but it has faced challenges in implementation. Research on optimizing the early introduction of potential food allergens and ways to overcome potential barriers was presented at the 2024 AAAAI Annual Meeting.

Following these presentations, featured expert Ruchi Gupta, MD, MPH, was interviewed by Conference Reporter Associate Editor-in-Chief Mona Shah, PharmD. Dr Gupta’s clinical perspectives on these findings are presented here.

It is very exciting that we have research showing that the prevention of food allergies is possible. A lot of the data are specific to peanut allergies. The National Institute of Allergy and Infectious Diseases (NIAID) guideline recommendations prior to the publication of the LEAP trial were that infants who are at high risk of developing a food allergy should be taken to an allergist and be tested. The issue in the United States is that if a primary care provider sees a 4-month-old infant with severe eczema in the clinic and that infant is then referred to an allergist, it may take some time for them to be seen by the allergist. So, we are wasting valuable time for that infant. And, for many low-income children and children who are living in rural areas, it is even more difficult to see an allergist in a timely fashion.

After the LEAP study showed that infants who are considered to be at high risk of peanut allergies (ie, those with severe eczema and/or existing egg allergies) benefit from the early introduction of peanuts, the NIAID updated its guidelines accordingly to recommend the early introduction of peanut-containing foods in this group after physicians strongly consider peanut-specific IgE testing and/or skin prick testing.

In terms of a consensus regarding preventing the development of food allergies, knowing where we are now can be a little confusing for pediatricians. Do they tell parents to introduce peanuts early? Do they send high-risk infants to an allergist? The important thing is that the high-risk infants are introduced to peanut products between 4 and 6 months of age when they are ready to start eating solid foods. We are really trying to encourage pediatricians to talk to their patients’ parents about starting peanut products early. The earlier you start, the better, and the higher the chances are that you will be able to prevent peanut allergy.

In addition, there is a lot of good evidence for the early introduction of eggs. Therefore, we are also encouraging introducing eggs early, along with, honestly, all common potential food allergens, such as milk, tree nuts, wheat, soy, and sesame. At Northwestern University, we are currently doing a study looking at the top 8 food allergens. We are trying to determine if we can prevent those food allergies from happening if we introduce the allergens early. Overall, right now, we are just trying to get caregivers to introduce these allergenic foods to their infants as soon as possible. And not only introduce them but also keep them in their diets. One thing that we often see is that a food will get introduced once with no reaction, but then 2 months later, the infant reacts when eating that food for a second time. Therefore, it is important to keep these foods in the diet on a regular basis.

Provider comfort with early food introduction was assessed in an abstract presented at the 2024 AAAAI Annual Meeting (abstract 347). I think that most providers are on board with early introduction and agree with it and want to do it. I would say that parents are also often on board, but they are scared. I hear a lot of stories from parents saying, “Well, we did it—but we did it in your waiting room” or “We introduced it in the parking lot at the Emergency Department, just in case.” Those are things that we need to deal with because parents want to do early introduction, but they are nervous about something happening. A big responsibility for us as providers is to encourage parents and to let them know that it is safe and that they can do it at home. When young infants have an allergic reaction, typically their symptoms are vomiting and hives, and they do not generally have as much trouble breathing or the anaphylaxis that older children have during an allergic reaction.

The big issue for pediatricians is time because we are asking them to talk to families at 4- and 6-month well-child visits. And there are a ton of things that pediatricians have to do during those well-child checks. The parents are really concerned about, first of all, whether the infant is healthy and developing well. Often, there is also a discussion regarding sleeping, eating, immunizations, and all types of other issues. So, there is a lot to talk about during those visits.

How do we help pediatricians get this message across quickly? Even when I try to do it in the clinic, it is easily a 10-minute conversation because you have to explain how to mix it, how to feed it, and what to look out for. One of our goals with the iREACH study was to determine whether we can help pediatricians convey these messages faster and more easily to families. I think that helping the caregiver with awareness education through the use of clinical decision support tools, resources, and handouts for the family is an important way to improve the adoption of early introduction (abstract 138).

There were several other interesting abstracts presented at the 2024 AAAAI Annual Meeting on this topic. Abstract 345 discussed the rate of the early introduction of allergenic foods and found that families with food-allergic siblings are more likely to implement the early introduction of allergenic foods. So, understanding family history is important. Another abstract evaluated the provider implementation of the NIAID recommendations and found that timely access to an allergist was an important barrier to allergist referral (abstract 344). Access to allergists is really important and may be best served by the use of telehealth, especially in rural areas. Telehealth may also make it possible for patients to get seen faster.