Training improves pediatricians’ eczema assessments before early peanut introduction

SAN ANTONIO — Training improved pediatricians’ adherence to guidelines for assessing eczema in infants before early peanut introduction, according to a presentation at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

“Pediatricians do so many things, and it’s very challenging to incorporate the guidelines in those very busy 4- and 6-month visits,” Ruchi Gupta, MD, MPH, professor of pediatrics and medicine at Northwestern University Feinberg School of Medicine, said in her presentation.

According to the 2017 NIAID Addendum Guidelines for the Prevention of Peanut Allergy, pediatricians should assess the severity of an infant’s eczema before determining when peanuts should be introduced into the infant’s diet.

However, a 2018 study found that only approximately 29% of pediatricians were using these guidelines to assess eczema in their infant patients.

“When we asked the pediatricians, ‘Do you want training?’ They said ‘Yes, yes, yes! Please train us on the new guidelines,’” said Gupta, who also is a Healio Allergy/Asthma Peer Perspective Board Member.

Pediatrician training

As part of the Intervention to Reduce Early (Peanut) Allergy in Children (iREACH), the researchers developed a clinician training module that comprised a series of videos summarizing these guidelines while also providing a clinical support tool.

The video included illustrations of infants with mild, moderate and severe eczema and explained how pediatricians should assess them based on the Infant Atopic Dermatitis Severity Scorecard.

Ruchi Gupta

“This is really important because when we started looking at tools for identifying eczema in infants, we really couldn’t find a lot, and we definitely couldn’t find it in different skin tones,” said Gupta, who is the founding director of the Center for Food Allergy & Asthma Research at Northwestern University as well.

Thirty practices with 290 pediatricians in the Chicago area were randomly selected to participate in the study, including 14 control sites and 16 intervention sites. Six of the sites were Federally Qualified Health Centers.

The percentage of pediatricians who correctly answered all the multiple-choice questions pertaining to seven clinical scenarios increased from 72.6% in the pretraining assessment to 94.5% in the post-training assessment (P < .001).

Also, identification of severe eczema and application of the corresponding guideline improved from 63.4% to 97.6% (P < .001), and correct answers to guideline application questions improved from 29% to 70.4% (P < .001).

Support tools

Next, the researchers embedded a “scorecard” clinical decision support tool identifying mild, moderate and severe eczema into the electronic health records of the participating practices so pediatricians would have it during the 4- and 6-month well checks.

“Pediatricians typically use a template” during those visits, Gupta said, adding that “there is a ton of stuff on there because every other specialty is coming and saying, ‘Oh, add this and add that,’ so it is pretty comprehensive and very long.”

When pediatricians hovered over the word “eczema” in the record during these visits, the scorecard would appear, enabling them to quickly access it.

“This pop-up was to make them aware that this infant is either 4 or 6 months, and they need to be assessed for severe eczema,” Gupta said. “If the child does have severe eczema, it prompts them immediately to be able to order a peanut-specific IgE or to go ahead and refer them to allergy. Then the allergy services will come up, and they can automatically refer.”

When appropriate based on the eczema assessment, pediatricians would recommend peanut introduction to parents during the 4-month and 6-month well visits.

The after-visit summary, which is handed directly to the caregiver, includes patient instructions and a copy of the referral.

“When parents are in that room, they’re probably going to remember three things we say, so giving them something they can take home with them and refer to is really critical,” Gupta said.

These instructions include a handout on the when, what and how of feeding solid foods to infants, which Gupta said parents are really interested in. A second handout on adding peanut protein to the infant’s diet includes recipes for introducing peanut and symptoms of peanut allergy.

“This is all now available to all of you, so please, please utilize them,” Gupta said. “Our residents are actually making a couple of edits to this, so it will be continuously updated.”

Finally, the electronic health records were amended to include prompts during the 9-month and 1-year well visits to ask caregivers if they had incorporated peanuts into their infants’ diets.

In practice

The practices in the study then conducted 30,522 well child visits for 18,460 infants, who were majority white but approximately equal in division by sex, Gupta said. About 5% of the infants in the intervention cohort and about 2.3% of those in the control arm were considered high risk for peanut allergy.

The high-risk infants in the intervention group included infants with eczema (80%), infants with egg allergy (18%) and infants with both (2%). The breakdown of the high-risk infants in the control arm was similar, Gupta said.

Using generalized linear mixed models, the researchers compared how well the clinicians in the intervention and control groups adhered to the guidelines.

Among low-risk infants, 80% of the pediatricians in the intervention group and 26% of those in the control group followed the guidelines, which Gupta said indicated a very significant improvement.

But among the high-risk infants, only 17% of the pediatricians in the intervention group followed the guidelines despite their training, while 8% of those in the control group followed the guidelines, which Gupta called a “really interesting” finding.

“It was still significant, but it was low,” Gupta said.

Also, 69% of the pediatricians in the intervention group and 26% of those in the control arm recommended peanut introductions, although this increased to 49% of the pediatricians in the control group treating high-risk infants.

In terms of follow-up, 9.8% of the pediatricians in the intervention group referred patients to an allergist, and approximately 7% ordered testing for specific IgE.

“Maybe this is something we have to really, really train pediatricians on,” Gupta said. “They can order a specific IgE. If it’s negative, introduce, based on the data. If it’s positive, the hard step is getting them to allergy. That’s always our challenge in a timely fashion.”

Overall, the percentage of pediatricians in the intervention group who said they followed the guidelines improved from 22% at baseline to 81% after 18 months.

“They got a lot of positive feedback,” Gupta said.

Next steps

“We’re very, very excited to see if it actually made an impact on decreasing the incidence of peanut allergy in infants,” Gupta said.

The researchers are now surveying the families that were involved to see if they followed the recommendations they received during the well visits, and about a quarter of them have responded.

Pediatricians also will be taking pictures of the eczema they encounter, and dermatologists will validate these assessments. The researchers will continue to monitor pediatrician adherence to these guidelines as well.

“Do the best you can until you know better,” Gupta said. “Then when you know better, do better.”