Fact checked byKristen Dowd

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January 16, 2024
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Some children avoid peanuts despite negative oral food challenges

Fact checked byKristen Dowd
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Key takeaways:

  • About one in 10 children avoided peanut and one in five infrequently ingested peanut after a negative oral food challenge.
  • Parent-reported peanut allergy was the most common reason for avoidance.

Children from families with a history of allergic conditions may avoid peanut ingestion even after they have had negative oral food challenges, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

Targeted strategies may encourage these families to include peanut in their diets, the researchers wrote.

Allergic diseases among children who avoid peanut at age 4 years include other food allergy (51.9%), other food sensitizations (71.4%) and eczema (63%).
Data were derived from Leong O W-Y, et al. J Allergy Clin Immunol Pract. 2023;doi:10.1016/j.jaip.2023.10.050.

“Given the paradigm shift in food allergy prevention from widespread allergen avoidance in infancy to active introduction, unnecessary allergen avoidance following a negative oral food challenge is a significant concern,” Omega Wai-Yan Leong, BMedSci, MBBS(Hons), FRACP, researcher, and Rachel L. Peters, PhD, associate professor, both of population health, Murdoch Children’s Research Institute, Australia, told Healio in a joint statement.

Study design, results

Using the population-based HealthNuts study, the researchers assessed the frequency of unnecessary allergen avoidance following negative peanut OFCs.

Also, the researchers examined whether there were any characteristics that clinicians could be mindful of to identify families who may require additional education on the importance of allergen consumption for food allergy prevention.

The study examined data from 593 children who participated in an OFC for peanut at age 1 year, including 420 whose OFCs were negative. The children with negative OFCs included 164 who had a skin prick test result of 0 mm and 233 with a SPT result of 1 mm or greater at the time of the OFC.

At age 4 years, 296 (70.5%) of the caregivers of children with negative OFCs completed a questionnaire, and 10.2% (95% CI, 6.9%-14.4%) reported that they were still actively avoiding peanut in their child’s diet.

Reasons for continuing to avoid peanut included a parent-reported peanut allergy in the child (67.9%) and a family history of food allergy (17.8%). Also, 14.3% gave their reason as “other,” which included peanuts being a choking hazard, children disliking the taste or children being fussy eaters.

The 28 children whose parents excluded peanut from their diets at age 4 years included 22 who had SPT at age 4 years. Eighteen of these children were not sensitized and considered tolerant. One was sensitized but passed an OFC.

Also, three of these children were sensitized, and an OFC confirmed late-onset peanut allergy. These three children also had positive peanut SPT at age 1 year.

Overall, 18.3% (95% CI, 13.9%-23.3%) of the children with negative peanut OFCs at age 1 year infrequently ingested peanut, defined as a range of never to less than three times. Proportions of children with infrequent ingestion were similar between children with negative or positive peanut SPTs at recruitment.

“Despite having a negative OFC and tolerating two teaspoons of peanut butter without reaction in infancy, almost one in five children were not eating peanut frequently by age 4 years,” Leong and Peters said.
The children with a negative peanut OFC at age 1 year along with other allergic diseases were more likely to avoid peanuts at age 4 years than those who did not have other allergic diseases, the researchers said.

Specifically, children who avoided peanut included 51.9% of those who had another food allergy and 25.3% of those who did not; 71.4% of those with other food sensitizations and 35.9% of those who did not; and 63% of those who had eczema and 43.1% of those who did not.

Despite a negative OFC, the researchers continued, children were less likely to have eaten peanut more than three times if they had a sesame or egg allergy, if the family had a history of food allergy or if the caregivers believed the child was at risk for food allergy before the peanut OFC at age 1 year.

Most of the children had not eaten peanut before age 1 year, the researchers added, but the children who did were more likely to continue peanut ingestion.

Conclusions, next steps

Based on these findings, the researchers urged clinicians to identify factors associated with peanut avoidance or infrequent peanut ingestion in patients with negative OFCs and initiate interventions to encourage peanut consumption.

“Peanut avoidance in early life has been linked to the development of peanut allergy, and continued avoidance of peanut after resolution of peanut allergy has been associated with recurrence of the allergy,” Leong and Peters said.

The researchers said they were surprised that the most common reason given for not eating peanut was that the child had a peanut allergy, despite passing the OFC.

“Children who had other food allergies, or if there was family history of food allergies, were more likely to be avoiding peanut than children without a personal or family history of food allergy,” Leong and Peters said.

The researchers recommended discussing the complications that may follow peanut avoidance with these families, providing printed and online resources, sending automated reminders to include peanut in diets via email or text, follow-up telephone calls and follow-up allergy clinic visits within 3 to 6 months of a negative OFC.

“Clinicians can encourage families to incorporate peanut into the diet of infants following a negative OFC by educating families and increasing awareness of the importance of allergen ingestion to prevent food allergy,” Leong and Peters said. “Further evaluation of the effectiveness of these strategies would be useful.”

For more information:

Omega Wai-Yan Leong, BMedSci, MBBS(Hons), FRACP, can be reached at omega.leong@mcri.edu.au. Rachel L. Peters, PhD, can be reached at rachel.peters@mcri.edu.au.