Clinical decision support tool increases discussions about early peanut introduction
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Key takeaways:
- 79.1% of pediatric providers were comfortable using the tool.
- At 4 months, 56.6% of families planned to introduce peanut into their infant’s diet.
- At 12 months, 62.8% of families had introduced peanut.
A clinical decision support tool prompted pediatric providers to ask families about introducing peanuts into their infants’ diets during well child visits, according to a study published in The Journal of Allergy & Clinical Immunology.
These providers also said they felt more comfortable and knowledgeable about discussing early introduction with families, Annabelle F. Rowland, MD, resident, department of pediatrics, Emory University School of Medicine, and colleagues wrote.
Guidelines published in 2021 recommend that caregivers introduce peanuts between ages 4 and 6 months, the researchers said, but their implementation has been challenging as many providers fail to make these recommendations to the families they treat, and the families themselves may not be aware of or willing to follow these guidelines.
The researchers built a clinical decision support (CDS) tool that used automated prompts in the well child visit note, including reminders, point-of-care education, disappearing text, branching logic and documentation assistance with drop-down menus.
The tool was included in the history of present illness (HPI), assessment and plan (A/P) and after-visit summary (AVS) of the note templates for the 4-month, 6-month and 12-month well child visits, and it was implemented on Nov. 3, 2022.
Pediatric residents attended a formal didactic lecture that explained previous literature about early introduction and how the CDS tool worked. Also, physicians who were familiar with the tool reviewed it and provided live support for users as they saw patients.
Providers completed surveys before the CDS tool was implemented (n = 79; average number of years of practicing experience, 2.1 years) and about 6 months afterward (n = 48; average number of years of practicing experience, 2.7 years) as well.
The pre-intervention survey included residents (89.9%) and attendings (10.1%). The post-intervention survey included residents (87.5%), attendings (8.3%) and nurse practitioners (4.2%).
Percentages of providers who were aware of the 2021 guidelines included 17.7% in the pre-intervention survey and 66.7% in the post-intervention survey (P = .0001).
Also, percentages of providers who said they always or sometimes discussed peanut introduction included 41.7% in the pre-intervention survey and 95.9% in the post-intervention survey (P = .0001).
Percentages of providers who said they never or rarely discussed peanut introduction included 58.2% in the pre-intervention survey and 4.2% in the post-intervention survey (P = .0001).
Percentages of providers who were aware of the CDS tool during well child visits included 75% at 4 months, 72.92% at 6 months and 68.75% at 12 months.
The post-intervention survey also found that 81.8% of the providers were comfortable or very comfortable using the CDS tool across all three well child visits, with a mean score of 4 on a scale of 1 (very uncomfortable) to 5 (very comfortable).
With 92.1% reporting that the CDS tool was helpful overall in introducing the topic of early peanut introduction into well child visits, percentages who said prompts in the progress notes were useful included 91.7% at 4 months, 94.3% at 6 months and 87.9% at 12 months. During the 4-month well child visit, 91.7% said the CDS tool was helpful in assessing barriers to introduction as well.
The study included 3,178 visits before the CDS tools were implemented, with an average time of 122 minutes per visit, and 1,735 after implementation, with an average time of 117 minutes per visit.
Documentation of peanut at the 4-month well visit increased from 2.4% to 81.2% in the progress notes and from 2.3% to 65.3% in the AVS between pre-implementation and post-implementation (P = .0001 for both).
Similarly, documentation of peanut at 6 months increased from 3% to 84.2% in the progress note and from 17% to 73.7% in the AVS between pre-implementation and post-implementation (P = .0001 for both).
Increases in documentation of peanut at the 12-month well child visit included 2.7% to 82.9% in the progress note and 30% to 62.8% in the AVS between pre-implementation and post-implementation (P = .0001 for both).
However, peanut was less likely to be documented during these visits when patients were Spanish vs. English speaking (OR = 0.02; 95% CI, –0.001 to –0.110).
Noting that 56.5% of families said they planned on introducing peanut into their infant’s diet during the 4-month well child visit, the researchers said the CDS tool includes a prompt to ask about barriers to peanut introduction, which was used 160 times.
Families who did not plan on introducing peanut into their infant’s diet included 79.1% who said they were unaware of the benefits of early introduction, 3.1% who said the infant had a history of eczema and 2.4% who were afraid of a reaction. Other reported barriers included family history of food allergy, fear of choking, a lack of a desire to have the infant eat peanut products and peanut-free households.
The 6-month visits included 78.2% of families who said they were ready to introduce peanut into their infant’s diet, 10% who said they were not ready and 11.7% who said they already had tried peanut and had no concerns. None of the families reported any reactions.
A/P notes for 6-month well child visits included recommendations to introduce peanut (77.2%), continue regular feeding of peanut (22.1%) and strict avoidance (1%).
The 12-month well child visits included 62.8% of families who said they had introduced peanut without any concerns and 36.8% who said they had not tried peanut yet. One patient (0.4%) tried peanut and had a nonimmediate reaction but was then advised to continue regular consumption at home.
A/P notes for 12-month well child visits included recommendations to introduce peanut (51.4%), continue regular feeding of peanut (47.4%) and strict avoidance (1.1%).
Nine families were instructed to avoid peanuts, according to the AVS. Two of seven families (28.5%) were told to avoid peanut because their infants were not developmentally ready for solids during the 4-month well child visits. Notes for the other five families included instructions for peanut introduction, suggesting that the instructions to avoid peanut in their AVS may have been a mistake, the researchers said.
Providers advised three of five families (60%) to avoid peanut because of a history of eczema during the 6-month well child visit and referred these families to allergy.
The 12-month well-child visits included a patient who was told to avoid peanut because of eczema and a family history of allergies before referral to allergy without any prescription for an epinephrine autoinjector or serum IgE testing.
A second patient had a documented IgE-mediated reaction to peanut during an earlier visit and was instructed to avoid peanut during the 12-month visit. This patient also was referred to allergy and received a prescription for an epinephrine autoinjector.
The post-intervention survey further showed that 15 of 38 (39.5%) providers encountered a patient with a concern for reaction to peanut and nine of 14 (64.3%) said the CDS tool helped them differentiate whether these reactions were IgE mediated or not.
Also, five of 14 (35.7%) said they had encountered a true IgE-mediated reaction to peanut, three of five (60%) said the CDS tool helped them to remember to refer patients to allergy and four of five (80%) said the CDS tool helped remind them to prescribe epinephrine autoinjectors.
All five of these providers additionally said the AVS helped them provide an emergency treatment plan and anticipatory guidance about how to avoid peanuts.
Based on these findings, the researchers concluded that their CDS tool effectively changed provider behavior and influenced family behavior, with significant increases in the number of visits that documented “peanut” in progress notes and AVS instructions.
The researchers further said that other clinics can consider using their CDS tool, which may aid in achieving quality metrics for other diseases.
Perspective
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Quality improvement (QI) methodology is an effective tool for projects such as this iteration of early peanut introduction. Plan-do-study-act cycles can achieve outcome measures more rapidly than other research methods.
Because CDS tools generate feedback from users and stakeholders, QI is well-suited to adapt to project needs in real-time.
Now that several studies have shown the concept of CDS tool bundles in targeting early peanut introduction, it is time to use our knowledge in this field and understand health equity’s role in successfully introducing allergenic foods.
Now, we must prioritize identifying racial, cultural, ethnic and language differences within early introduction projects so that providers can tailor education and guidance to meet the needs of all children and families in their respective communities.
Tracking barriers to early peanut introduction, as this project has done, provides the field with the building blocks for the next iteration of these projects.
Perspective
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The timing of introduction of peanut for the purpose of preventing peanut allergy is critical. Not only do parents need advice on when to start peanut products, but they also need to know to keep peanut in an infant’s diet after the initial feeding.
The Emory program was successful in increasing the rate at which pediatricians counseled parents about peanut introduction. Unlike other interventions aimed at supporting early peanut introduction, the Emory program built in several opportunities to discuss peanut allergy prevention with parents during the first year of an infant’s life.
Similar to the Emory findings, pediatric clinicians in our iREACH intervention also recommended peanut introduction quite often for infants at high risk for peanut allergy. The Emory team present data to suggest that pediatricians were aware of the consensus guidelines even before their intervention. Given that the consensus statement was published by the three major North American allergy organizations, it was unclear within our work that pediatricians were aware of these guidelines. To our knowledge, the AAP has not published the consensus statement in general pediatric journals.
Deciding whether to incorporate risk-stratification within CDS tools is important. Although most infants present during the first year of life with low risk for peanut allergy, high-risk infants (those with severe eczema and/or egg allergy) are the most likely to have reactions upon peanut ingestion. Evidence from positive oral food challenges to peanut in infancy show that reactions can be multi-systemic and require epinephrine. Pediatricians need to weigh this risk with the benefit of early peanut introduction not delayed by allergy referrals or IgE testing.
The Emory intervention had many valuable components. Learning more about which components work best in practice more widely is key. Understanding the awareness of pediatricians regarding the consensus statement is another important next step.
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