Access to care, education may improve early introduction of allergens into infant diets

Key takeaways:

• Geography, insurance coverage and declining numbers of providers may inhibit access to allergy care.
• Awareness of guidelines among pediatricians and primary care providers could be improved.

SAN ANTONIO — Despite evidence and guidelines, obstacles remain in the prompt introduction of allergenic foods into infant diets, Michael Pistiner, MD, MMSc, told Healio at the 16th Annual Allergy, Asthma & Immunology CME Conference.

“While existing guidelines all support early introduction of peanut as early as 4 to 6 months of life, they have nuanced differences including but not limited to the importance of risk stratification, the inclusion of screening, and mention of other foods such as egg,” Pistiner, who is director of food allergy advocacy, education and prevention at Mass General for Children, said.

Knowing the recommendations

Although these recommendations are available, he continued, broad implementation is lacking, and significant delays continue.

Michael Pistiner

“Barriers to early introductions of allergens are varied and include issues of access to care and access to information,” Pistiner said.

Insurance coverage, clinician availability, geographic location, wait times and availability of procedures such as oral food challenges can impact access to coordinated care, he explained.

“Access to information, eg, the importance of early allergen introduction, can be impacted by factors that relate to the individual family and their care team including their primary care clinician and the available allergy specialist,” Pistiner said

Misinformation or a lack of understanding of current recommendations among the members of this coordinated care team will compromise effective shared decision making, effective use of time and available resources for food allergy prevention, he said.

But when the partners on this coordinated care team all share a role-specific awareness about available guidelines for early introduction, a family- and patient-centered approach that works with available resources can be successfully implemented, Pistiner said.

“Some of the barriers are going to vary on a case-by-case basis and will require shared decision making to effectively approach them. A cookie cutter solution may not be effective,” Pistiner said.

Pistiner called recommendations for screening children with severe eczema or egg allergy before introducing peanut into their diets an excellent example.

The 2017 Addendum National Institute of Allergy and Infectious Diseases Guidelines support this screening, and they are echoed by the Dietary Guidelines for Americans 2020-2025 and the American Academy of Pediatrics 2019 Position Statement, he said.

“While in some locales, resources and clinician availability allow for prompt access to allergy specialists to assist with screening steps like skin prick testing and oral food challenges,” Pistiner said “In others, a child may need to wait for months before an initial appointment and then need to wait additional time for a food challenge if indicated.”

Pistiner noted a 2021 study indicating that the odds for developing a peanut allergy significantly increase with each month beyond age 6 months among infants with moderate or severe eczema.

Also in 2021, Pistiner continued, a consensus statement from the American Academy of Allergy, Asthma & Immunology, the American College of Allergy, Asthma Immunology and the Canadian Society of Allergy and Clinical Immunology supported the early introduction of peanut and egg to all infants at approximately age 6 months without requiring any screenings.

“They recommend engaging families in shared decision making and offering screening when and if requested,” Pistiner said. “If implemented universally, this approach can save some infants months of waiting until access for screening steps or avoidance of introduction all together if the family doesn’t want their child evaluated by an allergy specialist, blood or skin tested, or food challenged.”

However, Pistiner advised that older infants closer to age 1 year with severe eczema have significantly higher odds for already having peanut allergy than they had when they were closer to age 6 months, so there may be increased utility in screening.

“So, the cookie cutter approach, or one size fits all, may not necessarily apply to early introduction guidelines,” Pistiner said. “Elements of both approaches may be more or less appropriate given the specific child/family, their primary care team and access to an allergy specialist comfortable in managing infants with availability for oral food challenges.”

Access to care

Compared with some areas of the country, such as the Boston metro region, where there are several major tertiary care hospitals, Pistiner explained, rural areas might not have allergy practices that feel comfortable caring for infants or providing skin testing. Or, he continued, access to labs for blood tests may also be limited.

“In these settings, it is important for primary care clinicians to support families in early introduction of peanut, egg and other allergens without screening, as access is significantly limited,” he said.

Another issue is insurance coverage, even in major cities where clinicians are available, Pistiner said, and this is causing health disparities.

“There are some providers that may not take certain insurances or do take them but with limited capacity,” he said. “Within the Boston area, there is an access crunch.”

Further, clinicians who are part of a family’s preferred health care plan and “in network” might not be specifically comfortable with performing tests for pediatric allergy.

“Those kids may then wind up getting on very long wait lists, may wind up going to clinicians who don’t feel comfortable, may need to be seen out of network, creating high medical costs for the family, or wind up not getting any allergy care at all,” he said. “Longer waits mean increased odds of developing a peanut allergy and possibly other food allergies if the child doesn’t have the opportunity at the appropriate time because they are waiting.”

Another issue is educating pediatric and family care providers about early introduction, the available guidelines and why it is important to partner with patients despite the time these conversations require, Pistiner said.

But although awareness of these recommendations is growing among pediatric-trained clinicians, he added, the numbers of pediatricians and allergy specialists are not growing fast enough to meet the clinical demand.

“There has been a slowdown in interest in pediatrics, and there’s been a slowdown in interest in pediatric specialties,” he said, noting how advanced practitioners can play a greater role in this care.

“It’s so important to be able to increase our workforce beyond even physicians, and to be able to do it with pediatric-trained physician assistants and nurse practitioners is really important,” he said.

This year, Pistiner said that there were fewer matches in pediatric slots compared with previous years, which will lead to fewer pediatricians and fewer allergists trained in pediatrics who will be able to implement food allergy prevention strategies.

“Not only are people less likely to go into pediatrics in the first place, but then pediatric subspecialties are down in a major way,” he said.

Compounding this problem, he continued, the current workforce is aging.

“We have a significant proportion of the allergy work force that is approaching retirement. There aren’t a lot of [Accreditation Council for Graduate Medical Education] spots for fellowship for allergy,” he said. “Increasing our workforce is going to be key.”

Pediatricians who can communicate the importance of early introduction to the families they treat are essential in preventing the development of food allergy, he said, as many people may have misconceptions about early introduction.

“They need the opportunity to be educated and, in some cases, re-educated,” he said.

Families need to be told that early introduction is now standard practice and helpful instead of dangerous at multiple points in the care of their infants, he continued.

“If the families are hearing these messages during pregnancy, during the newborn period of time, at discharge from the hospital, all the times before the kid is expected to eat, then by the time it’s around 4 months, they already have this background knowledge and comfort,” Pistiner said.

“We’re hoping that they’ve already engaged in conversations with their primary care team, so they will be ready when it’s time,” he said. “And if the child has severe eczema or any potential food allergy, we can attempt to get an allergy referral to get guidance and address it.”

Support tools

Pistiner and his colleagues have been developing support tools for primary care clinicians so they can have this shared decision-making with these families, implement prevention strategies as early as possible, encourage early introduction of allergens, refer to allergy if and when needed, and prevent screen creep when possible.

The Food Allergy Management and Prevention for the Infant and Toddler (FAMP-IT) clinician support platform includes dot phrases that can be added to electronic medical records to help with documentation and discharge education.

“We incorporate the most up-to-date guidelines, data from the most up-to-date studies and present it in a way that can be used practically by a primary care clinician,” Pistiner said.

Educational materials also are available in English and Spanish as hyperlinks or as PDF files that clinicians can print out and share with families. The platform includes educational materials for clinicians as well.

“The support platform itself is created for the primary care clinician so they will be able to look through and learn the content with links to the guidelines and other relevant literature,” Pistiner said.

“We try to organize it and simplify it so they’ll be able to get what they need, to be able to ultimately support the kids who do need an allergy referral while they wait, and to also understand some of the timing issues,” he continued.

PCPs should be able to use the tool to manage infants and children who do not need a referral for allergy care, Pistiner said, and to identify those who do and work with allergy teams to ensure timely access.

“We’re really hoping that as they use the toolkit and work with their available allergy clinicians, they’re going to figure out what they can manage on their own and what they need to refer to allergy,” he said.

Pistiner and his team also have created a quality improvement continuing medical education offering for Maintenance of Certification type 4 with the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners.

Feedback from clinicians who have used the platform has been positive, Pistiner said.

“People have been using it in their after-visit summaries,” he said. “Once they put it into their templates, into their electronic medical record, it just really sped things up.”

Looking ahead, Pistiner also said that addressing issues of access to allergists comfortable managing infants will be increasingly critical and is hopeful that the FAMP-IT platform and increased interest by pediatric trained NPs and PAs may be steps in the right direction.

References:

• Keet C, et al. J Allergy Clin Immunol. 2021;doi:10.1016/j.jaci.2020.11.033.
• Pistiner M. Food introduction and allergy prevention. Presented at: Allergy, Asthma & Immunology CME Conference; Aug. 1-4, 2024; San Antonio.

For more information:

Michael Pistiner, MD, MMSc, can be reached at mpistiner@mgh.harvard.edu.