New NIH Guidelines on Infants and Peanuts

[Macabre]

https://www.washingtonpost.com/news/to-your-health/wp/2017/01/05/new-nih-guidelines-on-infants-and-peanuts-may-contradict-everything-youve-heard-before

New NIH guidelines on infants and peanuts may contradict everything you’ve heard before

On Thursday, the National Institute of Allergy and Infectious Diseases released formal, detailed guidelines for pediatricians and allergists.

The document, published in six medical journals, includes three separate sets of recommendations based on the level of risk an infant has for developing a peanut allergy. Those at highest risk are defined as babies with severe eczema — a skin condition where patches of skin become inflamed, itchy, red and cracked — or egg allergy or both. Those in the middle group have mild-to-moderate eczema. And those in the lowest-risk group have no eczema or food allergies.

[gvmom]

I think it is just me today, but I am really sort of done with these sorts of studies.  Why is it that nobody is starting with the premise that the child is actually born with the allergy?  That no amount of perfect timing or looking for factors a child has is what is going to give them their allergy?

According to that study, my DS2 should have the peanut allergy.  He had eczema so bad he had skin infections.  The allergist that we saw at a big medical place was more worried about his skin than his egg allergy.  And, we found out about his egg allergy at 5 months old after he accidentally got egg residue on his hand.  I shudder to think of what would have happened had we actually set out to feed him eggs at that time like the suggestion is in the article.

And, for DS1, again, his allergy was discovered at 11 months, within the range of the article, and through residue.  His reaction would have likely been fatal had we set out to feed him like is suggested.

I would also add that the better predictors of our kids' allergies has been to look at the history of DH and I, allergies, eczema, hay fever, food issues..... along with the foods I craved & ate heavily as protein sources when I was pregnant. 

Everyone is so darn set on trying to figure out when to feed a kid what so that they don't get an allergy .... really?  641 kids is going to determine that? 

Why not have a study about just how early some of us actually find out about the allergies?  How many of us and our kids don't follow this model that they seem to be really trying hard to make the standard for food introduction? 

So many of these studies coming out and if I was so scared of my kids developing food allergies that I followed them all of my kids would likely have ended up with major anaphylaxis or with a fatality. 

Am I just the only one that thinks that kids are born with their allergies?  I know we aren't the only ones that have weirdly discovered their kids' allergies so young.  I still wonder how they find people for their studies too. 

[Mr. Barlow]

The best advice I can offer right now, even to those not looking for advice, is don't respond in a "hot" moment.  This roll out on an organizational level is accompanied by organizational behavior that is entrenched, ready (and excited) to defend against essentially what they deem silly parents who get medical advice on Facebook.  Doesn't matter what sort of professional alphabet soup we allergy mommies might have after our names or how cool under pressure we are in dire circumstances in the real world.

These studies will always exclude the most vulnerable population of juvenile patients.  These studies will ignore that the first wave of patients were never subjected to the idea of abstaining from potent allergens.  We had pets, fed table foods at 6 months, didn't believe in peanut allergy, traveled internationally, played in the dirt.  I breastfed for 3 years.  Unfortunately, both grandpas from the old country farms who also didn't know jack schitt about allergens have a well-established history of severe allergies, asthma, and anaphylaxis. 

We need to grit our teeth and ride this out.  We need to stay on top of epinephrine autoinjector diversity, affordability, and access here in USA and elsewhere as it presents.  We need to hold education agencies accountable for FAPE.  We need to keep going with what is, sadly, unchanged for the majority of us.

Many of us come from a time where our children's first reactions were not under the auspices of delayed introduction.  This is an unthinking reminder of how much it continues to suck having no answers or reliable treatments that promote sustained unresponsiveness.  Yes, moms will shoulder blame in the court of public opinion once again.  Nothing new there.  Simultaneously we will have to counter the alt-med pseudoscience woo continuing the war on two fronts.

For the population of infants that are "high-risk" excluding ironically the most at risk, this could be a blessing.  If we are lucky it also will begin to positively reduce the amount of suspected allergies, clarifying to those who have a history of clinical response not merely false positive testing through panels.

Adding one last note, perhaps FAS' own Breaking Bad, PhD will expound upon or not: researchers can become sloppy in their science when presenting results they are excited about.  Word of estimative probability morph from the scientific gold standard describing the direction and strength of relationships in correlation, i.e. "strongly suggests," to "shows" and "proves" which studies, particularly correlation even with low alpha and structural equation modeling or other causal inference, cannot do.

This doesn't mean we reject conclusions outright because it doesn't fit so-called anecdata, but does suggest perhaps need for qualitative analysis that would address the discrepancies between what the quants suggest and the lived experience outside of the data set examined. 

[CMdeux]

I guess this makes me Walter White, doesn't it?




In all seriousness, I found myself nodding to both your posts.   Yeah, yeah, yeah... I DIDN'T buy into a lot of thinking about "delaying" introduction-- until after DD had anaphylaxed at 11mo old.


AFTER the weeping eczema... extended and really-- knowing what I know now-- EXTREME "colic" (which lasted.. hmmm... months and months and months... so much for "that's just babies.")


you know the drill.  So sure.  DD probably DID have early exposure.  Didn't seem to help her to do anything but actually sensitize to a horrifying number of anaphylaxis triggers, quite frankly.  But she has bad, bad genetics. 

She's probably not the kind of children who will be helped by this advice.  But are those kids a real population?  Sure.  They're probably just the tiny minority that they've always been.  For the larger population of kids with food allergies, it seems highly probable to me that SOMETHING that we are/aren't doing is contributing to them sensitizing-- and then failing to outgrow when they used to.

Kids like mine are outliers.  Not part of that population, probably, to begin with.  {shrug}

I don't begrudge new advice aimed at the main part of the population.  I do still begrudge the fact that outliers are called unicorns, however.  We do exist, thank you very much.    And we're NOT crazy.  Just unlucky in the genetic lottery.

[eragon]

I thought this was about introducing before 6 months to prevent allergy?

6 months is a very recent idea isnt it? 1930's solids advised at 3 months, so perhaps this was a good idea depending on the food?

Also worth noting that this advice to USA has been given before England / UK, who are still working on the guidelines. This is based on a UK study, and I am wondering why? Are we too slow at change, or still refining advice? Or has USA decided to move quickly to give advice to feed early. After all, and being cynical here, the biggest market for peanuts is in USA.

[gvmom]

At 6 months old or earlier.... how do you expose the child, who doesn't classify according to the study, to be at high risk?  You put some peanut butter on a finger and shove it in their mouths to give them a taste?

That could have very easily killed my DS1. 

But, wait, you don't feed it early if they have an egg allergy..... and who is testing with good verifiable results on 6 months or younger?

Have they suddenly decided that all the allergy tests are fantastically accurate on 4 month olds? 

Has anyone been told by a doctor that allergy testing on infants is actually accurate?  Especially at 2 or 3 months old?

[YouKnowWho]

Tests without previous exposure - sketchy results.  Tests on eczema inflamed skin - sketchy results.  Introducing food that early - sketchy.  (Eragon when I was born in the early 70's, my mom was sent home with me at 6 days old and told to start me on cereal ASAP because I was starving.  I was on fruits by 1mo).

DS1 tested positive via SPT for wheat, egg, peanuts and tree nuts at 6mo.  He was not allergic to peanuts and tree nuts but I had to find an allergist who had a clue about food allergies and not environmental allergist parading as a food allergy expert. 

So on the flip side - what about kids like my son who tests positive to everything under the sun (wheat, rye, barley, oats, rice, corn, eggs, dairy, soy, peanuts and tree nuts) but who is only allergic to wheat, rye, barley and egg.  I struggled with a FTT child - can you see what would happen if child was supposedly allergic to everything?

[eragon]

https://www.youtube.com/watch?v=S_Pt06pSLY8   



link to youtube with Prof Lack explaining the study.

[Mr. Barlow]

I thought this was about introducing before 6 months to prevent allergy?

That is part of the guideline, highly qualified by other variables and exclusive of others.  I'm unsure what your question refers to. 

The purpose is mainly aimed at clinicians reversing their own position.  For the defined population it should start the ball moving in the right direction eliminating the few years clinicians (but not necessarily the patient population) believed in delaying introduction of potent allergens based on (1) unsubstantiated belief; (2) co-morbid indicators in allergic disease that were thought by clinicians to indicate predictive value in clinical response.

I think the point CM was making earlier was that the fear of developing a peanut allergy may have caused the shift in the non-allergic population to delay but they were never going to develop clinical response.  Then there's the segment that could HIGHLY benefit from a structured, early introduction, and that is really what this seismic institutional shift is. 

Now, the  stirring clickbait media this will produce will probably be quite detrimental towards families already hit hardest.  We here tend to be a crop of outliers that don't fit nicely into data sets, which arguably drives us to figure out living in between appointments and seismic institutional shifts.  This doesn't really affect us one way or another because there's a good chance we're part of the exclusions that were never studied, or in a category that would not merit early introduction as described.

The boo hiss anecdata here will tell you no one followed any guideline to begin with.  It would probably trend with the non-allergic population until wham-o anaphylaxis.  We tend to predate any introduction guideline or even heard of one.  I know I didn't bother with the nut allergic child.  We just introduced table foods because we had never really believed in food allergies.  Then with second child we didn't tackle any top 8 prior to 6 months then WHAM; anaphylaxis to a non-top 8 at 7 months.  We challenged milk in office because he was tolerating extensively hydrolyzed milk formula, we had hope.  No dice, round #2 of anaphylaxis in infancy to a second allergen. 

Not to sound cavalier but since my allergist is also a food allergy parent he lives first hand, so this doesn't move much on the chessboard for us.

[gvmom]

Here is the rub for me watching the video.  They've got 640 kids in the study.  Around 10 minutes in the guy starts to talk about 98 kids who are skin tested that have small bumps.... sensitized as he calls them.  Then he says there are also 76 kids who are excluded because they develop large welts from the skin test.  They don't fit the study because they HAVE the allergy... and the study is only about prevention.

I would argue that the whole problem from the get go is that there are all of these people out there so afraid that their kids might get an allergy they do something that is dangerous because kids are clearly born with the allergy, and early introduction in the hopes of preventing it to me seems like a red herring to try and make it seem like there is actually something that doctors are doing about figuring allergies out. 

Excluding the kids .... those 76..... the ones that clearly are allergic and won't ever prove that early introduction prevents allergies is part of the problem.  Yes, you obviously can not feed those kids the double blind anything ..... and you aren't going to be able to put any prevention or prevented label on them.

But, for the next few days, there is going to be a flurry of articles and headlines, clickbait all over the internet, about feeding kids peanuts early so they don't get allergies.  There will be people "out there" that figure that "see, not feeding my kid stuff" is the problem.  And, people will believe that if you only just fed your kid x,y, and z, they wouldn't have their allergies.  You are too overprotective.

Without, of course, anyone knowing that they've excluded the group of kids that they aren't trying to figure anything out about.  Those 76.  Who already are producing large enough skin reactions to be believed to have an allergy severe enough at 4months old to be excluded.

Those 76 unicorns.  My 3.  All the other unicorns that apparently are really not that uncommon because there are plenty of us that seem to not fit any of the outlines of "typical" that are getting crammed in the articles along with "feed your kids peanuts early". 

Not to mention the fact that by eliminating 76 of the group, you skew your numbers to make it so that the percentages reflect what?  That a group of kids, that have already had the allergic ones removed, can eat peanuts early on, because what?  Somehow they were going to develop an allergy to begin with at some point when someone could feed them food?

What if you eliminated the only kids that really would have the allergy by eliminating those 76?  That your group that was left never really would develop allergies in the same way anyway because they are the percentage of the population that won't?

I guess I need to finish watching the video.... but I find it already annoying, and I don't think the guy is that great a speaker.

[eragon]

what are you looking for a total cure? This is a study that will prevent the few who qualify from developing peanut and egg allergies. same for any other current  'cure' out there.

There is a difference in being 'sensitised' and those that have  the allergy. seems entirely sensible to me. 
the other children fit the bill with regard to having the potential to develop those allergies. That was the whole point of the study, to halt that development.
This isnt for our kids, or all kids or every single allergic kid, it is to halt it developing.


But, what you havent picked up on, is that England, where this study came from has not published any guidelines on this  as yet. But USA has, and that is a puzzling thing to me.   

[gvmom]

Sorry, keep having to deal with kids.

I actually came back because I wanted to mention the list of groups he has in a slide that it is implied they've changed their guidelines based on this study.  AAAAI is there.  Also American Academy of Pediatrics.

This is a study that had 4 groups.  A total of 834 children.  101 were eliminated because they didn't have egg allergy or atopic issues.  76 were eliminated because of their already having an allergy.  You have 194 kids, 2 of 4 of the groups for study, eliminated right away.

In addition, he has a slide he puts up to thank for funding, which includes the FARE logo.

I think for me, my main thing is with this study, and everything else out there similar to it, is that I want something better if they are going to be affecting the guidelines that may impact any medical care or coverage my kids get or anyone elses gets. 

I think a body like AAAI should not be changing their guidelines for thousands of children based on a study like this where 50% of the groups are eliminated because they don't fit. 

I will also just add that why shouldn't the whole point of figuring out food allergies be a total cure?  Why not?  A partial maybe preventative "cure" for kids who likely wouldn't have developed it in the first place?  I think it is easy to say that they did a great job of preventing allergies when they eliminate almost 200 kids from the study. 

And, studies "out there" should be about all of our kids.... because my allergic kids matter just as much as the other kids who they are guinea pigging with this stuff who don't have allergies and likely won't get them.  If they are going to figure something out for the food allergic why not the ones that are already living it? 

Anyway...... in general, this sort of study, that gets lots of attention, all it really does to me is make a lot of non food allergic people figure that there is a "cure" for all of us annoying peanut families.  The reality is that nobody really that doesn't live with this cares about it unless it is an inconvenience, and this does nothing to help anyone already living with food allergies. 

[Janelle205]

At 6 months old or earlier.... how do you expose the child, who doesn't classify according to the study, to be at high risk?  You put some peanut butter on a finger and shove it in their mouths to give them a taste?

That could have very easily killed my DS1. 

But, wait, you don't feed it early if they have an egg allergy..... and who is testing with good verifiable results on 6 months or younger?

Have they suddenly decided that all the allergy tests are fantastically accurate on 4 month olds? 

Has anyone been told by a doctor that allergy testing on infants is actually accurate?  Especially at 2 or 3 months old?

This is not a recommendation at all, so no one take it that way.  I am massively atopic (environmental allergies, MFA, eczema, severe asthma, the whole shebang), DH gets sniffly for a few weeks each spring.  My allergist actually does not test or see infants (they start at 2) but told me that the research was going in the direction of early exposure, so that is what we did with DS.  He would have and would still be considered to be in the middle group - mild eczema - pretty easy to treat with moisturizing and only on the backs of his lower legs for now. 

He had peanuts and tree nuts at about 6-7 months, starting with tiny amounts of PB and other nut butters mixed into barley cereal.  I don't know that there is another way to do it at that age, aside from using nut flour the same way, because giving PB straight or whole nuts is a choking issue. 

I honestly don't know what I would have done if I didn't have my doc to talk things over with. (DS's doc was surprised that I went that early with it, but was more worried about choking, and said that the way that we did it was good for that)  And honestly, I don't know that it will make any difference at all.  He has atopic genes from both sides, but I'm one of those weirdos that developed multiple allergies to atypical foods in adulthood.

[gvmom]

This is going to be it for me today.... but did want to say, that the PB on the finger was more thinking back to ages ago when a Grandma might put a bit of something on their finger to try and get a baby to taste something.  Or maybe that was my Grandma only.

The thing is, my DS1 poked at a mini bagel that had just the most transparent bit of PB on it.  He wanted nothing to do with it.  I figured he'd at least try it since he loved the little bagels.  But nothing.  He just poked it once.  I didn't think he got anything on him.  I cleared it away, cleaned off his tray, and when I turned back around he was breaking out in hives and purple splotches.

If I had hidden PB in something, and he'd gotten a full bite, I just don't even want to think what would have happened.  I didn't have epipens or benedryl.  Nothing but probably hope and maybe an ambulance would have helped.

But, shouldn't any of the peanut given for early exposure also not be hidden?  If you mix it into something, how do you know it isn't the barley or wheat or whatever that causes the reaction? 

Just in general, introducing solids early on is risky anyway.... especially to 4 months old.... and if you watch the video he talks about 3 months, and possibly how to do it earlier..... to try and reach those 76 kids who somehow got their allergies earlier than those allowed to stay in the study. 

Main thing for me though is I don't think the study works.... especially enough to alter guidelines as implied.   

[Janelle205]

But, shouldn't any of the peanut given for early exposure also not be hidden?  If you mix it into something, how do you know it isn't the barley or wheat or whatever that causes the reaction? 

Just in general, introducing solids early on is risky anyway.... especially to 4 months old.... and if you watch the video he talks about 3 months, and possibly how to do it earlier..... to try and reach those 76 kids who somehow got their allergies earlier than those allowed to stay in the study. 

We had been doing plain barley cereal for a while before I added to it, so that I would be pretty sure that we could know that if we had an issue, it wasn't the cereal.  We started 'flavoring' the cereal with other things (cinnamon, mashed banana, etc.) before we got to PB and other nuts as well, but DS has always been a little bit unusual in that he seems to prefer highly flavored foods more than the average American baby - tonight was chicken tikka masala that my Mom said was too spicy.