For parents of young children, the list of potential hazards can seem endless. Items they likely have around the house that they’d never given a second thought to can end up being surprisingly dangerous if kids get their hands on them. There have even been calls to redesign the hot dog to mitigate the risk of choking. (With all due respect to my fellow pediatricians, I’ve always been in the “tell people to cut them up” camp on that one.)
It looks like peanut butter, at least, may be off the hook.
According to a new study published in the New England Journal of Medicine, consumption of foods containing peanut before the age of 11 months significantly reduced the risk of developing peanut allergy later in life. Researchers enrolled over 600 infants considered high-risk for developing peanut allergy (defined as having severe eczema, egg allergy, or both), and randomized them into groups given peanut-containing foods and ones told to avoid them. Subjects included infants with a negative reaction to skin-prick testing for peanut allergy, and those with a mildly positive reaction. Those with a stronger reaction were excluded from the study.
What the authors found is that when subjects were tested for peanut allergy at five years of age, those who had been given peanut-containing foods as infants were much less likely to have developed an allergy to them than those who had been in the avoidance group. (Peanuts themselves are a choking hazard, and should be avoided in young children for that reason.) This reduced risk was found in both groups, those with a previous reaction to skin-prick testing and those without.
This new report builds on evidence from an earlier one published in 2008. In that study, Jewish infants in the United Kingdom (where peanut avoidance was the norm) were compared with similar children in Israel (where peanut consumption in the first year of life was common). It found that infants in the UK were ten times as likely to develop peanut allergy than their Israeli counterparts.
These data are part of a wholesale reversal with regard to the advice we give about lowering the risk of peanut allergy. In 2000, the American Academy of Pediatrics (AAP) issued guidelines for using formula in children who had developed symptoms of food allergy while breastfeeding. Tucked in at the end were recommendations that infants considered high risk for food allergies should avoid certain foods until getting older, putting off eggs until age two and peanuts until three.
These recommendations rapidly became the norm for all children, even those not considered high risk. They even found their way into an episode of “Six Feet Under,” in which Lisa (Lili Taylor) berated Ruth (Frances Conroy) for giving peanut butter to her daughter while babysitting and putting her at risk of “horrible allergies.” A bemused Ruth was left to ponder all the times she had given it to her own kids growing up without worrying about it.
Score one for Ruth, it turns out. During the years following the recommendations to avoid peanut ingestion, the prevalence of allergies to it continued to climb. In 2008, the AAP revisited their recommendations and reported that there was little evidence of a protective effect from delaying the introduction of certain foods. Two years ago, it issued new guidelines for starting solid foods in infants, and advised that once infants between 4-6 months of age had started solids there was no reason to avoid foods like eggs and peanut-containing foods. Despite this, however, the discarded recommendations can still be found online, and many parents still express surprise when I tell them they can do otherwise.
Truth be told, I was never particularly convinced by recommendations to avoid peanuts to prevent allergies in the first place. The 2000 paper couched them with a tepid “the following recommendations seem reasonable at this time” after conceding that conclusive studies in support of them were thin on the ground. When parents would ask me, I’d express my lack of conviction, but would tell them that if they wanted to err on the side of caution, the conventional wisdom seemed to support it.
These new data are a couple of nails in the peanut avoidance coffin. While it’s a good idea for parents of a higher risk child (such as one with an allergic sibling) to talk things over with their own pediatrician, for the general population there is no reason that peanut butter should be on a list of forbidden foods. It’s an inexpensive protein source, and yummy to boot. Given how large PB&J sandwiches loom on my own kids’ menu of preferred lunch items, I’m happy to see parents have as many options as possible when it comes to feeding their families.