Early Peanut Introduction: Practical Advice on When, How Much and How Long?

peanut allergy early introduction

In 2015, a landmark study, The LEAP Study (Learning Early About Peanut-Allergy), demonstrated that early consumption of peanuts in infants 4-6 months of age can prevent the development of peanut allergy. Since then, early peanut introduction in infants has become almost mainstream but many parents are pursuing this without any guidance. So for the parents out there – let’s review.

The original study original was born out of a curious observation that school-aged children in Israel have a significantly less peanut allergy and EpiPen use for peanut allergy. After careful observation, researchers from the UK found to that Israeli children were desensitized in the first year of life due to consumption of the insanely popular peanut snack known as Bamba!

As the son of Isareli immigrants – I can attest to the ridiculous amount of consumption of this snack in infants and young children. The popularity stems from the fact that the peanut/corn puff dissolves int he mouth of infants making safe for infants (no choking risk). Infants can be seen in strollers all over Israel chowing down on Bamba – their faces covered in peanut dust.

The Bamba phenomenon led to the Leap Study – a large-scale placebo controlled study evaluating early peanut exposure, desensitization and prevention of peanut allergy. The findings were remarkable. Early peanut exposure resulted in decrease risk of peanut allergy and Epipen use later in life. This was especially true for those infants already at high risk for peanut allergy including infants with severe eczema.

The guidelines for early introduction of peanuts to infants suggests the following:

Severe Eczema (requiring medium-dose steroids such as Triamcinalone 0.1%): See Pediatric Gastroenterologist or Pediatric Allergy for allergy testing prior to early introduction, as early as 4 months of age.

Mild-to-Moderate Eczema: Introduce peanuts at home at 6 months after discussion with Pediatrician or Pediatric Gastroenterologist or Allergy physician.

No Eczema: Introduce peanuts at home at 6 months or later in accordance with cultural/personal beliefs.

Peanuts should never be a first food. Your infant must demonstrate they can tolerate a number of “safe” foods prior to peanut introduction. Finally, although eczema appears to be a strong risk factor for peanut allergy and need for early-introduction – parents should ask their Pediatrician about other risk factors such as infant asthma or strong family history of peanut/food allergy which may trigger allergy testing prior to introduction.

For those parents that have been cleared for early peanut introduction – guidelines recommend 6g per a week. This should be continued at least 2-3 years but some recommend up to 5 years! That is some commitment! But it seems entirely worth it when you consider the alternative – a lifetime of allergy and the need for Epipen to be available at all times!

The 6g/week is equal to about 2 tsp of organic peanut butter 3x/week mixed into other solids or purees. This link provides recipes using both peanut butter, peanut flour and increasingly popular Bamba snack (now available at Trader Joe’s!). The American Academy of Allergy and Immunology has provided a tip sheet for parents/providers on early peanut introduction. Always be sure to consult with your Pediatrician, Pediatric Gastroenterologist or Pediatric Allergist for guidance.

early peanut introduction infants
peanut allergy infant eczema

Poop smarter (not harder): Does the Squatty Potty really work?

Does the #SquattyPotty really work? The truth is that it’s not the specific “Squatty Potty” step-stool that helps, it’s being in a squatting position that helps (i.e. any step-stool that helps your child be in a squatting position while having a bowel movement would help). People in certain parts of the world continue stool in the squatted position. For example, in certain areas of Asia, you may frequently encounter squat toilets. While the below 3 minute video is very cheesy and quite odd, it does accurately show why being in a squatting position helps with stooling. It’s very difficult to hold your stool in, as children/toddlers often do – if you are in a squatting position. Check out this video to see why the squatting position allows a person to evacuate stool more efficiently. Happy watching (and try to focus on the medical illustration)!

 

 

Does My Child Have a Food Allergy or Sensitivity (and what’s the difference)?

                           

The gastrointestinal tract is uniquely suited to digest all the different foods we eat to help our children grow and thrive. However, there are times when the body reacts to certain foods and cause discomfort.

 A food allergy occurs when the body sees food as harmful and the immune system reacts to the allergens. When the response involves antibodies known as immunoglobulin E (IgE), symptoms such as hives, trouble breathing, or vomiting can appear quickly. Other times, non-IgE mediated allergies may cause symptoms such as abdominal pain or diarrhea that are delayed up to three days. The most common food allergens in children include milk, soy, egg, wheat, peanuts, tree nuts, fish, and shellfish.

 A food intolerance or food sensitivity occurs when the body has trouble digesting certain foods, but the immune system is not involved. A common example is lactose intolerance where the intestinal enzymes cannot completely process the ingested milk sugar. Food intolerance can lead to similar symptoms as food allergies, but the reactions tend to be less severe.

In many cases, treatment of allergies and intolerances involves removing certain foods from the diet. However, overly restricting a child’s diet could have a negative impact on their nutrition and growth. In certain situations, medications may be useful as well. Your child’s pediatrician or pediatric gastroenterologist can help guide you through the diagnosis and treatment of these conditions.

Picture retrieved April 30, 2016 from www.fix.com/blog/food-allergies/

5 Most Common Causes of Constipation in Kids Ages 2+

  1. Inadequate Hydration – Aside from losing fluids by using the bathroom, most children are very active and sweat quite a bit. These “insensible losses” force the colon to draw out more water from digested food leading to incredibly hard poops! Keeping them hydrated especially on warm days is important! Beginning in toddler-hood, kids should be getting about 1 liter a day minimum.
  1. Stool Holding – Kids are some busy people! They are engaged in school, after-school activities, playing with friends, video games etc. Making the time for them to sit on the toilet is important. Toilets at schools are gross. “Toilet Time” at home is particularly important in toddlers and young children learning to develop healthy stooling habits. The colon is naturally squeezing 20-30 minutes after breakfast and dinner making these good times to encourage sitting.
  1. Diet – Getting the right proportions of food can be challenging in early childhood. Kids are picky – and lets be honest, most parents don’t have time to plan an elaborate meal. The key to a balanced diet is allowing for adequate fiber in the form of whole grains, fruits or vegetables at least 5-9 servings per day (a serving is the size of your child’s fist). You can also calculate how many grams of fiber your child is getting a day. For children >2 years old, the goal is: Age + 5 = Grams of Fiber Per Day. See my list of fiber rich foods here.
  1. Milk-Protein Allergy and Other Food Allergies – Food protein intolerances (different from classic anaphylactic allergy) often result in abdominal pain, occasional nausea/vomiting and diarrhea. The constipation is secondary to the limited variety of foods available to those children suffering from allergies. Using food diaries and coming up with a comprehensive nutrition plan with your pediatrician or pediatric gastroenterologist is important to prevent vitamin deficiencies and constipation.

These area some less common but more insidious causes of constipation and cannot be missed! They include: celiac disease, IBS, thyroid disease, medication-related constipation, and anal fissures. If you worry that there may be an underlying reason for your child’s constipation that isn’t listed above, we are here to help!

Are FODMAPs causing your child’s abdominal pain?

One new diet trend that is becoming increasingly popular is the low-FODMAP diet. FODMAPs (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are foods that are poorly absorbed by the human intestine and are very easily digested by bacteria that normally line our gut. The bacteria feed on these sugars and sugar substitutes allowing them to grow out of control and produce and excessive amount of gas. The high-FODMAP foods can cause inflammation along your intestine, excessive gas, bloating and discomfort. A well-balanced, low-FODMAP diet is recommended for some children with chronic unexplained abdominal pain. Consult your pediatrician or pediatric gastroenterologist before instituting any restrictive diet such as low-FODMAP.

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Picky Eaters 101

One of the most common questions we get in our office is, “How can I get my child to eat more healthy foods?” While there is no magic pill, we will be posting some of our favorite tips over the next few weeks. Keep in mind, this is just a phase, things will get easier!

Quick Tip #1: It is normal for small children are afraid of trying new things, including trying new foods (food neophobia). Reassurance does not always work. But… the more familiar they are with a food the more likely they will try it and like it. It may take several exposures to new foods before the child will accept them and eat them – sometimes as many as 15 attempts! Neophobia peaks at age two years old. It is less of a problem at three, four and five years old. Continue to offer your child to foods they don’t want to eat, but never force them to eat it.

Remember parents are responsible for providing healthful food that is appropriate for the age of the child. Children are responsible for how much they eat or if they eat at all.

If all else fails, follow #mykidcanteatthis for some sympathy and a good laugh.

Perry RA, Mallan KM, Koo J, Mauch CE, Daniels LA, Magarey AM. Food neophobia and its association with diet quality and weight in children aged 24 months: a cross sectional study. Int J Behav Nutr Phys Act. 2015 Feb 13;12:13. doi: 10.1186/s12966-015-0184-6. PubMed PMID: 25889280; PubMed Central PMCID: PMC4335451.

Preventing Peanut Allergies

 

Peanut allergies often develop in childhood and can persist through adulthood. Once a peanut allergy develops, there is no cure or treatment other than avoidance. Reactions can range from mild to life-threatening and can place a significant burden on the child and family.

The National Institute of Allergy and Infectious Diseases have recently issued guidelines on the introduction of peanuts in infants to prevent the development of peanut allergy. A randomized controlled clinical trial involving more than 600 infants demonstrated that earlier exposure to peanuts helps build tolerance and decreases the risk of developing peanut allergies. The age of introduction depends on your infant’s risk factors.

For more information visit the NIH summary guidelines. Your pediatrician or pediatric gastroenterologist can assist you in formulating a plan to safely introduce peanuts to your infant.

Know Thy Poop

The Bristol Stool Chart is a great way to get an idea of how well your colon is working (or not working). Type 1-2, likely constipated. Type 3-4, ideal consistency. Type 7 is diarrhea. A stool log including frequency, Bristol type and associated symptoms will help you and your pediatric gastroenterologist arrive at a diagnosis and help treat your child.

Bristol_stool_chart
References:
1. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997 Sep;32(9):920-4. PubMed PMID: 9299672.
2. Saad RJ, Rao SS, Koch KL, Kuo B, Parkman HP, McCallum RW, Sitrin MD, Wilding GE, Semler JR, Chey WD. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol. 2010 Feb;105(2):403-11. doi: 10.1038/ajg.2009.612. Epub 2009 Nov 3. PubMed PMID: 19888202.
3. Russo M, Martinelli M, Sciorio E, Botta C, Miele E, Vallone G, Staiano A. Stool consistency, but not frequency, correlates with total gastrointestinal transit time in children. J Pediatr. 2013 Jun;162(6):1188-92. doi: 10.1016/j.jpeds.2012.11.082. Epub 2013 Jan 11. PubMed PMID: 23312678.