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Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy

Published:January 19, 2021DOI:https://doi.org/10.1016/j.jaci.2020.11.033

      Background

      Whether to screen high-risk groups before early peanut introduction is controversial.

      Objective

      We sought to determine the risk of peanut allergy (PA) before peanut introduction for infants with (1) moderate-severe eczema, (2) another food allergy (FA), and/or (3) a first-degree relative with peanut allergy (FH).

      Methods

      Infants aged 4 to 11 months with no history of peanut ingestion, testing, or reaction and at least 1 of the above risk factors received peanut skin prick test and, depending on skin prick test wheal size, oral food challenge or observed feeding.

      Results

      A total of 321 subjects completed the enrollment visit (median age, 7.2 months; 58% males); 78 had eczema only, 11 FA only, 107 FH only, and 125 had multiple risk factors. Overall, 18% of 195 with eczema, 19% of 59 with FA, and 4% of 201 with FH had PA. Only 1% of 115 with FH and no eczema had PA. Among those with eczema, older age (odds ratio [OR], 1.3; 95% CI, 1.04-1.68 per month), higher SCORing Atopic Dermatitis score (OR, 1.19; 95% CI, 1.06-1.34 per 5 points), black (OR, 5.79; 95% CI, 1.92-17.4 compared with white), or Asian race (OR, 6.98; 95% CI, 1.92-25.44) and suspected or diagnosed other FA (OR, 3.98; 95% CI, 1.62-9.80) were associated with PA.

      Conclusions

      PA is common in infants with moderate-severe eczema, whereas FH without eczema is not a major risk factor, suggesting screening only in those with significant eczema. Even within the first year of life, introduction at later ages is associated with a higher risk of PA among those with eczema, supporting introduction of peanut as early as possible.

      Graphical abstract

      Key words

      Abbreviations used:

      LEAP (Learning Early About Peanut Allergy), NIAID (National Institute of Allergy and Infectious Diseases), OFC (Oral food challenge), OR (Odds ratio), SCORAD (SCORing Atopic Dermatitis), SPT (Skin prick test)
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      Linked Article

      • Shorter “time to peanut introduction” can prevent peanut allergy and avert false Ara h 2 screening results in infants
        Journal of Allergy and Clinical ImmunologyVol. 148Issue 1
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          We echo the importance of estimating precise pretest probabilities based on the degree of appropriate risk factors—a task potentially enabled by data presented by Keet et al1,2—to fully evaluate the utility of screening tests for the purposes of infant peanut introduction. Diagnostic test operating characteristics are central to the screening controversy in peanut allergy prevention.3 Assuming the authors’ data are generalizable to the US population of infants with moderate to severe eczema, Ara h 2 component IgE appears to be superior to skin prick testing and to peanut-specific IgE testing, with Ara h 2 having the greatest area under the receiver-operating characteristic curve.
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