Guidelines to prevent peanut allergy recommend introducing peanut products to infants early, especially to those at high risk who have severe eczema or egg allergy. However, pediatric clinician adherence to the guidelines is low, authors reported in a new study.

The researchers, led by Ruchi S. Gupta, MD, MPH, attending clinician at the Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, found in the randomized Intervention to Reduce Early Peanut Allergy in Children (iREACH) trial that a clinical decision support (CDS) tool and targeted education sharply increased pediatric clinician adherence to the National Institute for Allergy and Infectious Diseases’ 2017 Addendum to the Prevention of Peanut Allergy Guidelines for infants at both high and low risk of developing peanut allergy. Findings were published in Pediatrics.

Practices in the intervention group received clinician education with online training modules, a CDS tool embedded in the electronic health record (EHR) system, and visual aids, including what severe eczema looks like with different skin tones. Those in the control group did not receive the supports. The trial included 30 pediatric practices across three networks and included six Federally Qualified Health Centers.

Adherence More Than Double for Intervention Group

Overall, 18,480 infants (intervention group, n = 9290; control group, n = 9190) were seen by 290 clinicians. Among low-risk infants (n = 18,182), intervention clinicians were adherent for 83.7%, whereas control clinicians were adherent for 34.7% (odds ratio [OR], 14.6; 95% CI, 7.0-30.5; P < .001). Among high-risk infants (n = 298), intervention clinicians were adherent for 26.8%, whereas control clinicians were adherent for 10.4% (OR, 3.1; 95% CI, 1.1-8.8; P = .03).

The primary outcome was clinician adherence to guidelines, documented in EHR data from 4- or 6-month well-child visits. Clinicians were adherent for low-risk infants (who had no, mild, or moderate eczema and no egg allergy) if they recommended the introduction of peanut-containing foods. They were considered adherent for high-risk infants (severe eczema and/or egg allergy) if they ordered a peanut-specific immunoglobulin E test and counseled appropriately or referred to an allergist.

In an accompanying presentation of the data online, Gupta said that the intervention in high-risk infants actually significantly improved clinician adherence, but during the study timeframe new consensus guidelines were introduced after infants’ families found it was hard to get an appointment with an allergist. That affected the results. However, “overall, almost 80% of pediatricians in the intervention arm were adhering to someguidelines for high-risk infants,” Gupta explained.

Intervention Addresses Pediatricians’ Lack of Time

Maria Garcia-Lloret, MD, pediatric allergist with University of California Los Angeles Health, Los Angeles, told Medscape Medical News that Gupta’s team’s results were impressive and “very hopeful.” She said she wasn’t surprised the increase in adherence was so high with the intervention because the reasons for the low adherence are primarily the lack of pediatricians’ time, their uncertainty about exactly how to implement the guidelines, and lack of confidence in correctly introducing peanut. The intervention would be easily implemented on a broad scale, she said. 

“If we give [pediatricians] the tools, they will do it,” Garcia-Lloret said. She said this intervention is particularly important because referring to pediatric allergy specialists is growing increasingly difficult. In her practice, she said, “it may be 3 months” to get an appointment. That trend may worsen, she said, with an increase in the number of babies born with eczema increasing the load for specialists. “Determining what is severe eczema is a bit subjective,” she said.

Garcia-Lloret added that her institution has found that educating parents with one-page instructions on which allergic reactions do and don’t need provider attention also helps ease the burden for pediatricians.

Gupta said the next step is to see whether adherence to guidelines translates to reduction in peanut allergy numbers. “We know that if we intervene with pediatricians at those 4- and 6-month visits, we can have clinicians recommend peanut products to infants,” she added. “Now the big question is, if pediatricians do recommend it, are the families going to do it? It’s a two-step approach,” she said.

Gupta declared receiving support from Food Allergy Research & Education (FARE), Melchiorre Family Foundation, Sunshine Charitable Foundation, The Walder Foundation, UnitedHealth Group, Thermo Fisher Scientific, and Genentech; she also declared serving as a medical consultant and advisor for Genentech, Novartis, Aimmune LLC, Allergenis LLC, and FARE and having ownership interest in Yobee Care, Inc. Garcia-Lloret reported having no relevant financial relationships.

Marcia Frellick is an independent, Chicago-based healthcare journalist and a regular contributor to Medscape Medical News.