Despite the sweeping change in guidelines for preventing peanut allergy in infants following the landmark LEAP study, national surveys in 2021 showed that 70% of parents and caregivers said they hadn’t heard the new recommendations, and less than a third of pediatricians did them.
Now, in a 5-year National Institutes of Health-funded study called iREACH, researchers are testing whether a two-part intervention that includes educational videos and a clinical decision support tool will help pediatricians follow guidelines and ultimately reduce peanut allergy .
Early results from iREACH, presented at the 2023 American Academy of Allergy, Asthma and Immunology (AAAAI) Annual Meeting in San Antonio, showed mixed results with a strong increase in clinical knowledge of the guidelines but only a modest increase in their implementation practice with children at risk.
Ruchi Gupta, MD, MPH, director of the Center for Food Allergy and Asthma Research at Northwestern University Feinberg School of Medicine in Chicago, who is raising a child with food allergies while working as a pediatrician herself, understands the importance and challenge of translating published findings into practice.
During a typical 4- to 6-month visit to a healthy child, pediatricians must review the baby’s growth, perform a physical exam, discuss milestones, ask questions about sleep and defecation and colic, and — if familiar with the latest guidelines familiar – explain why it is important to feed peanuts early and often.
“Pediatricians get material from every single specialty and the guidelines are constantly changing,” she said Medscape Medical News.
The current feeding guidelines, released in 2017 after the landmark LEAP study, changed from “introduce peanuts at age 3 years old” to “introduce peanuts now,” Gupta said.
But the recommendations are not entirely simple. They require pediatricians to make an assessment when the baby is around 4 months old. If the child is at high risk (severe eczema or an egg allergy), they will need a peanut-specific immunoglobulin E (IgE) test. If the test is negative, the pediatrician should encourage introduction of the peanut. If positive, they should refer the child to an allergist.
“It’s a bit complicated,” Gupta said.
To promote understanding and adherence, Gupta’s team developed the intervention tested in the iREACH study. It includes a series of educational videos, a clinical decision support tool embedded in the Electronic Medical Record (EHR), with pop-ups reminding the physician to discuss early introduction, menus for ordering peanut IgE -Testing or referral to an allergist if needed and a guide for caregivers explaining how to add peanuts to the baby’s diet. (You can find these resources here.)
The study involved 290 pediatricians at 30 local practices who examined 18,460 babies from a variety of backgrounds, about a quarter of whom were from publicly insured families. About half of the clinicians received the intervention, while the other half served as a control arm.
The training videos seemed effective. Physicians’ knowledge of the guidelines increased from 72.6% at baseline to 94.5% after the intervention, and their ability to recognize severe eczema increased from 63.4% to 97.6%. This resulted in 70.4% success in applying the guidelines when different clinical scenarios were presented versus 29% at baseline. These results are in press JAMA network open.
The next set of analyses, preliminary and unpublished, monitored real-world compliance using natural language processing to pull EHR data from 4- and 6-month Well Check visits. It was “AI [artificial intelligence] for notes,” Gupta said.
In low-risk infants, training and the support tool embedded in the EHR significantly improved physician compliance. 80% of clinicians in the intervention arm followed the guidelines compared to 26% in the control group.
Effects on high-risk infants
In high-risk infants, the effect was much weaker. Even after the video-based training, only 17% of the pediatricians followed the guidelines—that is, ordered a peanut IgE test or referred to an allergist—compared to 8% in the control group.
Why such a low intake?
Pediatricians are under time pressure. “How to add [early introduction] other 10 or 15 things you’d like to talk about with a parent at the 4-month visit?” said Jonathan Necheles, MD, MPH, a pediatrician with Children’s Healthcare Associates in Chicago.
It can also be hard to tell if a baby’s eczema is “severe” or “mild to moderate.” The EHR integrated support tool included a scorecard to assess eczema severity across a range of skin tones. The condition can be difficult to see in patients of color. “You don’t get the redness the same way,” said Necheles, who worked with Gupta to develop the iREACH intervention.
Curiously, although the AI analysis found that fewer than one-fifth of pediatricians followed guidelines for high-risk infants, 69% of them recommended introducing peanuts.
One interpretation is that busy pediatricians may be “doing the minimum” — introducing the concept of early induction and telling parents to try, “but not giving any additional sort of guidance about who’s high risk, who’s low risk.” who should see the allergist who should be screened,” said Edwin Kim, MD, allergist, immunologist and director of the Food Allergy Initiative at the University of North Carolina at Chapel Hill.
The final impact of iREACH is yet to be seen. “The end goal is if pediatricians recommend it, will parents follow and will we reduce peanut allergy?” Gupta said.
Gupta advises or acts as a consultant to Genentech, Novartis, Aimmune LLC, Allergenis LLC and Food Allergy Research & Education (FARE); receives research grants from Novartis, Genentech, FARE, the Melchiorre Family Foundation and the Sunshine Charitable Foundation; and reports ownership interests of Yobee Care, Inc.
Necheles does not report any financial disclosures.
Kim reports consultations with Allergy Therapeutics Ltd, Belhaven Biopharma, Duke Clinical Research Institute, Genentech, Nutricia and Revolo; Member of the Advisory Boards of ALK, Kenota Health and Ukko Inc; and grant support from the National Institute of Allergy and Infectious Diseases, the Immune Tolerance Network, and the NIH’s Food Allergy Research and Education.
2023 American Academy of Allergy, Asthma, & Immunology (AAAAI) Annual Meeting. Presented on February 25, 2023. Symposium 2521
Esther Landhuis is a freelance science and health writer based in the San Francisco Bay Area. You can find her on Twitter @elandhuis.
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