What are the American Academy of Pediatrics (AAP) guidelines for introducing peanut products into an infant's diet?

AAP Guidelines on Introducing Peanut into Infant Diet

The American Academy of Pediatrics (AAP) now recommends introducing peanut-containing foods as early as 4-6 months of age for infants at high risk of peanut allergy (those with severe eczema and/or egg allergy), following appropriate risk assessment and testing. 1

Risk-Based Approach to Peanut Introduction

The AAP and National Institute of Allergy and Infectious Diseases (NIAID) guidelines stratify infants into three risk categories:

1. High-Risk Infants (Severe Eczema and/or Egg Allergy)

• Introduce peanut as early as 4-6 months of age 1
• Required before introduction:
  • Evaluation by peanut-specific IgE measurement and/or skin prick testing
  • Possible referral to specialist based on test results
• Introduction protocol based on test results:
  • If peanut-specific IgE <0.35 kUA/L or skin prick test wheal ≤2mm: Safe for home introduction
  • If skin prick test wheal 3-7mm: Supervised feeding in medical setting recommended
  • If skin prick test wheal ≥8mm: Likely allergic, maintain specialist care 1

2. Moderate-Risk Infants (Mild to Moderate Eczema)

• Introduce peanut around 6 months of age
• Can be introduced at home without prior testing
• Medical supervision optional based on family/provider preference 1

3. Low-Risk Infants (No Eczema or Food Allergies)

• Introduce peanut with other age-appropriate foods according to family preference
• No testing required before introduction 1

Safe Introduction Methods

The guidelines provide specific instructions for introducing peanut safely 1:

• Total weekly consumption: Aim for 6-7 grams of peanut protein weekly, divided over 3+ feedings
• Safe preparation options:
  1. Thinned smooth peanut butter (2 tsp peanut butter mixed with 2-3 tsp hot water)
  2. Peanut butter puree (2 tsp peanut butter mixed with 2-3 tbsp pureed fruit/vegetables)
  3. Peanut flour/powder (2 tsp mixed with pureed fruit/vegetables)
  4. Bamba® peanut puffs (21 pieces, softened with water for infants <7 months)

Important Safety Considerations

• Choking hazards:
  • Never give whole nuts to children under 5 years
  • Never give undiluted peanut butter directly from a spoon to children under 4 years 1
• First feeding:
  • Should be at home, not daycare or restaurant
  • When infant is healthy (no illness)
  • With full adult supervision and ability to observe for 2 hours after feeding
  • Start with small amount, wait 10 minutes, then give remainder if no reaction 1

Integration with Breastfeeding Recommendations

The AAP continues to recommend exclusive breastfeeding for about 6 months, but acknowledges that early peanut introduction at 4-6 months for high-risk infants is compatible with breastfeeding 1:

• Introduction of peanut did not affect breastfeeding duration or frequency in studies
• For most infants, complementary foods including potential allergens should be introduced around 6 months 1
• Maternal diet restriction during pregnancy or lactation is not recommended for allergy prevention 1

Implementation Challenges

Despite these clear guidelines published in 2017, implementation has been challenging. A 2020 survey found that while 93.4% of pediatricians were aware of the guidelines, only 28.9% reported full implementation 2. Common barriers included parental concerns about allergic reactions, uncertainty in correctly applying the guidelines, and challenges with in-office supervised feedings 2.

By following these evidence-based guidelines for early peanut introduction, healthcare providers can help reduce the rising prevalence of peanut allergy in children.