How Much Peanut Butter Should He Take?

Patient Presentation
A 6-month-old male came to clinic for his well child examination. He had a history of mild eczema that was treated with emollients and occasionally 1% hydrocortisone cream. Through the national press, his mother had seen that the guidelines for introducing peanut foods had recently changed and she asked about if she should start peanuts in his diet and if so, how she should do it. The pediatrician reviewed his dietary history, which showed him to be tolerating thinned cereals and pureed fruits along with breastfeeding without difficulty. “I always breastfeed him first and then try the cereals or fruits later on, but he seems to really enjoy them and he’s never had a problem with anything he’s eaten,” his mother noted. The family history was positive for eczema in his 3-year old brother who did not have any food allergies and his father who had “dry skin.” “I’ve always stayed away from peanuts because I didn’t want his brother to choke on them,” his mother offered.

The pertinent physical exam showed a healthy male who was growing at the 10-25% with normal vital signs. His skin examination showed reddened areas in the flexural surfaces of his elbows and knees and some mild general xerosis. The diagnosis of a healthy male with mild atopic dermatitis was made. The pediatrician told the mother that the guidelines had recently changed and she could try adding some peanut to his diet. “I’ll give you a handout about how to mix it and give the peanut. It should be done over 3 or more feedings in a week,” the pediatrician noted.

Discussion
Peanut allergy is an increasing problem with ~2% prevalence in the United States. It is also the leading cause of food-related death. The LEAP trial (Learning Early about Peanut Allergy trial) was a randomized trial of early introduction of peanut foods to try to prevent peanut allergy. It found a significant decrease in peanut allergy at 60 months of age with early introduction of peanut foods to infants. This finding occurred in participants with baseline negative skin testing (13.7% in peanut avoidance group versus 1.9% in peanut consumption group) or those with measureable peanut skin testing at study entry (35.3% in peanut avoidance group versus 10.6% in peanut consumption group).

The National Institute of Allergy and Infectious Disease along with other organizations recommend early introduction of peanut foods to infants who are at increased risk for becoming peanut allergic.
They recommend for infants with:

• Severe eczema, egg allergy or both
  • Strongly consider evaluation by peanut serum IgE level and/or skin prick test, and if necessary, by oral food challenge. Based on the results introduce peanut containing foods at 4-6 months.
  • If the 4-6 month time period is missed for introduction, the infant may still benefit by early peanut food introduction.
  • Additional serum IgE levels for other potential food allergies are not recommended.
• Mild to moderate eczema
  • Introduce peanut containing foods around 6 months of age
• No eczema or any food allergy
  • Introduce peanut containing foods when age appropriate and consistent with family preferences and cultural practices

Children who are identified as peanut allergic should strictly avoid peanut foods.
In the situation where family members are peanut allergic, health care providers and families should discuss the risks and benefits of early introduction of peanut food to infants versus the potential risks of further sensitization or accidental peanut exposure to the family member.

Learning Point
Breastfeeding or formula feeding should be continued as appropriate for the age of the infant or child.
Peanut foods should not be the first solid food the infant eats. Other solid foods should be introduced first to make sure the child is developmentally ready to appropriately ingest solid foods and to make sure that non-specific signs and symptoms if they occur, are not confused with IgE mediated food allergy.
Chunky peanut butter should never be used because of choking risks.

Peanut dosing

• The recommended amount of peanut is ~6-7 grams of peanut protein per week, given over 3 or more feedings.
• 2 grams of peanut protein is equivalent to
  • 2 teaspoons (10 ml) of smooth peanut butter (= 9-10 g)
  • ~10 whole peanuts that will be ground to a fine powder/paste (8 grams of peanuts or ~ 2.5 teaspoons of ground peanuts)
  • 2 teaspoons of peanut flour or peanut butter flour (these are distinct products but can be used interchangeably for feeding infants)
  • 21 sticks of Bamba (a peanut puff product made in Israel – other similar products that contain the same amount of peanut protein can also be substituted)
• Recipes
  • Thinned smooth peanut butter
    • Mix 2 level teaspoons of smooth peanut butter (Never use chunky peanut butter) with 2-3 teaspoons of hot water
    • Mix until dissolved, thin, and well-blended
    • Make a mixture of comfortable consistency for the infant by adding more water if needed or adding previously tolerated infant cereal to thicken
    • Let cool before serving to the infant
  • Smooth peanut butter puree (Never use chunky peanut butter)
    • Measure 2 level teaspoons of smooth peanut butter
    • Add 2-3 tablespoons (60-90 ml) to previously tolerated pureed fruit or vegetable and mix well
    • Make a mixture of comfortable consistency for the infant by adding more or less puree
    • Serve to the infant
  • Peanut flour or peanut butter powder
    • Measure 2 level teaspoons of peanut flour or peanut butter powder
    • Add ~2 tablespoons (60 ml) to previously tolerated pureed fruit or vegetable and mix well
    • Make a mixture of comfortable consistency for the infant by adding more or less puree
    • Serve to the infant
  • Bamba (or other similar products that contain the same amount of peanut protein can also be substituted)
    • For infants < 7 months of age or older children who cannot manage dissolvable textures
      • 21 pieces are mixed with 4-6 teaspoons of water
      • Wait until the pieces are softened
      • Serve to child making sure to monitor the child for possible choking
    • For infants > 7 months of age or older children who can manage dissolvable textures
      • 21 pieces can be served “as is” to the infant

First feeding instructions

• The infant should be healthy and well so if there is a reaction it is not confused with an illness; do not feed the infant if they have a cold, vomiting, diarrhea etc.
• The first feeding should be at home, not a restaurant or child care
• At least 1 adult should be able to watch the infant for a minimum of 2 hours without other distractions or responsibilities to monitor for possible allergic symptoms
• A full feeding (see recipes above) should be prepared.
• Give a small amount of the peanut food on the tip of a spoon for the infant to “taste” the peanut food
• Wait 10 minutes
• If no allergic reaction, then give the rest of the peanut food at the infants usual feeding speed
• Monitor the child for at least 2 hours after feeding the peanut food for possible allergic reaction symptoms

  Possible allergic reaction symptoms include:

  • Mild symptoms
    • New rash, or
    • Few hives (welts) around mouth or face
  • More severe symptoms which can include 1 or more these
    • Lip swelling
    • Face or tongue swelling
    • Choking
    • Problems swallowing
    • Vomiting
    • Hives over the body
    • Any problem breathing
    • Wheezing
    • Coughing
    • Sudden change in skin color such as being blue or pale
    • Sudden tiredness, lethargy or seeming limp

If the parent has ANY CONCERNS about their child’s reaction to eating peanut, they should seek medical attention/call 911

Questions for Further Discussion
1. What are indications for allergy testing? To learn more click here
2. What are the most common food allergies?

Related Cases

Disease: Peanut Hypersensitivity | Food Allergy

Symptom/Presentation: Health Maintenance and Disease Prevention | Eczematous Dermatitis

Specialty: Allergy / Pulmonary Diseases | Dermatology

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Food Allergy

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Academy of Allergy, Asthma and Immunology. Newly issued Clinical Guidelines from the NIAID Recommend Early Peanut Introduction, Not Avoidance.
Available from the Internet at https://www.aaaai.org/about-aaaai/newsroom/news-releases/early-peanut-introduction (rev. 1/5/17, cited m3/13/17).

Togias A, Cooper SF, Acebal ML, et. al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel.
J Allergy Clin Immunol. 2017 Jan;139(1):29-44.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital