key: cord-0784777-md467pk7
authors: Mack, Douglas P.; Hanna, Mariam A.; Abrams, Elissa M.; Wong, Tiffany; Soller, Lianne; Erdle, Stephanie C.; Jeimy, Samira; Protudjer, Jennifer LP.; Chan, Edmond S.
title: Virtually-supported home peanut introduction during COVID-19 for at-risk infants
date: 2020-06-10
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2020.05.048
sha: b3003b92f3c8bbd5ef34b3f965980d17ea53c954
doc_id: 784777
cord_uid: md467pk7

nan

Recently published North American guidelines for the management of allergic disease during the 93 COVID-19 pandemic recommend service adjustments such as virtual visits or postponing 94 appointments. 1 While it is reasonable to delay treatment for some allergic conditions, the 95 guideline notes that other scenarios such as peanut avoidance in a high-risk infant requires 96 expedited assessment and active management. Therefore, the time sensitive nature of food 97 introduction presents a dilemma for both parents and clinicians. While some guidelines 98 recommend that families introduce peanut without physician evaluation, 2 NIAID guidelines have 99 suggested screening and in-office introduction of peanut for at-risk and sensitized populations. 3 100

As many clinics currently offer limited in-person services, the inability to follow these guidelines 101 places these infants at risk of missing the preventative window. Further, parental concerns of 102 reactions requiring emergency department visit with potential COVID-19 exposure, compounds 103 an already stressful experience. 4.5,6 With no consistent guidance or concrete plan regarding the 104 reopening of medical services, and variance in COVID-19 risk by region, access to in-office food 105 introduction remains uncertain. We report the first known use of a virtually-supported home 106 introduction option for infants at risk of developing peanut allergy. 107 108 In April 2020, infants were evaluated virtually in a private-practice allergist setting using the 109 telehealth platform Doxy.me. These infants were identified as either being: at risk for the 110 development of peanut allergy (e.g., egg allergy or severe eczema); 3 tested previously as per 111

guidelines; perceived higher-risk by parents (e.g., family history, other food allergy); or there 112 was caregiver hesitation to feed (Figure 1a ). 5 During the initial virtual consultation, shared 113 decision-making was utilized to review the risks and benefits of the following options: peanut 114 avoidance until in-office assessment; or participation in a virtually-supported food introduction epinephrine autoinjector and rupatadine, to be obtained prior to the virtually-supported 117 introduction. Parents were instructed to prepare peanut butter as per Figure 1a .7 Families 118 subsequently met virtually with the physician on Doxy.me where they were counselled about 119 food introduction, possible symptoms and treatment (Figure 1b) . Parents then proceeded to 120 gradually introduce 2 g peanut protein over 45 minutes -1 hour. Families could contact the 121 physician immediately through the virtual platform with questions or concerns, or if the child 122 reacted. Below, three cases demonstrate the utility and potential application of this approach. 123

Case 1: 10-month-old infant with severe eczema pre-emptively tested for multiple foods with a 124 6 mm epicutaneous wheal and 0.95 kU/L serum sIgE for peanut and 5.71 kU/L serum sIgE for 125 whole egg. During virtual peanut introduction, parents had concern about respiratory status, but 126 on virtual reassessment, the child was happy and in no distress, with a normal respiratory rate, no 127 accessory muscle use, and no cutaneous lesions. Introduction proceeded with no reaction, 128 although only 1 g of peanut protein was ingested and parents were instructed to try peanut puffs. 129

At follow up, parents had successfully given up to 2 g peanut on a regular basis. 130

Case 2: 7-month-old with mild eczema, sibling with peanut allergy and parental reluctance to 131 feed. Barrier cream was applied around mouth pre-emptively and peanut was introduced without 132 difficulty. There was brief virtual communication with the physician during the introduction 133 clarifying the volume to be introduced. Following initial introduction, parents continued to give 134 peanut at home regularly without difficulty. 135

Case 3: 6-month-old infant had mild eczema with a history of anaphylaxis requiring 2 doses of 136 epinephrine following sesame introduction. Due to the traumatic experience and a fear of emergency department presentation during the COVID-19 pandemic, parents expressed 138 reluctance to introduce peanut. During introduction, the patient had a small exposure to peanut, 139 but expressed distaste, and the full amount could not be introduced. There was no evidence of 140 adverse reaction, and parents continued to offer similar small amounts at home. Following this 141 experience, parents reported feeling more comfortable introducing tree nuts and have 142 successfully introduced almond at home. 143

These three cases demonstrate the feasibility and practicality of a virtually-supported food 144 introduction program. Case 1 was considered "high-risk" as per NIAID guidelines, 3 

Case 2 was not technically "high-risk", siblings of patients with a peanut allergy show a higher 146 long-term risk of developing an allergy, especially if families continue to avoid peanut. 5 All 147

families expressed significant concern about peanut introduction (as a result of a previous severe 148 reaction in Case 3) and this reluctance is consistent with North American survey data. 4,5 These 149 patients tolerated peanut during the introduction and on subsequent exposures. Each family 150 virtually interacted with the physician at the beginning of the introduction and 1-2 times during 151 the actual procedure. Families could immediately and easily contact the physician during the 152 process through the virtual platform if they had concerns. These interactions were brief and not 153 burdensome to the clinician. All families reported significant appreciation and satisfaction with 154 this virtually-supported approach. 155

In each case, parents were counselled beforehand about the possibility of severe reaction. No 156 reactions were reported during these introductions, which is consistent with our prior clinic 157 experience. Our findings are consistent with current evidence that severe anaphylaxis to peanut 158 in infants is rare, with no life-threatening reactions reported on first ingestion in infancy, and mild reactions can generally be managed with antihistamine and/or observation. 8 Recent 160 clinical guidelines suggest a framework for at-home management of anaphylaxis. 9 Should a 161 severe reaction have occurred during this procedure, the physician and family would have 162 utilized the guidance of those recommendations. 163

Even before COVID-19, lack of allergist resources presented significant barriers to the 164 introduction of peanut to at-risk patients where there was hesitancy. During COVID-19, the need 165 to provide alternative forms of care is heightened. Virtually-supported introduction may 166 represent a future option post-COVID-19 to improve access for patients that live in remote areas, 167 or otherwise have limited access to allergists, or for clinicians with overburdened clinics. 168

However, the successful implementation of such a strategy requires formal evaluation of safety, 169 cost-effectiveness, caregiver/physician acceptability, sustainability, and patient satisfaction. This 170 pandemic will persist for the foreseeable future and has highlighted the need to move towards a 171 virtual platform. There is simply too much at stake for prolonged peanut avoidance due to lack 172 of in-office access. 173 Parent to obtain epinephrine autoinjector (ideally 2) and antihistamine Ensure child is healthy Prepare peanut solution: Dissolve 2 teaspoons of smooth peanut butter in 2-3 teaspoons of hot water and allow to cool. If necessary, prepare food vehicles (tolerated infant food ie. cereal, or pureed fruit).

If yes

COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic

Australian Consensus on Infant Feeding Guidelines to Prevent Food Allergy: Outcomes 187

From the Australian Infant Feeding Summit

Addendum 190 guidelines for the prevention of peanut allergy in the United States

National Institute of Allergy and Infectious Diseases-sponsored expert panel

Caregiver 194 and expecting caregiver support for early peanut introduction guidelines

Des Roches A. Introduction of peanuts 197 in younger siblings of children with peanut allergy: a prospective, double-blinded 198 assessment of risk, of diagnostic tests, and an analysis of patient preferences

Special Article: Risk Communication During COVID-19

Allergy Canada and Canadian Society of Allergy and Clinical Immunology

Food Challenge and Community-Reported Reaction Profiles in Food

Children Aged 1 and 4 Years: A Population-Based Study

Acute At Home Management of Anaphylaxis 210

During the Covid-19 Pandemic

Child is healthy Availability of epinephrine and antihistamine Review of potential reaction signs and symptoms Treatment strategies including antihistamine, epinephrine (and EMS activation) How to notify physician if concern about reaction Steps for oral challenge administration and planned discharge time