1. Greg Rex Department of Pediatrics, Division of Allergy IWK Health Centre Immunology and Allergy Update

2. Faculty/Presenter Disclosure Faculty: Gregory Rex, MD, FRCPC Relationships with commercial interests: Speakers Bureau/Honoraria: Takeda, Merck CFPC CoI Templates: Slide 1

3. Disclosure of Commercial Support None CFPC CoI Templates: Slide 2

4. Mitigating Potential Bias Today I will discuss topics unrelated to the companies mentioned in the previous slide. CFPC CoI Templates: Slide 3

5. Objectives Review current recommendations for food/allergen exposure in infancy Review recent advances in peanut allergy prevention Discuss which “at risk” infants would be appropriate for specialist referral.

6. Peanut (PN) Allergy PN allergy prevalence: 1.4% to 3% in Western countries; quadrupled in past 13 yrs Leading cause of anaphylaxis and death due to food allergy Significant psychosocial/economic burdens on patients/families Develops early in life and is not commonly outgrown

8. “Becoming Allergic – Immunology 101” Need exposure to sensitize (placenta, breast milk, infant diet) ? Immature gut ? Immature immune system

11. AAP Guidelines Based on infant feeding trials Made “immunologic sense” Some data fradulent “Solid foods should not be introduced into the diet of high-risk infants until 6 months of age, with dairy products delayed until 1 year, eggs until 2 years, and peanuts, nuts, and fish until 3 years of age.” -AAP Statement 2000

13. “Although solid foods should not be introduced before 4 to 6 months of age, there is no current convincing evidence that delaying their introduction beyond this period has a significant protective effect on the development of atopic disease.” -AAP Statement 2008 AAP Guidelines Rates of PN allergy and atopy continued to rise Data becoming “better” and showing no benefit to delaying introduction

14. Observational Data Koplin et al, JACI 2010 2589 children followed and skin tested / challenged with egg at 1 year; comparing introduction at 4-6 months vs later Much higher (OR of 3.4) risk of egg allergy with delayed egg introduction

15. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy Methods  5171 Jewish school children in UK and 5615 Jewish school children in Israel were compared for food allergies and atopy.  Questionnaire based assessment of peanut allergy validated by challenges.  Infant weaning for peanut and other foods was determined in infants using a validated FFQ. Du Toit G et al. J Allergy Clin Immunol 2008; 122: 984-91.

16. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy Du Toit G et al. J Allergy Clin Immunol 2008; 122: 984-91. Prevalence of Peanut Allergy in Children 4- 18yrs % PA Prevalence 1.85% 0.17% United Kingdom 5171 Israel 5615 p < 0.001 Peanut Protein Consumption 8-14 month Median gms of peanut protein / week 0 g/week 7.1 g/week p < 0.001

17. Canadian Position Statement Joint statement of CSACI and CPS Do not delay the introduction of any specific solid food beyond six months of age. Later introduction of peanut, fish or egg does not prevent, and may even increase, the risk of developing food allergy. (Evidence II-2B) Chan E and Cummings C, Paediatr Child Health 2013;18(10):545-9

20. LEAP Study Learning Early About Peanut allergies

21. Learning Early About Peanut Allergy (LEAP Study) 4-11 months 1 yr 2.5 yr 5 yr ♦ Randomisation/ Stratification 4-11 month old children eczema and/or egg allergy Screening Intervention group Peanut consumed 3 times per week(n≈320) Control Group Peanut avoidance (n≈320) V 0V 12V 30V 60 V -1

24. Issues What about SPT > 4 mm? Does it need to be 6 g of PN protein per week? What if gaps in regular consumption? What about general population? What about other foods…milk, eggs, tree nuts?

25. EAT Study - Early Weaning Trial Infants exclusively breastfed (EBF) at 3 months of age 1302 subjects Early introduction (4 months of age) of allergenic foods & breastfeeding Early introduction (4 months of age) of allergenic foods & breastfeeding 1 and 3 yr assessment Food allergy Eczema Atopic wheeze Cumulative allergy 1 and 3 yr assessment Food allergy Eczema Atopic wheeze Cumulative allergy 6 months EBF (UK infant feeding guidelines) Randomization (3 months)

26. Moving forward Well done study: randomized, prospective, controlled Results clearly show that in this “at risk” group, early introduction of PN dramatically decreases the risk of development of PN allergy (70-80%) Guideline changes are “in the works”

27. What does this mean to MDs? Need for GPs and pediatricians to recognize these “at risk” children and refer them ASAP Need for allergists to find a way to see these infants in a timely manner, so not to delay introduction Need to change mindset of population towards early introduction. Need to get the message out Statements and guidelines coming

28. Thank You