Virtually Supported Home Peanut Introduction is Viable Option

Douglas Mack, MD

With the impact of the coronavirus disease 2019 (COVID-19) lockdown measures continuing to be felt across the US, access to healthcare resources for the management of allergic disease are still limited. And although in-person services may be offered by clinics, concern or fear over exposure to the virus can certainly hinder patient use of such services.

And yet, certain allergic conditions, such as peanut allergies in high-risk infants, require expedited assessments and active management.

A report written by Douglas Mack, MD, Assistant Clinical Professor, Pediatrics, McMaster University, and colleagues detailed the first known use of a virtually supported home peanut introduction in infant patients at risk of developing peanut allergy. The program was conducted earlier this year in April.

Prior to initiation of the virtual program, infants were screened for eligibility in a private-practice allergist setting using the telehealth platform Doxy.me.

Patients were eligible if they had physician-diagnosed severe eczema, physician diagnosed egg allergy, SPT≥3 mm or ≥0.35 kU/L without prior ingestion, perceived high-risk by caregiver, or had caregiver anxiety to introduce a particular food.

Excluded from the study were patients with a history of systemic IgE-mediated reaction to the food in questions; had certain underlying conditions, such as uncontrolled asthma, cardiac conditions, respiratory conditions; or used a beta-blocker.

During this first consultation, parents or guardians were informed about the risks and benefits of either prolonging peanut avoidance until the first in-person visit or participating in the virtually-support food introduction process.

If they chose to proceed with the program, then consent was obtained, and they were prescribed an epinephrine autoinjector and rupatadine.

In the next visit with the physicians, caregivers were then informed about the process, possible symptoms, and treatment.

Then they were instructed to prepare peanut putter by dissolving 2 teaspoons of it in 2-3 teaspoons of hot water, then letting it cool.

Caregivers then gradually introduced 2 g of peanut butter every 10-15 minutes over 45 minutes – 1 hour.

If any symptoms occurred, the guardian used the telehealth program to contact the physicians for further assessment. If the physicians were unable to be reached, then caregivers were instructed to administer epinephrine and/or antihistamine or contact emergency medical services.

However, if no symptoms occurred, then the physicians would advise ingestion of the food of similar or increased amounts 2-3 per week.

Mack and colleagues referenced recent clinical guidelines that provide a framework for at-home management of anaphylaxis. They suggest that using these guidelines would be necessary in the event of such reactions during the virtually supported food introduction.

Nonetheless, they noted that no reactions were reported during the food introduction process, which they considered to be consistent with the current evidence that anaphylaxis is rare and non-threatening with first ingestion in infancy. Thus, they emphasized that mild reactions can generally be managed with antihistamine and/or observation.

“Even before COVID-19, lack of allergist resources presented significant barriers to the introduction of peanut to at-risk patients where there was hesitance,” they wrote.

“During COVID-19, the need to provide alternative forms of care is heightened. Virtually supported introduction may represent a future option after COVID-19 to improve access for patients who live in remote areas, or otherwise have limited access to allergists, or for clinicians with overburdened clinics.”

They acknowledged that the implementation of such a strategy requires formal evaluation of safety, cost-effectiveness, caregiver/physician acceptability, sustainability, and patient satisfaction.

The report, “Virtually supported home peanut introduction during COVID-19 for at-risk infants,” was published online in The Journal of Allergy and Clinical Immunology: In Practice.