Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States

Abstract

IMPORTANCE The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States recommend that pediatricians assess infant peanut allergy risk and introduce peanut in the diet at age 4 to 6 months. Early introduction has the potential to prevent peanut allergy development. OBJECTIVES To measure the rates of guideline awareness and implementation and to identify barriers to and factors associated with implementation among US pediatricians. DESIGN, SETTING, AND PARTICIPANTS This population-based study survey used a 29-item electronic survey instrument that was administered to pediatricians practicing across the United States from June 1, 2018, to December 1, 2018. Invitations to complete a survey were emailed to all pediatricians in the American Academy of Pediatrics vendor database. Eligible participants were nonretired US-based pediatricians providing general care to infants aged 12 months or younger. MAIN OUTCOMES AND MEASURES The primary outcome was the prevalence of guideline implementation, which was measured by 1 survey item about awareness followed by a second item about implementation. Secondary outcomes included identification of guidelines-focused services provided by pediatricians, knowledge of the guidelines (measured with 3 clinical scenarios), barriers to guideline implementation, need for training, and facilitators of guideline implementation. RESULTS A total of 1781 pediatricians were eligible to participate and completed the entire survey. Most respondents self-identified as white (1287 [72.5%]) and female (1210 [67.4%]) individuals. Overall, 1725 (93.4%; 95% CI, 92.2%-94.5%) pediatricians reported being aware of the guidelines. Of those pediatricians who had knowledge of the guidelines, 497 (28.9%; 95% CI, 26.8%-31.1%) reported full implementation and 1105 (64.3%; 95% CI, 62.0%-66.6%) reported partial implementation. Common barriers to implementation included parental concerns about allergic reactions (reported by 575 respondents [36.6%; 95% CI, 34.3%-39.1%]), uncertainty in understanding and correctly applying the guidelines (reported by 521 respondents [33.2%; 95% CI, 30.9%-35.6%]), and conducting in-office supervised feedings (reported by 509 respondents [32.4%; 95% CI, 30.1%-34.8%]). Many pediatricians (1175 [68.4%; 95% CI, 66.1%-70.5%]) reported a need for further training on the guidelines. CONCLUSIONS AND RELEVANCE This survey found that most pediatrician respondents appeared to know of the 2017 guidelines, but less than one-third of respondents reported full implementation. Results of this study may inform future efforts to eliminate barriers to guideline implementation and adherence, thereby reducing the incidence of peanut allergy in infants.

Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI

“…The greatest barriers to Guidelines implementation that the survey identified were parental concerns about allergic reactions, parents who were not interested in early feeding, and lack of referrals. In both this survey of allergists and our survey of US pediatricians, 9 parental concern about allergic reactions was the most frequently identified barrier to implementation, a finding that is not surprising at this early stage of Guidelines implementation and consistent with surveys of parental acceptance of the early introduction of peanut-containing-foods. 11,12 Lai and Sicherer 12 reported that the most common physicianperceived implementation barrier was parental acceptance, and the most common parent-identified barriers were fear of reaction and choking, although 90% of parents indicated comfort with early peanut introduction when answering yes or no.…”

“…In a parallel survey we conducted on US pediatricians, the need for additional educational efforts among pediatricians was clearly identified. 9 One limitation of this study is the survey response rate. Among AAAAI members, 29% answered at least 1 question in the survey and 24% completed the survey.…”

“…These authors also conducted a similar survey among US pediatricians. 9 Of 1868 pediatricians who responded to the survey (5% of the targeted sample), 93.4% reported awareness of the Guidelines, and among pediatricians aware of the Guidelines, 64.3% reported partial Guidelines implementation and 28.9% full implementation. Major identified barriers included parental concerns about allergic reactions, uncertainty in understanding and correctly applying the Guidelines, and conducting in-office, supervised feedings.…”

Early intervention and prevention of allergic diseases

“…The 2000 AAP policy 167 recommended avoidance of allergenic foods for breastfeeding mothers and delayed introducing allergenic foods to infants to prevent FA was based on expert opinion informed by a limited number of low quality studies. 168 These guidelines influenced infant feeding practices for almost 20 years, 169 while FA only continued to increase, rather than decrease. These guidelines were reversed in 2008, but not replaced with comprehensive guidelines, only limited recommendations.…”

Needs Assessment for an Infant and Toddler Food Allergy Curriculum for Pediatric Residents

“…2,3 Recent publications have highlighted clinical practice deficits, including the inappropriate treatment of anaphylaxis 4 and the lack of implementation of peanut feeding guidelines by primary care clinicians. 5 Although pediatricians are frontline providers for infants (<12 months) and toddlers (12-35 months) with FA, the Accreditation Council for Graduate Medical Education (ACGME) does not require a pediatric allergy curriculum as part of pediatric residency training.…”