Clinical Tools Keeps Pediatricians Aligned with Food Allergy Guidelines

October 16, 2019
Kevin Kunzmann

Following the ground-breaking LEAP findings in 2015, and updated clinical guidelines in 2017, there's a noted disparity of adherence among pediatric clinics.

Lucy A. Bilaver, PhD

A clinical decision support (CDS) tool designed by pediatricians is associated with a greater clinician adherence to infant peanut allergy prevention guidelines—which were shaped by the crucial Learning Early About Peanut Allergy (LEAP) study results, according to new research.

An assessment into the Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) training and CDS tool showed its implementation among treating pediatricians in clinics is associated with a significantly greater adherence to the 2017 Addendum Guidelines for the Prevention of Peanut Allergy.

The LEAP study—largely considered to be a ground-breaking assessment into the potential of early allergen exposure as a food allergy prophylaxis in 500-plus young children—was originally published in 2015, with the follow-up LEAP-On trial published a year later, and the official addendum to National Institute of Allergy and Infectious Diseases (NIAID) treatment guidelines being published a year after that.

In a recent DocTalk podcast interview with MD Magazine®, Whitney Morgan Block, MSN, CPNP, FNP-BC, president, chief executive officer and founder of the National Allergy Center, explained the findings of LEAP led to a new understanding that introducing peanut to allergy-risk patients between 4-6 months old reduced their chances of developing a peanut allergy by 81%.

This finding bucked global clinical recommendations, which almost universally advised a delayed exposure to peanut allergen in at-risk patients.

“And that's the reason why this one study turned all of those guidelines kind of on their heads and said, 'Wow, maybe we're not telling people the right thing’,” Block said. “Maybe if we introduced the food earlier, we would actually prevent these kids from having peanut allergy.”

To assess the influence of CDS tools such as iREACH on clinic-by-clinic updated guideline adherence, a team of investigators from Northwestern University Feinberg School of Medicine collected and compared data of at-risk infants treated at either an iREACH-trained clinic (n = 151) or an untrained clinic (n = 312).

Tools included in the iREACH program included the following: an order set for peanut-specific IgE or allergy referral for high-risk infant patients; a prompt to evaluate peanut allergy risk; a prompt indicating peanut product-introduction counseling; an instructional handout for caregivers; and a best-practice advisory for infants with known atopic dermatitis or an egg allergy.

Full pediatrician adherence was achieved if they recommended peanut product introduction in low-moderate-risk patients’ records, and an ordered peanut-spefici IgE or allergist referral in high-risk patients’ records. Partial adherence was defined as the pediatrician providing an instructional handout to families and/or a peanut recommendation, in low-moderate-risk patients.

Investigators, led by Lucy A. Bilaver, PhD, observed a 93% partial guideline adherence rate among pediatricians treating low-moderate risk patients in the iREACH clinic, and a complete adherence rate of 52.4%. In the control clinic, a complete adherence rate of just 14.1% was observed (P <.001)

Just 8 infant patients were considered at high risk for peanut allergy at the iREACH clinic; pediatricians were adherent in 5 cases—2 resulting in peanut-specific IgE orders and 3 resulting in allergist referral. Only 1 patient was considered at high risk at the control clinic; pediatricians were non-adherent.

Investigators were interested to learn more infants at low-moderate risk had received the specific IgE order or allergist referral than infants at high risk in the iREACH clinic. That said, their findings were limited by the rate of participating clinic sites and patient size, and the lack of randomization of patients to one of the 2 care options.

“Since well-child visits for infants aged 4 to 6 months focus on a range of preventative and anticipatory guidance, an effective CDS tool such as iREACH may facilitate pediatrician guideline adherence,” Bilaver and colleagues wrote. “Further long-term research is necessary to study if iREACH reduces PA incidence.”

The study, “Effectiveness of Clinical Decision Support Tools on Pediatrician Adherence to Peanut Allergy Prevention Guidelines,” was published online in JAMA Pediatrics.

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