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

This survey study describes the self-reported level of adherence, familiarity, and implementation needs associated with national peanut allergy prevention recommendations among pediatricians caring for infants.


Introduction
Food allergy affects approximately 8% of children in the United States 1 and is an increasing public health concern. 2 The most common pediatric food allergy is peanut allergy, which has been reported in 2.2% of US children, 1 is the least frequently outgrown among food allergies, 3 and is often associated with severe reactions. 4In 2000, the American Academy of Pediatrics (AAP) released recommendations to delay the introduction of peanut to the diet until the child is aged 3 years. 5[8] In 2015, the Learning Early About Peanut Allergy randomized clinical trial demonstrated that early introduction of peanut to infants between age 4 and 11 months who were at high-risk for developing peanut allergy resulted in a considerable reduction (81%) of peanut allergy prevalence by age 5 years. 9Based on these findings, the National Institute of Allergy and Infectious Diseases convened an expert panel, representing professional organizations, patient advocacy groups, and government agencies, to produce the Addendum Guidelines for the Prevention of Peanut Allergy in the United States. 10The guidelines were published in 2017 and included 3 recommendations.
Recommendation 1 is that infants with severe eczema and/or egg allergy should undergo evaluation for allergic sensitization to peanut through specific IgE (sIgE) test and/or skin prick testing and, if necessary, an oral food challenge.Depending on the test results, peanut products should be introduced into the diet as early as 4 to 6 months of age (Figure).Recommendation 2 is that infants with mild to moderate eczema should begin peanut consumption around age 6 months.
Recommendation 3 is that infants with no eczema or food allergy may consume peanut when age appropriate, in accordance with family preference and cultural practices. 10ginning with the 4 to 6-month well-child visits, pediatricians can have a vital role in guideline implementation and reduction in peanut allergy incidence.2][13] Moreover, these studies 14 included a small number of pediatricians in localized areas of the US and lacked an in-depth assessment of potential barriers to guideline implementation among pediatricians.We conducted the present study with the aim to measure the rates of guideline awareness and implementation as well as to identify barriers to and factors associated with implementation among US pediatricians.

Study Design and Participants
The online survey was administered in 2 waves.Nonretired US pediatricians who provide general care to infants aged 12 months or younger were eligible to complete the survey.Eligibility was determined through the first 2 questions of the survey (eFigure in the Supplement).In wave 1, we used a vendor database obtained from the AAP to randomly select 7200 pediatricians with an email address, a US mailing address, and a listed practice type (excluding unclassified or other practice types).Because of the low survey response in wave 1, we conducted wave 2 with the remaining 37 446 pediatricians in the AAP vendor database who were not included in wave 1. Potential respondents in wave 2 and in the first 3 weeks of wave 1 were offered a $10 gift card as an incentive to complete the survey.Potential respondents in the last 2 weeks of wave 1 were offered a $50 gift card as an incentive, in our effort to increase the survey response rate.

Outcome Measures
The primary outcome was the prevalence of guideline implementation, assessed by 1 item that asked about awareness of the guidelines, followed by a second item that asked about implementation (not using, using only parts of the guidelines, or using the guidelines as published and with few deviations) among those who were aware of the guidelines.Secondary outcomes were the guidelines-focused services provided by respondents, knowledge of the guidelines (measured with 3 clinical scenarios), barriers to implementation, need for training, and facilitators of implementation.

JAMA Network Open | Allergy
Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the US

Statistical Analysis
Waves 1 and 2 data were combined for analyses.Frequencies and percentages with 95% CIs were calculated for categorical responses.) and in an urban location (34.7% in the present survey vs 49.5% in the AAP report 15 ).
Participant demographic characteristics and a comparison with the AAP membership report are presented in Table 1.Demographic characteristics did not vary by wave, and no differences in sex, number of years since medical school graduation, and practice region were observed between survey participants and nonparticipants.

Implementation Barriers and Facilitators
Among respondents who were fully or partially implementing the guidelines, the barriers were categorized into 3 types (Table 4).Of the pediatrician-and practice-related barriers to implementation, the most frequently identified were conducting in-office supervised feedings of peanut (n = 509 [32.4%; 95% CI, 30.1%-34.8%]) and lack of clinic time (n = 450 [28.7%; 95% CI, Figure.Recommendations for Evaluating Children With Severe Eczema and/or Egg Allergy Before Early Introduction of Peanut-Containing Products 10ese recommendations are from the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States by the National Institute of Allergy and Infectious Diseases expert panel.10OFCindicates oral food challenge; sIgE, specific IgE; SPT, skin prick testing.
MethodsThis population-based survey of US pediatricians was administered from June 1, 2018, to December 1, 2018.The study was reviewed and approved by the institutional review board of Ann & Robert H.
Bivariate associations (practice location, practice region, academic affiliation, type of practice, percentage of patients with Medicaid, number of hours spent on pediatric care per week, mean number of years since medical school graduation, guidelines-focused services provided by pediatricians, and knowledge of the guidelines) with guideline implementation were tested with χ 2 ResultsParticipantsOf the 41 048 email invitations sent, 2 135 pediatricians (5.2%) responded to the first question (What is your primary medical specialty?).After exclusion of ineligible pediatricians who did not primarily specialize in pediatrics and/or did not provide general pediatric care to infants aged 12 months or younger, a total of 1868 pediatricians were eligible to participate.Among the 1868 pediatricians, 1781 (95.3%) completed the full survey (eFigure in the Supplement).Most participants self-identified as white (1287 [72.5%]) and female (1210 [67.4%]) individuals.More than half of the respondents (972 [54.4%]) practiced in a suburban location, whereas 196 (11.0%) practiced in a rural location.Practicing without an academic affiliation (1222 [68.3%]) and in a private group practice (799 [44.9%]) were most common.The demographic characteristics (sex and race/ethnicity) of the study sample were similar to statistics reported by the AAP, with the exception of practicing in a private group practice (44.9% in the present survey vs 33.3% in the AAP report

Table 2 .
Guideline Implementation, Knowledge, and Training NeedsPediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the US 5%-31.0%]).Participants also reported that conducting peanut-specific IgE antibody testing was a barrier to implementation (n = 231 [14.7%; 95% CI, 13.0%-16.6%]).Of the familiarity or acceptance barriers, more than one-third of respondents reported that understanding and correctly applying the guidelines were a barrier (n = 521 [33.2%; 95% CI, 30.9%-35.6%]).Among the parental concerns as b The term guidelines refers to the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States by the National Institute of Allergy and Infectious Diseases expert panel. 10c Implementation of the guidelines and sources of information on the guidelines were reported by pediatricians who were aware of the guidelines.JAMA Network Open | Allergy JAMA Network Open.2020;3(7):e2010511.doi:10.1001/jamanetworkopen.2020.10511(Reprinted) July 15, 2020 6/14 Downloaded From: https://jamanetwork.com/ on 09/17/2023 26.

Table 3 .
Survey Responses to 3 Clinical Scenarios Regarding Peanut Allergy Prevention

Association With Pediatrician and Practice Characteristics eTable
2 in the Supplement presents associations between practice characteristics and selected outcomes (guideline implementation, need for training, and barriers to implementation).Specifically, having more patients with Medicaid and practicing in a rural location were associated with higher rates of not implementing the guidelines, with 24 respondents serving 76% to 100% patients with

Table 4 .
Implementation Barriers and Preferred Practice Aids or Office Materials a The term guidelines refer to the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States by the National Institute of Allergy and Infectious Diseases expert panel. 10JAMA Network Open | Allergy Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the US and urban areas (n = 28 [16.8%;95% CI, 11.4%-23.3%]vs n = 61 [7.0%; 95% CI, 5.4%-9.0%]and n = 57 [10.8%; 95% CI, 8.3%-13.8%];P < .001).