New Guidelines Lead to Decline in Peanut Allergies (Premium)

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For many parents, a child’s peanut allergy is a constant source of vigilance and concern. Everyday situations can feel risky. School lunches, going to a restaurant, kids’ parties, visiting a friend’s home, swapping of snacks—all of these carry an element of danger. Label reading becomes second nature but so much is beyond one’s control.

Caregivers are torn between wanting to foster a sense of inclusion and needing to put safety first. Many keep epinephrine injectors — EpiPens — close by and mentally rehearse what to do in case of a reaction. Part of their mind is always planning: Did we pack the EpiPen? Who knows how to use it? How far are we from an urgent care center or a hospital?

For decades, the incidence of peanut allergy has been rising. Now that it’s clearly declining, it’s important to understand why.

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We share this article by Samantha Anderer of JAMA Medical News. The news release was published online November 7, 2025.

After Ruchi Gupta, MD, MPH, gave birth to her daughter in 2006, the food allergy researcher didn’t introduce peanuts into the infant’s diet early on. The decision aligned with advice from the American Academy of Pediatrics (AAP), which since 2000 had recommended that children avoid peanuts until aged 3 years. Nevertheless, her daughter developed a peanut allergy.

Childhood peanut allergies increased substantially in the US around the turn of the century, from 0.4% in 1997 to 1.4% in 2008. A 2018 study by Gupta and colleagues found that peanut allergy affected more than 2% of children. Although the mechanisms behind such food allergies are complex and not fully understood, the fact that peanut allergy cases rose so quickly during this time suggests an environmental component, Gupta said, noting the potential influence of greater cleanliness—aka the “hygiene hypothesis”—as well as changes in diets and an increase in cesarean deliveries and antibiotic use in infancy, all of which may shape a child’s gut microbiota.

And as peanut allergies became more prevalent and caused anaphylaxis, the idea was that children could sidestep the hazard by avoiding the top allergens, Gupta said.

“In the early 2000s, there was caution about introducing peanut early,” said Stanislaw Gabryszewski, MD, PhD, an attending physician in the Division of Allergy and Immunology at the Children’s Hospital of Philadelphia and a lead author of a new study on recent trends in peanut allergies. “The advice was opposite of what is currently recommended, which was to delay peanut for high-risk infants.”

But many now believe that the guidance to avoid peanuts in the first years of life likely backfired, as introducing them early may protect against peanut allergies.

gainst that backdrop, the push toward early introduction of allergenic foods to children has grown steadily in recent years. Randomized clinical trials have demonstrated that early peanut introduction may actually help prevent allergy.

And now, Gabryszewski’s new research reveals that, in the years following an overturning of the old guidance to avoid peanuts early in life, peanut allergy cases have decreased.

Peanut Allergies on the Decline At Last

The new study, published in Pediatrics, examined changes in peanut allergy incidence following the release of a 2015 consensus statement—authored by organizations including the AAP; the American Academy of Allergy, Asthma & Immunology; and the World Allergy Organization—that recommended early peanut introduction for high-risk infants.

The researchers looked at the incidence of immunoglobulin E–mediated food allergy (IgE-FA)—the most common cause of anaphylaxis—to determine how diagnoses changed from the 2012-2014 preguidelines period to the 2015-2017 postguidelines period. They examined diagnosis codes and epinephrine prescriptions from the Collaborative Electronic Reporting Network, including children aged 0 to 3.9 years across 48 primary care practices in the US.

Nearly 38 600 children were enrolled during the preguidelines period and about 46 700 participated in the postguidelines period, and both groups were observed for at least 1 to 2 years. The researchers found that the cumulative incidence of peanut IgE-FA decreased significantly over the 2 periods, from 0.79% to 0.53%—a 33% relative decline.

In 2017, the organizations released addendum guidelines with suggestions for lower-risk infants. Gabryszewski’s team found that peanut allergies decreased even more, to 0.45%, in a postaddendum group of nearly 39 600 children. And even though both the 2015 and 2017 recommendations were peanut specific, the researchers also found that overall IgE-FA declined after their releases.

“There have been some concerns over recent years that perhaps the implementation of the guidelines of early introduction have not had the same population-level impact that we had expected,” said Derek Chu, MD, PhD, Canadian Institutes of Health Research (CIHR) chair and an assistant professor in allergy and clinical immunology at McMaster University, who was not involved with the new analysis. “This study is a very welcome addition to that body of information, which seems to bolster the sentiment that, yes, rigorous randomized trials can inform clinical practice and can revolutionize and turn on its head old guidance.”

How the Approach Has Changed

In 2008, the AAP revoked the recommendation that parents avoid early peanut introduction until aged 3 years, citing limited clinical evidence. But, erring on the side of caution, the organization didn’t go so far as to recommend early introduction.

After all, about 9500 pediatric hospitalizations related to food allergy occurred annually from 2004 to 2006.

“One of the things that we learn as medical providers in taking the Hippocratic oath is to do no harm,” Gabryszewski said. “We did not have strong evidence at the time to proactively encourage early introduction of peanut, and so the intent was to not do harm.”

Then, in 2015, the landmark Learning Early About Peanut Allergy (LEAP) trial shifted the landscape. LEAP was a randomized clinical trial of 640 high-risk infants aged 4 to 11 months who were randomly assigned to either eat or avoid peanuts until age 5 years. The results were staggering: early and sustained introduction of peanuts was associated with an 86% relative risk reduction. Only about 2% of infants who ate peanuts developed an allergy, compared with 14% of those who didn’t.

Gupta, who coauthored a commentary on the recent study in Pediatrics and is the founder and director of the Center for Food Allergy & Asthma at Northwestern University Feinberg School of Medicine, said evidence points to the importance of when and how food is introduced. She referenced a theory that if a food protein is exposed through the skin before the gut, the body may treat it as an invader and attack. Alternatively, if it passes through the gut during an early stage of life, the body will view it as safe. Possibly for this reason, children are at greater risk of peanut allergy if they have eczema, a condition in which the skin barrier is disrupted.

“There’s a little saying: if it’s through the skin, allergies begin,” she said. “Through the diet, they stay quiet.”

Considering the fresh evidence from the LEAP trial, a cascade of increasingly permissive recommendations followed its publication: the 2015 consensus statement recommended early peanut introduction for high-risk infants, such as those with severe eczema or egg allergy. The 2017 guidance included information for low- and moderate-risk infants as well as advice on whether testing is needed. The most recent iteration, published in 2021, advised the introduction of peanut, egg, and other major food allergens for all infants, “irrespective of their relative risk,” at roughly 6 months of age.

The 2021 guidelines removed screening requirements based on atopic history and acknowledged the difficulties that come with food allergy testing, including accessibility, explained Gupta.

“It’s often difficult to get to an allergist,” she said. “It may take a month to get in, and by that time, they may have missed their window to start introducing peanut products.”

Gabryszewski added that food allergy testing comes with high false-positive rates, which may create further delays.

Are Parents and Clinicians Listening?

The paradigm shift toward early peanut introduction has had real-world benefits, Gabryszewski and his coauthors concluded. Still, their study had its limitations.

For one, the sample wasn’t nationally representative. It was collected from the subset of practices that had continuous data, so it’s not broadly generalizable to other health systems, Gabryszewski said. Additionally, although diagnosis codes serve as a close approximation of disease, he said it’s possible that some diagnoses may have been missed. And beyond that, the study didn’t collect data about actual infant feeding patterns, such as at what age specific foods were introduced and in what amounts or frequencies.

“We don’t know if those families actually went home and introduced peanut products,” Gupta said. She noted that because this wasn’t tracked, it’s not possible to attribute the decline in peanut allergies to early introduction or the change in recommendations.

Whether individuals are following the guidelines is another open question. Survey studies found that only 29% of general pediatricians and 65% of allergists supported full implementation of the 2017 guidelines, and about 17% of caregivers endorsed giving infants peanuts before 7 months of age after the 2021 guidelines were released. Chu compared the relative risk reduction in the recent real-world study, which was around 30% to 40%, with that of LEAP, which was more than 80%.

Still, he said that the findings “reinforce very much the sentiment that we’re in the right direction, that this seems to be an apparent reduction in allergy.”

In addition to peanuts, Chu and Gupta emphasized the importance of early introduction for all sorts of foods, especially top allergens such as milk, eggs, and shellfish.

“We’ve started medicalizing early introduction and how we feed, and we’ve got to get away from that…and get away from a lot of these rules and regulations around what we can introduce and how frequently,” Gupta said. “Babies are resilient, and they’re made to try new foods.”

Peanut Allergies on the Decline At Last

How the Approach Has Changed

Are Parents and Clinicians Listening?

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