Peanut allergies have long plagued kids. Inside the scientific U-turn that’s shaken trust in pediatrics
In the late 1990s, scientists and physicians increasingly reported a little-known health threat: peanut allergies. Estimates from the time suggest that only 0.4% of children had a peanut allergy. But the tide, it seemed, was changing — and changing fast.
In 1988, Canadian doctors published what is likely the first case study on the topic, recounting how a 24-year-old woman with a known nut allergy died moments after biting into a piece of cake topped with hazelnut icing. Hundreds more studies followed, documenting not only a rise in peanut allergies but an increasing number of people with allergies so severe that they resulted in death.
Americans took notice. Newspapers published alarming stories: “Peanut Allergies Have Put Sufferers on Constant Alert,” read one 1995 Wall Street Journal headline; “Nut Allergy Girl’s Terror; Girl Almost Dies from Peanut Allergy,” reported the Daily Mirror.
The Centers for Disease Control and Prevention (CDC) estimated that by 1997, 3.4% of children were allergic to at least one food.
In response to these rising allergy rates, the American Academy of Pediatrics (AAP) has published guidelines recommending that parents avoid exposing infants to common food allergens until at least one year of age, and that nursing mothers also avoid consuming those foods. The guidelines’ authors acknowledged a lack of scientific evidence underlying their recommendations, including the push to delay introducing nuts until children were 3 years old. But the guidelines, they wrote, seemed “reasonable.”
For decades, this guidance was “gospel” among pediatricians and parents, according to medical experts who spoke with Straight Arrow News. However, skeptical scientists later disproved these recommendations, prompting the AAP to retract its guidelines in 2008 and reverse them in 2017.
By then, an untold number of parents had withheld peanuts and other allergenic foods from their kids, increasing the risk of food allergies. Outside of its policy reversal, however, the AAP offered little public acknowledgment of how its earlier recommendations may have contributed to the rise in peanut allergies. The debacle went down in the record as another misstep, fueling the public’s waning trust in science.
The toll of food allergies
The National Institute of Allergy and Infectious Diseases (NIAID) estimates that today 8% of children and 11% of adults — some 33 million Americans — have at least one food allergy.
For some, a food allergy is a minor inconvenience; for others, it is a life-threatening condition. Dr. Jennifer Protudjer, an associate professor at the University of Manitoba, has spent years studying the effects of food allergies on individuals and communities. She and her team estimated that individuals with allergies and their families spend up to $1,700 more on allergy-friendly foods per year.
A recent study estimated that food allergies cost $22,234 per patient per year, totaling $370 billion annually, when considering direct medical costs, household out-of-pocket expenses for specialty foods and broader societal costs such as lost work or reduced household productivity.
Another study found that the odds of being food insecure were 39% greater among families whose kids have food allergies, compared to those without them, Protudjer told Straight Arrow News.
People with food allergies and their caregivers even have a poorer quality of life, studies have found, and may suffer from food allergy anxiety.
“We think that burden stems from the persistent threat of exposure to a food to which children might be allergic, but it also stems from the fact that the management of food allergy typically requires avoidance of the food in most or all forms,” Protudjer said.
Guideline reversal
After the AAP released its guidelines, the number of children with a peanut allergy continued to rise; rates more than tripled from 1997 to 2008. In January of that year, the AAP revised its position, noting that current evidence did not support withholding allergenic foods from infants or nursing moms. But the new guidance stopped short of instructing parents to feed their infants these foods.
Later in 2008, British researchers published a study that found the prevalence of peanut allergies among Israeli children — who commonly ate products containing peanuts from a young age — was 0.17% while the rate among U.K. children was 1.85%. The study led by Gideon Lack, a professor at King’s College London, presented landmark evidence debunking the guidance to avoid peanuts and other allergens.
In 2015, Lack led another critical study in which researchers randomly assigned 640 infants to either avoid or consume peanuts for the first five years of life. Researchers selected infants who either had egg allergy, severe eczema or both — conditions that predisposed the babies to develop a peanut allergy.
At the end of the study, 13.7% of the children who avoided peanuts developed a peanut allergy, compared with 1.9% of children who ate peanuts. Researchers concluded that introducing infants to peanuts and other allergenic foods prevented allergies, contradicting the AAP’s earliest guidance.
In 2017, NIAID formally published new guidelines instructing parents to introduce peanut-containing foods around six months of age. For higher-risk infants, such as those with eczema or egg allergy, parents were instructed to introduce foods containing peanuts even earlier, starting at four months.
The number of children who developed food allergies dropped sharply, from 1.46% of children studied before the new guidelines to 0.93% after, a recent study found. That translates to almost 60,000 fewer children developing a food allergy.
The rate of kids developing a peanut allergy, specifically, fell by 46%. The shift was so significant that eggs overtook peanuts as the most common allergen among children. The study contributed to a growing body of evidence suggesting that withholding certain foods from infants may spur, rather than prevent, food allergies.
Lack of accountability and erosion of public trust
Trust in science is waning. Fewer than 60% of Americans believe science has a mostly positive effect on society, and only 73% are confident that scientists act in the public’s best interests, according to a Pew Research Center poll.
Many studies have pointed to the COVID-19 pandemic as a major inflection point. However, the reversal of earlier guidance on peanut allergies has also highlighted how shifting advice and a lack of accountability can erode public trust.
Some have criticized the AAP for releasing guidelines based on “consensus statements and groupthink rather than evidence‐based medicine,” as one medical ethics researcher described it.
“Hindsight is always 20-20, and I agree a lot of times we make guidelines based on very little data. And that’s what happened in 2000,” Dr. Ruchi Gupta, a professor of pediatrics and the director of the Center for Food Allergy & Asthma Research at Northwestern University, told Straight Arrow News.
“I think there was just a lot of fear, because we started getting these headlines in the news of people dying from peanut exposure. And so, you know, I hate to blame anyone, but we really just didn’t know,” she said.
Gupta stressed that the guidelines were developed at a time of uncertainty and had no malicious intent.
“Everybody’s doing their best. I don’t think anyone’s trying to put something out there that, you know, may not be correct or may do harm,” she said. “And that’s our first thing: Do no harm. So, like with the peanut thing, once we saw a rise, I think the instinct of every pediatrician is do no harm, protect our babies, you know. And so that was an easy way to potentially do that.”
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Nine major allergens — milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, soybeans and sesame — account for 90% of food allergies in the U.S., according to the FDA.
Others, including a representative from the AAP who spoke with Straight Arrow News, noted that those original guidelines were more of a sidenote embedded in a report about hypoallergenic infant formulas.
“There wasn’t really a huge focus on peanuts, but there was a comment in the report that, based on some hypothesis-generating types of data from what was available at the time, that for kids with high-risk developing food allergy, that they might benefit from delayed introduction,” Dr. Drew Bird, chair of the AAP’s’ Section on Allergy and Immunology, told Straight Arrow News.
“I don’t know that I necessarily call that a huge endorsement by the AAP to change the way kids are fed. But regardless, that is how it evolved. It seems that that became a bit of the gospel that was communicated to pediatricians or that was interpreted. And over time, it became kind of widespread that parents should delay introduction of allergenic solids, including peanuts, until they were older,” he said.
The authors of the original guidelines do head off their recommendations with the following statement: “Conclusive studies are not yet available to permit definitive recommendations. However, the following recommendations seem reasonable at this time…”
Dr. Anthony Fauci, who served as the director of NIAID from 1984 to 2022, characterized the AAP’s guidelines as a “wrong call.”
“I didn’t make the recommendation,” Fauci told CBS in 2019. “I wouldn’t say it was an error. I think what it was, it was a judgment call, that in the retrospect was the wrong call.”
Gupta pointed out that the AAP still maintains current recommendations around infant feeding that are not supported by scientific evidence. She pointed to guidance that instructs parents to introduce infants to foods one at a time every three to five days.
“Why are we saying that when there’s still no data around that?” she asked. “You’re reducing the diversity in their diet at that really critical age, that early age where their immune systems are developing.”
Gupta and her colleagues are working to change these guidelines.
“I think a lot of our guidelines make no sense, you know, and don’t have any data behind it,” she said.
What do we know now about the causes of food allergies?
Scientists still do not fully understand food allergies or their risk factors. Some studies have linked the higher risks of food allergies to C-section deliveries and increased antibiotic use during early childhood. Other scientists have found that breastfeeding may lower infants’ risk.
Many aspects of modern life likely factor in.
“It’s the sun exposure we are not getting, it’s the foods we are not eating and the foods we are eating, it’s the chemicals we are exposed to, it’s the pollutants in our air, it’s the stress in our lives,” said Waheeda Samady, a physician, professor and the codirector of clinical research at Northwestern University’s Center for Food Allergy and Asthma Research.
“It is all of it combined that is probably causing our bodies to be dysregulated and cause these allergic processes,” she explained.
Unfortunately, while introducing infants to allergenic foods as soon as they are able to eat solids has been shown to reduce overall rates of food allergy, it does not guarantee prevention.
Scientists are starting to gain some clarity around how food allergies develop. One leading theory centers around how infants are first exposed to a potential allergen. Infants who are first exposed through their skin — for instance, a mother eats peanuts before touching her infant and some peanut oil residue transfers onto the baby’s skin — are more likely to develop an allergy than those who are exposed through ingesting peanut butter, Samady said.
When an infant is first introduced to an allergen through their gut, they build tolerance rather than develop an allergy, Samady explained. This may be why feeding infants foods as early as possible is key: It allows exposure through their gut rather than their skin.
How should parents handle allergens?
For the average child, Samady instructs parents to start feeding their infant as soon as they are ready to eat, meaning they can sit up, hold their head up, and show an interest in food. Once an infant is ready to eat, parents should offer them a variety of foods as long as they are safe and do not present a choking hazard.
“If you’re concerned about food allergies, then all the more reason to give them and to give them often. Don’t avoid any food, certainly not peanut butter, egg and milk. There’s now evidence that all three of those foods, if given early, you can avoid food allergies,” she told Straight Arrow News.
Scientists also recommend giving allergenic foods more often.
“You want to avoid what I call the ‘one and done,’ which is like, ‘We gave him peanut butter at 5-and-a-half months. He really liked it. It was good, and then we never gave it again,’” Samady said. “That is not enough to prevent food allergies.”
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Ella Rae Greene, Editor In Chief
