The N E W E N G L A N D J O U R N A L o / M E D I C I N E

Marshall Plaut, M.D.

data suggest that increasing peanut consumption during pregnancy could potentially enhance the risk of peanut allergy, not decrease it. Peter H. Sayre, M.D. Greenhawt and colleagues disagree with our Immune Tolerance Network recommendation that the results of the LEAP San Francisco, CA study be extended to all infants at risk for pea­ Since publication of their article, the authors report no fur­ nut allergy since we do not have the supportive ther potential conflict of interest. medical infrastructure required to perform the 1. Lack G. Update on risk factors for food allergy. J Allergy Clin volume of skin testing and food challenges that Immunol 2012;129:1187-97. 2. Rochon J. Issues in adjusting for covariates arising post­ would result. Indeed, as they indicate, we agree randomization in clinical trials. Drug Info J 1999;33:1219-28. that there is an urgent need to better define 3. Santos AF, Douiri A, Becares N, et al. Basophil activation test which infants are truly at risk. However, in light discriminates between allergy and tolerance in peanut-sensitized children. J Allergy Clin Immunol 2014;134:645-52. of the fact that infants with eczema (and not just 4. Sicherer SH, Wood RA, Stablein D, et al. Maternal consump­ those with severe eczema) are known to be 11 tion of peanut during pregnancy is associated with peanut sen­ sitization in atopic infants. J Allergy Clin Immunol 2010;126: times as likely to have peanut allergy by the age 1191-7. of 12 months than are infants without eczema,2 5. Fox AT, Sasieni P, du Toit G, Syed H, Lack G. Household we simply suggest that as the new guidelines are peanut consumption as a risk factor for the development of pea­ being developed, the working group should con­ nut allergy. J Allergy Clin Immunol 2009;123:417-23. sider all available evidence and determine whether DOI: 10.1056/NEJMcl504021 this evidence is sufficient to apply prevention strategies to lower-risk populations. We believe the editorialists reply: The question of whether this decision should be driven by data and not by to encourage or discourage pregnant women to health care resources. ingest allergenic foods has been debated for Rebecca S. Gruchalla, M.D., Ph.D. years. The weight of the evidence tends to favor University ofTexas Southwestern Medical Center Bernstein’s suggestion — that it may be more Dallas, TX prudent to expose the infant to peanut in utero [email protected] rather than delaying it until after birth in an at­ Hugh A. Sampson, M.D. tempt to decrease the prevalence of peanut allergy Icahn School o f Medicine at Mt. Sinai in developed countries. However, it may not be New York, NY that straightforward. Sicherer et al.1 evaluated Since publication of their article, the authors report no fur­ 503 infants between the ages of 3 and 15 months ther potential conflict of interest. who probably had milk or egg allergy but no pre­ 1. Sicherer SH, Wood RA, Stablein D, et al. Maternal consump­ vious diagnosis of peanut allergy. They found tion of peanut during pregnancy is associated with peanut sen­ that in contrast to decreasing peanut sensitiza­ sitization in atopic infants. J Allergy Clin Immunol 2010;126: 1191-7. tion or allergy, frequent peanut consumption 2. Martin PE, Eckert JK, ICoplin JJ, et al. Which infants with during pregnancy was strongly associated with a eczema are at risk of food allergy? Results from a populationhigh level of peanut sensitization (i.e., peanut- based cohort. Clin Exp Allergy 2015;45:255-64. specific IgE level, >5 kU per liter). Thus, these DOI; 10.1056/NEJMclS04021 National Institute o f Allergy and Infectious Diseases Bethesda, MD

Community-Acquired Pneumonia among U.S. Children In the Etiology of Pneumonia in the Community (EPIC) study, Jain et al. (Feb. 26 issue)1 update the data on the incidence and in­ fectious causes of community-acquired pneumo­ nia in the pediatric population. The authors care­ fully limited the study sample to children with disease that meets the clinical criteria for acute respiratory infection and has been confirmed on

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chest radiography and excluded those with con­ founding conditions, including an “alternative diagnosis of a respiratory disorder.” However, the authors inexplicably included patients with “asthma or reactive airway disease.” It is well known that patients with asthma can have radiographic abnormalities, including abnormalities used to define pneumonia in this study.2-3 It is

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MAY 28, 2015

Copyright © Massachusetts Medical Society 2015.

Peanut consumption in infants at risk for peanut allergy.

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