Pediatric Clinician Adherence to Peanut Allergy Prevention Guidelines

A new randomized trial has demonstrated that a targeted, practice-based intervention can significantly improve pediatric clinicians’ adherence to national guidelines aimed at preventing peanut allergy in infants.

The Intervention to Reduce Early Peanut Allergy in Children (iREACH) trial evaluated whether a combination of clinician education, electronic health record (EHR) tools, and visual aids could enhance compliance with the 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States. These guidelines, issued by the National Institute of Allergy and Infectious Diseases, recommend early introduction of peanut-containing foods during infancy as a strategy to reduce the risk of developing peanut allergy.

Despite these national recommendations, previous research has shown that adherence among pediatric clinicians remains low. The iREACH trial was designed to address that gap.

Conducted across 30 pediatric practices, the cluster randomized trial assigned half of the practices to receive the iREACH intervention, while the other half continued standard care without additional supports. The intervention included structured clinician education, a clinical decision support tool integrated into the EHR, and visual prompts designed to encourage timely discussions with parents during well-child visits.

A total of 18,480 infants were seen during the study—9,290 in the intervention group and 9,190 in the control group—by 290 pediatric clinicians. Adherence was measured at 4- and 6-month well-child visits, based on guideline-consistent recommendations documented in EHRs.

For low-risk infants—those without egg allergy and with no or mild-to-moderate eczema—clinicians were considered adherent if they recommended early peanut introduction. Among this group (n = 18,182), adherence was dramatically higher in the intervention arm: 83.7% versus 34.7% in the control group. This difference was statistically significant (odds ratio [OR], 14.6; 95% confidence interval [CI], 7.0–30.5; P < .001).

In the high-risk group—infants with severe eczema and/or egg allergy—adherence was defined as ordering a peanut-specific IgE test, along with appropriate counseling or referral to an allergist. Although overall adherence was lower in this group (n = 298), clinicians in the intervention group still outperformed those in the control arm: 26.8% versus 10.4%, respectively (OR, 3.1; 95% CI, 1.1–8.8; P = .03).

The authors concluded that the multifaceted intervention significantly improved guideline adherence across risk groups. They emphasized the potential for broad dissemination of the approach, noting that increased adherence could help lower the incidence of peanut allergy if implemented at scale.