Feasibility and safety of introducing cashew nut spread in infant diets-A randomized trial

BACKGROUND

To reduce peanut allergy prevalence, infant feeding guidelines now recommend introducing peanuts in an age-appropriate form (such as peanut butter) as part of complementary feeding. However, due to a lack of randomized trial evidence, most infant feeding and food allergy prevention guidelines do not include tree nuts. The aims of this trial were to determine safety and feasibility of dosage consumption recommendations for infant cashew nut spread introduction.

METHODS

This is a parallel, three-arm (1:1:1 allocation), single-blinded (outcome assessors), randomized controlled trial. General population term infants were randomized at 6-8 months of age to either a one teaspoon (Intervention 1 n = 59) or increasing dosage regime of one teaspoon at 6-7 months, two teaspoons at 8-9 months, and three teaspoons from 10 months of age onwards (Intervention 2 n = 67) cashew nut spread, both three times per week, or no specific advice on cashew introduction (Control n = 70). At 1 year of age, food challenge proven IgE-mediated cashew nut allergy was assessed.

RESULTS

Compliance in Intervention 1 (92%) was higher than Intervention 2 (79%), p = .04. Only one infant had delayed (at 5 h) facial swelling and eczema flare to cashew introduction at 6.5 months, but no cashew allergy at 1 year. Only one infant (Control) had cashew allergy at 1 year, and this infant had not been introduced to cashew prior to 12 months of age.

CONCLUSION

Regular infant consumption of one teaspoon of cashew nut spread three times per week from 6 to 8 months of age was found to be feasible and safe.

TreEAT trial: Protocol for a randomized controlled trial investigating the efficacy and safety of early introduction of tree nuts for the prevention of tree nut allergy in infants with peanut allergy

INTRODUCTION

Children with peanut allergy are at increased risk of developing tree nut allergies, which can be severe and for most lifelong. Introduction of peanut in the first year of life can reduce the risk of peanut allergy; however, prevention strategies for tree nut allergies have not been established. We aimed to test the efficacy and safety of a novel strategy, a supervised multi-nut oral food challenge (OFC) compared with standard care for tree nut allergy prevention in infants at high risk of developing tree nut allergy, TreEAT.

METHODS AND ANALYSIS

TreEAT is a 2-armed, open-label, randomized, controlled trial (RCT). Infants (n = 212) aged 4-11 months with peanut allergy will be randomized 1:1 at peanut allergy diagnosis to either a hospital-based multi-tree nut (almond, cashew, hazelnut, and walnut) OFC using multi-nut butter or standard care (home introduction of individual tree nuts). All infants will be assessed at age 18 months, with questionnaires and SPT to peanut and tree nuts. Peanut and tree nut OFCs will be performed as required to determine the allergy status for each nut. The primary outcome is tree nut allergy at age 18 months. Secondary outcomes include peanut allergy resolution, proportion, and severity of adverse events related to tree nut ingestion, number and frequency of tree nuts ingested, quality of life and parental anxiety, and allergy-related healthcare visits from randomization to 18 months of age. Analyses will be performed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

TreEAT was approved by the Royal Children's Hospital Human Research Ethics Committee (#70489). Outcomes will be presented at scientific conferences and disseminated through publication.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID: NCT04801823.