P2.O286: Improving the rates of early peanut introduction in a resident primary care clinic

Purpose/Objectives: The Learning Early About Peanut Allergy (LEAP) trial found that high-risk infants introduced to peanuts between 4-6 months of age were significantly less likely to develop a peanut allergy. This led to the 2017 National Institute of Allergy and Infectious Disease (NIAID) addendum guideline which recommended (1) all infants should be introduced to peanuts along with other solid foods, (2) infants with mild to moderate eczema should be introduced to peanuts by 6 months, and (3) infants with severe eczema and/or egg allergy should be screened for peanut sensitization before introduction. Recent evidence suggests that sustained exposure to peanuts is equally important for developing tolerance. Our project aimed to increase the rate of peanut counseling to 55% for all 4 and 6-month well-child checks. Our secondary goals were to achieve a 50% rate of sustained exposure counseling in this same population and to increase the introduction counseling rate to 80% for patients with eczema

Design/Methods: Patients seen at 4 and 6-month well-child checks were targeted for each intervention. Charts were manually reviewed for each visit. Patient age, spoken language, peanut counseling documentation, eczema history, egg allergy history, examining physician’s level of training, and sensitization screening – if indicated- were recorded for each visit. Baseline data was collected, and we then completed four intervention cycles. First, residents receive an informative lecture on current evidence for peanut introduction. Second, we created a peanut counseling dot phrase in the Electronic Health Record (EHR) to improve documentation. Third, a graphic reminder to counsel on early peanut introduction was placed on clinic computers. Lastly, we modified the EHR dot phrase to incorporate a peanut introduction clinical decision tool. The rate of pneumococcal vaccination was analyzed as a balancing measure.

Results: A total of 1,077 visits were reviewed from July 2023 to April 2024. At baseline, 17% of patients had documented counseling of peanut introduction. After our final intervention, 65% of patients received counseling. The most significant improvement occurred during cycles 2 through 4. Additionally, 82% of patients with eczema received introduction counseling after cycle 4. At completion, sustained introduction counseling was at 38%. Similar results were seen regardless of patient language or physician level of training. Only 5 patients met the criteria for screening before peanut introduction, with 3 being referred for allergy testing. The remaining 2 were seen during cycle 1 of the project. The rate of pneumococcal vaccination remained near 100% for each month analyzed.

Conclusion/Discussion: EHR strategies are effective at increasing the rates of peanut introduction counseling among infants with and without eczema in our clinic. This was shown regardless of patient language or physician level of training. Sustained exposure counseling requires further iterations to reach our goal.