WSJ article about the rise in peanut allergies

[SKL]

I found this article interesting.  Not sure if you can all access it.  If you trust my quick read, it basically says that after a focus on peanut allergies in the 1990s (when these existed but were rare and usually mild), UK pediatrician groups started recommending that kids under 3 not be given peanuts, and the US pediatrician groups followed suit.  Fast forward and the US and UK have extremely high rates of peanut allergies compared to countries where no similar precautions were taken.  The article ends with what I read as a warning against all-or-nothing health advice when we actually aren't sure what's best.

This policy has various results, from removing an affordable, palatable, and pro-environment source of protein from many diets to creating a need for expensive pharmaceuticals.  The beneficiaries of these policies are not the children, and especially not poor children.

I think some of these concerns extend beyond peanuts.

What do y'all think?

https://www.wsj.com/health/how-pediatricians-created-the-peanut-allergy-epidemic-952831c4?mod=hp_trending_now_article_pos3

Edited September 20 by SKL

[marbel]

Is this it? This is supposedly an unlocked gifted article.  I say "supposedly" as I am a subscriber and have access to it, and I'm too lazy to log out and check it. 

https://www.wsj.com/health/how-pediatricians-created-the-peanut-allergy-epidemic-952831c4?st=mbU9dU&reflink=desktopwebshare_permalink

Edited September 20 by marbel

[SKL]

1 minute ago, marbel said:

Is this it? This is supposedly an unlocked gifted article.  

https://www.wsj.com/health/how-pediatricians-created-the-peanut-allergy-epidemic-952831c4?st=mbU9dU&reflink=desktopwebshare_permalink

Yes, thanks.

[TheReader]

I know that a friend of mine, with much younger children than mine, said that between her 1st and 2nd kiddo (2nd kiddo is turning 5 or 6), her pediatrician said "you know, actually, we think it's better you go ahead and feed peanut butter early, because it seems like the removal of it has maybe contributed to the rise in peanut allergies...." 

So, the info is definitely out there & getting out there. 

[YaelAldrich]

It's interesting because in Israel they introduce Bamba, a peanut butter based puff laced with vitamins and minerals, to even very small children and infants as a first food. Peanut allergies are extremely rare in Israel. But sesame allergies are pretty high. But I don't think any medical people said to not feed children sesame early in life in Israel. My daughter has a peanut allergy that was desensitized by oral immunotherapy when she was 7 years old. Homeschooling helped because I needed a full day to take her to her appointment an almost 5-hour drive away. She was unresponsive to peanuts with rare exceptions until about 4 months ago. She had a pretty good reaction to eating peanuts and then taking a fast walk in the heat in the summertime. Admittedly, she had been slacking off on eating peanuts, which is required by the desensitization process. She is supposed to eat peanuts at least three or four times a week. She doesn't like them so it's harder for her to eat them. The allergic reaction scared her into restarting to eat peanuts more frequently. She just moved out of the house and is in Israel on a gap year program and she's got to figure out when she's got at least 2 hours of down time because you're not allowed to get hot, sweaty or raise your pulse very high when you've eaten your allergen.

[scholastica]

Well, in our case, that would have likely resulted in death for our oldest child. Born late 90s, allergic at birth to peanuts, dairy and eggs. Anaphylactic for nuts. Pediatrician actually referred for allergy testing when he was 9 months because of all the foods I had to avoid while breastfeeding. She rarely referred a child under 5. Confirmation at that time. With vigilance on our part, he outgrew the dairy and egg allergies. He will never outgrow the nuts. He is now 26 and just had his first ever airborne  reaction. Every situation is different.

[KSera]

18 minutes ago, YaelAldrich said:

It's interesting because in Israel they introduce Bamba, a peanut butter based puff laced with vitamins and minerals, to even very small children and infants as a first food.

This idea was introduced to me by a lactation consultant about 13 years ago. When I had my first kids, they had thought avoiding peanuts would be the best way, but I guess then they discovered there was actually no way to do so, so early exposure was better. That was well-known and advised by eight years ago and my youngest had peanut puff type products as an early food (meaning after six months, but before 12). 
 

i’m not sure what you’re (eta: sorry, meaning OP, @SKL) getting at with the other part of your question. I feel like you have something specific in mind. 

Edited September 20 by KSera

[prairiewindmomma]

Our peanut allergy kid developed the allergy at 15 months, while still b-feeding from a peanut eating mom, and having had a few exposures to peanut butter at this point.

It is true that for some early low exposures make it less likely to develop reactions, and that our allergist does recommend now early exposure to peanut butter…..but also, our kids who had no exposure to peanut butter for years (peanut free house because of cross contamination risk) have not developed a peanut allergy now that they are exposed. 

Immune systems are weird and complex.

[KSera]

1 hour ago, KSera said:

i’m not sure what you’re (eta: sorry, meaning OP, @SKL) getting at with the other part of your question. I feel like you have something specific in mind. 

A different thread I just read here actually raised some examples that sounded like maybe the kind of thing you’re talking about? @Harriet Vane posted a link to this article about three medical practices that our thinking is changing on https://www.nytimes.com/2024/09/14/health/medical-practices-treatments-patients.html?unlocked_article_code=1.ME4.O2uR.bu9yi6ICogSZ&smid=nytcore-ios-share&referringSource=articleShare&sgrp=c-cb&ngrp=mnp (I thought I would be paywalled when I read it but perhaps she shared a gift gift link, so hopefully you can read it as well). In any case, I do think this happens pretty frequently in medicine where as they study more and learn more about some thing, they find certain treatments are not supported and maybe/hopefully they might discover better ones that are. It’s not uncommon to find out things they are doing in medicine aren’t just not helpful, but are actually harmful. This is more likely to happen with things that are not evidence based but just based on some notion of “common sense” someone had that turns out to not be valid. Childbirth practices are rife with this. Think episiotomy, shaving, enemas. Fortunately as things have become more evidence based, those things have increasingly been abandoned.
 

Edited September 20 by KSera
Typos

[Carrie12345]

I’m not going to pretend to think there’s one answer for every instance, but I’ll share anecdotes.

My firstborn (1998) had a reaction (hives) to PB when he hit whatever the age was that we were told he could try it. Because we didn’t miss peanut butter at all, we actually FORGOT until #2 was a toddler and I handed them both pb&j sandwiches. That’s how much of a mush my brain was after having 2 and 3 back to back!

Anyway, he was fine and went on to eat peanut stuff to this day.

The two kids we know with the most severe anaphylactic allergies have both gone through exposure tests and passed as teens. (They still carry epis and we avoid peanuts around them, but the fear of accidental exposure is reduced.)

My #5 outgrew his MSPI, but not taking the proper precautions could have killed him as an infant. He was genuinely FTT when finally dx’ed.

I’m happy to go with the best science at the given time.

[wintermom]

I don't have the study to link, but I have heard some reports of early childhood exposure to farm animals being helpful to reduce allergies. This would be very interesting to explore, as perhaps you don't have to focus on just one or two very specific potential allergens. Rather, exposure to lots of different 'stuff on the farm' could have multiple positive affects. But how many city folks can get regular access to farm animals - and even then, what farm owners would allow strangers with little children access to their animals without risking law suits? Maybe research into what it is about being in contact with farm animals that may reduce allergies would be more useful. I'm all about somehow introducing more farm animals to a wider audience, though! Bring on the baby lambs! 😉 

 

[KSera]

4 minutes ago, wintermom said:

I don't have the study to link, but I have heard some reports of early childhood exposure to farm animals being helpful to reduce allergies. This would be very interesting to explore, as perhaps you don't have to focus on just one or two very specific potential allergens. Rather, exposure to lots of different 'stuff on the farm' could have multiple positive affects. But how many city folks can get regular access to farm animals - and even then, what farm owners would allow strangers with little children access to their animals without risking law suits? Maybe research into what it is about being in contact with farm animals that may reduce allergies would be more useful. I'm all about somehow introducing more farm animals to a wider audience, though! Bring on the baby lambs! 😉 

 

Just owning pets provides some of the same benefits. In general, not striving for a sterile (bacteria-wise) home environment. Playing outside in the dirt, etc.

[ikslo]

1 hour ago, scholastica said:

Well, in our case, that would have likely resulted in death for our oldest child. Born late 90s, allergic at birth to peanuts, dairy and eggs. Anaphylactic for nuts. Pediatrician actually referred for allergy testing when he was 9 months because of all the foods I had to avoid while breastfeeding. She rarely referred a child under 5. Confirmation at that time. With vigilance on our part, he outgrew the dairy and egg allergies. He will never outgrow the nuts. He is now 26 and just had his first ever airborne  reaction. Every situation is different.

Same. My DS had multiple allergies since birth. Would not have made a difference in our case.

[prairiewindmomma]

Farm life isnt a panacea either. I had to move off of the farm to breathe. I tested allergic to over 40 things despite growing up on a working farm, eating mostly organically from stuff we grew, and otherwise doing all of the “right” things. 
 

It’s kind of like our ped allergist who said, “Oh, with the severity of dd’s allergies, at least won’t ever get cancer. Her immune system is so robust!. “ (bad narrator voice: In fact, he was wrong. 3 months after this appointment, dd was diagnosed with terminal cancer)

Correlation and causation are two very different beasts. 

[Faith-manor]

The immune system is pretty complex and bizarre. While I can maybe see the value of introduction to PB early, it definitely is not a panacea. I have no evidence for this, but I suspect one factor is just how much we have in our environments now that children's immune systems must react to, ie. pollution and chemical sensitivity. Possibly we being in an immune state of constant hyperactivity could contribute. Of course, maybe not. I would like to see some research into this. Genetic factors too. So much is just simply coded into our DNA, and the mutations lurking in our bodies. 

[wintermom]

14 minutes ago, prairiewindmomma said:

Farm life isnt a panacea either. I had to move off of the farm to breathe. I tested allergic to over 40 things despite growing up on a working farm, eating mostly organically from stuff we grew, and otherwise doing all of the “right” things. 
 

It’s kind of like our ped allergist who said, “Oh, with the severity of dd’s allergies, at least won’t ever get cancer. Her immune system is so robust!. “ (bad narrator voice: In fact, he was wrong. 3 months after this appointment, dd was diagnosed with terminal cancer)

Correlation and causation are two very different beasts. 

So sorry about your dd. 😌

I hear ya with growing up with animals not necessarily being a deterant. I grew up with cats and dogs, and I'm allergic to cats and dogs. It's minor, though, and I still have cats and dogs. I grew up with trees, and am also allergic to a ton of trees. 

[historically accurate]

2 hours ago, KSera said:

A different thread I just read here actually raised some examples that sounded like maybe the kind of thing you’re talking about? @Harriet Vane posted a link to this article about three medical practices that our thinking is changing on https://www.nytimes.com/2024/09/14/health/medical-practices-treatments-patients.html?unlocked_article_code=1.ME4.O2uR.bu9yi6ICogSZ&smid=nytcore-ios-share&referringSource=articleShare&sgrp=c-cb&ngrp=mnp (I thought I would be paywalled when I read it but perhaps she shared a gift gift link, so hopefully you can read it as well). In any case, I do think this happens pretty frequently in medicine where as they study more and learn more about some thing, they find certain treatments are not supported and maybe/hopefully they might discover better ones that are. It’s not uncommon to find out things they are doing in medicine aren’t just not helpful, but are actually harmful. This is more likely to happen with things that are not evidence based but just based on some notion of “common sense” someone had that turns out to not be valid. Childbirth practices are rife with this. Think episiotomy, shaving, enemas. Fortunately as things have become more evidence based, those things have increasingly been abandoned.
 

We had to make our 19 yo dd wear her shoes on the wrong feet for years to correct in-toeing while walking. Very annoying as everywhere we went, people commented about her shoes. She still in-toes a little, and a recent doctor asked her about it. He chuckled when I said she wore her shoes wrong for years to correct it, and said, "We don't do that anymore; it can cause some serious foot problems." Fortunately, she doesn't have any foot problems due to it. 

[knitgrl]

I read an article online probably 12 years ago, so I will never be able to find it again. But the jist of it was that the American Pediatric Association came up with all those recommendations about allergens and infants, based on.....nothing. It just seemed like a good thing to do. And they thought it would probably help. But there were no studies that they used to come to these conclusions. Which is just wild, to say the least.

ETA - Maybe it was the American Academy of Pediatrics? Like I said, it was a long time ago.

Edited September 20 by knitgrl

[kbutton]

1 hour ago, prairiewindmomma said:

Farm life isnt a panacea either. I had to move off of the farm to breathe. I tested allergic to over 40 things despite growing up on a working farm, eating mostly organically from stuff we grew, and otherwise doing all of the “right” things. 

Side comment…We had pets, and I was regularly exposed to farm animals. I developed “allergies” to just about everything but food as an adult and got shots, which helped. Then I started having food sensitivities and got diagnosed with MCAS. My MCAS allergist is a different doctor (my first one retired), and he said that testing positive for a ton of allergies at one time (especially as an adult) is a red flag for MCAS or another global problem.

And weirdly, my SIL who has some MCAS symptoms too, would test as allergic to “everything” even when she knew something wasn’t a problem! Her doctor switched to testing her for one thing at a time, and she didn’t react to nearly as many allergens.

I think we’re just scratching the surface (pun intended) on some of this stuff.

[Alice]

As a pediatrician I have some thoughts...

-There are tons of instances in medicine where we give advice based on the best knowledge at the time and then turn out to be wrong. The author is right that often the medical world gets entrenched in beliefs and doesn't want to change long held dogma. 

-I do think that there are a few misleading things in the article and a similar one from the NYT I was sent (I think he just wrote a book so is promoting it everywhere). Peanut allergies started to rise in the 90's. He makes it sound like they were rare, and they were rare but it was still an exponential rise. All kinds of alleriges/asthma rose. Here is a great article : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617537/ with some cool graphs showing the rise of allergies/asthma. We still don't really know why. This is important to underline....we really do not know why the increase and it is probably multifactorial and not one simple reason.  There are lots of hypotheses but to say "pediatricians caused the peanut allergy epidemic" is a bit of a click-bait headline. Did we contribute to it? Yes. But the advice to avoid peanuts came after the rise in allergies (which was not just a media fueled hysteria as he seems to imply). There wasn't evidence for why but it there was some early evidence that babies who delayed allergy exposure did not have as many allergies. I don't have the time to go back and find those articles but it was anecdotal and in retrospect incorrect, but it was the best thought at the time. 

-The advice to avoid early allergen exposure came out in 2000. In 2007-2008 there were reports that the delayed introduction seemed to be making things worse. At that time (2008)  the AAP came out with a statement saying that there was no evidence to support delaying introduction and that introducing allergens early might be beneficial. But there wasn't strong evidence for early introduction...this article makes it sound like Dr. Lack's article was conclusive. It was suggestive that early introduction was helpful based on a population based study in Israel. And it itself concluded by saying that. Most pediatricians I know (including my own practice) at that time started telling people exactly that "we don't really know but it seems to be that delaying is not helpful" and our recommendation was that when solids were introduced allergens could be given. 

-There was a very large study done (the LEAP study) that came out in 2015 that showed that there was strong evidence that early introduction was protective. The AAP followed up with recommendations reflecting that study and since that time the recommendation has been to introduce allergens, in particular peanuts early (between 4-6 months). 

-There is a difference between what an individual doctor recommends and what the AAP recommends. The AAP by design is a very large organization and it is going to make recommendations that are based on scientific evidence (the best available) and be slow to adopt new statements/policies. It also is more of a public-healthy/community based organization so it is going to make recommendations that might be the best for most people most of the time but not necessarily the best for a specific patient. An individual pediatrician can read the latest evidence and make changes more quickly and can tailor their advice to a specific patient. The best current example I have of this is the stupid sleep guidelines that the AAP puts out that are horrible. They might be based on the best population evidence to prevent SIDS but when I see individual patients who are struggling or who have individual needs...my advice often goes against the guidelines. But that's because I can have a conversation with an individual parent and explain the nuance. Big organizations putting out policy statements aren't really about nuance. 

[YaelAldrich]

4 hours ago, KSera said:

Just owning pets provides some of the same benefits. In general, not striving for a sterile (bacteria-wise) home environment. Playing outside in the dirt, etc.

My house ain't never been clean, much less sterile! 😉

My peanut allergic DD touched a OB covered knife when she was less than 6 months old and got hives all over her neck and torso. 

We are a ton of PB back in those days. The day we got the go ahead to bring PB back in the house during oral immunotherapy was a joyous day I tell you. 

[scholastica]

1 hour ago, Alice said:

As a pediatrician I have some thoughts...

-There are tons of instances in medicine where we give advice based on the best knowledge at the time and then turn out to be wrong. The author is right that often the medical world gets entrenched in beliefs and doesn't want to change long held dogma. 

-I do think that there are a few misleading things in the article and a similar one from the NYT I was sent (I think he just wrote a book so is promoting it everywhere). Peanut allergies started to rise in the 90's. He makes it sound like they were rare, and they were rare but it was still an exponential rise. All kinds of alleriges/asthma rose. Here is a great article : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617537/ with some cool graphs showing the rise of allergies/asthma. We still don't really know why. This is important to underline....we really do not know why the increase and it is probably multifactorial and not one simple reason.  There are lots of hypotheses but to say "pediatricians caused the peanut allergy epidemic" is a bit of a click-bait headline. Did we contribute to it? Yes. But the advice to avoid peanuts came after the rise in allergies (which was not just a media fueled hysteria as he seems to imply). There wasn't evidence for why but it there was some early evidence that babies who delayed allergy exposure did not have as many allergies. I don't have the time to go back and find those articles but it was anecdotal and in retrospect incorrect, but it was the best thought at the time. 

-The advice to avoid early allergen exposure came out in 2000. In 2007-2008 there were reports that the delayed introduction seemed to be making things worse. At that time (2008)  the AAP came out with a statement saying that there was no evidence to support delaying introduction and that introducing allergens early might be beneficial. But there wasn't strong evidence for early introduction...this article makes it sound like Dr. Lack's article was conclusive. It was suggestive that early introduction was helpful based on a population based study in Israel. And it itself concluded by saying that. Most pediatricians I know (including my own practice) at that time started telling people exactly that "we don't really know but it seems to be that delaying is not helpful" and our recommendation was that when solids were introduced allergens could be given. 

-There was a very large study done (the LEAP study) that came out in 2015 that showed that there was strong evidence that early introduction was protective. The AAP followed up with recommendations reflecting that study and since that time the recommendation has been to introduce allergens, in particular peanuts early (between 4-6 months). 

-There is a difference between what an individual doctor recommends and what the AAP recommends. The AAP by design is a very large organization and it is going to make recommendations that are based on scientific evidence (the best available) and be slow to adopt new statements/policies. It also is more of a public-healthy/community based organization so it is going to make recommendations that might be the best for most people most of the time but not necessarily the best for a specific patient. An individual pediatrician can read the latest evidence and make changes more quickly and can tailor their advice to a specific patient. The best current example I have of this is the stupid sleep guidelines that the AAP puts out that are horrible. They might be based on the best population evidence to prevent SIDS but when I see individual patients who are struggling or who have individual needs...my advice often goes against the guidelines. But that's because I can have a conversation with an individual parent and explain the nuance. Big organizations putting out policy statements aren't really about nuance. 

 

Thank you for your thoughts. This is helpful.

Do you as a pediatrician educate families on what an anaphylactic reaction would look like? I had no education about food allergies and anaphylaxis until my son was diagnosed. I don’t know that I would have known what was going on if he’d had one as a toddler. I hope this has changed and when doctors talk about introducing foods, they also educate about food allergies and what to watch for. 
 

 

[wathe]

2 hours ago, Alice said:

As a pediatrician I have some thoughts...

-There are tons of instances in medicine where we give advice based on the best knowledge at the time and then turn out to be wrong. The author is right that often the medical world gets entrenched in beliefs and doesn't want to change long held dogma. 

-I do think that there are a few misleading things in the article and a similar one from the NYT I was sent (I think he just wrote a book so is promoting it everywhere). Peanut allergies started to rise in the 90's. He makes it sound like they were rare, and they were rare but it was still an exponential rise. All kinds of alleriges/asthma rose. Here is a great article : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617537/ with some cool graphs showing the rise of allergies/asthma. We still don't really know why. This is important to underline....we really do not know why the increase and it is probably multifactorial and not one simple reason.  There are lots of hypotheses but to say "pediatricians caused the peanut allergy epidemic" is a bit of a click-bait headline. Did we contribute to it? Yes. But the advice to avoid peanuts came after the rise in allergies (which was not just a media fueled hysteria as he seems to imply). There wasn't evidence for why but it there was some early evidence that babies who delayed allergy exposure did not have as many allergies. I don't have the time to go back and find those articles but it was anecdotal and in retrospect incorrect, but it was the best thought at the time. 

-The advice to avoid early allergen exposure came out in 2000. In 2007-2008 there were reports that the delayed introduction seemed to be making things worse. At that time (2008)  the AAP came out with a statement saying that there was no evidence to support delaying introduction and that introducing allergens early might be beneficial. But there wasn't strong evidence for early introduction...this article makes it sound like Dr. Lack's article was conclusive. It was suggestive that early introduction was helpful based on a population based study in Israel. And it itself concluded by saying that. Most pediatricians I know (including my own practice) at that time started telling people exactly that "we don't really know but it seems to be that delaying is not helpful" and our recommendation was that when solids were introduced allergens could be given. 

-There was a very large study done (the LEAP study) that came out in 2015 that showed that there was strong evidence that early introduction was protective. The AAP followed up with recommendations reflecting that study and since that time the recommendation has been to introduce allergens, in particular peanuts early (between 4-6 months). 

-There is a difference between what an individual doctor recommends and what the AAP recommends. The AAP by design is a very large organization and it is going to make recommendations that are based on scientific evidence (the best available) and be slow to adopt new statements/policies. It also is more of a public-healthy/community based organization so it is going to make recommendations that might be the best for most people most of the time but not necessarily the best for a specific patient. An individual pediatrician can read the latest evidence and make changes more quickly and can tailor their advice to a specific patient. The best current example I have of this is the stupid sleep guidelines that the AAP puts out that are horrible. They might be based on the best population evidence to prevent SIDS but when I see individual patients who are struggling or who have individual needs...my advice often goes against the guidelines. But that's because I can have a conversation with an individual parent and explain the nuance. Big organizations putting out policy statements aren't really about nuance. 

That is how I remember it, also.

(And I clearly remember a shift locally  in 2009, reversing previous advice on allergen avoidance in infants.   That was the year that our allergist advised "early and often" allergen exposure for peanut, and cited this 2008 paper to support his advice.)

[prairiewindmomma]

I remember that timeline also.  I was advised to start taking my other children out of the house and feeding them peanut stuff in 2009. I was to feed them,  wash their hands thoroughly, check their clothes and make them drink a lot of water to wash away stuff in our mouth before coming home to our highly anaphylactic peanut allergy daughter.  I was to try to regularly eat peanuts as well so that the proteins would pass through my milk to my infant.

 

[Clarita]

What I was told when I had children is that at one point pediatricians/medical community were telling parents to delay nut introduction because some children had severe allergies to nuts and severe reactions to them. The delay was to try and avoid severe reactions during babydom. After having made that suggestion they discovered more kids became allergic to nuts. So now the recommendation is introduce early but be vigilant for reactions when you introduce, and this really goes for all foods (hence the one food introduction at a time). Some people are going to have severe allergy to certain things no matter what. 

I don't think they did us some sort of evil disservice or is there a lesson to really be learned for the future (aside from the obvious introduce nuts early but be vigilant lesson). Sometimes you just have to learn from your mistakes because the outcome is unforeseeable.  

[Spryte]

17 hours ago, prairiewindmomma said:

I remember that timeline also.  I was advised to start taking my other children out of the house and feeding them peanut stuff in 2009. I was to feed them,  wash their hands thoroughly, check their clothes and make them drink a lot of water to wash away stuff in our mouth before coming home to our highly anaphylactic peanut allergy daughter.  I was to try to regularly eat peanuts as well so that the proteins would pass through my milk to my infant.

 

This is what we were advised as well, same time line.

DS arrived on this planet with multiple severe allergies, way past peanut, and we knew within 14 days so this whole debate doesn’t apply to our allergy experience. His first exposures to lots of foods caused traumatic moments. But when the next kid arrived — around the time mentioned above — we followed the same advice, giving peanut out of the house, carefully.

(Of course, DD developed anaphylaxis to dairy very suddenly at 7 yrs old, after eating dairy every day of her life, so really — I can’t claim to understand allergies at all. She was our easy, non-allergic kid and it came out of the blue.)

I did once have a hairstylist tell me it’s all because I keep our house too clean. To my credit, I did not laugh hysterically, but yeh, between two dogs, a cat, and turtles, and me not being the best housekeeper — I can definitely say it wasn’t my perfect housekeeping that caused our kids’ allergies. We were regular visitors at a farm, but also did not have our newborn infant exposed to farm-whatever before two weeks old. In our case, DS’s allergies are probably genetic, but we don’t know his complete history.

 

[scholastica]

1 hour ago, Spryte said:

This is what we were advised as well, same time line.

DS arrived on this planet with multiple severe allergies, way past peanut, and we knew within 14 days so this whole debate doesn’t apply to our allergy experience. His first exposures to lots of foods caused traumatic moments. But when the next kid arrived — around the time mentioned above — we followed the same advice, giving peanut out of the house, carefully.

(Of course, DD developed anaphylaxis to dairy very suddenly at 7 yrs old, after eating dairy every day of her life, so really — I can’t claim to understand allergies at all. She was our easy, non-allergic kid and it came out of the blue.)

I did once have a hairstylist tell me it’s all because I keep our house too clean. To my credit, I did not laugh hysterically, but yeh, between two dogs, a cat, and turtles, and me not being the best housekeeper — I can definitely say it wasn’t my perfect housekeeping that caused our kids’ allergies. We were regular visitors at a farm, but also did not have our newborn infant exposed to farm-whatever before two weeks old. In our case, DS’s allergies are probably genetic, but we don’t know his complete history.

 

Our youngest hit seven and developed nut allergies, as well. Also out of the blue after consuming them without incident her whole life. 

[Brittany1116]

My dad was in his 20s when he developed a shellfish allergy seemingly overnight. ER trip for the same meal he ate weekly. Allergies are weird. 

 

I also seem to remember something about disparity in PB allergies among income levels. Kids who would qualify for WIC were less likely to be allergic because they were more likely to have early/repeat exposure? Can't recall when or where I read this. 

[Terabith]

Peanut butter has always been one of my "safe foods," and I had nightmares about having a kid with an allergy to peanuts.  My kids were born in 2003 and 2005, and frankly, I did NOT delay peanut introduction, even though it was recommended at the time, because I just couldn't find it in myself to keep peanut butter out of the house.  I mean, if I had had a kid with a peanut allergy, we'd have done it, but man, that would have been rough.  

However, we also ate a ton of salmon, and my oldest had some scary reactions (although at first we thought it was mango and not salmon) that involved more than two body systems, and nobody had educated us on anaphylaxis enough to know that that was what it was.  I dumped the kid in the bathtub to wash off anything that might be on their body and gave them a bunch of milk (because I knew they'd drink it) and gave them benadryl.  Eventually, I figured out that it was the salmon and not the mango and we stopped eating salmon at home (sigh - this is sad and because my youngest was never introduced to seafood, they hate it and the smell of it so even tho oldest is at college, we don't really get to eat it), but I still fed them tuna on the regular even tho oldest hated it.  It wasn't till I took them to an allergist for random rashes after playing outside, thinking it was a grass allergy, but allergist said it was a viral induced rash after a cold but while we were there said, "Oh?  They're allergic to salmon?  Let's do a skin prick test" that we found out that they were allergic to all fish, but salmon and perch were at anaphylaxis levels.  That was also the first time I learned what anaphylaxis really was.  I had thought it involved throat closing but didn't realize hives plus upset stomach could indicate it. 

But no, pediatricians didn't cause the rise in allergies.  They were going with what their best advice was based on the evidence at the time.  

[Happy2BaMom]

Well, I can't access the article, but the title deliberately feeds the 'lets-blame/not trust-physicians' mindset that is being deliberately cultivated in certain circles.

[SKL]

I guess the title could have been better.  I don't think the blame is on individual pediatricians, but on whoever provided a guideline without any scientific basis.

It seems to me that the better choice would have been to do a limited study with a control group and see if it supported a recommendation.  Instead, they essentially used a whole generation of US and UK babies to test their hypothesis, which turned out to be wrong - with big consequences.

I'm not a doctor, but if I were a pediatrician, I think I would assume that AAP guidelines were backed by more than just someone's thought that XYZ might help.

So how many other medical guidelines are like this?  Has this been fixed?  Should there be accountability?

 

[regentrude]

5 minutes ago, SKL said:

So how many other medical guidelines are like this?  Has this been fixed?  Should there be accountability?

Probably a huge number of medical guidelines are nothing more than best guesses. We know very little about how the human body works, and many studies merely indicate correlations, not causality (albeit there is a striking degree of conflating these two very different things). 

Medical advice, given to the best of that time's understanding, has constantly been changed based on new findings and understanding. 

How do you envision "accountability"? Who do you want to blame for not having perfect answers? Science is a method, not an infallible truth. Upon new evidence, ideas and approaches are corrected. In the absence of proven facts, medicine does the best it can with incomplete information and understanding. Who do you want to hold accountable for what?

[scholastica]

1 hour ago, SKL said:

I guess the title could have been better.  I don't think the blame is on individual pediatricians, but on whoever provided a guideline without any scientific basis.

It seems to me that the better choice would have been to do a limited study with a control group and see if it supported a recommendation.  Instead, they essentially used a whole generation of US and UK babies to test their hypothesis, which turned out to be wrong - with big consequences.

I'm not a doctor, but if I were a pediatrician, I think I would assume that AAP guidelines were backed by more than just someone's thought that XYZ might help.

So how many other medical guidelines are like this?  Has this been fixed?  Should there be accountability?

 

Peanut allergies and really all food allergies were already on the rise and accelerating when they made the recommendation. Who knows if they changed it right around the time that there was a natural plateau in growth? It could be a coincidence. The science hasn’t really been done as you say. 

[SKL]

1 hour ago, regentrude said:

Probably a huge number of medical guidelines are nothing more than best guesses. We know very little about how the human body works, and many studies merely indicate correlations, not causality (albeit there is a striking degree of conflating these two very different things). 

Medical advice, given to the best of that time's understanding, has constantly been changed based on new findings and understanding. 

How do you envision "accountability"? Who do you want to blame for not having perfect answers? Science is a method, not an infallible truth. Upon new evidence, ideas and approaches are corrected. In the absence of proven facts, medicine does the best it can with incomplete information and understanding. Who do you want to hold accountable for what?

There should be some standards for the AAP (or other guiding entity) making recommendations that affect lives.

In this case, it seems they had no evidence at all that this was a good idea.  In fact, the link between earlier exposure and lower allergy incidence (of allergens in general) was proposed before 1990.  Nobody thinks it's an issue that it took more than 10 years to revisit the peanut recommendation?

Why isn't there a requirement that some actual research be done before making a nationwide health recommendation?

And also, knowing that this hasn't been done in the past, pediatricians should demand to know the scientific basis, research results, etc. behind each such recommendation.  Maybe the AAP (and similar organizations) shouldn't even be allowed to make a recommendation without citing real scientific research.

I also notice that we require different levels of scientific evidence, depending on which way the wind is blowing.

[SKL]

3 minutes ago, scholastica said:

Peanut allergies and really all food allergies were already on the rise and accelerating when they made the recommendation. Who knows if they changed it right around the time that there was a natural plateau in growth? It could be a coincidence. The science hasn’t really been done as you say. 

I've read that the incidence of peanut allergies has decreased since the stopped recommending that babies/tots not be allowed to eat peanuts.  So I don't think it was purely a coincidence. 

[Clarita]

12 minutes ago, SKL said:

Why isn't there a requirement that some actual research be done before making a nationwide health recommendation?

The thing is even in this case there is something to back up their recommendation. Babies and toddlers can have anaphylaxis reaction to nuts. They wanted to prevent babies and toddlers from not breathing. Even if there's some evidence that early exposure could reduce the amount of children with nut allergies they would not know the extent and whether the suggestion to save some babies and toddlers from having a severe reaction is worth the increase in nut allergies. All of that depends on how much of an increase in nut allergy we really see, which may be hard to determine unless the sample size is big enough.

In the meantime of them getting that study of allergens done, journalist will also be up in arms about why babies are going to the hospital for nut related allergies and why isn't the medical community doing anything about this. Heaven forbid the outcome of the study show there isn't a significant increase in nut allergy because if that's were the case you can imagine how we'd all feel about that especially if in that time some babies were harmed. 

[wathe]

1 hour ago, regentrude said:

Probably a huge number of medical guidelines are nothing more than best guesses. We know very little about how the human body works, and many studies merely indicate correlations, not causality (albeit there is a striking degree of conflating these two very different things). 

Medical advice, given to the best of that time's understanding, has constantly been changed based on new findings and understanding. 

How do you envision "accountability"? Who do you want to blame for not having perfect answers? Science is a method, not an infallible truth. Upon new evidence, ideas and approaches are corrected. In the absence of proven facts, medicine does the best it can with incomplete information and understanding. Who do you want to hold accountable for what?

Thank you

Medicine is definitely both art and science.  Much of medical practice is guided by tradition and consensus.  It is a very human endeavour.  Evidence-based medicine is a relatively new concept.  Medical understanding is constantly evolving.  

We know a lot about how the human body works, but there is an awful lot that we don't know.

[SKL]

9 minutes ago, Clarita said:

In the meantime of them getting that study of allergens done, journalist will also be up in arms about why babies are going to the hospital for nut related allergies and why isn't the medical community doing anything about this. Heaven forbid the outcome of the study show there isn't a significant increase in nut allergy because if that's were the case you can imagine how we'd all feel about that especially if in that time some babies were harmed. 

They could make an announcement that they are doing the study and how parents can watch for reactions and make a decision based on what they observe.

I would note that the article indicated that while there were peanut allergies before the AAP recommendation, they were not only much more rare, but also usually milder.  There doesn't seem to be evidence that in the absence of an essential ban on peanut butter before age 3, there would be many cases of infant death.

Back in 1973, my new teacher visited all of her students' houses to meet the parents.  She came into our house and, for whatever reason, mentioned that she was allergic to dust and grass.  (My mom was like, hmm, you might not want to stay here long.  😛)  The fact that some people are born allergic to dust and grass did not justify a ban on dust or grass.  I don't think anyone whose kid is allergic to these allergens is up in arms and suing the government for not banning them.

[prairiewindmomma]

21 hours ago, Brittany1116 said:

 

 

I also seem to remember something about disparity in PB allergies among income levels. Kids who would qualify for WIC were less likely to be allergic because they were more likely to have early/repeat exposure? Can't recall when or where I read this. 

This was based on hygiene theory. Our ped allergist told us this early 2000s. In actuality, recent studies point to them being more likely to have asthma and other things due to housing and exposure to exhaust from living near busy roads. 
 

In my not-a-doctor opinion, I am concerned about overall body burdens of toxicity given how widely we are exposed to a vast number of chemicals through food packaging, food prep, etc. I suspect these disrupt our body’s microbiome and increase the permeability of our gut linings thus creating more allergies as our body seeks to distinguish safe food proteins from harmful stuff. 
 

I also suspect that since our gut is where a lot of happy hormones are created (the gut/mind connection) that this is also tied partially (in a multifactoral way) to why we are seeing such a rise in mental health issues.

[wathe]

48 minutes ago, SKL said:

There should be some standards for the AAP (or other guiding entity) making recommendations that affect lives.

In this case, it seems they had no evidence at all that this was a good idea.  In fact, the link between earlier exposure and lower allergy incidence (of allergens in general) was proposed before 1990.  Nobody thinks it's an issue that it took more than 10 years to revisit the peanut recommendation?

Why isn't there a requirement that some actual research be done before making a nationwide health recommendation?

And also, knowing that this hasn't been done in the past, pediatricians should demand to know the scientific basis, research results, etc. behind each such recommendation.  Maybe the AAP (and similar organizations) shouldn't even be allowed to make a recommendation without citing real scientific research.

I also notice that we require different levels of scientific evidence, depending on which way the wind is blowing.

There is, and has been for decades.  As long as I have been in practice, there have been evidence grading systems embedded in medical guidelines and society practice position statements.   There was much attention put on grading evidence in guidelines in medical education when I went through in the late '90's.  Most currently use the GRADE system.  As an example, see the current Canadian Paediatric Society position statement on Dietary exposures and allergy prevention in high-risk infants.  

The AAP wasn't just making stuff up.  They made the best recommendation they could with the information that was available at the time.  

Science is messy.   Medicine is both art and science, and is even messier.   Things that seem obvious and true to all of us right now may prove to be false, and seem absolutely ridiculous in 20 or 30 years.  Hindsight is always 20/20.

 

[wathe]

Excerpts from a 2003 review article on allergy prevention guidelines (including AAP's 2000 recommendation):

"Limitations in knowledge, societal compliance, and resources have been obstacles to prevention"

"Food allergy prevention strategies must consider its ability to 1) predict the high-risk infant and child, 2) demonstrate effectiveness of the intervention strategy, 3) use acceptable interventions, 4) minimize adverse effects, and 5) generate cost-effective outcomes.

Challenges exist in all of the above criteria; however, nutritional committees from the American Academy of Pediatrics (AAP)5 and jointly the European Society for Pediatric Allergology and Clinical Immunology and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition have published recommendations for the primary (prophylaxis) and tertiary (treatment) prevention of food allergy. These recommendations are works in progress based on best interpretations of existing data, and as noted in a footnote to the AAP recommendations, “This statement does not indicate an exclusive course of treatment or serve as a standard of medical care.”

Zeiger, R. S. (2003). Food allergen avoidance in the prevention of food allergy in infants and children. Pediatrics (Evanston), 111(6), 1662–1671. https://doi.org/10.1542/peds.111.s3.1662

Loads of references, including best available studies.

In other words, doing the best they could with the data they had.  Not just making stuff up.

 

[scholastica]

5 hours ago, SKL said:

They could make an announcement that they are doing the study and how parents can watch for reactions and make a decision based on what they observe.

I would note that the article indicated that while there were peanut allergies before the AAP recommendation, they were not only much more rare, but also usually milder.  There doesn't seem to be evidence that in the absence of an essential ban on peanut butter before age 3, there would be many cases of infant death.

Back in 1973, my new teacher visited all of her students' houses to meet the parents.  She came into our house and, for whatever reason, mentioned that she was allergic to dust and grass.  (My mom was like, hmm, you might not want to stay here long.  😛)  The fact that some people are born allergic to dust and grass did not justify a ban on dust or grass.  I don't think anyone whose kid is allergic to these allergens is up in arms and suing the government for not banning them.

How many people have an anaphylactic reaction to dust and/or grass? Many people who are allergic to foods are at risk of death from exposure. Dust and grass are not in the same category for reactions. I am allergic to both dust and grass and have never been at risk of death from either, despite extreme reactions at times. 

[Terabith]

5 hours ago, SKL said:

They could make an announcement that they are doing the study and how parents can watch for reactions and make a decision based on what they observe.

I would note that the article indicated that while there were peanut allergies before the AAP recommendation, they were not only much more rare, but also usually milder.  There doesn't seem to be evidence that in the absence of an essential ban on peanut butter before age 3, there would be many cases of infant death.

Back in 1973, my new teacher visited all of her students' houses to meet the parents.  She came into our house and, for whatever reason, mentioned that she was allergic to dust and grass.  (My mom was like, hmm, you might not want to stay here long.  😛)  The fact that some people are born allergic to dust and grass did not justify a ban on dust or grass.  I don't think anyone whose kid is allergic to these allergens is up in arms and suing the government for not banning them.

And if their only concern was research, that probably is the way to go.

But the number one concern of pediatricians is the health of children.  It makes sense to give recommendations on something based on best available information when there is a crisis and health/ lives are on the line, even if a full fledged research study hasn't been done.  

Pediatricians didn't cause the rise in peanut allergies; they were already rising dramatically, which is what led to the recommendation.  The American Association of Pediatrics isn't some fear mongering group; they were trying to use the best available information at the time.  

They were wrong, and they course corrected not even ten years later.  Sometimes experts get it wrong.  That doesn't mean they're evil or reckless or stupid.  They just didn't have enough information.

[Spryte]

52 minutes ago, scholastica said:

How many people have an anaphylactic reaction to dust and/or grass? Many people who are allergic to foods are at risk of death from exposure. Dust and grass are not in the same category for reactions. I am allergic to both dust and grass and have never been at risk of death from either, despite extreme reactions at times. 

Yeh, environmental and seasonal allergies (which include dust and grass) are a different beast. We really should have a different name to distinguish between “being around this makes me feel miserable like I have a cold” and “coming into contact with this makes me stop breathing and you will be the one calling 911 because I could be unconscious.”

(And yes, I know all about mild anaphylaxis, too, been there lived it with kids and myself — ideally we camp at the ER parking lot in those cases.)

[kbutton]

4 hours ago, wathe said:

Food allergy prevention strategies must consider its ability to 1) predict the high-risk infant and child, 2) demonstrate effectiveness of the intervention strategy, 3) use acceptable interventions, 4) minimize adverse effects, and 5) generate cost-effective outcomes.

I think the above is revealing in hindsight. It would seem like delaying PB would be a low tech and low cost way of solving a problem. I could argue a lot even inside my own mind about how it balanced the five priorities, but my take on it as a parent of older kids is informed by how hard it was to deal with difficult babies (one temperamentally/lip ties and one because of reflux/nursing issues probably related to a hypermobile jaw) and for whom I received little to no help with those difficulties. The burden is and ever shall be on the parent to follow cost effective stuff that may or may not ever benefit them personally. Those cost effective guidelines have multiplied like guppies in the 20 years since my first was born. If I had the same kids NOW—I’d have to be on suicide watch, but I wouldn’t be because I already didn’t trust the doctors who were supposed to help but made everything my problem. 

I honestly think number five trumps everything, and it pressures parents who are already wanting to get everything right.

It’s too easy to default to prioritizing the fifth concern.

4 hours ago, wathe said:

These recommendations are works in progress based on best interpretations of existing data, and as noted in a footnote to the AAP recommendations, “This statement does not indicate an exclusive course of treatment or serve as a standard of medical care.”

I’m quoting you, not arguing you, FWIW.

I’m gobsmacked that stuff that places a fairly big burden on parents (when combined with other “free” prevention that is difficult) is not considered standard of care, and parents were not told this. I wasn’t.

Tons of people can’t get evidence-based standard of care for stuff that kills far more people per year.

5 hours ago, wathe said:

There was much attention put on grading evidence in guidelines in medical education when I went through in the late '90's.  Most currently use the GRADE system.  As an example, see the current Canadian Paediatric Society position statement on Dietary exposures and allergy prevention in high-risk infants.  

I was all excited to read this, but GRADE is basically stating whether an article is reliable, and it says right on the page that it’s subjective to the authors, IIRC. It’s not so much about guidelines.

I didn’t look at the current position statement because most infants are not high risk.

Before clicking, I thought it was going to be rigorous about the guidelines, and this came to mind: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001106

Obviously guidelines that robust cannot be made about very early educated guesses on a new recommendation, but again, because it’s low cost, by all means, put it on the parents.

I felt kinda bad for the doctors in the middle of this discussion, but I am back to being annoyed at the lack of support for the guidelines. We can somehow in this country convince parents across the board to take it upon themselves to keep their babies safe in a million inexpensive ways while literally about 100,000 people a year die from blood clots, and MANY of those people do not get standard of care—care that had been fairly standardized for twenty years. Oh, and many times it’s on the patient to convince the doctor that they even have symptoms much less deserve testing. Whole organizations are dedicated to teaching people how to recognize signs of a blood clot and advocate for themselves. 

Look up how many people die of peanut allergies each year. It’s not close to 100,000.

It’s incomprehensible to me, and his sight makes it look like the parenting version of hygiene theater, but for peanuts, not Covid.

I have a fairly minority view though because I have kids that are not normal by measurements. If I could go back and talk to my younger self, I would be like, “save your energy for something more statistically relevant” except I wouldn’t have had the confidence to take them to the pediatrician without worrying about a CPS visit.

[kbutton]

11 minutes ago, Terabith said:

And if their only concern was research, that probably is the way to go.

But the number one concern of pediatricians is the health of children.  It makes sense to give recommendations on something based on best available information when there is a crisis and health/ lives are on the line, even if a full fledged research study hasn't been done.  

Pediatricians didn't cause the rise in peanut allergies; they were already rising dramatically, which is what led to the recommendation.  The American Association of Pediatrics isn't some fear mongering group; they were trying to use the best available information at the time.  

They were wrong, and they course corrected not even ten years later.  Sometimes experts get it wrong.  That doesn't mean they're evil or reckless or stupid.  They just didn't have enough information.

Even after what I wrote, I agree with this, but they could’ve said more clearly that they were sitting on a puff of smoke, not a solid wooden stool.

[SKL]

And honestly, a lot of experienced parents just ignore these types of guidelines, and can you blame them?  But the fact that the damage was mitigated by parents ignoring the guidelines does not excuse the recommendation.  So, thanks to stubborn parents, the incidence of peanut allergy only tripled.  😛 Otherwise maybe it would have increased by 5-10x.

I'd like to learn more about whether the severity as well as the incidence of reactions has increased over the same time frame.  The linked article implied that it has, but I can't find this in my lay googles.

[wathe]

If well-child care were restricted to practices based on good evidence, there wouldn't be very much left.

What would be left is breastfeeding, vit d supplementation, iron supplementation, avoidance of juice and high sugar foods, introduction of allegens; counselling on firearms, safe sleep, car seats, night waking and healthy sleep habits, postpartum depression, food security, 2nd hand smoke, tummy time, no otc cough syrup, dental care, poisons/how to access poison control, bike helmets; doing newborn screening tests for rare metabolic disorders, hearing screen, and vaccinations, and looking at eyes and tonsils.  That's about it for practices with good evidence to support them.

Note what's missing above:  inquiry and observation of all developmental milestones (only fair evidence to support).  A whole bunch of nutrition topics. Loads of very important child safety and injury prevention topics. Almost the entire physical exam.

Recommendations for for provider advice on carbon monoxide detectors, choking/safe toys, crying, soothability, siblings, cannabis, sun-exposure, fever advice/thermometers, sun screens, insect repellent, burns, footwear, parental fatigue/stress, toilet learning, peer relationships, menstrual issues, healthy food choices/junk food, supplements (with the exception of vitamin d and iron), CAM, body image, electronic media, trampoline safety, water safety, substances and addictions, screening for TB risk factors; and pretty much the entire physical exam (except checking for a red reflex, strabismus screening, visual acuity and looking at tonsil size) are all based on consensus or inconclusive evidence.  

We counsel and make guidelines for this stuff anyway because it is very probable that more kids would die if we didn't.   Medicine is a messy art.

ETA: pulled from the Canadian Pediatric Society vetted Rourke Baby Record and Greig Health Record up to age 9, (known colloquially as the providers well-child care cheat sheet.)

ETa again: I missed introduction of allergens on the supported by good evidence list.

Edited September 23 by wathe

[wathe]

Adding:  a lot of the stuff for which we do not have evidence means that we just don't have evidence yet.  

Maybe a conclusive, well-designed study will come out in the future proving that some of our recommendations are wrong.  For example, maybe slicing grapes and cherry tomatoes and other choke-able foods for babies and toddlers actually does more harm than good.  Or maybe carbon monoxide detectors somehow harm kids.  And future boardies will think that the current medical community was absolutely ridiculous to ever recommend them without supporting evidence  Even though, at the present time, they just seems like commons sense.

Edited September 23 by wathe

[Acorn]

27 minutes ago, wathe said:

If well-child care were restricted to practices based on good evidence, there wouldn't be very much left.

What would be left is breastfeeding, vit d supplementation, iron supplementation, avoidance of juice and high sugar foods; counselling on firearms, safe sleep, car seats, night waking and healthy sleep habits, postpartum depression, food security, 2nd had smoke, tummy time, no otc cough syrup, dental care, poisons/how to access poison control, bike helmets; doing newborn screening tests for rare metabolic disorders, hearing screen, and vaccinations, and looking at eyes and tonsils.  That's about it for practices with good evidence to support them.

Note what's missing above:  inquiry and observation of all developmental milestones (only fair evidence to support).  A whole bunch of nutrition topics. Loads of very important child safety and injury prevention topics. Almost the entire physical exam.

Recommendations for for provider advice on carbon monoxide detectors, choking/safe toys, crying, soothability, siblings, cannabis, sun-exposure, fever advice/thermometers, sun screens, insect repellent, burns, footwear, parental fatigue/stress, toilet learning, peer relationships, menstrual issues, healthy food choices/junk food, supplements (with the exception of vitamin d and iron), CAM, body image, electronic media, trampoline safety, water safety, substances and addictions, screening for TB risk factors, and pretty much the entire physical exam (except checking for a red reflex, strabismus screening, visual acuity and looking at tonsil size) are all based on consensus or inconclusive evidence.  

We counsel and make guidelines for this stuff anyway because it seems probable that more kids would die if we didn't.   Medicine is a messy art.

I’m curious how common these food and safety topics are. At my kids’ well child appointments, we are asked if I/they feel they eat a well balanced diet including fruits/veg. We get a printed form with bullet points of safety like wear a bike helmet. Then they ask if I have questions and concerns. I can’t imagine doctors having time to talk about the topics in your post. I know that things like peanut butter, trampolines, gun locks, cosleeping can relate to children’s health but those topics have never come up. Maybe the medical questions that I do have take up all the time the doctors can give us?

eta: I once horrified a whole table of moms that I had just met at a playground because I unpacked pbj for my 2 and 4 year old. I eat pb and nuts nearly daily. There are no food allergies in my family and I breastfed without any concerns. I know that an allergy can happen at any time but I honestly think that could happen if a kid is 3 or 6. You need to pay attention during meals.

Edited September 23 by Acorn