==== Front JAMA Netw Open JAMA Netw Open JAMA Network Open 2574-3805 American Medical Association 36961467 10.1001/jamanetworkopen.2023.4706 zld230030 Research Research Letter Online Only Pediatrics Evaluation of Training to Increase Knowledge of the Addendum Guidelines for the Prevention of Peanut Allergy in the US Training to Increase Knowledge of the Addendum Guidelines for the Prevention of Peanut Allergy Training to Increase Knowledge of the Addendum Guidelines for the Prevention of Peanut Allergy Samady Waheeda MD 1 2 Bilaver Lucy A. PhD 2 Jiang Jialing BA 2 Iyer Anahita BA 2 Laurienzo Panza Joy RN BSN 3 Togias Alkis MD 3 Gupta Ruchi S. MD MPH 1 2 1 Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois 2 Northwestern University Feinberg School of Medicine, Chicago, Illinois 3 National Institute of Allergy and Infectious Diseases, Bethesda, Maryland Article Information Accepted for Publication: February 7, 2023. Published: March 24, 2023. doi:10.1001/jamanetworkopen.2023.4706 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Samady W et al. JAMA Network Open. Corresponding Author: Ruchi S. Gupta, MD, MPH, Northwestern University Feinberg School of Medicine, 750 N Lake Shore Dr, Ste 633, Chicago, IL 60611 (r-gupta@northwestern.edu). Author Contributions: Drs Bilaver and Gupta had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Samady, Bilaver, Jiang, Laurienzo Panza, Togias, Gupta. Acquisition, analysis, or interpretation of data: Bilaver, Jiang, Iyer, Gupta. Drafting of the manuscript: Samady, Bilaver, Jiang, Iyer. Critical revision of the manuscript for important intellectual content: Bilaver, Jiang, Laurienzo Panza, Togias, Gupta. Statistical analysis: Bilaver. Obtained funding: Bilaver, Jiang, Gupta. Administrative, technical, or material support: Samady, Jiang, Gupta. Supervision: Jiang, Gupta. Conflict of Interest Disclosures: Dr Gupta reported receiving research support from the National Institutes of Health (NIH), Food Allergy Research & Education (FARE), Melchiorre Family Foundation, Sunshine Charitable Foundation, The Walder Foundation, UnitedHealth Group, Thermo Fisher Scientific, and Genentech; she also serves as a medical consultant/advisor for Genentech, Novartis, Aimmune LLC, Allergenis LLC, and FARE; and Dr Gupta has ownership interest in Yobee Care Inc. Dr Bilaver reported receiving research support from the NIH, National Institute on Independent Living, Disability, and Rehabilitation Research, FARE, Thermo Fisher Scientific, National Chocolate Association, Yobee Care, Before Brands, Novartis, and Genentech outside the submitted work. Dr Samady reported receiving research support from the NIH outside the submitted work. Ms Jiang reported receiving research support from the NIH outside the submitted work. No other disclosures were reported. Funding/Support: This study is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID): U01AI138907. Role of the Funder/Sponsor: NIH scientific staff assisted with the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. They did not participate in collection of the data. Disclaimer: Dr Togias’ and Ms Laurienzo Panza’s co-authorship of this report do not constitute endorsement by the National Institute of Allergy and Infectious Diseases, the NIH, or any other agency of the United States Government. Data Sharing Statement: See the Supplement. Additional Contributions: We would like to thank Dr Stephanie Leeds, MD (Yale School of Medicine), and Dr Alanna Higgins, MD, MPH (Ann & Robert H. Lurie Children’s Hospital of Chicago), for their support with editing. We would also like to thank Haley Hultquist, BS (Northwestern University Feinberg School of Medicine), and Tegan Morcott, BA (Northwestern University Feinberg School of Medicine), for their support with recruitment for the study. No compensation was received for their roles. 24 3 2023 3 2023 24 3 2023 6 3 e2347069 11 2022 7 2 2023 Copyright 2023 Samady W et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License. jamanetwopen-e234706.pdf This survey study examines changes in pediatric clinicians’ knowledge of eczema identification and the 2017 Addendum Guidelines for the Prevention of Peanut Allergy after an educational intervention. ==== Body pmcIntroduction Peanut allergy (PA) affects 2.2% of US children.1 The 2017 Addendum Guidelines for the Prevention of Peanut Allergy recommend high-risk infants (severe eczema and/or egg allergy) be evaluated for peanut sensitization before early introduction of peanut and be referred to an allergist depending on results. Infants with mild-to-moderate eczema should be introduced to peanut around 6 months of age.2 Successful guideline implementation falls on pediatric clinicians during 4- and 6-month well-child visits. However, previous studies reported high training needs,3 low implementation rates,3 and low knowledge of the guidelines4 among clinicians. This study aims to measure changes in pediatric clinicians’ guideline knowledge and eczema identification after an educational intervention. Methods This survey study was approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago institutional review board. Participants provided implicit consent by completing the survey. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) study is a 2-group, cluster randomized clinical trial aiming to increase pediatric clinician adherence to guidelines. Experts developed a training video with content on PA prevention, guidelines, iREACH interventional tools, and eczema categorization. This 21.5-minute video was offered to 16 intervention practice sites in Illinois, including urban clinics, suburban clinics, rural clinics, private practices, and Federally Qualified Health Centers (FQHC). An online 34-item pretraining survey and 7-item posttraining survey were administered to all pediatric clinicians at the intervention practice sites from November 4, 2020, to January 27, 2022. Survey questions included: demographics, guideline usage, awareness, knowledge, and eczema identification. Race (American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, and other) and ethnicity (Hispanic/Latino and non-Hispanic/Latino) were self-reported. The McNemar test was used to measure proportional differences in pediatric clinicians’ knowledge pre- and post-training. Significance threshold was 2-sided P < .05 and testing was 2-sided. All statistical analyses were performed using SAS version 5 (SAS Institute) from December 2021 to September 2022. Results Overall, 185 clinicians participated (100% completion rate). Among clinicians, 29 (15.7%) were Asian, 5 (2.7%) were Black, 20 (10.8%) were Hispanic or Latino, 134 (72.4%) were White, and 155 (83.8%) were female; 96 (51.9%) had been in clinical practice for 0 to 10 years, 50 (27.0%) for 11 to 20 years, and 23 (12.4%) for 21 to 30 years; 94 (50.8%) practiced at an FQHC. Most pediatric clinicians (89.7% [166 of 185]) reported previous awareness. Among those aware of the guidelines, 40 (21.6%) reported full implementation and 127 (68.7%) reported no prior training (Table 1). Table 1. Guideline Implementation, Knowledge, and Training Prior to the Intervention to Reduce Early (Peanut) Allergy in Children Training Questions and answers Clinicians, No. (%) (N = 185) Prior to this survey, were you aware of the Guidelines for peanut allergy prevention that recommend the early introduction of peanut-containing foods into the diets of infants to prevent peanut allergy? (n = 185) Yes 166 (89.7) No 19 (10.3) Which statement best describes your use of the Guidelines for peanut allergy prevention in your practice? (n = 166) Not implementing 19 (10.3) Partially implementing 106 (57.3 Fully implementing 40 (21.6) Have you received any training around the Guidelines for peanut allergy prevention? (n = 166) Yes 38 (20.5) No 127 (68.7) Do you believe you need more education or training on the Guidelines for peanut allergy prevention? (n = 38) Yes 30 (16.2) No 8 (4.3) Which of the following items have been a barrier or concern for you in using the Guidelines for peanut allergy prevention? (Select all that apply.) (Among partial or full guideline implementation) Access to allergists for referrals 14 (7.6) Insufficient insurance coverage or reimbursement 3 (1.6) Lack of clinic time 54 (29.2) Conducting an in-office supervised feeding of peanut 34 (18.4) Indicate your level of agreement with the following statement: The early introduction of peanut-containing foods is an effective method for the prevention of peanut allergy (n = 185) Strongly agree 112 (60.5) Agree 69 (37.3) Neither agree nor disagree 4 (2.2) Disagree 0 (0.0) Strongly disagree 0 (0.0) After training, the percentage of participants correctly answering all knowledge questions improved from 72.6% [119 of 164] to 94.5% [155 of 165] (P < .001) (Table 2). Questions using visual eczema vignettes had the most improvement: severe eczema identification and guideline application improved from 63.4% (104 of 165) to 97.6% (160 of 165) correct (P < .001) and moderate eczema improved from 53.1% (87 of 164) to 78.1% (128 of 164) correct (P < .001). The percentage answering all guideline application questions correctly improved from 29.0% (47 of 162) to 70.4% (114 of 162) post training (P < .001). Table 2. Pre– and Post–Intervention to Reduce Early (Peanut) Allergy in Children Training Responses for Guidelines Knowledge Questionsa Questions and answers Clinicians, No. (%) P valueb Pretraining survey Posttraining survey For an infant aged 6 mos who does NOT have eczema or any food allergies, what would you typically do next with respect to peanut allergy prevention? (n = 165) Order a peanut-specific IgE/RAST test 1 (0.6) 0 NAc Refer to an allergist for consultation and testing 0 0 Recommend avoidance of peanut-containing foods 0 0 Offer an in-office feeding of a peanut-containing food 0 0 Recommend the introduction of peanut-containing food, in accordance with family preferences and cultural practicesc 159 (96.4) 165 (100.0) I would not take any additional steps with respect to peanut allergy prevention 4 (2.4) 0 Other 1 (0.6) 0 For an infant aged 6 mos who has mild-to-moderate eczema, what do the Guidelines recommend next with respect to peanut allergy prevention? (Select only one.) (n = 164) Order a peanut-specific IgE/RAST test 7 (4.3) 7 (4.3) <.001 Refer to an allergist for consultation and testing 11 (6.7) 0 Recommend avoidance of peanut-containing foods 3 (1.8) 0 Offer an in-office feeding of a peanut-containing food 4 (2.4) 0 Recommend the introduction of peanut containing foodsc 132 (80.5) 156 (95.1) I would not take any additional steps with respect to peanut allergy prevention 6 (3.7) 1 (0.6) Other 1 (0.6) 0 For an infant aged 6 mos who has severe eczema and/or egg allergy, what do the Guidelines recommend next with respect to peanut allergy prevention? (Select all) (n = 165) Order a peanut-specific IgE testc 55 (33.3) 160 (97.0) .002 Conduct peanut-specific skin prick testing in my office 1 (0.6) 3 (1.8) Recommend the introduction of peanut containing foods 7 (4.2) 0 Refer to an allergist for consultation and testingc 126 (76.4) 93 (56.4) Recommend avoidance of peanut-containing foods 20 (12.1) 11 (6.7) Offer an in-office feeding of a peanut-containing food 3 (1.8) 3 (1.8) Recommend the introduction of peanut-containing food 11 (6.7) 3 (1.8 I would not take any additional steps with respect to peanut allergy prevention 1 (0.6) 0 Other 1 (0.6) 0 Knowledge of Guidelines Question Summary (n = 164) 3 correct answers 119 (72.6) 155 (94.5) <.001 Eczema identification and guideline application questions A four-month-old infant presents with dry itchy skin lesions on the face and upper extremities. You quickly recognize this as atopic dermatitis. The lesions are erythematous (dull red) and indurated, and you note lichenification. There is also some crusting. The lesions are primarily on the face and arms. How would you rate the severity of the atopic dermatitis? (n = 165) Atopic dermatitis Mild 9 (5.5) 9 (5.5) .03 Moderatec 139 (84.2) 150 (90.9) Severe 17 (10.3) 6 (3.6) A two-month-old African American infant presents with deep purple skin lesions on their face, scalp, extremities, and trunk. The lesions are pruritic, with lichenification, induration, oozing, and crusting. What is your diagnosis? (n = 163) Bruising, secondary to a bleeding disorder 1 (0.6) 0 .02 Atopic dermatitis Moderate 14 (8.6) 5 (3.1) Severec 148 (90.8) 158 (96.9) [After viewing pictures of infant with severe eczema] In following the NIAID peanut prevention guidelines, what is the appropriate next step? (n = 165) Obtain a peanut sIgE/RASTc 104 (63.4) 160 (97.6) <.001 Start peanut containing products in the infant’s diet immediately 10 (6.1) 3 (1.8) Advise the family to wait until the child is at least 9 mos old before starting peanut containing products 1 (0.6) 1 (0.6) Diagnose patient with a peanut allergy 0 0 I don’t know 49 (29.9) 0 A4. [After viewing pictures of infant with moderate eczema] When should this infant's parent add peanut containing foods to the baby's diet? (n = 164) Around 6 months of agec 87 (53.1) 128 (78.1) <.001 They should wait until after 11 mos of age 0 0 Only after they have been tested and cleared by an Allergist 18 (11.0) 7 (4.3) Peanut-containing foods can be introduced based on family preferences and cultural practices 38 (23.2) 29 (17.7) I don't know 21 (12.8) Eczema Identification and Application Question Summary (n = 162) 4 correct answers 47 (29.0) 114 (70.4) <.001 Abbreviations: NA, not applicable; NIAID, National Institute of Allergy and Infectious Diseases; RAST, radioallergosorbent test. a Pre- and postresponse frequencies are only presented for respondents who answered the question in both surveys. b P values are from the McNemar test of the null hypothesis of no treatment effect. c There was no variation in responses pre- and posttraining as 100% of clinicians answered correctly at posttraining. Therefore, a P value could not be calculated. Discussion The iREACH training modules were developed to meet the educational needs of pediatric clinicians as they implement the guidelines. This study demonstrates how training can significantly improve guideline knowledge and application among a large group of clinicians serving diverse populations. This is consistent with past research which demonstrated that awareness among pediatricians did not reflect appropriate guidelines implementation.5,6 Baseline knowledge did not differ based on years of practice, highlighting the need for training across the spectrum of pediatric clinicians. The robust posttraining improvement for high-risk infants is notable as these infants require early identification to facilitate testing and/or referral. Furthermore, using standardized visual tools were effective to improving guideline application knowledge. A limitation of this study was that long-term knowledge retention was not assessed. This study found that iREACH training is an effective and accessible method to improving guideline implementation while facilitating PA prevention. This training can also be easily updated to reflect emerging evidence on prevention of other common food allergies. Supplement. Data Sharing Statement Click here for additional data file. ==== Refs References 1 Gupta RS, Warren CM, Smith BM, . The public health impact of parent-reported childhood food allergies in the United States. Pediatrics. 2018;142 (6 ):e20181235. doi:10.1542/peds.2018-1235 30455345 2 Togias A, Cooper SF, Acebal ML, . Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139 (1 ):29-44. doi:10.1016/j.jaci.2016.10.010 28065278 3 Gupta RS, Bilaver LA, Johnson JL, . Assessment of pediatrician awareness and implementation of the addendum guidelines for the prevention of peanut allergy in the United States. JAMA Netw Open. 2020;3 (7 ):e2010511. doi:10.1001/jamanetworkopen.2020.10511 32667655 4 Alvarez A, Gupta M, Poowuttikul P, Baptist AP. Are primary care physicians following National Institute of Allergy and Infectious Disease guidelines for the prevention of peanut allergy? a survey-based study. Allergy Asthma Proc. 2020;41 (3 ):167-171. doi:10.2500/aap.2020.41.200019 32375960 5 Bilaver LA, Martusiewicz MN, Jiang J, Gupta RS. Effectiveness of clinical decision support tools on pediatrician adherence to peanut allergy prevention guidelines. JAMA Pediatr. 2019;173 (12 ):1198-1199. doi:10.1001/jamapediatrics.2019.3360 31609434 6 Mehta P, DeFelice ML, Malloy C, Hossain J, Gordon H. Pediatric provider knowledge of early peanut introduction recommendations. Ann Allergy Asthma Immunol. 2020;125 (5 ):602-603.e3. doi:10.1016/j.anai.2020.06.037 32621991