Q. What are some of the problems facing the peanut-allergic infant and toddler?

A. Consider this real-life example:

Matthew is a 2-year-old boy who first developed a peanut allergy at age 1. He was exclusively breastfed until age 12 months and was not completely weaned until age 18 months. He had developed eczema on his face, arms, and legs at 2 months. The eczema seemed to flare after his mother ate peanut butter and then nursed him. On his first contact with peanut butter, when he touched some on a cracker, he developed swelling of his face, followed by hives all over his body, and required Benadryl and epinephrine in his pediatrician's office. He has been kept on a strict peanut- and nut-free diet since then, and his mother eliminated peanut products from her diet. He had no problems until he was kissed by a relative who had just eaten a piece of candy containing peanut, and hives erupted where he was kissed.

How Babies & Kids Are Affected
 
Infants and toddlers have no control over their environment. How often they get into trouble is directly related to how carefully they are watched and cared for. A strict peanut-free diet and environment can be achieved for this age group more successfully than for any other age group. The ideal situation would be a baby that is exclusively breastfed by a mother who is herself adhering to a peanut-free diet in a household with no peanut products. Daycare would be avoided completely or at least delayed until age 3.

Unfortunately, this ideal situation is seldom achieved and is a bit unrealistic. Siblings who are not old enough to understand that peanut butter can be dangerous should not be given peanut products except under supervision, so that accidental contacts with and exposures of the allergic child do not occur. The major mistakes occur when care of the child is given over to people who may not be as knowledgeable about peanut-free diets or who do not care to be. This is where you need to educate others about the seriousness of the allergy and how often peanut products can be "hidden." Any caretaker responsible for the baby needs to be fully trained in handling an emergency situation and in the use of epinephrine.

Daycare Center Efforts
 
In the daycare setting with multiple children, it is the responsibility of the daycare provider to maintain a safe environment for all of his or her charges. How this is achieved certainly will vary from provider to provider. With very young active children who are playing with and touching each other, it is quite difficult to monitor every child. Although skin contact typically results in minor skin reactions and not anaphylaxis, young children often put their fingers in their mouths, which can result in potentially more severe reactions. The chances for accidental contact and exposure increase with the number of children present.

In an ideal world, the easiest way to maintain control would be to have a completely peanut-free environment. Because this is often difficult to achieve, however, it is up to you, as parents, to be in frequent contact with the daycare providers, to give them information, hands-on support, and help.

When looking at various daycare centers, inquire whether they have had children with allergic conditions, such as peanut allergy, and how the situation was handled. The more experience the daycare provider has had, the more confident you can be about the safety of your child. The Food Allergy & Anaphylaxis Network has a special educational package devoted to daycare centers and preschools. The Allergy and Asthma Foundation of America (AAFA) has a new program to train childcare centers on dealing with food allergies, asthma, and other common allergy problems. Your local AAFA chapter will also direct you to the nearest support group and educational lectures given by community physicians and local experts. This is an invaluable source of information and a forum for sharing experiences and giving mutual support.