Intervention to Reduce Early (Peanut) Allergy in Children (iREACH)

iREACH is a five-year NIH funded study aimed at assessing and improving pediatric clinician adherence to the 2017 NIAID Prevention of Peanut Allergy (PPA) Guidelines. iREACH has been developed as an electronic health record (EHR) integrated Clinical Decision Support (CDS) tool together with educational modules on the PPA guidelines to assist clinicians in implementing the 2017 NIAID PPA Guidelines. A practice-based, two-arm, cluster-randomized clinical trial will evaluate the effectiveness of iREACH in increasing pediatric clinician adherence to the PPA Guidelines and explore the end-goal of reducing peanut allergy incidence by age 2.5 years in the intervention vs control group. This study has the potential to: 1) provide evidence regarding the effectiveness of iREACH in promoting clinical processes and outcomes related to the PPA Guidelines, 2) provide important insight about practice-based implementation of PPA Guidelines by pediatric clinicians, allergists and caregivers, and 3) facilitate rapid, widespread implementation of PPA Guidelines and reduce peanut allergy incidence across the US.

A minimum of 30 pediatric practice sites will be randomized to the iREACH intervention arm or to the control arm. Primary Objective To determine the effectiveness of iREACH in increasing adherence to the PPA Guidelines among pediatric clinicians. Secondary Objective To determine the effectiveness of iREACH in decreasing the incidence of peanut allergy by age 2.5. Exploratory Objectives To determine allergists' adherence to the PPA Guidelines To identify common barriers/facilitators for PPA Guideline adherence among pediatric clinicians and caregivers To determine caregiver adherence to the PPA Guidelines All pediatric clinicians within each participating practice (n≈200 total) will be assigned to the arm to which their practice is randomized. The trial will be conducted over an 18-month period. During this time, approximately 500 high-risk infants and 10,000 low-risk infants are expected to be seen for 4- and 6-month well child care visit (WCC). The primary outcome, pediatric clinician adherence to the PPA Guidelines, will be assessed using EHR data for each infant following the 6-month WCC. Data for the secondary outcome will be obtained by a combination of EHR data extracted after the infant's 6-month WCC and data collected from caregivers. EHR data extraction will be performed to obtain data from the infant's 9-, 12-, 15-, 18-, 24-month WCC and any sick visits and allergist progress notes entered from 4-30 months of age. Caregivers' data will be collected via surveys of caregivers of children seen for 4- or 6-month WCC visits during the study period. Caregivers will be recruited and asked to provide informed consent at the time of the child's first birthday and questions will be asked to determine the incidence of peanut allergy. A follow-up survey will be sent to caregivers after the child's second birthday. Data for exploratory outcomes will be obtained through EHR data extraction and surveys of pediatric clinicians and the caregivers of infants seen for 4- or 6-month WCC. Pediatric clinicians in the intervention arm will be asked to provide informed consent and will complete three surveys over approximately 21 months. Pediatric clinicians in the control arm will be asked to provide informed consent following completion of data collection for the primary outcome and will complete one survey. Finally, caregivers, through the two surveys conducted at the time of their child's first and second birthdays, will provide information for exploratory outcomes.

Food Allergy, Peanut Allergy Incidence, Clinical Decision Support Tool, Infants, Peanut Allergy Prevention

Pediatric clinicians in this arm will receive the iREACH CDS tool and education on the PPA Guidelines to support adherence to the Guidelines.

No study procedures will be implemented in the control practices, and their pediatric clinicians will not receive extra PPA Guidelines education, nor will any EHR modifications be made in their practices to support adherence to PPA Guidelines.

Pediatric clinicians in the intervention arm will 1) receive the iREACH education module, 2) have the iREACH CDS tool integrated into the EHR templates for use at the 4-, 6-, 9-, 12-month WCC, and 3) will be reminded by EHR-embedded prompts at the 9-month WCC to ask caregivers whether peanuts were introduced and tolerated.

The primary endpoint is the percentage of infants within each trial arm whose pediatric clinician adhered to the guidelines regarding peanut introduction assessed after completion of either a 4- or 6-month WCC. The primary endpoint concerns only the peanut introduction recommendation by the treating pediatric clinician and not additional behavior by the treating allergist or by caregivers. The primary endpoint will be measured separately by risk category as follows: % of infants at low risk for peanut allergy whose pediatric clinician adhered to the guidelines for that infant. % of infants at high risk for peanut allergy whose pediatric clinician adhered to the guidelines for that infant.

The secondary endpoint is the incidence of peanut allergy by age 2.5 years and is assessed through a combination of parent survey data and extracted EHR data. Secondary endpoints will be measured separately by risk category as follows: % of infants at low risk for peanut allergy who developed peanut allergy by age 2.5. % of infants at high risk for peanut allergy who developed peanut allergy by age 2.5.

What factors serve as barriers and facilitators for clinicians and caregivers to adhere to guidelines.

Whether or not caregivers follow recommendations provided by clinicians - infant peanut product introduction and feeding frequency

Inclusion Criteria: Practice sites The practice utilizes a centrally-integrated EHR. The practice has signed a legally-binding engagement agreement with Lurie Children's Pediatric Practice Research Group. The practice employs at least one physician who has completed a residency in general pediatrics and is practicing as a general pediatrician. Pediatric Clinicians: Clinician is a physician, physician assistant, resident, advanced practice nurse, family practitioner, or pediatric nurse practitioner working in a pediatric practice. Clinician is employed by a practice that is a member of one of the participating practices in the study. Clinician provides well child care to infants ages 4 or 6 months. Infants • Infant has been seen by a pediatric clinician in the intervention or control arm for a 4- and/or 6-month WCC. Caregivers Is the caregiver of an infant seen for a 4- and/or 6-month WCC by a pediatric clinician in a practice belonging to the study's intervention or control arms. Is 18+ years of age or has parent or guardian permission to participate. Is able to understand the study and provide informed consent for the 12- and 24-month (child's age) survey. Exclusion Criteria: Practice Sites Sees <50 newborn patients/year. Has only temporary pediatricians on staff. The practice pediatric clinicians do not use an EHR system. Pediatric clinicians The clinician is a temporary employee. The clinician begins employment at participating practice less than three months prior to end of the 18-month study enrollment period. Infants The infant has a medical condition that chronically inhibits the ability to take food orally (i.e., dysphagia, muscular dystrophy, gastrostomy). The infant has past or current medical problems or findings from physical examination or laboratory testing not listed above for which the pediatric clinician indicates that implementation of PPA Guidelines may pose a medical risk other than allergic reactions or may interfere with the infant's appropriate implementation of the PPA Guidelines or study investigators conclude that implementation of the PPA Guidelines was not possible or may have impacted the quality or interpretation of the data obtained from the study. Caregivers • Caregiver's primary language is not English or Spanish.