New Guidance For Preventing Food Allergies In Children From Leading Allergy Organizations
The leading allergy organizations in the United States and Canada have released new guidance on strategies for preventing food allergy through nutrition, recommending that all infants start peanut and egg around 6 months of life to prevent allergies from developing to those foods. The report also recommends that all other allergens be introduced around that time as well and that once introduced, regular consumption should be maintained.
The consensus document by the American Academy of Allergy, Asthma and Immunology (AAAAI), American College of Allergy, Asthma and Immunology (ACAAI) and the Canadian Society for Allergy and Clinical Immunology (CSACI) builds on current recommendations from the 2017 National Institute of Allergy and Infectious Diseases Addendum Guidelines for the Prevention of Peanut Allergy, which are limited to peanut. The report incorporates the evolution in research and published data “to cover a broader range of topics for which additional but crucial data were unavailable for inclusion at the time.”
We’ve broken down the key recommendations from the recent guidance to make it easy for busy parents!
KEY RECOMMENDATIONS:
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Consider infants with severe eczema at the highest risk of developing food allergy. Consider infants with mild to moderate eczema, a family history of atopy in either or both parents, or infants with one known food allergy potentially at some increased risk for developing food allergy (or an additional food allergy). Be aware that food allergy often develops in infants who have no identifiable risk factors.
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Introduce peanut-containing products to all infants irrespective of their relative risk of developing peanut allergy, starting around 6 months of life, though not before 4 months of life. Peanut introduction should occur after the successful introduction of other solid foods. Once peanut is introduced, regular ingestion should be maintained. Screening is not required for early introduction, though should be an option if preferred by the caregivers.
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Introduce egg or egg-containing products to all infants, irrespective of their relative risk of developing allergy, around 6 months of life, though not before 4 months of life. Egg introduction should occur after the successful introduction of other solid foods. Screening is not required for early introduction, though should be an option if preferred by caregivers.
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Do not deliberately delay the introduction of other potentially allergenic complementary foods (cows milk, soy, wheat, tree nuts, sesame, fish, shellfish), once introduction of complementary foods has commenced at around 6 months of life, but not before 4 months. There may be potential harm in delaying the introduction of these foods. Once introduced, regular consumption of these foods is recommended.
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Upon introducing complementary foods, infants should be fed a diverse diet, as this may help foster prevention of food allergy. There is observational evidence but no randomized controlled trials to support this recommendation, but there is no known harm in a diverse diet.
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Do not use any Hydrolyzed Formulas for the specific prevention of food allergy as this has not been proven to be effective.
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Do not exclude common allergens during pregnancy and lactation as a means to prevent food allergy. While exclusive breastfeeding is universally recommended for all mothers, there is no specific association between exclusive breast-feeding and the primary prevention of any specific food allergy.
OTHER IMPORTANT FINDINGS:
Application To A Low-Risk Population:
Food allergy prevention recommendations appear to be most salient for those at highest risk, although they likely apply to the general population in westernized countries as well.
Note that draft copies of guidelines were recently released by EEACI and the USDA, both also suggesting that peanut and egg in age-appropriate forms can be introduced to all infants after 4 months of life to help reduce the risk of developing allergy to those foods.
Adherence:
Previous recommendations to avoid specific foods until after age 1 are still followed by many parents and clinicians, but are out-of-date and must be actively addressed and reversed.
Risk Factors:
Current data do not clearly support that siblings of peanut-allergic children are at increased risk of developing peanut allergy based on any genetic or heritable factor.
Testing:
At a population level, universal allergen introduction at home without screening is associated with far superior health and economic outcomes compared with preassessment screening tests and in-office oral food challenges.
Compared with other options (screening skin/sIgE testing and/or in-office observed introduction or oral food challenge), universal introduction costs less, prevented more cases of food allergy, and produced more net benefit to the patient. Attempts should be made to minimize any screening procedures, however screening should be an option if caregivers prefer.
The vast majority of infants with a positive skin or sIgE test results should still be offered consideration for an oral food challenge. It is imperative that there is urgency for these infants to be prioritized and have an oral food challenge performed as soon as possible so as not to miss the window for prevention.
SUGGESTIONS FOR HOW TO INTRODUCE COMMON FOOD ALLERGENS:
Nuts and nut butters are a choking hazard for babies and must never be given to infants in their natural form. Many other allergenic foods are also a choking risk to babies, so the AAAI recommends several safe ways to include allergenic foods in infant diets.
Peanut: Peanut puffs, smooth peanut butter mixed with hot water and then cooled, peanut flour or peanut powder.
Egg: Give fully cooked/baked egg to start with (such as low-sugar cookies, muffins, or pancakes).
Tree Nuts: Tree nut butter mixed with hot water and then cooled
Milk: If you have not given your baby infant formula, try starting with milk in baked foods or yogurt (cheese can be given later in infancy from around 6 to 7 months)
Soy: Offer your baby soy milk, soy yogurt, or tofu.
Fish/Shellfish: Give your baby a few portions of the fish/shellfish species that you tend to eat as a family and continue with regular intake. (Don’t give more than 2 portions of fatty fish per week according to the FDA).
Sesame: Try some hummus and tahini.
Wheat: Try softly cooked pasta or bread.
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By Catherine Mitchell Jaxon, Co-founder of Mission MightyMe
