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Having a child that is at high-risk for food allergies can be one of the most terrifying experiences for parents. An initial anaphylactic episode, with a subsequent visit to the hospital emergency room, can create a feeling of pure panic with every social experience for your child. As more and more people become aware of the challenges of kids with food allergies, there is increased acceptance of creating nut-free and peanut-free schools, daycares and play areas. What if I told you that there is now some new hope out there for decreasing the incidence of peanut allergies in children? Thanks to new research published in February in the New England Journal of Medicine, there is.
This latest research comes to a conclusion that is dramatically different than previous recommendations. Since 2000, the AAP’s infant feeding guidelines recommended that breastfeeding mothers of infants at high risk for developing allergy (first-degree family history of allergy, eczema, or asthma) should avoid cow’s milk, egg, fish, peanuts and tree nuts. If mothers were unable to breastfeed, it was recommended that they use a hypoallergenic formula as an alternative to breastfeeding. Parents were also instructed that no solid foods should be introduced to these high-risk infants until 6 months of age, with dairy products deferred until 1 year, eggs until 2 years, and peanuts, nuts and fish until 3 years of age.1
Current food introduction recommendations
Then, in 2008, the AAP reviewed more recent research and recommended that based on meta-analyses of the literature, that solid foods, including potential allergens, are no longer restricted after 4-6 months of age (unless your infant is already experiencing
allergic food reactions). It was recognized at this time that introducing solid foods BEFORE an infant is four months of age may increase the risk of developing food allergies. This meta-analysis also suggested that withholding solid foods until after the infant is 6 months of age does not appear to prevent the development of allergies or eczema.2
New guidelines for peanut introduction
Now, as of February 2015, the previously mentioned study from the New England Journal of Medicine looked further at peanut allergy guidelines in particular.3 In this study, the authors evaluated strategies of peanut consumption and avoidance to determine which strategy is most effective in preventing the development of peanut allergy in infants at high risk for the allergy.
For their methods, they randomly assigned 640 infants with severe eczema, egg allergy, or both to consume or avoid peanuts until 5 years of age. Participants, who were between 4 to 11 months of age at randomization, were assigned to separate study groups on the basis of preexisting sensitivity to peanut extract. This was determined with the use of a skin-prick test. One group showed no measurable skin wheal after testing and the other group showed a skin wheal measuring 1 to 4 mm in diameter. The primary outcome, which was assessed independently in each group, was the proportion of participants with peanut allergy present at 5 years of age.
Their conclusion: The early introduction of peanuts (between 4 and 11 months of age) significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy. This early introduction also showed a modulation of the immune response to peanuts (a change from reactive to non-reactive). Overall, this is very good news for all parents!
Introducing highly allergenic foods to infants
The safest way to introduce highly allergenic foods has not been sufficiently studied. It is possible for an allergic reaction to occur the first time a food is eaten. Experts recommend giving highly allergenic foods (cow’s milk, eggs, peanut butter, soy, wheat, fish, and shellfish) to high-risk children in the following manner1:
- The infant should be given an initial taste of one of these foods at home, rather than at day care or at a restaurant.
- If there is no apparent reaction, the food can be introduced in gradually increasing amounts.
- If the infant has signs or symptoms of an allergic reaction or develops a skin rash after eating a food, consultation with your child’s healthcare provider and/or allergist is suggested before other new foods are offered, especially the highly allergenic foods.
- If an infant has a sibling with documented food allergy (for example, peanut allergy, which has a 7 percent risk of peanut allergy among siblings), has a previous food allergy, or has moderate to severe eczema that is difficult to control, an evaluation with an allergy specialist may be recommended prior to introducing the highly allergenic foods.
Overall, we as physicians are learning more and more about how to recommend food introduction to infants in the safest way possible. Though more studies need to be done, we can feel more confident in working with kids with a high-risk of food allergies.
Tamara (Cullen) Evans, ND is a 1999 graduate of Bastyr University and currently practicing primary care medicine, with a focus on pediatrics, in Seattle, Washington. She currently serves as the Advanced Pediatrics professor at Bastyr University and she sits on the American Board of Naturopathic Pediatrics, an organization dedicated to the creation of a Naturopathic Pediatrics Board Certification Exam. Additionally, she was a founding Board member of the PedANP and has lectured both nationally and internationally. To date, her greatest accomplishment is raising her teenage son, Max.
- Duryea, TK, Fleischer, DM. Up-to-Date: Patient information: Starting solid foods during infancy (Beyond the Basics) . 2015.
- Restricting diet to prevent food allergies. kids with food allergies. Available at: http://www.kidswithfoodallergies.org/resourcespre.php?id=108&title=restricting_diet_to_prevent_food_allergies#sthash.qjmupie5.dpuf.
- Du Toit. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine. 2015;372(9). Available at: http://www.nejm.org/doi/pdf/10.1056/nejmoa1414850.