Minimizing Risk of Food Allergy in Infants

According to data collected in 2021 by the Centers for Disease Control and Prevention, almost 6% of children in the U.S. have been diagnosed with a food allergy, and the percentage increases with age: 4.4% for ages 0-5, 5.8% for ages 6-11, and 7.1% for ages 12-17. Although concerns still exist regarding the incidence of food allergies being on the rise, more promising research has been published in recent years focusing on their prevention.

Current infant feeding practices recommend the early introduction of highly allergenic foods, such as eggs, nuts and fish, due to evidence suggesting that either delaying the introduction of solid foods (beyond 4 to 6 months) and/or avoiding potentially allergenic foods might actually increase the risk of food allergy in infants.

To date, most of the research has focused on peanut allergy with the most renowned being the Learning Early about Peanut Allergy Study. The LEAP study, which was a randomized, open-label controlled trial, assessed the prevalence of a peanut allergy in infants, (4 to 11 months of age), who had an existing allergic condition (i.e., egg allergy, severe eczema or both). A significant decline in high-risk children developing a peanut allergy at age 5 was attributed to the introduction and sustained consumption of age-appropriate peanut products during the first year of life.

The findings from this landmark trial prompted an addendum to the 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel in 2015; and, in 2017, Addendum Guidelines for the Prevention of Peanut Allergy were released by the National Institute of Allergy and Infectious Diseases. The addendum guidelines include specific recommendations or suggestions (depending on the strength of evidence) for the introduction of peanut-containing foods and vary depending on whether the infant has been diagnosed with severe- or mild-to-moderate eczema, egg allergy or both.

The guidelines recommend that infants with a preexisting egg allergy and/or severe eczema are tested for peanut allergy prior to the introduction of peanut-containing foods. Also, the introduction of solid foods may need to be supervised and conducted in a clinical setting for children who are at high risk of food allergy or who have an existing food allergy. Strict avoidance is recommended when a food allergy has been confirmed.

Although more evidence is needed regarding the relationship of introducing other highly allergenic foods relative to risk reduction, there is consensus among authoritative sources, including the 2020-2025 Dietary Guidelines for Americans, that “there is no evidence that delaying introduction of allergenic foods, beyond when other complementary foods are introduced, helps to prevent food allergy.” It is recommended that other solid foods be given to an infant prior to potentially allergenic foods, though.

Monitoring for signs of developmental readiness will determine the timing of introducing solid foods, which usually occurs between 4 and 6 months of age. Infant feeding guidelines still encourage breastfeeding, when possible, as the sole source of nutrition for the first 6 months of life and to supplement complementary feeding. However, the advice for introducing potentially allergenic foods is still relatively new for some practitioners and parents, so acceptance and implementation of complementary feeding practices can vary.

For example, Canadian health care practitioners were surveyed on their implementation of the new guidelines in practice and results found that physicians and pediatricians wait longer to recommend introducing allergenic foods (between 6 months to 1 year) than allergists, who are more likely to recommend earlier introduction (between 4 to 6 months of age).

Another survey assessed the attitudes of parents regarding infant feeding practices from birth to 24 months. Approximately half of the parents reported dissatisfaction with the guidance available about transitioning to solid foods. Lack of knowledge regarding where to locate reliable advice, which foods to introduce and their timing were cited as concerns. The risk of an allergic reaction was conveyed, but it appeared to be more of a concern for parents of infants younger than 6 months old. Most of the parents surveyed introduced solid foods between 6 and 12 months of age; however, mothers were more likely to offer baby foods at 6 months, compared to fathers who waited until 12 months.

Assisting parents and other caregivers with the introduction of nutritious and age-appropriate foods is critical at this life stage and can help to minimize the risk of food allergies. As part of an interdisciplinary team, registered dietitian nutritionists can help families determine appropriate ways to integrate culturally relevant foods while still promoting adequate nutrition to support infant health and growth.

References

• Zablotsky B, Black LI, Akinbami LJ. Diagnosed allergic conditions in children aged 0–17 years: United States, 2021. NCHS Data Brief, no 459. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:123250.
• Du Toit, Sayre P, Roberts G, et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med. 2016;374(15):1435-1443.
• Togias A, Cooper SF, Acebal ML, et al. Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Summary of the National Institute of Allergy and Infectious Diseases-Sponsored Expert Panel. J Acad Nutr Diet. 2017;117(5):788-793.
• U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
• Abrams EM, Singer AG, Soller L, Chan ES. Knowledge gaps and barriers to early peanut introduction among allergists, pediatricians, and family physicians. J Allergy Clin Immunol Pract. 2018. Published online August 2018. Accessed November 2018.
• International Food Information Council. Parents Uncertain About Times of Children's Dietary Transitions; Gap Exists Between Expectations and Reality. October 2018. Accessed February 2019.