These sections contain the same information as in the PDF handouts throughout this section but are formatted for easier placement within EMR systems to place in after visit patient handouts.
Helpful Tips and Tricks for Allergy Prevention
The dual exposure hypothesis is a belief that the ability to eat a food without a reaction (tolerance) is developed by having the GI tract see the food, whereas the potential for food allergy is developed by skin exposure to the food, which can be worsened by eczema or skin breakdown. It is important to try to prevent repeated skin exposure to foods that your child has not eaten yet. To try to limit skin exposure it is best to avoid eating allergenic foods in your child’s play area and restrict eating to the table. It is important to clean surfaces where food is prepared or eaten to help reduce your child’s environmental exposure to any food allergens. Limit snacking throughout the house to reduce the amount of food dust/particles that get on rugs, carpets, etc. It is best to wash your hands before applying lotions and creams and after handling foods.
Why should I introduce peanut products to my baby so early in life?
Introducing peanut products to your baby early in life can help prevent him from developing a peanut allergy later on. Ask your doctor when it is right to introduce peanut products for the first time.
What should I do before giving my baby peanut products for the first time?
Talk with your baby’s doctor about whether he is ready to try peanut products.
If your baby has other known food allergies or very bad eczema (dry, scaly patches of skin), ask your doctor if your baby should have an allergy test or see a pediatric allergist (allergy doctor).
How do I introduce peanut products?
Safety tips
Give the first taste when your baby is healthy. Do not give the first taste if he has a cold, fever, diarrhea or other illness.
Give your baby his first taste of peanut products at home. Do not give the first taste at daycare or in a restaurant.
Timing tips
Set aside at least 2 hours after the first taste to watch your baby for a reaction. Make sure you or another family member can give full attention to your baby.
For the very first taste, give a small amount, the tip of a small spoon. Wait 10 minutes between the first and second taste. If your baby does not have any reaction after 10 minutes, give the rest of the peanut butter at his normal eating speed.
Give your baby 2 teaspoons (6 grams) of peanut products at least 3 times per week. This will help prevent him from developing a peanut allergy later in life.
Tips while your child eats:
Prepare a full serving of peanut butter from the recipe below.
Offer the first taste on a small spoon.
For babies and children under age 4, mix peanut butter with 1 safe food at a time. Do not give plain peanut butter to any baby or child under age 4.
Do not push your baby to eat more than he wants.
Peanut recipes for babies
Option 1: Peanut butter puree
You will need:
2 tsp. smooth, all-natural peanut butter (with no added ingredients)
2-3 tbsp. of plain yogurt or pureed (smooth) fruit or vegetable that your baby likes
Mix peanut butter and yogurt or fruit or vegetable puree. Add more water if you want the puree to be thinner.
Option 2: Peanut butter powder sauce
You will need:
2 tsp. powdered peanut butter or peanut flour
2-3 tbsp. of warm water, oatmeal, applesauce or mashed banana
Mix peanut butter or peanut flour with the water, oatmeal, applesauce or banana.
Let the mixture cool.
Add more water if you want the mixture to be thinner.
Option 3: Bamba® peanut butter puffs
You will need:
21 Bamba® peanut butter puffs
For babies aged 7 months and under, soften puffs in 4-6 tbsp. of water. Feed your baby one puff at a time.
For babies older than 7 months or who can eat dissolvable solids, feed puffs one at a time as normal.
A note about choking
Only give your baby smooth peanut butter.
Never give your baby chunky or crunchy peanut butter. Your baby can choke on the small peanut pieces.
Never give your baby whole peanuts or pieces of peanuts.
A note about food allergies
When your baby is trying a peanut product for the first time, it is important to watch him for signs of a food allergy. An allergic reaction can happen up to two (2) hours after trying a new food.
What is a food allergy?
A food allergy is when your body mistakes a certain food for something dangerous or unknown.
What are common signs of a food allergy?
Rash or hives (swollen red bumps) around the mouth or on the face or body
Swollen lips, tongue or face
Itching
Vomiting
Coughing
Change in skin color (blue or pale)
Wheezing (whistling sound when you breathe in)
Trouble breathing
Suddenly feeling tired or drowsy
Feeling like your body is going limp
What to do if your baby has an allergic reaction
Call 911 or take your baby to the emergency room right away.
If your baby’s allergist (allergy doctor) has created a Food Allergy Action Plan, follow the steps.
Helpful Tips and Tricks for Allergy Prevention
The dual exposure hypothesis is a belief that the ability to eat a food without a reaction (tolerance) is developed by having the GI tract see the food, whereas the potential for food allergy is developed by skin exposure to the food, which can be worsened by eczema or skin breakdown. It is important to try to prevent repeated skin exposure to foods that your child has not eaten yet. To try to limit skin exposure it is best to avoid eating allergenic foods in your child’s play area and restrict eating to the table. It is important to clean surfaces where food is prepared or eaten to help reduce your child’s environmental exposure to any food allergens. Limit snacking throughout the house to reduce the amount of food dust/particles that get on rugs, carpets, etc. It is best to wash your hands before applying lotions and creams and after handling foods.
It is best to introduce new foods to your child in an age-appropriate and culturally appropriate manner. The foods should be free of choking hazards, such as whole nuts and thinned by mixing them with formula, breast milk, or pureed fruits or vegetables. There is no reason to delay the introduction of foods that are considered “allergenic” like, tree nuts, eggs, dairy, soy, wheat, sesame, fish, and shellfish beyond 4-6 months of exclusive breat feeding. We recommend that you start with a tip of a teaspoon and double this every 10 to 20 minutes until your child has reached about 2 grams of the allergen protein. The amount of protein can be found on the nutrition label. For example, about 2 teaspoons for nut-butters, and sesame tahini) and about 1/3rd of a large egg have 2 grams of those specific proteins.
This initial food introduction can also be done more slowly if you or your provider have any concerns. It is important to be aware of the signs of an allergic reaction or anaphylaxis. These symptoms include hives, swelling, wheezing, cough, shortness of breath, nausea, vomiting, difficulty breathing, or loss of consciousness. If you have any concerns it is important to call 911. Please let your provider know if there are any signs of a reaction because a referral to an allergist will be made. If foods are tolerated it is important to keep them in the diet in regular intervals.
What Parents Should Know [English]: https://players.brightcove.net/6056665225001/5cmMqFpv5_default/index.html?videoId=6216466727001
What Parents Should Know [Spanish]:
https://players.brightcove.net/6056665225001/5cmMqFpv5_default/index.html?videoId=6216471682001
When is an infant ready for solid food, and what foods are developmentally appropriate?
If serving purees, aim for a smooth, even texture for your baby’s first few foods. First finger foods given to an infant should be very soft and easy to smash between your thumb and forefinger. For thicker foods, such as nut butters, it is best to thin them out with warm water or mix them into something smoother, such as applesauce. Some signs that a baby is ready to try solid foods are:
Some infants may show developmental signs of readiness before age 6 months but introducing complementary foods before age 4 months – or waiting until after 6 months – is not recommended.
The American Academy of Pediatrics states that: “There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease.”
Why is infant nutrition so important?
During an infant’s first year of life, infants should receive adequate amounts of essential nutrients because these foods are needed for healthy brain development and overall growth. Also, establishing healthy dietary patterns early in life can influence eating behaviors and overall health throughout the course of life.
Key Recommendation
Between ages 0-4 months: Exclusive breastmilk and/or formula feeding
Between 4-6 months: When your child is ready, start to introduce complementary foods
Between 6-12 months: Introduce complementary foods no later than 6 months
How do I know if my child is at high risk of developing a peanut allergy?
Recommendations: age-appropriate, peanut-containing foods should be introduced to the diet as early as age 4 to 6 months.
Establishing Healthy Dietary Patterns in an Infant’s First Year of Life
Dietary Components to encourage:
Dietary Components to limit:
Dietary Components to Avoid:
Introducing your child to the 9 major allergens:
The 9 major potentially allergenic foods should be introduced as complementary foods. There is evidence that introducing peanut-containing foods in an infant’s first year of life can reduce the risk that s/he will develop a peanut allergy There is no evidence that delaying introduction of allergenic foods beyond 6 months prevents food allergy.
Dot phrases modified from PDF found at: https://famp-it.org/wp-content/uploads/aap-statement-FAMPIT_Nutrition-Education_less12mo.pdf
Nutrition Education Adapted from the 2020-25 Dietary Guidelines’ New Chapter on Infant and Toddler Nutrition
Following healthy dietary patterns early on is important for maintaining proper growth, and nutritional needs, and reducing the risk for chronic disease later in life. You can help your child establish healthy eating habits by encouraging them to eat a variety of nutrient-dense foods from all the food groups. You can start by replacing less healthy snacks and ingredients with nutrient-dense alternatives!
Dietary Components to LIMIT:
Dietary Components to AVOID:
It is important to choose nutrient-dense foods from each food group!
Dot phrases modified from PDF found at: https://famp-it.org/wp-content/uploads/FAMPIT_Nutrition-Education_more12mo.pdf
For Early Food IntroductionThis section can be used to document the patient’s history of exposure or reaction to the most common allergens. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
Egg: [SELECT ONE: in diet and tolerated, never, tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Peanut: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Tree nut (e.g. almond, walnut, cashew, pecan, pistachio, hazelnut, brazil nut): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Dairy: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Wheat: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Soy: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Sesame: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Fish: (e.g. cod, tuna, salmon, haddock, tilapia, etc): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Shellfish: (e.g. shrimp, clam, lobster, crab, scallop, mussels): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
This text includes information on how to manage peanut introduction for infants at high risk of developing a peanut allergy, as well as how to guide parents on early food introduction for foods other than peanut. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
[PLEASE LEAVE IN IF PATIENT HAS NOT EATEN PEANUT]
Food Introduction (Peanut)
Per the addendum NIAID/LEAP guidelines, babies at high risk for peanut allergy should be introduced to peanut between 4-6 months of age in an age appropriate way (i.e. no loose nuts until age 5 and use of thinned out peanut butter). The Guidelines define high risk as patients with severe eczema, egg allergy, or both. Per the NIAID guidelines, if the eczema is severe then a peanut specific IgE and/or peanut skin testing should be done before introduction. [FOR PROVIDER: PLEASE CONSIDERING SPEAKING TO COMMUNITY ALLERGIST TO DISCUSS IF BLOOD TEST SHOULD BE SENT BY PROVIDER OR THE PATIENT SHOULD BE REFERRED TO AN ALLERGIST FOR SKIN TESTING].
Pathway:
Referral to Allergist
The patient is considered high risk for peanut allergy due to their severe eczema or IgE mediated food allergy to another food. The patient will be referred to an allergist for peanut skin testing evaluation. Until the testing has been done the patient should avoid any consumption of peanuts. After the peanut skin test the allergist will decide if it is safe for the patient to eat peanut. The patient was given a hand out on how to read a label and cross contact patient education. [NOTE TO DOCTOR TO PROVIDE LABEL READING AND CROSS CONTACT PATIENT EDUCATION].
Blood test
The patient is considered high risk for peanut allergy due to their severe eczema or IgE mediated food allergy to another food. Peanut IgE with reflex components was ordered. If the testing is negative (<0.35), please introduce peanut into the child’s diet using the introduction resource as guidance. If the testing is positive, an appropriate epinephrine auto-injector two pack will be prescribed and a referral for Pediatric Allergy/Immunology evaluation will be placed as well as an allergy anaphylaxis plan. Instructions on allergen avoidance and label reading will be provided. [NOTE TO DOCTOR TO PROVIDE LABEL READING, ALLERGY ANAPHYLAXIS PLAN AND CROSS CONTACT PATIENT EDUCATION]. If the patient is able to introduce peanut at home the office will provide a hand out on peanut introduction at home.
Food Introduction (Allergenic Foods OTHER THAN Peanut)
The 2019 AAP Clinical Report recommends dietary interventions to prevent atopic disease, and states that there is no evidence that delaying introduction of other allergenic foods beyond 4-6 months prevents atopic disease. The dual exposure hypothesis theorizes that tolerance to a food is developed by exposure through the GI tract, whereas sensitization to a food is developed by cutaneous exposure. There is also data to show that the sensitization is increased by eczema and compromises in the skin barrier. Therefore the family was counseled that repeated cutaneous exposure to highly allergenic foods not yet eaten can lead to sensitization and if there are any concerns please call the office. Discussed that in order to limit the child’s cutaneous exposure to allergenic foods not eaten it is best to avoid them in the child’s play area; restrict eating to a table that is thoroughly cleaned after ingestion as well as dishware and wash hands after handling foods and before touching the child or applying creams or lotions.
We recommend food introduction in an age-appropriate (and culturally appropriate) manner free of choking hazards (i.e. do not give whole peanuts, tree nuts, and/or seeds; recommend thinned nut butter mixed in cereal/formula/breastmilk/pureed fruit or vegetables). We recommend gradual introduction, starting with a pea sized amount and doubling this every 10 to 20 minutes until they have reached about 2 tablespoons, but this can be done more slowly in a higher risk patient. When introducing foods at home the family was counseled to be aware of the signs of anaphylaxis. Symptoms of anaphylaxis can include hives, swelling, wheezing, cough, shortness of breath, nausea, vomiting, difficulty breathing, dizziness, or loss of consciousness. If foods are introduced and tolerated it is important to keep them in the diet at a regular interval.
If there is any concern please call our office at [INSERT PHONE NUMBER] or call 911.
Early Introduction of Complementary FoodsThe American Academy of Pediatrics states that: “There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease.”
When counseling families on food introduction, it is important to discuss how to tell when an infant is ready for solid food and what foods are developmentally appropriate. If serving purees, families should aim for a smooth, even texture for the baby’s first few foods. First finger foods given to an infant should be very soft and easy to smash between the thumb and forefinger. For thicker foods, such as nut butters, it is best to thin them out with warm water or mix them into something smoother, such as applesauce. Some signs that a baby is ready to try solid foods are:
Some infants may show developmental signs of readiness before age 6 months, but introducing complementary foods before age 4 months – or waiting until after 6 months – is not recommended (1). Chapter 2 of the USDA Dietary Guidelines for Americans 2020-2025 encourage the introduction of potentially allergenic foods along with other complementary foods. In addition to peanuts, the Dietary Guidelines for Americans 2025 recommend eggs, cow milk products, tree nuts, wheat, crustacean shellfish, and soy be introduced when other complementary foods are introduced. Although only peanut has guideline-based recommendations for quantity and frequency (2 grams of peanut protein, 3x a week), there are currently no guideline recommendations for quantity or frequency of other allergenic foods. Looking at available studies, including the LEAP study (1), EAT study (2), and others, 2 grams of allergen protein twice a week may be a reasonable target. For foods like egg, dairy, wheat, and soy, more frequently may make sense, as these foods are ubiquitous in our diets. In the case of fish and shellfish, slightly less frequently (e.g., once a week) may equally be reasonable based on family and household consumption and accessibility.
One may determine the grams of protein by using the specification on the nutrition label of the grams of protein in a particular serving size of the food, and utilizing this measurement to calculate the goal dose of 2 grams. For the case of nut butters and sesame tahini, a little more than 2 teaspoons may be the target. In the case of egg, about 1/3 of a large egg may be the target. For fish and shellfish, in general, the serving size is about the size of the palm of a child’s hand; however, 2 grams is also the goal.
There are many factors to take into account when deciding what foods parents should introduce to their children, and when each food should be introduced. Because there are no official guidelines for most foods, it is important to utilize a shared decision-making process with the family and take into account preferences they may have. This allows for the personalized application of recommendations based on the most current and promising research. See Shared Decision Making for the Allergist for the full study (3).
An important aspect to consider when deciding what foods to introduce is to consider what foods the family eats regularly, as environmental exposures to allergenic foods may be a risk factor in developing allergies. It is also important to consider what foods fit with a family’s preference, taste, and culture.
Under the dual-exposure hypothesis, if a child avoids oral exposure of an allergenic food (e.g. peanuts), but experiences frequent environmental exposures through their skin, they may be more likely to develop a sensitivity or allergy to peanut. When a child is exposed to a food allergen via the skin (e.g. food touches the skin), the immune cells of the skin are more likely to cause sensitization to that food. This is especially true if the skin is inflamed or irritated, as is the case with eczema. However, when a child is exposed to a specific food via the oral route (e.g. food is consumed), the immune cells in the digestive system create a tolerance to that food. (4,5)
Under the dual-exposure hypothesis, if a child does not already have an allergy and is routinely exposed to the allergen (e.g. peanut) orally, through the gut this may lead to induction of tolerance to that allergen. T-regulatory cells within mesenteric lymph nodes may play a role (lack).
References:
The USDA HHS Dietary Guidelines for Americans 2020-2025 encourages the introduction of complementary foods at about 6 months and recommends that potentially allergenic foods be introduced along with other complementary foods. In addition to peanuts, the Dietary Guidelines for Americans 2025 recommend eggs, cow milk products, tree nuts, wheat, crustacean shellfish, and soy be introduced when other complementary foods are introduced. Some infants may show developmental signs of readiness before age 6 months, but introducing complementary foods before age 4 months – or waiting until after 6 months – is not recommended (1).
This section provides a summary of the current research for other common allergens as well as links to the papers cited.
Reference
There is moderate evidence that egg introduction at around 6 months is associated with a lower prevalence of egg allergy versus later introduction.
Egg allergy currently impacts approximately 2% of the US population under 5 years of age. Current guidelines emphasize the importance of early introduction of highly allergenic foods, including egg, as a means of food allergy prevention. This shift in guidance has led to a younger patient population presenting with egg allergy concerns, and currently, there is limited research on egg restriction’s impact on the nutrition, growth, and development of infants and toddlers.
Egg products can be prepared in a variety of ways, including as baked-in egg, and lesser cooked forms of egg including pancakes/waffles, French toast, and scrambled/fried egg. Baked egg is egg as a minor ingredient in a baked good that is fully cooked through in dry oven heat, while scrambled/fried egg is an egg that has been cooked on a stove top heat. If a patient reacts to scrambled egg (one of the lesser cooked forms of egg), but is able to tolerate more cooked forms of egg such as pancakes/waffles, it is beneficial to maintain the least cooked form of egg tolerated in that patient’s diet.
There is some evidence that early and regular exposure to cow’s milk protein as a supplement to breastfeeding may promote tolerance. Delayed introduction was associated with higher rates of cow’s milk allergy.
Cow’s milk protein can be served to infants in the form of plain, whole milk yogurt, soft, pasteurized cheeses including ricotta, mascarpone, and mozzarella, or whole cow’s milk used as an ingredient in oatmeal or chia seed pudding. Do not serve cow’s milk as a beverage to infants under the age of 12 months.
Early introduction of sesame is safe, and there is some evidence that it may help reduce sensitization.
Sesame should be served in its paste form (i.e., “tahini”) and either drizzled over soft-cooked vegetables, spread into a thin layer on strips of toast, mixed into a familiar puree, or thinned with a little breast milk, formula, or water and served on a spoon.
There is some evidence that the introduction of wheat cereal before 6 months of life is associated with a reduced risk of wheat allergy.
Wheat can be served in the form of fortified infant wheat cereal, wheat germ mixed into a familiar puree, tender-cooked pieces of pasta, or strips of whole wheat toast topped with mashed avocado or another nutritious spread.
There are no studies specific to the timing of introducing tree nuts or soy. There is also no data to support delayed introduction.
Tree nuts can be served ground into a powder and mixed into a familiar puree or sprinkled over soft-cooked vegetables. Alternatively, tree nuts can be processed into a nut butter and spread into a thin layer on toast strips, mixed into a familiar puree, or thinned with a little breast milk, formula, or water before serving to an infant.
Soy can be served as silken tofu served on a spoon, in strips of firm tofu, or as mashed or pureed edamame.
Recent studies, including the Learning Early About Peanut (LEAP) study, demonstrate that early introduction of peanuts in children considered at high risk of developing peanut allergy can decrease peanut allergy. Based on the LEAP study, the NIAID Addendum Guidelines were released in 2017 and outline strategies for the early introduction of peanuts into the diets of all children in the United States [3]. They currently recommend the introduction of developmentally appropriate forms of peanut (with a goal of about 2grams of peanut protein, 3x a week) and outline timing, developmentally appropriate forms of peanut, how to assess risk, etc [3].
The American Academy of Pediatrics (AAP), the US Department of Agriculture (USDA), and the US Department of Health and Human Services (HHS) have released guidance documents that support the above recommendations. The NIAID guidelines suggest screening in high-risk children, those with severe eczema and/or an egg allergy, and no screening is necessary for children with no risk factors. Screening is also unnecessary for positive family history of allergy, and mild and moderate eczema.
The AAP released a 2019 Clinical Report that endorsed the NIAID Addendum Guidelines. This report includes the mention of potential issues with the screening recommendation. In this report, they stated that “It is hoped that the screening process for the infants at highest risk (specific IgE measurement, skin-prick test, and oral food-challenge test) will not be a deterrent or generate “screening creep” for infants not in the high-risk category.” These guidelines may be difficult to follow in communities without access to the medical care needed for implementation. Also relevant is the statement, “The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate” (6).
Main Takeaways
| Infant Criteria | Recommendations | Earliest Age of Peanut Introduction |
|---|---|---|
| Severe eczema, egg allergy, or both | Strongly consider evaluation with peanut-specific IgE and/or skin prick test and, if necessary, an oral food challenge. Based on test results, introduce peanut-containing foods. | 4 to 6 months |
| Mild to moderate eczema | Introduce peanut-containing foods. | Around 6 months |
| No eczema or any food allergy | Introduce peanut-containing foods. | Age appropriate and in accordance with family preferences and cultural practices |
Infants considered high-risk for peanut allergy are those with severe eczema, egg allergy, and/or any other known IgE-mediated food allergy. The NIAID defines severe eczema as “Persistent or frequently recurring eczema with typical morphology and distribution assessed as severe by a healthcare provider and requiring frequent need for prescription-strength topical corticosteroids, calcineurin inhibitors, or other anti-inflammatory agents despite appropriate use of emollients (3).” Hospital systems may have varied approaches to implementing the NIAID guidelines.
According to the guidelines, referring them to a pediatric allergist for evaluation and possible skin testing is recommended. You can also send a blood test for peanut-specific IgE, and if that is positive, order a referral for a pediatric allergist.
If the peanut-specific IgE is negative, you can advise the family to introduce peanuts at home when the infant is 4-6 months of age or ready to try solid food. You can provide them with a copy of the handout entitled “Introducing Peanut Products to Your Baby.”
Feel free to view the sample approach by Lurie Children’s Hospital on implementing the NIAID guidelines within their system.
These infants are those with mild to moderate eczema or another food allergy. For these infants, you can recommend the families introduce peanuts at home, starting at 6 months of age, and follow the family’s preferences and cultural practices. Consider referring the family to an allergist to manage the known food allergy, but do not delay peanut introduction. Provide them with a copy of the handout entitled “Introducing Peanut Products to Your Baby”.
Infants who have no eczema or food allergy are considered low risk. For these infants, recommend families to introduce peanuts at home according to their individual preferences and cultural practices. Provide them with a copy of the handout entitled “Introducing Peanut Products to Your Baby”.
Main Takeaways
The American Academy of Allergy, Asthma, and Immunology, the American College of Asthma, Allergy, and Immunology, and the Canadian Society of Allergy and Clinical Immunology support the recent publication- A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition that de-emphasizes the need for screening that is suggested in the NIAID Addendum Guidelines.
This consensus document recommends that all infants, irrespective of relative risk, introduce peanut-containing foods and egg at 4-6 months when the infant is developmentally ready for complementary foods. Also highlighted is the importance of shared decision-making as families consider the introduction (4).
Currently, the United States is the only country with a screening step. In countries including Australia, Israel, and the United Kingdom without similar screening steps that recommend peanut introduction, reactions are rare. Specifically, the British Society of Allergy and Clinical Immunology (BSACI) guidelines state– “The benefits of allergy testing in higher-risk babies before introducing egg or peanut needs to be balanced against the risk this could cause a delay (due to lack of available testing) and increase the risk of food allergy”(5). Even in infants who already have food allergies, including those with severe eczema, “The risk of a severe reaction (anaphylaxis) is low (1-2 per 1000) in these babies” (5).
Since the 2017 release of the NIAID guidelines and the 2019 release of the American Academy of Pediatrics Clinical Report, Keet and colleagues have published on the use of Arah2, and have reported that it is a more sensitive and specific screening tool for clinically relevant peanut allergy as compared to peanut-specific IgE or peanut skin prick test in high-risk infants (6).
Main Takeaways
Whether you adhere to the NIAID Addendum Guidelines or the Consensus Approach, it is important to target peanut introduction between 4 to 6 months of age.
In the recent publication Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy, Keet and colleagues demonstrated that in kids with severe eczema, the chance of peanut allergy significantly increases with time. While less than 20% of children under 6 months had a positive oral food challenge to peanuts, about 50% of children over 8 months had a positive oral food challenge to peanuts (7). These findings reinforce the importance of not delaying the introduction of peanuts.
You can start talking about peanut introduction with families even in the newborn period and help families anticipate the introduction of peanut-containing foods, as well as other allergens, as early as 4-6 months of life, especially in high-risk infants.
Main Takeaways
References
© 2024 MassGeneral Hospital for Children Food Allergy Center. All rights reserved.
