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For Early Food Introduction

Allergenic Food History:

This 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]

Allergenic Introduction Assessment and Plan:

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.

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For Early Food Introduction

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

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.

Peanut Introduction as per NIAID/LEAP

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.

Food Introduction (other than peanut)

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.

Videos for Parents for Peanut Introduction as per Addendum Guidelines

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

Introducing Complimentary Foods

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:

• Good head and neck control
• Ability to sit on their own with minimal support
• Opens mouth and leans forward when offered food
• Able to grasp larger objects and bring them up to the mouth

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.

Nutrition Guidance for Children During their First 12 Months of Life

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

• What form of milk? Human breast milk, iron-fortified infant formula, or a combination of both
• Do I need to supplement the milk with anything?
  •  You may need to provide a vitamin D supplement, depending on which form of milk you choose
    •  For exclusive human breastmilk feeding, vitamin D supplement of 400 IU per day
    • For breast milk/formula mixed feeding, vitamin D supplement of 400 IU per day
    • For exclusive iron-fortified formula feeding, no vitamin D supplement is needed since infant formula is vitamin-fortified

Between 4-6 months: When your child is ready, start to introduce complementary foods

• How do I know when my child is ready?
  • The ages infants show signs of readiness vary and are typically between ages 4 and 6 months.
  • Signs that your child may be ready for complementary foods include:
    • Being able to control the head and neck
    • Sitting up alone or with support
    • Bringing objects to the mouth
    • Trying to grasp small objects, such as food or toys
    • Swallowing food rather than pushing it back out onto the chin
    • Swallowing food rather than pushing it back out onto the chin
  • There is no evidence that delaying the introduction of allergenic foods helps prevent food allergy (Please see information specific to high-risk infants below)

Between 6-12 months: Introduce complementary foods no later than 6 months

• What complementary foods should I give my child?
  • Infants should be encouraged to consume a variety of complementary foods
    • Introduce iron-rich foods: meats seafoods, iron-fortified infant cereals
    • Introduce zinc-rich foods: meats, beans, zinc-fortified infant cereals
    • Introduce a variety of foods from all food groups: protein, fruits and vegetables, dairy, grains
    • Introduce potentially allergenic food groups: egg, dairy, peanuts, tree nuts, soy, shellfish, fish, wheat, sesame.

How do I know if my child is at high risk of developing a peanut allergy?

• Risk factors: If your child has severe eczema, egg allergy, or both, s/he may be at a higher 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:

• A wide variety of fruits, especially berries and whole fruits
• A wide variety of vegetables from each vegetable group, which includes dark green (ex. broccoli), red/orange (ex. carrots), legumes (i.e., beans, peas, lentils), starchy vegetables (ex. potatoes)
• Whole grains
• Unprocessed meat

Dietary Components to limit:

• Processed meats (ex. cold cuts)
• Refined grains
• 100% fruit juice
• Foods with high sodium content
• Foods containing added sugars

Dietary Components to Avoid:

• Honey and unpasteurized foods and beverages
• Sugar-sweetened beverages (ex. soda, sweet tea)
• Liquid cow’s milk, fortified soy beverages, and milk alternatives (such as plant-based milk) in place of breast milk or infant formula
• Caffeinated beverages
• Seafood with high mercury content
• Loose nuts and other choke-risk foods

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.

1. Dairy
2. Egg
3. Peanuts
4. Tree Nuts
5. Soy
6. Wheat
7. Fish
8. Shellfish
9. Sesame

Dot phrases modified from PDF found at: https://famp-it.org/wp-content/uploads/aap-statement-FAMPIT_Nutrition-Education_less12mo.pdf

Nutrition Guidance for Children After Their First Birthday

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:

• Processed meats (e.g., cold cuts)
• Foods with high sodium content
• Food containing added sugars
• 100% fruit juice, even if it doesn’t have added sugar

Dietary Components to AVOID:

• Sugar-sweetened beverages (e.g., soda, juice drinks, sports drinks)
• Caffeinated beverages
• Alcoholic beverages
• Seafood with high mercury content
• Loose nuts and other choke-risk foods

It is important to choose nutrient-dense foods from each food group!

• Fruit
  • All fresh, frozen, canned in 100% fruit juice, and dried fruits
  • Examples: apples, pears, oranges, grapefruit, berries (i.e., blueberries, raspberries, strawberries), bananas, melons, peaches, plums, raisins, papaya, pomegranate
  • Encourage whole fruits, limit fruit juice to 4 ounces per day
• Veggies
  • Dark Green Vegetables: broccoli, bok choy, collards, kale, mustard greens, spinach
  • Red & Orange Vegetables: carrots, pumpkin, squash, bell peppers, sweet potatoes, tomatoes
  • Beans, Peas, Lentils: black beans, garbanzo beans, edamame, kidney beans, lentils, split peas, pinto beans
  • Starchy Vegetables: plantains, white potatoes, corn, yam, yucca, water chestnuts
  • Other Vegetables: asparagus, beets, Brussels sprouts, cauliflower, green beans, eggplant, cucumber, turnips, seaweed
• Dairy
  • All fluid, dry, or evaporated milk (includes lactose-free/reduced products and fortified soy beverages)
  • Examples: milk, buttermilk, yogurt, kefir, cheese
  • Limit cream, sour cream, frozen yogurt, ice cream, and cream cheese
• Grains
  • Whole grains: brown rice, oats, quinoa, whole-grain cereals/crackers, dark rye, barley (not pearled), whole-grain cornmeal, whole-wheat bread
  • Refined grains: white rice, white breads, refined-grain cereals/crackers, pasta, cream of wheat/rice, corn grits
  • Encourage whole grains, limit refined grains
• Protein 
  • Meats, Poultry, Eggs: beef, goat, lamb, pork, chicken, duck, goose, turkey, organ meats, chicken eggs and other birds’ eggs
  • Seafood: anchovy, black sea bass, clams, cod, crab, flounder, haddock, lobster, oyster, salmon, sardine, scallop, shrimp, sole, squid, light tuna
    *avoid seafood high in mercury
  • Nuts, Seeds, Soy: tree nuts, peanuts, nut butters, seeds, seed butters, tofu, tempeh, soy protein isolate, soy concentrate

Dot phrases modified from PDF found at: https://famp-it.org/wp-content/uploads/FAMPIT_Nutrition-Education_more12mo.pdf