Newborn Nursery

Introduction 

The prevention of food allergies is a complex and quickly-changing issue that is not always addressed in the Newborn Nursery setting. There is evidence suggesting that delayed introduction of peanut, eggs, and other allergens may increase the likelihood of allergies to those foods. Early educational intervention in the newborn nursery may help prepare families for important food introductions without delay. Recent guidelines from the American Academy of Pediatrics released in 2022 recommend exclusive breastfeeding for the first 6 months of life while also introducing peanut-containing food as early as 4 months of life for high-risk infants. 

Guidelines History

Image 1: Timeline of Food Allergy Recommendations from 2000-2020 

In 2000, there were guidelines published which recommended the delaying the introduction of potentially allergenic to infants that were deemed high-risk. Following these recommendations, food allergies continue to rise. In 2008, the American Academy of Pediatrics withdrew those recommendations. They published a clinic report stating that “there is no evidence that delaying the introduction of allergenic foods including peanuts, eggs, and fish beyond 4-6 months prevents atopic disease”. 

In 2015, the Learning Early About Peanut (LEAP) study found that early introduction of peanut-containing food decreased the likelihood of developing peanut allergy. Based on these findings, the National Institute of Allergy and Infectious Diseases (NIAID) published the addendum guidelines for the prevention of peanut allergy in the United States which outlines strategies for the early introduction of peanut into the diet of all children in the United States. Subsequently, 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.

Skin Exposures’ Role in Allergies 

While early oral introduction of allergens like peanut may help induce tolerance to food, routine skin exposure to food may increase the risk of developing IgE to the food (sensitization) and ultimately the development of a food allergy (1,2,3).

Studies have demonstrated the presence of food proteins in the environment which then can be transferred onto an infant’s skin and mucous membranes. While the majority of studies have been done with peanuts, information learned may be helpful when approaching other foods (1).  There is evidence of peanut protein on high touch surfaces in kitchens, detected after peanut is consumed (5). Dust samples in carpets, mattresses, and play space have also been detected (3,4,5). Peanut proteins have also been shown on hands (6) and in saliva after consuming peanut (8). All can be sources of environmental food exposures. Cleaning surfaces and hands that come in contact with peanut may assist with decreasing environmental exposures to peanut and other allergens (5,6).

Several studies have linked the presence of environmental peanut allergen with sensitization and food allergy to peanut (1,3,4,7) Although this association has been shown in those with healthy skin, eczema may increase risk (4). Skin barrier dysfunction and inflammation may be components of eczema that increase risk of sensitization to environmental food exposure. Although the majority of studies have been on peanut similar trends likely exist for other foods as well.

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. (12,13)

Advise caregivers to wash their hands before applying creams or moisturizers and prior to diaper changes, especially after handling allergens.

Breastfeeding and Mother’s Diet 

The American Academy of Pediatrics published the policy statement “Breastfeeding and the Use of Human Milk” in 2022, which recommended exclusive breastfeeding through 6 months of age with appropriate complementary foods, including allergens, introduced at this time. Their recommendations suggest the earlier introduction of peanut-containing foods as early as 4 months of life to high-risk children in a consistent fashion with the NIAID addendum guidelines. 

Neither breastmilk nor formula reduces the risk of allergies. Breastmilk is known to decrease the risk of other allergies and eczema. There is no evidence that a mother should avoid allergens during lactation or while pregnant as it has not been shown to reduce atopic disease. 

Complimentary Foods 

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.”

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. An infant’s first foods should have a very smooth texture and not require chewing. For thicker foods, such as nut butters, it is best to thin them out with breast milk, formula, warm water or mix them into something smoother, such as applesauce. Some signs that a baby is ready to try solid foods are:

• Loss of tongue-thrust reflex
• Good head and neck control
• Ability to sit on their own with minimal support
• Opens mouth and leans forward when offered food
• Can 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 (9). 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 (9), EAT study (10), 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.

You can refer to the nutrition label for grams of protein in a particular serving size of the food and calculate the goal dose of 2 grams. In 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 that go into the decision about what foods should be introduced and when. Because there are no official guidelines for most foods, it is important to utilize a shared decision-making process between the family and the pediatrician. 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 (11).

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 for developing allergies. It is also important to consider what foods fit with a family’s preferences, tastes, and culture.

Barriers to Implementation and Roles of Newborn Providers 

Potential parental anxiety about early introduction of allergens along with possible unfamiliarity or discomfort with these guidelines on the part of the pediatricians can delay introduction beyond the recommended time frame. There is evidence that for every month that passes after six months without introducing peanut-containing food, there is a 30% increase in odds of developing a peanut allergy per month. The NIAID has a variety of recipes that can help familiarize parents and providers with safe introduction methods.  

Newborn providers are often the first healthcare individuals that new parents will interact with. They often lay the groundwork for healthy eating habits. It is important for newborn providers to outline the guidelines for early introduction and the importance of handwashing after food handling. They can also provide recommendations to discuss these topics with their pediatricians in the first few months and answer any questions the caregiver might have now.  

Newborn Staff Training: Advice for Allergy Prevention

References

1. Sheehan WJ, Taylor SL, Phipatanakul W, Brough HA. Environmental food exposure: what is the risk of clinical reactivity from cross-contact and what is the risk of sensitization. The Journal of Allergy and Clinical Immunology: In Practice. 2018 Nov 1;6(6):1825-32.
2. Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.
3. Brough HA, Kull I, Richards K, Hallner E, Söderhäll C, Douiri A, Penagos M, Melen E, Bergström A, Turcanu V, Wickman M. Environmental peanut exposure increases the risk of peanut sensitization in high‐risk children. Clinical & Experimental Allergy. 2018 May;48(5):586-93.
4. Brough HA, Liu AH, Sicherer S, Makinson K, Douiri A, Brown SJ, Stephens AC, McLean WI, Turcanu V, Wood RA, Jones SM. Atopic dermatitis increases the effect of exposure to peanut antigen in dust on peanut sensitization and likely peanut allergy. Journal of Allergy and Clinical Immunology. 2015 Jan 1;135(1):164-70
5. Brough HA, Makinson K, Penagos M, Maleki SJ, Cheng H, Douiri A, Stephens AC, Turcanu V, Lack G. Distribution of peanut protein in the home environment. Journal of allergy and clinical immunology. 2013 Sep 1;132(3):623-9.
6. Perry TT, Conover-Walker MK, Pomés A, Chapman MD, Wood RA. Distribution of peanut allergen in the environment. Journal of Allergy and Clinical Immunology. 2004 May 1;113(5):973-6.
7. Brough HA, Liu AH, Sicherer S, Makinson K, Douiri A, Brown SJ, Stephens AC, McLean WI, Turcanu V, Wood RA, Jones SM. Atopic dermatitis increases the effect of exposure to peanut antigen in dust on peanut sensitization and likely peanut allergy. Journal of Allergy and Clinical Immunology. 2015 Jan 1;135(1):164-70.
8. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. Journal of Allergy and Clinical Immunology. 2006 Sep 1;118(3):719-24.
9. Du Toit, G., Roberts, G., Sayre, P.H., Bahnson, H.T., Radulovic, S., Santos, A.F. et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015; 372: 803–813.
10. Perkin, M.R., Logan, K., Tseng, A., Raji, B., Ayis, S., Peacock, J. et al. Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016; 374: 1733–1743
11. Blaiss MS, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Annals of Allergy, Asthma & Immunology. 2019 May 1;122(5):463-70.
12. Du Toit G, Sampson HA, Plaut M, Burks AW, Akdis CA, Lack G. Food allergy: Update on prevention and tolerance. Journal of Allergy and Clinical Immunology. 2018 Jan 1;141(1):30-40.
13. Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.
14. 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.