Several years ago, there was a major shift in our understanding of the relationship between starting solid foods and the development of allergic diseases, including asthma, eczema, and allergies including food allergies. In the past, it was thought that delaying the introduction of foods prone to cause allergies (egg, fish, cow’s milk, peanut protein, tree nut protein, soy, wheat, shellfish) until 2-3 years of age would reduce the development of allergic diseases. Research, however, began to show that the opposite was true. In 2008, several expert committees issued similar guidelines stating that there was no benefit to delaying allergenic foods. However, these guidelines did not specify how and when to introduce allergenic foods.
Now, an expert committee of allergists has developed more specific guidelines on when and how to start solids, especially allergenic foods. They also attempted to better define which infants should be considered high risk. Interestingly, the goal of the recommendations is the primary prevention of allergic disease by optimal nutrition.
The recommendations include:
- Avoiding highly allergenic foods during pregnancy is not recommended. They do not need to be avoided during lactation. More research on peanut protein ingestion during pregnancy and lactation is needed.
- Exclusive breastfeeding for 4-6 months is recommended; it reduces the risk of wheezing, eczema, and cow’s milk allergy.
- If a high-risk infant is not breastfed, using hydrolyzed formula appears to help prevent allergic disease and cow’s milk allergy. Soy and amino acid formulas do not appear to have any benefit.
- Complementary (baby foods in addition to breastmilk or formula) should be introduced between 4-6 months of age.
- Introduce single-ingredient cereals, fruits, and vegetables between 4-6 months of age, one new food every 3-5 days.
- Delaying introduction of high-risk foods may actually increase the risk of food allergy or eczema.
- Acidic foods, such as citrus fruits, berries, and tomatoes, commonly cause reactions due to acid content or chemicals that cause histamine release. They can cause a rash around the mouth, diaper rash, or hives, which are not true allergic reactions. These foods should not be delayed due to allergy concerns.
- Do not introduce a highly allergenic food as one of the first complementary foods. It should be introduced once a few typical foods are introduced and well-tolerated.
- Cow’s milk should not be main drink before 1 year of age. Dairy products, yogurt and cheese, are safe complementary foods.
- Nuts are choking hazards nut butters and other formulations may be given as complementary foods.
They also offer specific advice how to introduce allergenic foods:
- Introduce an initial taste of highly allergenic foods at home, not in a restaurant or day care.
- Parents should be aware that for some foods like peanuts the reactions most often occur from the first exposure.
- If small taste is tolerated without any reaction, gradually increase the amount given.
- Give new foods once every 3-5 days.
- If an infant has moderate to severe eczema despite good skin management, or has an allergic reaction to a food, delay introducing any highly allergenic foods until seen by an allergy specialist.
- Children with one food allergy are at risk for others and evaluation by a specialist is recommended.
- If a child has blood allergy tests done which are positive for something not yet introduced in the diet, or negative for something that seemed to cause a reaction, evaluation by a specialist is recommended for food challenges or skin testing, confirmation, medication to treat severe reactions, and follow-up for possible resolution over time.
- A child with a sibling with peanut allergy has a 7% risk of having peanut allergy. This child may have food allergy evaluation before introducing peanut but it is not necessarily recommended. Parents should be advised that no fatal reactions have happened from first exposure, the risks of introducing peanut protein at home are low, and trying a taste at home first before allergy testing is encouraged.
These guidelines are simple, straightforward, and helpful. Both routine solid foods and highly allergenic foods should be introduced no earlier than 4 months and starting no later than 6 months of age. Delaying allergenic foods increases the risk of allergic disease. Introduce foods prone to cause allergy carefully at home, in increasing amounts, as soon as typical foods are tolerated. Children with moderate to severe eczema or a history of food allergy or possible allergy should see an allergist.
