clinical topic updates

Early Nutritional Intervention and Guidance on Food Allergy Prevention

by David M. Fleischer, MD

Overview

Historically, parents were advised to delay the introduction of foods commonly associated with allergy, in accordance with the school of thought that was predominant at the time. Today’s guidance, which encourages earlier, natural, age-appropriate food introduction, is more evidence based and reflects data from clinical studies. Still, there is a recognition that not all cases of food allergy will be prevented by early nutritional intervention.

Expert Commentary

David M. Fleischer, MD

Section Head, Allergy and Immunology
Professor of Pediatrics
Director, Allergy and Immunology Center
Children’s Hospital Colorado
University of Colorado Denver School of Medicine
Aurora, CO

“The latest guidance really gives parents a window of opportunity for introducing foods that are associated with allergy, such as peanuts. It does not have to be precisely at 4 to 6 months; one could introduce peanuts from 6 to 11 months of age.”

David M. Fleischer, MD

The current consensus is that parents should try to introduce foods such as peanuts before the age of 1 year, and they are encouraged to make it a natural introduction. In the early 2000s, parents were encouraged to delay the introduction of peanuts, tree nuts, and eggs until ages 2 to 3 years. At that time, the rationale was that a delayed introduction may allow for gut and immune system maturation and might help in food allergy prevention.

However, starting in 2008, observational studies began to emerge, suggesting that early food introduction may actually lower the risk of common food allergies, such as milk, egg, or peanut, and the guidance was therefore changed. Although this relatively rapid change was likely a cause of confusion and perhaps some skepticism initially, I believe that, today, we have gotten to the point where the current recommendations are more trusted, in part due to the findings of randomized clinical studies such as the LEAP trial. The LEAP trial randomized 640 infants between 4 and 11 months of age, with severe eczema and/or egg allergy, to consume or avoid peanut-containing foods until 60 months of age, when a peanut oral food challenge was conducted to determine the prevalence of peanut allergy. The prevalence of peanut allergy at 60 months of age was 13.7% in the peanut avoidance group and 1.9% in the peanut consumption group. In 2017, guidelines issued by the National Institute of Allergy and Infectious Diseases recommended peanut introduction between the ages of 4 and 6 months.

Additionally, pediatricians are on the front lines, talking to parents about early nutrition, and I think that we continue to refine the guidelines to be sensitive to that fact. For instance, we do not want to be asking pediatricians to perform tests and/or to schedule observed food introductions when they are not set up to do that. The latest guidance really gives parents a window of opportunity for introducing foods that are associated with allergy, such as peanuts. It does not have to be precisely at 4 to 6 months; one could introduce peanuts from 6 to 11 months of age. A 2021 consensus statement went beyond peanuts to recommend the early introduction of eggs and other top food allergens as a means of reducing the development of allergies to those foods.

Not every case of food allergy will be prevented, but our feeling is that parents should try to have children eat common food allergens before the age of 1 year, as naturally as possible and without worry over some strict frequency or the number of grams eaten. If the child enjoys peanut butter, for example, encourage them to eat it early and often, but do not stress about giving them exactly 2 grams 3 times a week. While parents do not necessarily have to bring their child to an allergist for testing prior to early food introduction, some may want to do so. However, allergy testing should be limited in the setting of an infant not having eaten a food such as peanut. In the event of a positive test but an absence of a clinical reaction to peanuts, that positive test is more likely to be a false positive, so an allergist-supervised oral food challenge would be warranted in such a case to determine whether or not the patient has a true allergy. And, if a child has already reacted to a food, they should consider being seen by an allergist before other major food allergens are introduced.

Any child can benefit from early food introduction, regardless of whether they are considered to be high risk. If parents are concerned about introducing a particular food to their child, pediatricians can refer them to an allergist who does infant oral food challenges. If the child has a reaction, the most common symptoms will be vomiting and hives. Anaphylaxis is a possibility even in infants and toddlers, but life-threatening reactions in infants are uncommon. Promoting early food introduction should decrease the occurrence of food allergies; however, early exposure is only 1 factor that is involved, and other factors play a role in the development of food allergies. New data are likely to show that introducing foods early is just a single aspect of preventing these allergies.

References

de Silva D, Halken S, Singh C, et al; European Academy of Allergy, Clinical Immunology Food Allergy, Anaphylaxis Guidelines Group. Preventing food allergy in infancy and childhood: systematic review of randomised controlled trials. Pediatr Allergy Immunol. 2020;31(7):813-826. doi:10.1111/pai.13273

Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol. 2008;122(5):984-991. doi:10.1016/j.jaci.2008.08.039

Du Toit G, Roberts G, Sayre PH, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy [published correction appears in N Engl J Med. 2016;375(4):398]. N Engl J Med. 2015;372(9):803-813. doi:10.1056/NEJMoa1414850

Fleischer DM, Chan ES, Venter C, et al. A consensus approach to the primary prevention of food allergy through nutrition: guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract. 2021;9(1):22-43.e4. doi:10.1016/j.jaip.2020.11.002

Fleischer DM, Sicherer S, Greenhawt M, et al. Consensus communication on early peanut introduction and prevention of peanut allergy in high-risk infants. Pediatr Dermatol. 2016;33(1):103-106. doi:10.1111/pde.12685

Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020

Koplin JJ, Osborne NJ, Wake M, et al. Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol. 2010;126(4):807-813. doi:10.1016/j.jaci.2010.07.028

Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel. J Allergy Clin Immunol. 2017;139(1):29-44. doi:10.1016/j.jaci.2016.10.010

Wei-Liang Tan J, Valerio C, Barnes EH, et al; Beating Egg Allergy Trial (BEAT) Study Group. A randomized trial of egg introduction from 4 months of age in infants at risk for egg allergy. J Allergy Clin Immunol. 2017;139(5):1621-1628.e8. doi:10.1016/j.jaci.2016.08.035

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