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JACI: No reason to delay allergy-prone foods

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Conflicting advice

Most parents have heard that guidelines from the American Academy of Pediatrics (AAP), published in 2000, advise delaying the introduction of highly allergenic foods in high-risk infants to prevent development of allergies: one year for cow's-milk dairy; two years for eggs; and three years for fish, tree nuts and peanuts. But an article that stands in stark contrast to the AAP guidelines was quietly released last year.

The article that could affect the way parents introduce highly allergenic foods to their babies was published in the Journal of Allergy and Clinical Immunology (JACI) in January 2013. JACI is the highly regarded journal of American Academy of Asthma, Allergy and Immunology (AAAAI). The article says that no current evidence suggests that delaying the introduction of solid foods beyond 4 to 6 months of age will prevent allergic disease, and that delayed introduction of solids, especially highly allergenic solid foods, may actually increase the risk of food allergy or eczema.

That followed a 2008 updated clinical report from the AAP's Committee on Nutrition and Section on Allergy and Immunology that also determined that no convincing evidence existed for delaying the introduction of specific highly allergenic foods.

The AAP update, however, did not provide guidelines on how and when to introduce highly allergenic foods. The January 2013 journal article "provides general guidelines and suggestions for practicing primary care physician colleagues and specialists who must address daily the question of what to tell parents and patients when they ask when and how to introduce the same highly allergenic foods to children."

Why the change?

Dr. Frederick E. Leickly, professor of Clinical Pediatrics and director of Pediatric Allergy Clinical Services at Riley Hospital for Children-IU Health in Indianapolis, says, "In those allergy-prone children, there seems to be a magical moment in time when the immune system will go towards tolerance versus sensitization to these foods."

Leickly says the guidelines people have been following for years were not evidence based. When food allergies started becoming more commonly diagnosed in the 1990s, experts thought at the time that delaying these highly allergenic foods would reduce the prevalence of allergies. In fact, the opposite proved to be true, and over the next decade, the prevalence of food allergies increased substantially.

Lieckly stresses the importance of these developments. Referring to the 2013 JACI article, he says, "This article is a valuable contribution to the world of food allergy. It dispels unconfirmed notions; it identifies areas where there is no evidence for past guidance; and it identifies future areas of investigation to help make a difference in the public health problem of food allergy."

Such a big change may not be easy for parents to adapt to, especially those who are familiar with the seriousness of food allergies. Leickly's clinic hosts sessions to help with food challenges that focus on introducing small amounts of an allergenic food in a clinical setting with medical supervision.

"These are drastically new recommendations in a world of increasing numbers of food-allergic children. It is a step towards primary prevention. It may make a difference. Families will be nervous, and we can address that in our clinic," Leickly says.

How to introduce first foods

*It is important to note that these recommendations from the JACI article are not intended for children who have already developed an allergic condition, such as food allergies or atopic dermatitis.

  • Do not start with the highly allergenic foods. Once a few complementary foods are tolerated, then the highly allergenic ones may be introduced.
  • You do not need to delay the introduction of acidic fruits even though some can cause perioral rashes or hives due to irritation from the acid on the skin and from histamine-releasing chemicals in the fruit. They do not usually result in a serious systemic reaction.
  • Avoid whole cow's milk until age 1. Cow's-milk-based infant formulas and other cow's-milk-based products, such as cheese and yogurt, are safe before age 1.
  • Whole peanuts and tree nuts have an aspiration risk and should be avoided; however, peanut and nut butters can be given.

Single-ingredient complementary foods:

  • Rice or oat cereal
  • Yellow or orange vegetables
  • Fruits
  • Green vegetables
  • Age-appropriate staged foods with meats

How to introduce the highly allergenic foods:

  • Give the initial taste of one of these foods at home, not at daycare or in a restaurant.
  • Parents should be advised that for some foods, like peanuts, most reactions occur with the initial ingestion.
  • If there is no reaction, the food can be given again gradually with increasing amounts.
  • Introduction of other new foods should occur with one new food every three to five days.

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