Preventing food allergies: New infant feeding guidelines

The newest recommendations for feeding infants* are a significant change from the recent past. Instead of avoiding or delaying introduction of certain foods, experts now encourage early introduction of “high-risk” allergy foods regardless of risk factors. Early food introduction is now seen as a way of preventing food allergies.

These new recommendations may come as a surprise since there has been varied guidance over the past two decades. Until now, experts have never encouraged actively introducing a wide range of foods.

• In 2000, parents were asked to delay introduction of certain foods (e.g., milk, egg, nuts, seafood) for “high-risk” infants.
• In 2008, experts reversed their advice and said it was no longer necessary to delay introducing these foods.
• In 2017, experts suggested allergy testing for peanut, but only for certain “high-risk” infants. 

The new message is straightforward: at around six months of age, and when your baby appears ready, be sure to steadily introduce foods like egg, dairy, wheat, soy, nuts, seafood, and seeds. Don’t avoid, and don’t delay. 

Once these foods have been tolerated, experts encourage feeding them to your baby on a regular basis as part of a diet with a wide variety of foods.

Allergy testing

The research suggests that routine allergy testing before introducing new foods, even if there is an older sibling with a food allergy, is only necessary in certain circumstances. If your baby has an allergic reaction to a new food, then it would be a good time to pause and see an allergist. It is best to consult with your pediatrician or allergist during this process to determine what is best for your baby.

These new infant feeding recommendations are based on up-to-date research and expert opinion. For example, food allergy experts have learned that waiting to introduce foods may increase the risk of developing an allergy to that food. It also appears that for infants, the risk of very severe allergic reactions is much lower than previously thought. Furthermore, food allergy testing can be particularly unreliable. Unreliable test results can lead to misdiagnosis, or unnecessary food avoidance. 

Introducing new foods

Experts suggest introducing new allergenic foods one at a time, and over about three days. They do not recommend a specific order, or length of time between foods. Here are some practical examples:

• Cow’s milk: Give baked forms of milk (e.g., milk as an ingredient in breads, muffins, cakes, or cookies) before uncooked forms. Once baked milk has been tolerated, move on to uncooked dairy foods like yogurt, cheese, and later milk. 
• Egg: Give baked forms of egg (e.g., egg as an ingredient in breads, muffins, cakes, cookies) before partially-cooked forms. Once baked egg has been tolerated, move on to partially-cooked egg, such as scrambled, fried, or boiled egg. 
• Wheat: Consider soft noodles or bread strips.
• Soy: Try a serving of soy milk, tofu, or soy yogurt. 
• Peanut: Baby's first peanut could be one or two teaspoons of creamy peanut butter thinned in warm water, apple sauce, or yogurt (to reduce the choking hazard). They may also try a handful of Bamba peanut snacks. Avoid whole peanuts or peanut pieces, which could be a choking hazard. 
• Tree nuts (almond, cashew, hazelnut, walnut, pecan, pistachio): Introduce tree nuts one at a time as a butter, or in a finely-ground form to reduce the choking risk. Avoid whole tree nuts or nut pieces. 
• Sesame: Consider a serving of hummus that contains tahini, a paste made from ground sesame seeds. 
• Seafood: If the family eats seafood, then they should introduce the types of fish and shellfish they typically enjoy.

Conclusions

Before the current era, food allergies were not common, and testing was not a routine event. In the early 2000s, a rapid rise in the incidence of food allergy coincided with a surge in food allergy testing and initial recommendations to avoid certain foods. At the time, food allergy experts were trying their best to understand the problem and prevent it from becoming worse. Food allergies surged despite their best efforts. Experts have since learned that delayed introduction to foods may actually lead to food allergies.

Despite its popularity, food allergy testing can be particularly unreliable, especially if not interpreted by a food allergy expert. Ironically, unnecessary food avoidance may actually lead to the food allergy you are trying to prevent.

As always, it’s important to be mindful of the risks presented by food allergies, and manage them appropriately. And for children and adults who already have a confirmed food allergy, there must be appropriate caution.

The newest recommendations for infant food introduction could be seen as a revolution, or simply a return to the pre-2000 world. For many years, parents have shared feelings of confusion and anxiety when it comes to feeding their infant. We hope the new infant feeding guidelines offer clarity, reduce anxiety, decrease the incidence of food allergy and encourage a healthy relationship with food.

Dr. Dooms is a board-certified pediatrician and allergist/immunologist who has been with Swedish since 2017 and practices at our Bellevue clinic. To make an appointment with Dr. Dooms, or another allergist at our Swedish First Hill, or our Mill Creek office (opens May 2021), call 206-838-9548 or visit https://www.swedish.org/locations/swedish-allergy-immunology-seattle.  

*A consensus approach to the primary prevention of food allergy through nutrition. JACI In Practice, Jan. 2021