Recommendations for Introducing Highly Allergenic Foods

Although pediatricians who have been in practice for some time may have previously asked parents to delay the introduction of highly allergenic foods, emerging evidence now suggests just the opposite. Earlier introduction of highly allergenic foods may actually prevent food allergy.

Contemporary Pediatrics, 2021

Best practice clinical guidelines for highly allergenic foods in childhood have shifted dramatically in the 21st century.

In 2000, the AAP recommended delaying the introduction of certain foods to children at high risk for developing food allergies. But new evidence since that policy statement shows that delaying introduction of foods that are highly allergenic to infants and children may increase—rather than decrease—the incidence of food allergies.

A 2008 AAP clinical report concluded that the data and evidence cited in the 2000 policy statement were insufficient to justify delaying the timing of complementary foods beyond the ages of 4 to 6 months. Furthermore, the AAP issued a replacement clinical report in 2019 that noted there is no evidence that delaying the introduction of highly allergenic foods such as peanuts, eggs and fish beyond ages 4 to 6 months prevents atopic disease. In fact, the report cites evidence that early introduction of peanuts may prevent peanut allergy.

In addition, current evidence does not support maternal dietary restrictions during pregnancy or lactation to help prevent development of food allergies in the child (Ibid.).

Introducing Peanuts

“Peanuts cause severe, sometimes fatal, allergic reactions in an estimated 1.1 percent of the global population” (University of Notre Dame, 2023). The most common therapy for a peanut allergy is strict dietary avoidance, but the risk of accidental exposure is high (Ibid.). There is no therapy to prevent allergic events from happening in the first place (Ibid.). However, research now shows that introducing age-appropriate, peanut-containing food as early as ages 4 to 6 months reduces the risk of peanut allergy.

Based on that research, an expert panel sponsored by The National Institute of Allergy and Infectious Diseases (NIAID) issued a 3-tier recommendation for introducing foods containing peanuts into an infant’s diet. The 2017 guideline provides recommendations for assessments by a primary care provider or specialist before introducing peanuts to children with high risk of allergy.

Peanut allergy prevention guidelines

“Addendum guidelines for the prevention of peanut allergy in the United States” (JAAPA, 2017)

Introducing Eggs

A study called The Prevention of Egg Allergy with Tiny Amount Intake (PETIT) demonstrated that introducing heated egg powder daily beginning at age 6 months lowered the rate of egg allergy compared with infants who avoided eggs completely until age 1 year (Natsume et al., 2017). A meta-analysis of five studies involving nearly 2,000 infants found with “moderate certainty” that introducing eggs between ages 4 and 6 months reduced the risk of egg allergy.

Randomized controlled trials demonstrated that infants benefit from eating eggs, which are nutrient rich. The data suggest that introducing eggs early may have a significant effect on growth and brain function and development and contribute to daily nutrient intakes. Avoiding or delaying egg consumption may contribute to nutrient shortfalls in infants.

Current AAP position statements take into account the lack of evidence that maternal dietary restrictions during pregnancy and lactation prevent atopic disease. The AAP recommendations maintain that solid foods should not be introduced to an infant before ages 4 to 6 months and that evidence does not support delaying introduction of eggs, fish and foods containing peanuts beyond this period to protect against developing atopic disease.

Previous guidelines may have led parents and caregivers to avoid or delay feeding eggs and food containing eggs to infants and toddlers. However, based on recent research, introduction of eggs during infancy does not increase the risk of allergy or egg sensitivity.

Recommendations for introducing highly allergenic foods have changed significantly during the past 20 years and research is likely to continue to bring changes. Health-care providers must examine current recommendations for introducing highly allergenic foods into a child’s diet based on each child’s risk and individual circumstances.