The American Academy of Pediatrics (AAP) has updated its recommendations for introducing peanuts to infants, continuing the decades-long shift in practice from delaying the introduction of food allergens to introducing them early and often.
According to board-certified allergist Katie Marks-Cogan, in 2000, based off just two observational studies that didn’t produce much hard data, the AAP recommended that parents hold off on introducing common allergens. At the time, it was recommended that parents wait until the baby was a year old (for cow’s milk), 2 years old (for eggs) and 3 years old (for peanuts and tree nuts).
Over the next several years, more observational studies were conducted that indicated that delaying allergen introduction actually wasn’t necessarily beneficial. In 2008, the AAP removed the 2000 guidelines but didn’t yet go so far as to recommend early introduction.
“Since then, better trials have shown that the opposite is true,” says Marks-Cogan, who practices medicine in the Los Angeles area. “Delaying can potentially be harmful, and early introduction can be preventative.”
So in March, the AAP updated its recommendations to focus specifically on infants at risk for developing a food allergy:
Those recommendations focus on a high-risk population—infants with severe atopic dermatitis and/or egg allergy—who are advised to introduce infant-safe forms of peanut as early as 4-6 months, in specified amounts, with consideration of pre-testing to rule out allergy. The guidelines recommend that infants with mild to moderate eczema be introduced to infant-safe peanut-containing foods as early as 6 months of age, and those without food allergy or risk factors do so when age appropriate and depending on family preferences, i.e., after 6 months of age if exclusively breastfeeding.
But Marks-Cogan expects these guidelines to be updated even further in the coming years to include early introduction of allergens to all infants.
“The current thinking (among the allergy community) is … that these foods should be introduced prior to one year of age,” Marks-Cogan says. “We’re trying to figure out this window of golden opportunity to mold the immune system, and we think it’s around 4-6 months of age.”
That means that for some babies—even those who aren’t considered high risk—Marks-Cogan believes waiting until they reach a year old may be too late to effectively protect them against an allergy.
How to introduce allergens
Introducing food allergens can be an uphill battle for some parents who are trying to follow their pediatrician’s recommendations for incorporating solid foods into their baby’s diet.
“Many pediatricians vary on when they advise parents to introduce infants to solid foods,” Marks-Cogan says. “So you’ll get a lot of opinions just on when to introduce solids, and parents will listen to what their pediatrician says.”
For the parents of her pediatric patients, Marks-Cogan says she writes out a detailed food schedule, focusing mainly on the top three food allergens: peanuts, egg and cow’s milk. She stresses that it’s important to introduce babies to non-allergen foods for several days or weeks first before moving onto allergens.
From there, she says parents can introduce peanuts with Bamba snacks or by mixing peanut butter with breastmilk or formula. Similarly, parents can puree a scrambled egg and mix with breastmilk or formula and incorporate yogurt into the baby’s diet.
“Once it’s in the diet, keep it in the diet,” Marks-Cogan says. “Write out a schedule, because it can be very overwhelming.”
She experienced the stress of it herself when her son was born in 2015. She had to ensure that her son’s outside caregivers all stuck to the detailed feeding schedule she had outlined.
“I’m an allergist, and I’m still nervous and it’s still hard (for me),” she says. That experience led her to help create Ready. Set. Food!, a system that enables parents to mix a daily dose of peanut, egg and milk into breastmilk, formula or food.
“We made sure it was very evidence-based; that was very important to me when I got involved,” she says. “We also wanted to really make it easy and take away a little bit of the anxiety and that overwhelming feeling.”
Introduce early AND often
Perhaps the most important point for parents to know regarding food allergens, Marks-Cogan says, is that once you’ve introduced it, you have to sustain the exposure.
“It’s important to stress that introducing your baby to allergenic foods once or twice has not been shown to be protective and, in fact, might be harmful,” she says. “I see a lot of those patients; they give it to them (once) at 6 months to make sure it’s fine, and then at 10 months, they have an allergy.”
She says in order for early introduction to be protective rather than harmful, infants need regular exposure to the allergen for many months.
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