By Carina Venter, RD, PhD
Both in the United States and around the world, guidance on allergen avoidance/introduction for the prevention of food allergies has changed many times, and in many directions, in the past few decades. Awareness of the guidelines is important to their implementation, but central to all of this is that the correct message should be conveyed to all involved. Unfortunately, word spreads slowly and sometimes incorrectly or in an incoherent manner. Therefore, many doctors and their patients are still living under old standards of care.
What can we learn from the United Kingdom?
In June 1998, the UK government’s Chief Medical Officer’s Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) published a report on peanut allergy. The key recommendation of this report was that ‘‘pregnant women who are atopic or for whom the father or any sibling of the unborn child has an atopic disease, may wish to avoid eating peanuts and peanut products during pregnancy and breast feeding.’’ Our research from the Isle of Wight, UK, has subsequently shown that this advice has either been misunderstood by mothers, or that those who communicated the advice (i.e. health professionals) have not fully explained who it is targeted at all.
The current version of the COT report has, partly prompted by this research, been revised. It now states:
– “Pregnant/breastfeeding women may eat peanuts or foods containing peanuts if they choose to do so as part of a healthy balanced diet, irrespective of whether they have a family history of allergies.”
– “If mothers choose to start giving their baby solid foods before 6 months (after talking to a health visitor or GP), they should not introduce peanuts or other allergens such as nuts, seeds, milk, eggs, wheat, fish or shellfish before this time. Furthermore, when these foods are introduced, they should be introduced one at a time so that they can spot any allergic reaction.”
Where are we going in the United States?
In 2017, the NAIAD guidelines were published highlighting three distinct groups of infants with different levels of risk of developing a peanut allergy. Distinctive advice regarding the need for screening, age of introduction of peanuts and location for peanut introduction were issued for these groups. In short, these guidelines recommend early peanut introduction from beginning around 4-6 months in infants with either severe eczema and/or egg allergy (higher-risk infants), and around 6 months for all other infants (lower risk infants). Screening (skin prick test/specific IgE test) may be required for the higher risk group, followed by a food challenge when indicated, and no screening is indicated for the lower risk group.
The nature of new guidelines is that they are always based on an evolving set of data and must necessarily been written with a degree of ambiguity, which of course can create confusion for both parents and professionals. As time goes by, various professionals try to hone the message. In this spirit, my colleagues and I, led by Dr. Matt Greenhawt, set out to explore how parents might introduce allergens in the first year of life. We also explored parental preferences of among 1000 current parents, and 1000 more who were expecting. We asked about their likelihood to consent to skin-prick testing and a food challenge to peanut in the first year of life. Study participants were randomly selected, from a nationally-representative sample who had completed a 32-item on-line survey.
Among these primarily white, married, female respondents, about one-third had no-or-limited awareness of the new early introduction guidelines, two-thirds had no-or-minimal concern for their child developing food allergy, but about half of respondents felt that timing of introduction has moderate-to-strong importance for developing food allergy. Only a third indicated willingness to introduce peanut before or around 6 months of life and almost 60% of both parents and expecting parents were unwilling to undergo to consent to skin prick test (screening) of the infant before 11 months of age.
Most interestingly however, about a third of parents indicated a willingness to introduce milk and peanut containing foods only after 12 months of age. These figures were 15% for egg, 45% for tree nuts an over 50% for seafoods. There is, however, the concern that parents were answering questions from the perspective of introducing these foods according to the AAP/FDA guidance on general weaning opposed to an awareness of early allergen introduction. These guidelines for each allergen can be found here:
Although the numbers for parental willingness seem to be disappointingly low, it is still much higher than the 5% of parents who introduced egg, peanut and/or fish in the infant’s diet as reported by Luccioli et al. 2014
Are we going in the right direction?
This survey indicates that some parents may be more flexible about introduction food allergens by six months of age than in the past, but the majority of parents are still reluctant to feed the allergens to their infants at a young age and undergo testing or food challenges prior to introduction. It is, however, unclear if some of the questions were answered by the parents from an allergy perspective vs. a focus in the AAP/ FDA guidance on infant feeding.
Figure redrawn from paper with numbers (%) rounded off
So what’s a concerned parent to do? Here are some practical pointers:
– Start introducing solids when the infant is developmentally ready
– Don’t be afraid of feeding allergens
– Make sure the textures are suitable to prevent choking risks i.e. feed diluted nut butters opposed to chunks of nut butters or whole/chopped nuts
– Use boiled or baked egg products
– Don’t feed fatty fish and seafood too often (use the FDA guidance)
– Full fat milk should not be a main drink until one year of age, but do use in cooking/baking or feed yogurts…
– Wheat containing products such as softly cooked pasta is a suitable wheat containing food…
– If you are wary of feed allergens at home or if your child has eczema or another food allergy, do discuss this with your primary care pediatrician who may refer you to an allergist
– Once you’ve started to feed the allergenic food to your infant – continue to feed it regularly
Dr. Carina Venter is currently an Assistant Professor of Pediatrics, Section of Allergy and Immunology at the Children’s Hospital Colorado and University of Colorado Denver School of Medicine, where she is conducting research and working with children and adults with a range of food allergies. Previously, she was appointed as an Assistant Professor/Dietitian at Cincinnati Children’s Hospital Medical Center. She is currently the chair of the International Network of Dietitians and Nutritionists in Allergy. She was a member of the EAACI food allergy guidelines on Allergy Prevention, as well as Diagnosis and Management of Food Allergy. She was also a member of the NICE (UK) food allergy guidelines. Since her arrival in the US, she was appointed to the expert panel of the National Institutes for Allergy and Infectious Diseases Peanut Allergy Prevention Guidelines. She blogs on https://carinaventeronline.wordpress.com, and she is a top twitter allergy activist at most international allergy meetings (@VenterCarina). Her previous contributions to this website can be found here and here.