By Carina Venter, RD, PhD
The new guidelines on “early” introduction of peanuts have received much attention in the past few days. For full background information and specific details, please read the guideline document. The information contained in this blog will serve as a practical guide for parents on introducing peanuts into the infants diet.
Weaning or introducing solid foods into your baby’s diet is meant to be a time of enjoyment, but with so much focus on allergen introduction, we risk “medicalizing” a process that should be part of normal development. I was very pleased to be invited as a member of the Expert Panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, to develop clinical guidelines on peanut allergy prevention.
The guidelines divide infants into 3 risk groups (guidelines 1, 2 and 3) and issued the following advice:
Group 1: Infants with severe eczema, egg allergy or both.
• Check with your doctor before introducing peanuts at home.
• Your doctor may recommend that your baby undergo allergy testing, followed by supervised peanut introduction if needed, before you introduce peanuts regularly at home.
• Once you start giving peanut at home, it is recommended to give 2 g of peanut protein, 3 times per week.
Group 2: Infants with mild to moderate eczema.
• Your doctor can tell you what “mild to moderate” eczema means and if it is safe for you to introduce peanut into you baby’s diet.
• For this group of infant, the new guidelines suggest to start giving peanut around 6 months of age, after other solid foods have been tried.
• Peanuts should be given based on the family’s eating preferences and given regularly to your baby.
Group 3: Infants with no eczema or food allergies
• Start weaning your baby when developmentally ready.
• Once a few foods are introduced, start giving your baby some peanut-containing foods.
• Continue with regular peanut intake, based on the foods that your family likes and regularly eats.
1. I thought peanuts can cause choking in children under 5 years of age, can I give it to my baby?
Yes – that is true – whole, shelled peanuts and lumps of peanut butter should not be given to children under 5 years of age due to the risk of choking; this is pretty much a recommendation all across the world. The new NIH guidelines recommend that you give your baby peanut puffs (e.g., Bamba), smooth peanut butter mixed with hot water and then cooled down, peanut flour, or peanut powder.
2. Why 2g peanut protein, 3 times per week?
The amount of peanut used in the LEAP study was based on the median monthly consumption of 7.1 g peanut protein in Israeli children where peanut allergy prevalence is relatively low.
3. What does 2 g of peanut look like, or is it actually 2 g of peanut protein?
It is 2 g of peanut protein. The NIH guidelines lists the following options for giving 2 g of peanut protein:
• 17 g Bamba (another peanut puff that is very similar to Bamba is called Cheeky Monkey)
• 9-10 g peanut butter depending on the brand
• 8 g of ground peanuts
• 4 g defatted peanut flour (e.g., defatted peanut flour from the Golden Peanut company) or peanut butter powder (e.g., PB2 powder or PB fit)
4. I don’t have kitchen scales…does that matter?
No – these amounts do not have to be that exact.
• 17 g of peanut puffs is about 2/3 of a bag of Bamba.
• 9-10 g peanut butter is either two level measured teaspoons or a “round full” (Picture, above right, courtesy of myself and George Du Toit – the one and only LEAP first author)
• 8 g of ground peanuts is 2 1/2 level measured teaspoons
• 4 g of peanut flour or peanut butter powder is 2 level measured teaspoons
5. What if my baby is sick and won’t eat, or if they are full and have not eaten the full portion?
We just do not know if smaller amounts or less frequent feeds will be as protective against the development of peanut allergy. However, according to LEAP authors, some of the babies got ill (as babies do) and some did not actually finish every feed, though most did. The main thing is to be as consistent as possible with regular peanut intake, even if your baby does not eat the full dose.
6. What if my baby/child loves the peanut puffs and want to eat more?
Yes! Some babies are good eaters and love peanut flavor. Eating more is allowed; I also think that older children (peanut was given up to age of 5 years in LEAP) may not be happy if you remove the bag of Bamba once 2/3 of the bag is eaten. In the LEAP study, the median amount of peanut protein in the consumption group was 7.7 g (interquartile range, 6.7 to 8.8).
7. I don’t think my baby will eat the peanut-containing foods in the NIH guidelines; is there anything else I can try?
I would say first try different options of the foods listed in the NIH guidelines. Peanut powder mixed with mango puree tastes very differently from diluted peanut butter mixed with baby rice or carrot puree. You could also try to crush the Bamba, dissolve it in water, and mix it into the baby’s pureed foods.
During the development of the NIH guidelines, we looked at other options, such as peanut-containing breakfast cereal or peanut containing candy (chocolate) and found that either the portion sizes would be too large (e.g., up to 6 cups of cereal) or the fat, sugar or salt content would be unsuitable for young children. If you are adventurous in the kitchen, try to bake low-sugar peanut cookies/biscuits – 1 cookie contains about 0.8 g of peanut protein, which means 2-3 cookies should give around 2 g of protein or cook peanut soup!
Any dietitian (irrespective of their knowledge of food allergy) can help you to find out what the peanut protein content of a food is by calculating it from the label (if peanut is the only ingredient) or from information obtained from the manufacturer. I am sure they will be happy to help ensure that you use foods that are culturally accepted and favorites of the family!
8. Which solid foods are best to start with?
In terms of introduction of solid foods, just use the usual weaning advice as suggested by the country in which you live. In most situations, this will be vegetable or fruit purees or infant fortified cereal-rice/oat.
9. Does it HAVE to be 4 months or 6 months?
I have mentioned in my introduction that weaning is part of normal development, and babies may be ready for solid foods at different ages; look out for developmental cues when starting to introduce solid foods – there is no need to set a clock to remind you that your baby is exactly 4 months of age! I absolutely love this fact sheet produced by colleagues of mine at the Infant and Toddler Forum.
The final knock out question:
My older child is peanut-allergic, I am not sure if it is safe to eat peanut around him?
This is a discussion that you should have with your baby’s doctor, as many factors will determine how to approach the situation.
These guidelines address preventing peanut allergy and do not apply to anyone with diagnosed peanut allergy. Peanuts should not be given to those with peanut allergy – always follow your doctor’s advice.
Carina Venter, PhD RD, is a Research Associate/Dietitian at Cincinnati Children’s Hospital Medical Center and currently the Chair of the International Network of Dietitians and Nutritionists in Allergy, a member of the AAAAI, BSACI and EAACI. She is a registered dietitian in the United Kingdom, United States and South Africa. She has had numerous publications in international journals, and has authored book chapters and edited a book on Food Hypersensitivity. She was, until recently, working as a Senior Lecturer at the University of Portsmouth, where she was doing research into food allergies and allergy prevention, based at the David Hide Centre on the Isle of Wight.
Carina was a member of the Expert Panel of the National Institutes for Allergy and Infectious Diseases Peanut Allergy Prevention Guidelines, making her the only dietitian to contribute to both US and European food allergy guidelines.