New Practice Parameters Contribute to Evolving Recommendations for Early Introduction

At the November 2020 meeting of the American College of Allergy, Asthma and Immunology (ACAAI), a new paper A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition was released. These new clinical guidelines were developed by a group of leading allergists and pediatricians in North America and have been endorsed by ACAAI; American Academy of Allergy, Asthma and Immunology (AAAAI); and Canadian Society for Allergy and Clinical Immunology (CSACI). The new guidelines represent an evolution of current guidelines that incorporate the latest research on early infant feeding, diet diversity, breastfeeding and more, because so much research has been published in this area since the National Institute of Allergy and Infectious Diseases (NIAID) published their addendum guidelines for preventing peanut allergies in 2017. It’s important to note that the NIAID guidelines still stand and are the current federal recommendations for early introduction of peanut to help prevent a potential peanut allergy.

Strong Recommendation for Early Introduction of Egg and Diet Diversity

There are a few big changes to the new recommendations, which are based on the latest research. In particular, these guidelines go beyond the NIAID guidelines, which only addressed the early introduction of peanut foods, to include a strong recommendation to include cooked egg starting at around 6 months, but not before 4 (the same recommendation as for peanut). In fact, they make a strong case for the inclusion of all allergens in the first year and then keeping these foods in the diet. They recommended the inclusion of a diverse diet once solid foods, including potential allergens, are started. Overall, the message is that infants, like adults, need a diet that includes a variety of nutrient rich foods, with the specific distinction for infants that allergens should be introduced early and eaten often.

More Details on Assessing Risk and Shared Decision Making

As with previous guidelines, having severe eczema is still considered an indicator of high-risk for developing food allergy. Further and similar to the NIAID guidelines, infants with mild to moderate eczema, a family history of atopy in either or both parents, or infants with one known food allergy potentially at some increased risk of developing food allergy (or an additional food allergy).  In addition, these guidelines do not recommend automatic referral to pediatrician or allergist for evaluation in advance of introducing peanut, egg, or any other allergenic food. However, they recommend shared decision making with the parents to help ensure that they do receive a referral if that will expedite or ensure the introduction of the allergenic foods, since some parents are so hesitant to introduce allergens otherwise. The new parameters do not recommend the use of hydrolyzed formulas nor do they support restricting maternal diets to reduce the risk of food allergies.

As research in the area of food allergy prevention grows along with our understanding of infant feeding, the guidelines and recommendations for caregivers will also change. These new recommendations, along with the Scientific Report of the 2020 Dietary Guidelines for Americans Advisory Committee earlier this year, encourage the normalization of potential allergens in infancy and a diverse nutrient rich diet for babies. Parents and caregivers with questions about when and how to introduce potentially allergenic foods should discuss these with their healthcare provider. For more information on preventing peanut allergies, visit PreventPeanutAllergies.org.