As an infant care provider, first-year well check visits often center around numbers and charts, like percentiles for height, weight and head circumference, how much baby is sleeping and more. Additionally, if the child had any issues at birth, like prematurity or a stay in the NICU, that can dominate these time-crunched visits too.
With so much already to talk about, when it’s time to introduce solid foods to a healthy baby, it can help to have guidance for the conversation with caregivers—especially when it comes to feeding the baby potentially allergenic foods like peanuts for the first time. It’s important to note that the LEAP study found that introducing peanut foods as early as 4-6 months can reduce the risk of developing a peanut allergy by up to 86%.1 In fact, the National Institute of Allergy & Infectious Disease advise introducing peanut foods as early as 4-6 months and the 2020-2025 Dietary Guidelines for Americans state, “Introducing peanut-containing foods in the first year reduces the risk that an infant will develop a food allergy to peanuts.”2, 3
To empower providers to discuss introducing peanut foods and other potential allergens with parents of infants, new mom Katie Brown recently talked with pediatrician Dr. JJ Levenstein. Check out the Q&A below, edited for clarity, and view the video (conversation starts at 5:30).
Talking with new parents early about introducing peanut foods and other common allergens may help stave off future issues, and can lead to a life of fun enjoying diverse and nutritious foods as a family. Download this helpful resource, How to Incorporate Early Introduction of Peanuts to Your Office Workflow, for additional guidance; watch the free American Academy of Pediatrics’ Peanut Allergy Prevention through Early Introduction Video Series; and find out more about preventing peanut allergies at PreventPeanutAllergies.org.
Q&A with Pediatrician Dr. JJ Levenstein & New Parent Katie Brown:
Dr. JJ: Tell me a little bit about yourself, Katie.
Katie: We adopted our son Theo nine months ago and he spent eight weeks in the NICU because he was born at 30 weeks on the day. A lot of our journey health-wise as far as what we talk about has been based around him being a preemie and spending a lot of time in the NICU.
Dr. JJ: And that makes total sense realistically on your part […] Has Theo had any eczema, breaks in his skin, itchy rashes that have persisted for months?
Dr. JJ: When was your last well care visit with Theo and what was the majority of that discussion about?
Katie: It was his six month and at that visit, it was still really about his growth. We talked a lot about his head shape, pulmonology and how is he breathing—and the next shots that were coming up.
Dr. JJ: To me the 4 and 6 month visits are the optimal place to start introducing the idea that our babies are actually going to grow up one day and eat […] Katie, I want to talk you a little more about nutrition. We know that Theo is growing and developing well, but I want to explore first with you, what’s your family’s food system? Are you vegetarian, are you carnivore, what’s your normal food jam?
Katie: We eat all the things! Everything.
Dr. JJ: If I told you that we have great science that’s been replicated and proven again and again over the last five years that shows us that if we give Theo everything in your pantry— except for honey because of the botulism risk—before he’s a year old, you can potentially reduce his chance of [peanut] allergy by up to 86%, how would you respond to that?
Katie: That makes me feel great because I don’t want him to have allergies. You don’t want your kid’s life to be more difficult than it already has to be. But it does also feel a little overwhelming of not knowing where to start and how to begin introducing those things. Because we’re going straight from formula to I’m like, do I just give him a piece of pizza? How do we go?
Dr. JJ: At the six-month visit, we should carve some time out for a discussion of nutrition […] The key thing to remember is feeding your kid the rainbow is a good idea. Foods with lots of colors, whether they’re vegetables or fruits, are going to have a high nutritional value. If you give your baby any cereals or grains, they should be fortified, which most prepared baby foods are. If you’re using your own grains, make sure they’re fortified.
But it is safe to give those things that some of your mom groups and some of your fellow friends and neighbors may be terrified about, i.e., dairy or eggs or peanuts, and it can be safely done. When a baby is at Theo’s developmental age, you can dilute smooth peanut butter in his formula, yogurt, water and mix it into any of his current favorite purees. Instead of “here, try the peanuts,” maybe mix it with something that he loves. Think about [the flavor of] a peanut butter and jelly sandwich.
There are other ways to get peanut into babies too. You can use dehydrated peanut butter. It’s called PB2 and you can get it at Costco. You can mix that into smoothies, yogurt, into cereals; you can make it into a sauce for some of his meaty proteins. There is also a peanut flour out there. You can find it at Trader Joes and some other markets. You can use peanut flour like you use all-purpose flour. Use it in muffins and pancakes and it [has a good amount of] protein and so it’s great nutritionally for him. There are a lot of products out there that are meant for his developmental age, something called Bamba, which is like a peanut Cheeto, or there are puffs that are peanut flavored. There are Cheerios that are peanut flavored.
There are lots and lots of creative and satisfying ways for Theo to enjoy these [potential] allergens frequently and often, and that’s really what we’re trying to aim for—just to give kids a very diverse diet.
Knowing that, does that give you more pause or are you worried about allergies or allergic reactions or anything like that?
Katie: It doesn’t give me more pause. It feels freeing to know that we can go ahead and give him all those things. But, in the case that maybe he does have a peanut allergy, what kind of things should I look for? Does it look the same as like an adult reaction or does it look different in kids?
Dr. JJ: To put that into perspective, for a child who has intact skin, it is very unlikely to have a food allergy or to have been sensitized to proteins in your environment. [Sensitized] means that somehow the skin has been a portal of entry for a food and it has signaled to his immune system in the wrong way. So, he’s very unlikely to have a reaction. But here’s the difference between a baby who just has a behavioral reaction to a food, which is like a ugh, bleh, this is the first time I’ve eaten it, flinging it back at the mom like the monkeys at the zoo.
A baby who has a behavioral reaction to something new will just look at you and they’ll laugh and they’ll just move on with their day. As opposed to a baby who may have an allergic reaction and it may take a few minutes; the food may land in the stomach and come right back up as vomiting, there may be flushing of the face, there can be actual hives either locally or widespread. [There may be] a look of distress or worry on the baby’s face. In older kids we call it a look or feeling of impending doom, but a baby can project that in a very worried way.
I think that one of the smart things you can do when you’re introducing an allergen especially, is do it in the light of day. Do it in the morning when you know you’re going to be able to watch your baby for a couple of hours. Do it when you know your pediatrician is in the office so that you know that you can pick up the phone and either be talked off the mountain or act appropriately.
And with a low risk baby it’s so unlikely, it does happen rarely, but what we know is that in the first year of life it’s almost unheard of to see anaphylaxis or a severe reaction in a child that appears at low risk like Theo does. So, I think you just forge ahead and remember the science has guided us here.
Katie: Is it different when you say vomiting when he has an allergic reaction versus spit up, like I’ll be able to tell?
Dr. JJ: Yes, because vomiting definitely has a velocity to it, for lack of a better term. But I think it’s important to make that distinction. To your maternal intuition, if something feels wrong to you, pick up the phone [and call your provider]. That’s really what it all boils down to. What you’re going to do is just free Theo and yourself to have a very widely exciting diet. When you go to restaurants and you can start feeding him off your plate and have a ball, he’ll just feel like he’s part of the party.
Providers can point caregivers of infants to these exciting recipes like PB Green Smoothie Popsicles, Peanut Butter Pumpkin Dip, Soft Peanut Butter Cookies, Peanut Butter Pancakes and Turmeric Peanut Butter Chicken Bowl created with infants in mind. Eggs and peanut butter are also the perfect pairing in these recipes for babies: Peanut Butter Egg Scramble, Peanut Butter Sweet Potato Souffle, Eggy Peanut Butter Muffins and Peanut Butter Oatmeal with Egg.
- Du Toit, et al. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813. https://www.nejm.org/doi/full/10.1056/nejmoa1414850
- Togias, et al. Addendum Guidelines for the Prevention Of Peanut Allergy in the United States: Report of the National Institute Of Allergy and Infectious Diseases–sponsored Expert Panel. 2017. niaid.nih.gov/sites/default/files/addendum-peanut-allergy-prevention-guidelines.pdf
- S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.