Early introduction of allergenic foods
may prevent food allergy in children
by David M. Fleischer, M.D., FAAAAI, FAAP
Primary prevention of allergy, which refers
to blocking initial immunologic sensitization, may help reduce the burden of the rising prevalence of allergic diseases, including
food allergy, asthma and atopic dermatitis.
In the inaugural issue of the Journal of
Allergy and Clinical Immunology: In Practice,
recommendations based on current literature and expert opinion are presented for
the primary prevention of allergic disease
through nutritional interventions (Fleischer
DM, et al. 2013;1: 29-36, www.jaci-inprac
tice.org/article/ S2213-2198( 12)00014-
For the first time, specific guidelines are
outlined for how and when to introduce
highly allergenic foods, including cow’s
milk, egg, soy, wheat, peanut, tree nuts, fish
and shellfish. In addition, detailed reasons
to consider allergy consultation for development of a personalized plan for complementary
food introduction are offered. These recommendations are intended for high-risk infants, which generally refer to infants with a first-degree relative (parent
or sibling) with an atopic disease.
Guidelines outline how and when to introduce highly allergenic foods,
including cow’s milk, egg, soy, wheat, peanut, tree nuts, fish and shellfish,
to help infants avoid food allergy.
or restaurant. Whole cow’s milk should be
avoided until 1 year of age (for reasons unrelated to allergy), but other milk-based products such as cheese and yogurt are safe before
age 1. Shelled peanuts and tree nuts carry
aspiration risks, but peanut and tree nut butters are safe at younger ages.
In certain clinical scenarios, patients should
be referred to an allergist for evaluation and
possible testing prior to the introduction of
highly allergenic foods. These scenarios
include, but are not limited to, patients with
moderate to severe atopic dermatitis that is
difficult to control despite adequate medical
management; patients with a history of an
immediate allergic reaction to a food; and
patients with one or more diagnosed food
allergies. All these patients are at higher risk
for food allergy or additional food allergies.
For other situations warranting referral to
an allergist, see the article in the Journal of
Allergy and Clinical Immunology: In Practice.
allergy, and the early introduction of allergenic foods
may prevent food allergy in infants/children. Therefore, Fleischer, et al. state that highly allergenic foods
can be introduced as complementary foods starting
at 4 to 6 months of age once a few other typical complementary foods have been introduced and tolerated
(e.g., cereals, fruits or vegetables).
The initial introduction of highly allergenic foods
should occur at home rather than at a child care facility
Dr. Fleischer is a member of the AAP Section on Allergy and Immunology.
Primary prevention of allergy
The following are evidence-based recommendations
for primary prevention of allergy:
• Avoidance diets during pregnancy and lactation
are not recommended at this time. However, more
research is needed, especially regarding avoidance
of peanut, since current studies are contradictory.
• Exclusive breastfeeding for at least 4 and up to 6
months of age is endorsed. For infants who cannot
be exclusively breastfed, hydrolyzed formula
appears to offer advantages to prevent allergic disease and cow’s milk allergy.
• Complementary foods can be introduced between
4 and 6 months of age.
Introduction of highly allergenic foods
as complementary foods
AAP recommendations published in 2000 advised
delayed introduction of the following highly allergenic
foods in high-risk infants to prevent the development
of allergy: cow’s milk until age 1 year; egg until age 2
years; and peanuts, tree nuts and fish until age 3 years.
After review of the available literature, the AAP
Committee on Nutrition and Section on Allergy and
Immunology published an updated clinical report in
2008 that determined there was no convincing evidence for delaying the introduction of specific highly
allergenic foods. This report, however, did not provide
guidelines on how and when to introduce the highly
Emerging data suggest that delayed introduction
of complementary foods may increase the risk of food