Over the past 30-40 years, there has been a steady rise in the prevalence of life-threatening food allergies, which affects 5% of adults and 8% of children.1
The ideal timing to introduce solids in an infant’s diet is considered to play a key role in the development of food allergies. However, guidelines about the ideal way to introduce foods to infants to help prevent food allergies often change.1
Below is a presentation to introduce the concept of food allergies, and nutrition and integrative approaches to help minimize the chance of developing life-threatening food allergies in infants.
Click here to download a reference sheet with key points to help keep your infant healthy by minimizing your infant’s chance of developing life-threatening food allergies.
WHY BE CONCERNED ABOUT LIFE THREATENING FOOD ALLERGIES?2
- The Center for Disease Control & Prevention (CDC) reports that the prevalence of food allergies in children has increased by 50% from 1997 to 2011.
- The prevalence of peanut or tree nut allergies has more than tripled in U.S. children between 1997-2008.
- Every 3 minutes, a food allergy reaction sends someone to the emergency room.
- ~40% of children with food allergies have experienced a severe allergic reaction (e.g. anaphylaxis)
- It costs $25 billion annually to care for children with food allergies
HISTORY OF FOOD ALLERGY FEEDING GUIDELINES1,3,4
- 1960s and earlier: Most infants were exposed to solids by 4 months of age—the average age of introduction of solids was 8 weeks old.
- 1970s: New guidelines recommended delaying the introduction of solids until after 4 months old. This is because it was believed that early introduction of gluten was causing an increase in rates of celiac disease. In addition, some studies believed that there were higher rates of eczema and asthma in infants who were fed solids too early.
- 1990s: The World Health Organization (WHO) recommended delaying solid food introduction until 6 months old. The guidelines also included delaying allergenic foods until much later, For example, delaying introduction of eggs until 10 months old and peanuts until 3 years old.
- 1998: The United Kingdom Department of Health recommended that peanuts not be consumed during pregnancy or breastfeeding. Recommendations also included infants considered “at risk” avoid peanuts until they were 3 years old. Notably, these recommendations were widely adopted by populations beyond those who were considered “at risk.”
- 2002: The WHO global review found no benefit in allergy prevention for those who exclusively breastfed for 6 months when compared to those who were introduced to solids between 4-6 months of age.
- 2002: The U.S. consensus document suggested that 6 months of age was optimal for introduction of solids. Other recommendations included avoiding the following: dairy until 12 months old; hen’s eggs until 24 months; and peanuts, tree nuts, fish or seafood until 36 months.
- 2008: The American Academy of Pediatrics (AAP) switched back to recommending early introduction of traditional foods between 4-6 months old. However, the AAP continues to recommend refraining from introducing cow’s milk until 1 year old.
- 2012: The AAP updated reports that there is no evidence that introducing “allergenic foods” (i.e. eggs, fish) after 4-6 months of age determines whether or not the infant will be allergic to the specific foods.
- 2013-2015: LEAP studies (Learning Early about Peanut Allergy) found that early introduction and consumption of peanuts until 60 months of age caused a reduction in peanut allergy. This positive outcome persisted at 72 months of age, even after 12 months of avoidance. No serious adverse effects were noted.
- 2016: EAT study (Enquiring About Tolerance) discovered the prevalence of egg allergy to be much lower in the early introduction group, alongside breastfeeding. No serious adverse effects were reported and researchers concluded that early introduction at 4 months of age was safe with no adverse effects or anaphylaxis.
- 2017: Ongoing research remains underway to determine the exact timing of introduction of allergenic foods, effectiveness of introduction of foods other than peanuts & eggs (studied heavily in LEAP & EAT studies), and strategies for those who are at high risk/those who have been sensitized already to allergens at a very young age (less than 4 months).
FOOD ALLERGY OVERVIEW
Unlike food intolerances, food allergies are immune responses to food substances. They occur with each exposure to the allergenic food, and the effects may be mild to severe.5,6
Signs & symptoms occur anywhere from a few minutes to 2 hours after initial exposure to the allergenic food.6
HOW DOES A FOOD ALLERGY DEVELOP?
A majority of food allergies develop during the first 2 years of life.7
While there are different types of food allergies, there is a similar underlying dysfunction.8
If your baby is susceptible and has a food allergy, the following happens:
- Your baby’s immune system recognizes the food as a foreign invader rather than a friend.9,10
- Immune cells then try to protect your baby by releasing compounds that activate IgE antibodies specific to the allergenic food.9-11
- Your baby develops signs & symptoms associated with food allergy.9
HOW COMMON ARE FOOD ALLERGIES?
Having an infant with food allergies might be scary, but you’re not alone! Prevalence in infants 1 year old is thought to be 6-8%,7,12 but may be closer to 10%.13,14
WHAT ARE THE MOST COMMON FOOD ALLERGENS?
The nine most common food allergens include9:
- tree nuts
In children, the most prevalent allergens include cow’s milk, peanut, & tree nuts.15
WHERE DOES A FOOD ALLERGY COME FROM?
A majority of food allergies develop in response to the protein in foods, but chemical compounds such as those in food additives may also trigger food allergies.5
There are a variety of risk factors for the development of food allergies. Importantly, food allergies tend to be dose- and allergen-dependent with threshold and allergen tolerance varying among individuals.16
Demographic studies in the U.S. suggest that boys are more likely than girls to develop food allergies to peanuts (10% males, 5.2% females), shrimp (2.4% males, 1.4 % females), and milk (0.6% males, 0.1% females). In addition, compared to non-Hispanic whites, non-Hispanic blacks are at increased risk for food allergy, especially hypersensitivities to peanuts and shrimp. And food allergies are higher among those living in poverty compared to those who are not. In addition, food allergy was increased among individuals who reported an asthma diagnosis made by their physician.16,17
When considering that children are seven times more likely to develop peanut allergy if they have a sibling or parent with peanut allergy, it is evident that genetic predisposition is a plausible risk factor. However, more research needs to be performed to clarify which, if any, genetic polymorphisms are relevant to peanut allergy and, by extension, food allergies in general.18
Other risk factors for life-threatening food allergies include mothers smoking cigarettes during pregnancy; not breastfeeding infants,19 especially those with family members who have a history of food allergies;20 and the presence of eczema and rhinitis.16,21 Interestingly, periods of illness (i.e. infections) increase the risk of having a life-threatening food reaction.16
Finally, researchers are looking into dietary patterns that might increase the risk of food allergies, especially as they relate to differences based on geographical location. These include an increase in omega-6 fatty acids consumption;22 insufficient antioxidants, especially beta-carotene, resulting from decreased fruit and vegetable intake;23,24 and insufficient levels of vitamin D.23,25,26
THE “WINDOW OF VULNERABILITY”
This is the period within the infant’s first year of life when highly allergenic foods are introduced to facilitate reduced incidence of allergic reactions. The timing of this optimal window to introduce highly allergenic foods is currently unclear, but evidence suggests it is between 4-7 months of life.27-30
There is evidence to suggest that this “window” may be different for each food. For example, infants introduced to milk at 4-6 months were more likely to develop a milk allergy when compared to those who were introduced to milk at a later time.31 Conversely, infants exposed to eggs at 4-6 months were less likely to be allergic to eggs when compared to infants exposed to eggs after 10 months of age.32
Even though the current treatment is avoidance of the allergenic food,3 there are ways to help manage & reduce the risk of food allergies.
HOW CAN I NOURISH MY BABY?
Breast milk is the optimal source of nutrition for most infants for the first 4-6 months, regardless of allergy risk.33
WHAT IS THE IDEAL FEEDING PROGRESSION TO MINIMIZE FOOD ALLERGIES?
If your baby is at risk (e.g. family history of food allergies, moderate/severe skin issues such as dermatitis/eczema) and hasn’t had any remarkable previous food allergy event, the recommendation for introducing highly allergenic foods is as follows:33,34
- Infant is at least 4 months of age & show developmental readiness (e.g. sits up without support) to consume complementary foods.
- Infant already demonstrated tolerance to other more typical, initial foods (e.g. fruits, vegetables, cereals).
- If the above two criteria have been met, give your infant an initial taste of one of these potential allergenic foods at home, while having an oral antihistamine available. Only introduce one food at a time, and wait 3-5 days between introductions to monitor for signs of intolerance.
- If there is no reaction, gradually begin increasing the amount of this food served.
- Exception: cow’s milk should be avoided in all infants less than 1 year old
* For infants with moderate/severe skin issues (e.g. eczema) who haven’t responded to optimal management, or those with signs/symptoms of an immediate allergic reaction while breastfeeding or upon introduction of any food, an evaluation with an allergist may be needed. Always check with your pediatrician for the most current, appropriate food introduction method.
With a foundational understanding of food allergies, supplements may be appropriate complements to nutritional interventions and lifestyle interventions.
- Research suggests that adequate vitamin D intake may help prevent food allergies, although the evidence is not entirely clear. However, it has been noted that as the prevalence of food allergies has increased, there has been a concurrent decrease in vitamin D levels. It has been estimated that 50% of people in Western countries are vitamin D insufficient and at least 10% are vitamin D deficient.35,36 Vitamin D not only plays a role in good bone health and assists in calcium absorption, but is also involved in immune system function.37
- Therefore, low vitamin D levels may increase the risk of developing food allergies.38 Vitamin D3 is the form most associated with raising the body’s level of active vitamin D.39,40 It’s the form of vitamin D that our bodies naturally make when unprotected skin is exposed to sunlight.
- Since many factors impact infants’ sun exposure (e.g. winter months, use of sunscreen), all infants may be at risk for vitamin D deficiency.
- Exclusively breastfed infants are at particular risk for vitamin D deficiency because each liter of breast milk only contains about 25 IU vitamin D.41 Thus, breastfed infants 0-12 months should be given 400 IU vitamin D3.42
- Infants naturally have an immature gut lining that allows a greater amount of undigested proteins to enter the bloodstream.43
- In addition to vitamin D3, infants, especially formula-fed infants, may benefit from probiotics to help reduce the risk of food allergies.44,45 Although it’s not yet clear which probiotic strains target specific allergies, research suggests you should look for a quality dairy-free infant probiotic that contains Lactobacillus and Bifidobacterium.45
INTEGRATIVE LIFESTYLE INTERVENTIONS
You can use powerful lifestyle interventions to help minimize the risk of food allergies in your infant. These are helpful tips for anyone with food allergies.
5 TIPS TO REDUCE THE RISK OF CROSS-CONTAMINATION46:
- Wash hands with soap & water before handling foods to prevent accidental cross-contact.
- Clean countertops before handling foods.
- Use different utensils for allergenic & “safe” foods.
- Keep food in the kitchen to prevent contaminating other areas of the home.
- Ask guests to wash their hands before touching or feeding your child.
There are a number of resources to help you explore food allergies and integrative interventions.
Here are a few well-respected organizations to get you started:
Life-threatening food allergies have a rich, complex history. The effects vary in severity and happen relatively quickly. Evidence-based practice guidelines regarding food introduction recommendations in infants, including those considered at-risk for developing food allergies, continue to change based on the most up-to-date findings. It is important to speak with your pediatrician/healthcare provider for an individualized plan for food introduction.
What steps have you taken to minimize the chance of developing life-threatening food allergies? Share in the comments below!
+ The information provided is for educational purposes only, and is not intended or implied to treat, diagnose or prevent any disease. It is not intended to replace a one-on-one relationship with a qualified health care professional, is not intended as medical advice, and is not a substitute for medical care. Consult your doctor/pediatrician before starting any supplement/intervention/protocol, especially if you or your child are taking medication and/or have a medical condition, and if you are pregnant or lactating.
1. Koplin JJ, Allen KJ. Optimal timing for solids introduction – why are the guidelines always changing? Clin Exp Allergy. 2013;43(8):826-834. doi:10.1111/cea.12090
2. Facts and statistics. Food Allergy Research and Education website. https://www.foodallergy.org/facts-and-stats. Accessed May 22, 2017.
3. Du Toit G, Foong RX, Lack G. The role of dietary interventions in the prevention of IgE-mediated food allergy in children. Pediatr Allergy Immunol. 2017;28(3):222-229. doi:10.1111/pai.12711
4. Kobernick AK, Burks WA. Active treatment for food allergy. Allergol Int. 2016;65(4):388-395. doi:10.1016/j.alit.2016.08.002
5. Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-Sponsored Expert Panel. J Allergy Clin Immunol. 2010;126(6):S1–S58. http://doi.org/10.1016/j.jaci.2010.10.007
6. Burks W. Clinical manifestations of food allergy: an overview. In TePas E, ed. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-food-allergy-an-overview. Updated October 23, 2015. Accessed May 22, 2017.
7. Wood RA. Food allergy in children: prevalence, natural history, and monitoring for resolution. In TePas E, ed. UpToDate. https://www.uptodate.com/contents/food-allergy-in-children-prevalence-natural-history-and-monitoring-for-resolution Updated July 12, 2016. Accessed May 18, 2017.
8. Bauer RN, Manohar M, Singh AM, Jay DC, Nadeau KC. The future of biologics: applications for food allergy. J Allergy Clin Immunol. 2015;135(2):312–323. http://doi.org/10.1016/j.jaci.2014.12.1908
9. Mahan LK, Raymond JL, eds. Krause’s Food and the Nutrition Care Process. 14th ed. St. Louis, MO: Elsevier; 2017.
10. Wawrzyniak M, O’Mahony L, Akdis M. Role of regulatory cells in oral tolerance. Allergy Asthma Immunol Res. 2017;9(2):107–115. http://doi.org/10.4168/aair.2017.9.2.107
11. Deo SS, Mistry KJ, Kakade AM, Niphadkar PV. Role played by Th2 type cytokines in IgE mediated allergy and asthma. Lung India. 2010;27(2):66–71. http://doi.org/10.4103/0970-2113.63609
12. Gupta RS, Springston EE, Warrier MR, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011; 128(1):e9-e17. doi:10.1542/peds.2011-0204
13. Molloy J, Koplin J, Ponsonby AL, et al. Prevalence of challenge-proven IgE-mediated food allergy in infants in the Barwon Region, Victoria, Australia. Clin Transl Allergy. 2015;5(Suppl 3):P89. doi:10.1186/2045-7022-5-S3-P89
14. Osborne NJ, Koplin JJ, Martin PE, et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol. 2011;127(3):668-676. doi:10.1016/j.jaci.2011.01.039
15. Mansouri M. Food allergy: a review. Arch Pediatr Infect Dis. 2015;3(3):e22470. doi:10.5812/pedinfect.22470
16. Smith PK, Hourihane JO, Lieberman P. Risk multipliers for severe food anaphylaxis. World Allergy Organ J. 2015;8(30). doi:10.1186/s40413-015-0081-0
17. Liu AH. Revisiting the hygiene hypothesis for allergy and asthma. J Allergy Clin Immunol. 2015;136(4):860-865. doi:10.1016/j.jaci.2015.08/012
18. Lack G. Epidemiologic risks for food allergy. J Allergy Clin Immunol. 2008;121(6):1331-1336. doi:10.1016/j.jaci.2008.04.032
19. O’Connell EJ. Pediatric allergy: A brief review of risk factors associated with developing allergic disease in childhood. Ann Allergy Asthma Immunol. 2003;90(6 Suppl 3):53-58. https://www.ncbi.nlm.nih.gov/pubmed/12839114. Accessed May 22, 2017.
20. Brown JE. Nutrition through the Lifecycle. 6th ed. Boston, MA: Cengage Learning; 2017.
21. Grimshaw KEC, Bryant T, Oliver EM, et al. Incidence and risk factors for food hypersensitivity in UK infants: results from a birth cohort study. Clin Transl Allergy. 2016;6(1). doi:10.1186/s13601-016-0089-8
22. Ahmed N, Barrow CJ, Suphioglu C. Exploring the effects of omega-3 and omega-6 fatty acids on allergy using a HEK-Blue Cell Line. Int J Mol Sci. 2016;17(2):220. http://doi.org/10.3390/ijms17020220
23. du Toit G, Tsakok T, Lack S, Lack G. Prevention of food allergy. J Allergy Clin Immunol. 2016;137(4):998-1010. https://doi.org/10.1016/j.jaci.2016.02.005
24. Patel S, Murray CS, Woodcock A, Simpson A, Custovic A. Dietary antioxidant intake, allergic sensitization and allergic diseases. Allergy. 2009;64(12):1766-1772. doi:10.1111/j.1398-9995.2009.02099.x
25. Hoxha M, Zoto M, Deda L, Vyshka G. Vitamin D and its role as a protective factor in allergy. Int Sch Res Notices. 2014;2014:951946. doi:10.1155/2014/951946
26. Mirzakhani H, Al-Garawi A, Weiss ST, Litonjua AA. Vitamin D and the development of allergic disease: how important is it? Clin Exp Allergy. 2015;45(1):114–125. http://doi.org/10.1111/cea.12430
27. Sansotta N, Piacentini GL, Mazzei F, Minniti F, Boner, A. L., Peroni DG. Timing of introduction of solid food and risk of allergic disease development: understanding the evidence. Allergol Immunopathol (Madr). 2013;41(5):337-345. doi:10.1016/j.aller.2012.08.012
28. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191. doi:10.1542/peds.2007-3022
29. Prescott SL, Pawankar R, Allen KJ, et al. A global survey of changing patterns of food allergy burden in children. World Allergy Organ J. 2013;6(21). doi:10.1186/1939-4551-6-21
30. Lack G. The concept of oral tolerance induction to foods. Clin Biochem. 2014;47(9):715. doi:10.1016/j.clinbiochem.2014.05.023
31. Katz Y, Rajuan N, Goldberg MR, Eisenberg E, Heyman E, Cohen A, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82. doi:10.1016/j.jaci.2010.04.020
32. Koplin JJ, Osborne NJ, Wake M, et al. Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol. 2010;126(4):807-813. doi:10.1016/j.jaci.2010.07.028
33. Fleischer DM. Introducing highly allergenic foods to infants and children. In TePas E, ed. UpToDate. https://www.uptodate.com/contents/introducing-highly-allergenic-foods-to-infants-and-children. Updated March 28, 2017. Accessed May 25, 2017.
34. Duryea TK. Introducing solid foods and vitamin and mineral supplementation during infancy. In Torcia MM, ed. UpToDate. https://www.uptodate.com/contents/introducing-solid-foods-and-vitamin-and-mineral-supplementation-during-infancy. Updated July 12, 2017. Accessed May 31, 2017.
35. Ginde AA, Liu MC, Camargo CA Jr. Demographic differences and trends of vitamin D insufficiency in the US population. Arch Intern Med. 2009;169(6):626-632. doi:10.1001/archinternmed.2008.604
36. Mansbach JM, Ginde AA, Camargo CA Jr. Serum 25-hydroxyvitamin D levels among US children aged 1 to 11 years: do children need more vitamin D? Pediatrics. 2009;124(5):1404-1410. doi:10.1542/peds.2008-2041
37. Vitamin D and food allergy. American Academy of Allergy Asthma and Immunology website. https://www.aaaai.org/conditions-and-treatments/library/allergy-library/vitamin-d-food-allergy. Accessed May 31, 2017.
38. Rudders SA, Carmargo CA Jr. Sunlight, vitamin D and food allergy. Curr Opin Allergy Clin Immunol. 2015;15(4):350-357. doi:10.1097/ACI.0000000000000177
39. Vitamin D supplements review (including calcium, vitamin K, magnesium). ConsumerLab.com website. https://www.consumerlab.com/reviews/vitamin_D_supplements_review/Vitamin_D/#types. Updated July 9, 2017. Accessed July 10, 2017.
40. Tripkovic L, Wilson LR, Hart K, et al. Daily supplementation with 15 µg vitamin D2 compared with vitamin D3 to increase wintertime 25-hydroxyvitamin D status in healthy South Asian and white European women: a 12-wk randomized, placebo-controlled food-fortification trial. Am J Clin Nutrition. 2017. http://ajcn.nutrition.org/content/early/2017/07/04/ajcn.116.138693.abstract. Accessed July 10, 2017.
41. Vitamin D supplementation. Centers for Disease Control and Prevention website. https://www.cdc.gov/breastfeeding/recommendations/vitamin_d.htm
42. Hoecker, J. L. (2014). Does my baby need a vitamin D supplement? Mayo Clinic website. http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/vitamin-d-for-babies/faq-20058161. Published June 7, 2017. Accessed July 1, 2017.
43. Kerr CA, Grice DM, Tran CD, et al. Early life events influence whole-of-life metabolic health via gut microflora and gut permeability. Crit Rev Microbiol. 2015;41(3):326-340. doi:10.3109/1040841X.2013.837863
44. O’Sullivan A, Farver M, Smilowitz JT. The influence of early infant-feeding practices on the intestinal microbiome and body composition in infants. Nutrition and Metabolic Insights. 2015;8(Suppl 1):1–9. http://doi.org/10.4137/NMI.S29530
45. Özdemir Ö. Various effects of different probiotic strains in allergic disorders: an update from laboratory and clinical data. Clin Exp Immunol. 2010;160(3):295–304. http://doi.org/10.1111/j.1365-2249.2010.04109.x
46. 12 tips for avoiding cross-contact of food allergens. Kids with Food Allergies website. http://www.kidswithfoodallergies.org/page/prevent-allergic-reactions-in-your-home.aspx. Updated July, 2014. Accessed May 22, 2017.