Infants and young children with a family history of atopy are at high risk for developing allergic disease, and those with a personal history of atopy, particularly those with moderate-to-severe eczema, are also at increased risk of developing other atopic diseases, including food allergies.
The American Academy of Pediatrics (AAP) had previously suggested in 2000 that the introduction of certain highly allergenic foods be delayed further in high-risk children:
- cow’s milk (CM) until age one year;
- eggs until age two years; and peanuts,
- tree nuts, and fish until age three years.
This recommendation was based upon early studies that suggested that delayed introduction of solid foods might help prevent some allergic diseases, particularly atopic dermatitis (AD).
However, this advice was modified in 2008 with the consensus that there was insufficient evidence to recommend any specific practices concerning the introduction of these foods after four to six months for the prevention of allergic disease in high-risk infants.
On the contrary, delayed introduction of solid foods may increase the risk of allergy and early introduction of certain foods (eg, egg, peanut) between four to six months of age may decrease the risk of allergy to that specific food. These findings suggest that the increased risk of peanut allergy seen in younger siblings of a child with peanut allergy, for example, is partly due to the delayed introduction, in addition to an underlying genetic susceptibility. Other risk factors, such as moderate-to-severe eczema, may also play a role in increasing this risk.
We recommend not delaying the introduction of complementary foods into the diet of high-risk infants beyond what is generally recommended for all infants.
We counsel parents to introduce highly allergenic foods (eg, cow’s milk [CM], hen’s egg, peanut, tree nuts, fish, and shellfish) in the following manner in infants who are at risk based upon family history but who have not had any significant prior allergic reactions to food or difficult-to-control, moderate-to-severe atopic dermatitis (AD):
- First, the child should be at least four months of age and have shown developmental readiness to consume complementary foods.
- In addition, the child should have tolerated a few of the more typical, initial complementary foods (such as cereals, fruits, and vegetables).
If these two criteria are met, then the child can be given an initial taste of one of these foods at home (rather than at daycare or at a restaurant), with an oral antihistamine available.
If there is no apparent reaction, the food can be introduced in gradually increasing amounts.
However, an allergy evaluation, including a detailed history and possible testing, before the introduction of highly allergenic foods is a reasonable option to consider in patients with the following histories:
- Recalcitrant, moderate-to-severe AD despite optimal management.
- Signs or symptoms of an immediate allergic reaction while breastfeeding or with the introduction of any food, especially one of the highly allergenic foods.
If you have any questions or concerns about introducing solids to your infant, please speak with your pediatrician.