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At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Vivian Hernandez-Trujillo, MD, FAAP, FAAAAI, FACAAI, division director, Allergy and Immunology, and fellowship training program director, Allergy and Immunology at Nicklaus Children’s Hospital in Miami, Florida presents a session on best practices for preventing food allergies in newborns and infants.
On the second day of the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Dr. Hernandez-Trujillo, division director, Allergy and Immunology, and fellowship training program director, Allergy and Immunology at Nicklaus Children’s Hospital in Miami, Florida began her session on essential advice for preventing food allergies in children by explaining, “Food allergy affects approximately 8% of children, roughly 2 children per classroom in the United States. “With the pediatrician playing a key role in early nutrition, discussion with parents regarding solid food introduction is essential.”
New parents and families often ask about the need for dietary restriction during pregnancy, noted Hernandez-Trujillo, but there is in fact a lack of evidence supporting dietary restriction during both pregnancy and lactation. Having said that, Hernandez-Trujillo pointed out, “exclusive breastfeeding during the first 3 to 4 months of a child’s life does decrease incidence of eczema in the child’s first 2 years.” Breastfeeding beyond 3 to 4 months protects against wheezing in the first 2 years as well.
Other questions that parents often ask pediatricians is about formula choice and delayed introductions of food, says Hernandez-Trujillo. On these points, there is no convincing evidence for use of soy-based formula in allergy prevention, little evidence that hydrolyzed formula prevents atopic disease, and no evidence supporting delayed introduction of solid foods beyond 4 to 6 months in protection against atopic disease.
“The times are changing: the recommendations of avoidance of solids and ‘allergenic’ foods until 3 to 5 years old are no longer advised,’ says Hernandez-Trujillo, but breastfeeding for 4 to 6 months is recommended, with no introduction of solids until at least 4 months of age.” In noting the Learning Early About Peanut Allergy (LEAP) study, Hernandez-Trujillo said, “the take-home message of this study was that the early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk.”
Next, Hernandez-Trujillo pointed to the 2016 Enquiring About Tolerance (EAT) study, which was designed to investigate the best time to introduce 6 allergenic foods to the infant diet: cow’s milk, peanut, egg, sesame, fish, and wheat. The study proved that early introduction of this food group resulted in lower food allergy prevalence, was achievable and safe.
Hernandez-Trujillo went on to discuss the addendum guidelines for the prevention of peanut allergy in the United States, a report from the National Institute of Allergy and Infectious Disease. The summary guidelines state that infants with either egg allergy, severe eczema or both should be evaluated by testing to peanut prior to introduction; infants with mild to moderate eczema should be introduced to peanuts at 6 months; and infants with no eczema or egg allergy should be introduced at the preference of parents.
When it comes to peanut introduction, says Hernandez-Trujillo, “always keep in mind the form of food given to an infant or toddler, and remember the choking risk.” Additionally, “regular consumption early on is needed to ensure tolerance: encourage consumption of 2 teaspoons of peanut butter 3 times per week,” she said. There should be no food introduction if the child is sick, and finally, she adds, “Adults should spend at least 2 hours after feeding to monitor possible allergic reaction.” Good peanut products to try, she suggested, include peanut puffs, thinned smooth peanut butter, smooth peanut butter puree, and peanut flour or peanut powder. And “while allergic reactions are rare at the time of introduction,” she warns, “if there is a severe allergic reaction, child should avoid the food and be evaluated and tested, with no reintroduction until the testing is completed.” She also reminded health care professionals that “anaphylaxis can be difficult to diagnose in infants, since they are non-verbal, so adults need to be able to monitor and identify any potential allergic reaction.” Finally she noted, “be aware of panel testing. Broad food panels can result in unnecessary avoidance of foods. Furthermore, children who eat a food and are tolerating it should continue to consume that food, something to keep in mind because while panel testing may be easy, it really does lead to some unnecessary avoidance of food and can impact the overall nutrition of the child.”
Hernandez-Trujillo concluded the session with highlighting overall strategies for safe introductions of foods which included open communication with parents regarding the benefits of early introduction; offering in-office feedings for patients who may be at risk of reaction; review of signs and symptoms of allergic reactions; and steps to take if an allergic reaction occurs. She also reminded practitioners to discourage dietary restrictions during pregnancy or breastfeeding to prevent atopic disease and to remember, “if a child has developed food allergy, treatment requires identification of the allergen and dietary restriction.”
1. Hernandez-Trujillo V. Essential advice on preventing food allergies. 2021 AAP National Conference & Exhibition, virtual. Accessed October 9, 2021.