Photo from Edwart Visser Flickr Creative CommonsThere’s new data out to support stronger recommendations for introducing peanuts during infancy. Like hemlines, it may seem like this data keeps changing. As time, the science and our understanding of risk unfolds we’ve seen shifts in advice about starting solids that have left many parents wondering what really is best when starting foods and wanting to decrease risk for food allergy.

Briefly, and in general, it’s best to start a variety of foods for your child during infancy, starting around 4 to 6 months of age. In fact its now believed that it may be protective to introduce things like wheat, egg, soy, fish, and peanuts even before a child takes their first step around a year of age. The 2013 recommendations (that exclude information about peanuts) are explained in this post, “When Should I start Baby Food?”

The recommendation to share diverse foods during infancy that includes fish and eggs may feel new to you. For example, when my babies were born (mid-2000’s) advice and consensus suggested that avoidance of peanuts until after a year of age was best — the thought that avoidance of peanut during critical development may be protective against severe allergy development. Now, concomitant with a doubling in food allergies, we face an utter and potentially embarrassing reality — perhaps medical advice and our work to improve allergy risk by restricting foods in  infancy did just the opposite. Perhaps avoidance was exactly the wrong thing to do. Maybe we’ve engineered part of the problem.

This kind of advice can feel intense when raising children. “Do this, don’t do that, do this now, don’t do this now!” Doing the right thing is what we all want but doing right can remain elusive, especially when recommendations shift. I remember a fellow pediatrician questioning my eating a peanut butter sandwich while I was pregnant with my second son. She couldn’t believe I’d made that choice. At the time I remember not only feeling judged but a little terrified too. Perhaps I’d not take the data seriously enough? Oh goodness, I thought, as I diligently didn’t introduce “high allergy” foods until toddlerhood for my boys. Today I realize that wasn’t all that right either. It can feel like another hemline change for sure and yikes these sure are shorter skirts!

Fast forward 7 years to 2015. A New England Journal of Medicine study out this past month systematically evaluated risk for development of peanut allergy in children who were at higher risk for developing the allergy in the first place. And they started with infancy and introduced peanuts early in some of the babies. Researchers found if infants were introduced to peanuts early in life (between 4 and 11 months of age) their risk of peanut allergy at age 5 years significantly decreased.

The early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy.  ~ New England Journal Of Medicine

Before I detail the numbers from this study let me also acknowledge that this is a science thing yes, but its also a feeling thing too. As a culture we’re living with new compassion and smarts about food allergies as we protect those with life-threatening allergies. From the Teal Pumpkin Project at Halloween, to the nearly universal option for peanut-free zones at school lunch, to more compassionate birthday party policies all help. Allergy family experts have communities like FARE (Food Allergy Research & Education) that support parents, coaches and educators in staying up to date on the science. Vocal parents wed with mom-to-mom storytelling helps us all understand better. But no question as this data comes out children still suffer in an environment that isn’t entirely kind or necessarily deft at creating a safe, welcoming environment for eating with a food allergy. Restaurants still warn about “no guarantees” for safety and up to a 1/3 of children with food allergy report being bullied because of their allergy. Parents are rightly motivated and amped to avoid the diagnosis of food allergy in the first place as we work to contribute to these cultural transitions and prevent this challenge all together.

No question anxiety drives quite a bit of our parenting choices at times as we navigate the opportunities to protect our children. Often anxiety about rising numbers of children with allergies stifles parents to introduce new foods. Most of us have heard that peanut allergies have doubled in the past decade, with an estimated 400,000 school aged children in the US suffering from mild to severe reactions if exposed to an allergen. For many children peanut exposure can be life-threatening. And while peanut allergies develop early in life up to 20 percent of kids will thankfully outgrow them. Learning to reduce risk is what we’re all hoping for.

Infants At Risk For Peanut Allergy, NEJM Study

Graph information from http://bit.ly/1zVVylk

  • Babies Included in Study: More than 600 British infants age 4 – 11 months-old were included in the study. Infants included were selected for the study after being deemed high-risk of developing peanut allergy. Risk for allergy in this case included an established egg allergy or significant eczema (a skin rash often seen in “allergic babies and children”).
    • Four Groups of Babies: Four groups of infants were created. Two groups consisted of infants who showed sensitivity in their skin to peanut testing, the other two groups did not. Those with no skin sensitivity were further divided, some were fed peanuts starting as young as 4 months, the others not. The group of children reactive to peanut by skin were divided similarly — some got peanuts during infancy, the others were restricted and got none during early childhood. All children were then evaluated for peanut allergy at age 5 years.
  • Results: Children who consumed peanuts starting during infancy were far less likely to be allergic to peanuts at age 5 years. Children with no skin reaction to peanuts were most protected: 13.7% of group that avoided peanuts tested positive for allergies while only 1.9% of the group that consumed peanuts tested positive for allergies at age 5. In children who initially had skin reactions to peanuts (98 of 640 infants) similar protection from eating peanuts was observed. Of those, 35% of children who avoided peanuts had a food allergy at 5 years while only 10% who ate peanuts throughout infancy and toddlerhood developed the allergy.

Researchers are quick to reiterate that this was a controlled study in a medical environment with children at increased risk for allergy. No question that this is new science and new discovery. If your child is at risk for peanut allergies, seek help from your pediatrician before giving your baby peanut foods (peanuts still a choking risk in toddlerhood and infancy!) or peanut butter in infancy. Researchers are also uncertain as to whether peanut allergies can develop when the regular feeding of peanuts (regulated by the study) stops. Ongoing evaluation will unfold.

The current American Academy of Pediatrics policy on food allergy introduction (revised in 2008) states there is insufficient evidence to support delayed introduction of potential food allergens to reduce the risk of developing allergies. This means holding back on foods during infancy isn’t recommended! We’re moving towards not waiting on any foods in late infancy and this data on peanuts is the beginning of understanding creating recommendations to start foods early.

Further know this about allergy testing: skin tests, the most common type of allergy testing, can sometimes create a false positive and don’t always properly portray the depth of the food allergy or a child’s tolerance of foods. You should always use skin and allergy blood tests together with life experience in determining your child’s allergy profile. If your child tested positive for a food allergy using a skin test, but you’d like to learn more about the severity of their allergy (or if there’s a chance the skin test misrepresents their tolerance) talk with your child’s doctor. The Seattle Children’s Food Allergy Challenge Clinic is a new treatment center for patients (ages 4 to 21) who have previously tested positive for severe food allergies to milk, eggs, peanuts, tree nuts or sesame seeds. Using a highly controlled protocol, the team can “challenge” these allergies by allowing a child to consume increasing amounts of a food to which they may be allergic while under the observation of trained medical staff. Staff at Seattle Children’s are highly experienced in treating anaphylaxis and are well qualified to perform these challenges so it can be a safe place to support your child and understand their allergy better. You can read more about the clinic here and I’ll post more from allergy experts in the months to come. Would love to include questions you may have.