Latest Guidelines for Preventing Food Allergies in Infants

The current recommendations for introducing three of the top allergenic foods in infancy, based on the latest studies, show a reduction in infant food allergies. These top 3 include eggs, peanut products, and milk products. 

Pictured are several of the most common allergenic foods including peanuts, tree nuts, eggs, milk, fish, and wheat.

Previous advice recommended delaying the nine most common allergenic foods  

• Peanuts

• Eggs

• Milk 

• Tree nuts 

• Fish 

• Shellfish

• Sesame

• Soy

• Wheat

until after the first or second year of life. 

Following these recommendations, we observed a significant increase in the incidence of food allergies.

Ten years ago, the LEAP study (Learning Early About Peanut Allergy Trial) showed that the early introduction of this common food allergen in infancy (peanuts given as peanut protein) led to a lower rate of peanut allergy at age five, compared to avoiding peanuts for the first five years. The rate of peanut allergy in the avoidance group was 13.7%, while the early introduction group had a rate of 1.9%. Children in both groups were considered high risk, with a history of either eczema, egg allergy, or both.

Excluding allergenic foods from the diet of infants, even those at high risk for food allergy, has not been shown to decrease or prevent food allergies.

The American Academy of Pediatrics (AAP) endorsed this policy of early peanut  introduction in 2015, based on the LEAP trial. Over the last decade, this policy has been adapted to other top allergenic foods, except for regular cow’s milk (other dairy, such as yogurt and cheese, are allowed). The recommendation for milk is to wait until one year. The AAP also concluded that there was no evidence to support dietary restrictions in the mother during pregnancy or breastfeeding as a way to prevent allergies in her child.

The EAT study (Enquiring About Tolerance), from 2016, showed that introducing and feeding peanut products and cooked eggs during the first year reduced the prevalence of these food allergies. 

The National Institute of Allergy and Infectious Diseases (NIAID) developed guidelines for early peanut introduction in infants and is supported by the AAP. This includes safe forms of peanut protein for infants, such as peanut butter thinned with water or mixed in a puree, peanut puffs, peanut flour or powder, and peanut oil.

The exception are high-risk infants: those with severe eczema or an egg allergy. It is recommended that these infants first be evaluated with a blood test for peanut allergy (IgE) or skin prick testing. If this is negative, then they can be given peanut protein, after other non-allergenic foods have been introduced.

For the majority of infants, once they are developmentally ready for food (4 to 6 months), and have been given non-allergenic foods, they can begin to be introduced to allergenic foods in age-appropriate forms. These foods can start as early as 6 months.

Peanuts and tree nuts can be introduced as nut butter, shown here, thinned with water, formula, or breast milk, or nut flours or puffs.

The following guidelines apply to introducing these foods.

1. Introduce only one food allergen at a time, waiting several days or up to a week before giving another allergenic food.

2. Ensure that the food is infant-safe, has an appropriate texture, and is cooked to the proper temperature if needed. 

3. Begin with a pea-sized amount and observe for 10-15 minutes before offering more. Continue observing over the next couple of hours.

4. Continue to feed the same food allergen several days a week, even when introducing another allergen. This is not a one-time event. Give the same new item two days in a row, then several times a week.

5. If your baby has eczema, continue to manage as prescribed. Let your doctor know if the eczema worsens with any foods. Try to avoid getting the food item on the baby's skin. Consider a layer of Vaseline around the mouth to protect the skin.

Signs of an allergic reaction to watch for:

Rash to face or body

Sudden coughing, wheezing, or any difficulty breathing

Vomiting

Itching or swelling of the face or tongue

Diarrhea or blood in the stool

There is no indication that introducing allergenic foods at 6 months is harmful. These foods should not be presented first, but after several non-allergenic foods have been given. There is also no reason for mothers to exclude these foods during pregnancy or breastfeeding, unless she is allergic.

Proceed slowly and safely and address any concerns with your doctor.