Written by: Kathleen Wang, MD, Pediatric Allergist

As babies near their half birthday, there are remarkable changes in their social, language and motor skills. Your baby may be starting to sit on his own, smiling and interacting more with those around him, becoming more vocal with babbling, and starting to show a curiosity for new things. This is also a time when your baby might take his first bites of solid food. For many families, the idea of starting solid foods is exciting, but for some, the idea of introducing foods, particularly “highly allergic foods” can be a source of anxiety. 

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The fear of introducing foods that may cause an allergic reaction, particularly peanuts, dates back many years. In 2000, the American Academy of Pediatrics (AAP) published feeding guidelines that included the recommendation that children at high risk of food allergies should delay introduction of dairy until 1 year of age, egg until 2 years of age, and peanut, nut, and fish until 3 years of age. This recommendation soon became widespread. 

Despite this recommendation, it was becoming clearer that delaying the introduction of these foods may not be successful in preventing food allergies. The number of people in the United States with food allergies continued to grow at alarming rates. In 2008, the AAP acknowledged that there was little evidence to support delaying introduction of foods to prevent development of allergic disease and they withdrew their previous recommendations.

Later that year, Drs. Gideon Lack and George Du Toit observed that peanut allergies were increasing in the United Kingdom, Australia, and the United States; countries where there were guidelines recommending avoidance of peanuts during infancy. Interestingly, peanut allergies were rare in Israel, where peanut is regularly ingested during infancy. They studied children in the United Kingdom and in Israel and found that the development of a peanut allergy was 10x as high among Jewish children in the UK as it was in Israeli children of similar ancestry! From this came the question of whether the early introduction of peanuts actually helped prevent the development of peanut allergies.

In 2015, the doctors published their findings in the landmark Learning Early About Peanut (LEAP) study, which provided clear-cut evidence that infants with a high risk of developing a peanut allergy (an identified egg allergy or severe eczema) had at least a 80% LOWER risk of developing a peanut allergy than similar infants where introduction of peanuts was intentionally delayed. 

Based on the findings in the LEAP study, the National Institute of Allergy and Infectious Disease (NIAID), a part of the National Institute of Health (NIH), established an expert panel to develop guidelines for the prevention of peanut allergies. These guidelines were published in 2017.

So what does it mean for your baby?

Based on the expert panel’s recommendations:

• If your baby does not have eczema or any food allergies, introduce age-appropriate peanut-containing foods freely at home according to your family’s preferences and cultural practices
• If your baby has mild to moderate eczema, introduce age-appropriate peanut-containing foods at home around 6 months of age to reduce the risk of a peanut allergy 
• If your baby has severe eczema, egg allergy, or both, it is strongly recommended that evaluation with a skin test or blood test for peanut be done first before deciding whether to or where to introduce peanut-containing foods. The introduction is ideally done as early as 4 to 6 months to reduce the risk of peanut allergy. Consult with your baby’s pediatrician to decide whether blood testing or a referral to an allergist for skin testing is the best route to take. Based on these results as well as you and your doctor’s preference, your child may be able to:
  • Start peanut-containing foods at home
  • Eat peanut-containing foods at the doctor’s office to monitor for reactions
  • Avoid peanut-containing foods   

For those who decide to introduce peanuts at home, how do you begin?

First, introduce other solid foods to make sure your baby is developmentally ready.

Next, it’s time to choose an age-appropriate peanut-containing food. There are several options. 

• Bamba, a snack food made from peanut butter and puffed maize, is a great option for babies who can feed themselves (This was the peanut source used in the LEAP study!)
• Smooth peanut butter can be mixed into a puree of fruits or vegetables your baby already eats. It can also be thinned by adding water.
• Peanut powder can be mixed into a puree of fruits or vegetables your baby already eats. 

Once you’ve picked a peanut containing food and your baby is ready, now what? How much do you give, how often, and for how long? 

• Six grams of peanut protein per week divided into three or more feedings until 5 years old. This is based on the LEAP study, which only studied high-risk infants, but is the best recommendation we have as we do not have data on other doses, alternative feeding schedules or lower-risk infants.
• To figure out how much peanut protein is in the food you are giving, look at the protein content in the nutritional label. Some math may be involved! 
• We don’t know if eating peanut-containing food in infancy will protect your baby from peanut allergies if they stop eating it later. This is being studied!

Are you still worried about introducing peanuts? Some concerns may include a parent or sibling with a peanut allergy, or your baby having another food allergy not mentioned in the guidelines such as a milk allergy. In these cases, it may be best to consult with an allergist to help determine whether allergy testing is needed. In some cases, peanuts can be introduced in the allergist’s office under observation.

If your baby develops hives, itching, swelling, runny or stuffy nose, cough, wheezing, or vomiting after eating food containing peanuts, these may be signs of an allergic reaction and your baby may benefit from an allergy evaluation.

For many years, parents delayed introduction of foods in an attempt to prevent food allergy. Our understanding of allergy development has come a long way in the last two decades and the LEAP study has completely changed the way we think about early introduction of foods, particularly peanut introduction. It showed that introduction of peanuts in the first year of life was not only safe but could PREVENT peanut allergy in high risk infants. How cool is that?

Dr. Kathleen Wang met Dr. Manasa Mantravadi (Ahimsa's Founder) through a Facebook Physician's group, but quickly realized Kathleen had trained under Dr. M's cousin!

Kathleen is in North Carolina by way of Illinois. She lives in Raleigh with her husband and "her apartment full of house plants!"

Working with children is her passion, but outside the hospital she is an avid reader and enjoys cooking and baking. She also just started to grow her own vegetables!

References: 

American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106(2);346-349.

Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. The 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.

Du Toit G, Katz Y, Sasieni P, et al. Lack early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol. 2008;122(5):984-991.

Du Toit G, Roberts G, Sayre, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-813.

Togias A, Cooper SF, Acebal et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Disease-sponsored expert panel. J Allergy Clin Immunol. 2017;139(1): 29-44.