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Cracking the Code on Early Food Introduction for Allergy Prevention

October 11, 2023

Editor’s Note: Dr. Alex Eaton (he/him) is a first-year resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center. He is interested in medical education and health disparities research, specifically the intersection of pediatric pain control and historic practices of race-based medicine. Alex is planning to pursue a fellowship specializing in pediatric critical care. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

In the world of food allergy prevention, significant buzz revolves around introducing allergenic foods to infants at an early age. The idea is simple – start feeding allergenic foods early in life to thwart allergies. But what sounds like a straightforward solution to a growing problem becomes more complex when one delves deeper. This week, Pediatrics is early releasing a State of the Art multi-institutional review by Dr. Elissa Abrams from the University of Manitoba and University of British Columbia and colleagues from 4 additional institutions across the US and Canada, entitled, “Updates in Food Allergy Prevention in Children,” that explores these twists (10.1542/peds.2023-062836). 

Beyond Peanut: The Allergen Puzzle. In 2015, the Learning Early About Peanut (LEAP) study garnered interest with impressive results for peanut allergy prevention through valuable insights into the development of food allergies. Importantly, it highlighted the critical role of early exposure in shaping the immune system's response to allergenic foods. LEAP has paved the way for more proactive and evidence-based guidelines to reduce the risk of food allergies in children, challenging the "avoid at all costs" approach that was previously followed.

In this State of the Art Review, Dr. Abrams and colleagues note that merely following the “peanut” approach of early introduction might not yield identical outcomes for all allergens, as recent studies have revealed that early food introduction might not be a one-size-fits-all solution.

The Regularity Factor. The secret ingredient to making early introduction effective is regularity. It's not just about introducing the allergenic food; it's about making it a regular part of your baby's diet – a culinary feat for most families. While “regularity” is poorly defined, the evidence is clear that irregular exposures may actually increase the risk of developing certain allergies. For example, one study demonstrated that daily exposure to cow’s milk resulted in a significantly decreased risk of developing this food allergy, when compared to irregular (<1/day) or delayed (none for 14 days) exposures. Further, children who were exposed to cow’s milk within the first 3 days of life were more likely to develop a milk allergy unless they maintained regular ingestion during the first 6 months of life.

Cooked vs. Raw: Cooking Matters. When it comes to certain foods, like eggs, how they’re prepared may hold the key to allergy prevention. Cooking at higher temperatures could potentially reduce the allergenicity of specific proteins – a cooking hack or trick for safeguarding your child's health.

The Screening Dilemma. The million-dollar question – should babies be screened for allergies before diving into foods that are highly allergenic? It's a controversial debate; some argue for testing, while others express concerns about potential overdiagnosis and resource constraints. In the end, it comes down to shared decision-making while avoiding unnecessary delays in early introduction solely for the purpose of conducting preliminary tests.

Practical Challenges and the Road Ahead. The journey of early food introduction is riddled with questions. Which allergens should you prioritize? How frequently should they be introduced? And for how long? The truth is, despite many studies and revised guidelines, we do not yet have the answers. This is perhaps most clearly illustrated in a 2022 article about the results from early allergen introduction, “While peanut introduction in the first year of life has increased more than 3-fold from 2007 to 2018 (before and after early introduction guidelines), there has only been a nonsignificant decrease in peanut allergy in the population over this time.”

Overcoming Barriers and Spreading Awareness. Clear communication and education are vital in ensuring that parents and healthcare providers are on the same page. Awareness is the seasoning that flavors the path to allergy prevention.

So, as we venture further into the realm of early food introduction, one thing is evident: preventing food allergies resembles a complex puzzle with numerous pieces. Early and consistent introduction is a promising piece, but there's more to uncover. With continued research and informed choices, we can strive to reduce the burden of food allergies in our patients and children.

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