Update on allergy prevention and food introduction

Interview transcript (edited for clarity):

Scott Sicherer, MD, FAAP:

Hi I'm Scott Sicherer, and I'm the director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai in New York.

Contemporary Pediatrics:

Can you explain the update you provided at AAP 2023, regarding food introduction and allergy prevention?

Sicherer:

So there was an incredible change in advice over the last 23 years. Back in 2000, the Committee on Nutrition came out with a clinical report that actually said that to prevent food allergy, a high risk infant meaning like there's a family history of allergy or some allergy in the baby, that they would avoid milk until age 1 egg until age 2, peanut, seafood like fish, until age 3 years.I mean, this meant that the baby couldn't have birthday cake. You know this was amazing advice that was based on 1 randomized trial and some observational studies and that information kind of stood out there for about 8 years. In 2008, the section on allergy of the AAP and the Committee on Nutrition got together and said "wait a minute, we're seeing some differences in the data coming out from the field, we're going to rescind that advice." So that got erased, although I think in the minds of many people, they were still like, "oh, you know, you're allergy prone, shouldn't have peanut shouldn't have egg," things like that. So then we fast forward to 2015, a study comes out New England Journal of Medicine, they spent a lot of observational data, it looked like maybe feeding babies, peanut and peanut is a choking hazard for babies, so we're not talking about peanuts or peanut butter that's a thick chocking hazard, but infancy forms like smooth out into applesauce, let's say. So this study, followed up on the idea that maybe your earlier introduction could help and they randomized babies to get peanut early, or to avoid it like they had been doing. And it turned out that there was a significant reduction in peanut allergy in the babies that ingested it early. They looked at this between the ages like 4 months and 11 months getting into the diet earlier. Maybe getting it in even earlier is better for some ideas that came out after. But ultimately it gave us this hard evidence in a randomized excellent trial, that this was a thing and that maybe early introduction of allergen was better. That led to multiple other countries, ours included, giving advice for early introduction of peanut in different scenarios. So that advice was summarized also in an AAP clinical report in 2019. That report gave, as part of its recommendation, advice that came through our National Institute of Allergy and Infectious Diseases (NIAID), talked about babies who had bad egg allergy or bad eczema would introduce peanut earlyinto the diet, maybe after some testing. Kids with eczema should probably also get a peanut in early, we're talking about 4 to 6 months or around 6 months and people with no risk factors, maybe they shouldn't delay introduction of it. So that was 2019, but things changed again, and there's even more information out the more information that's out is saying, okay, you know, maybe such as peanut, there's evidence for egg, and there's no reason to suspect that any allergenic foods. So now we're talking about this a lot of allergens out there. Fish, shellfish, sesame, these are a lot of allergens. So maybe earlier introduction, around 6 months, not before 4 months, that kind of window, any of that that can be introduced early might be protected. Part of the things that I spoke about in my talk was that there are nuances here like is it really necessary to pretest people? Well, there's a lot of countries with this advice saying don't do any allergy testing, just let them add the food to the diet. There's questions about you know, how much? The studies had a pretty substantial amount, some of them think that you need to have an equivlent of 2 teaspoons of peanut 2 or 3 times a week's worth to really get an effect. But you know, there's not a lot of studies on that aspect of it. If we're looking at egg and peanut, what about all the other foods and it becomes a practical problem. A baby can't eat 15 different foods in large quantities. So you kind of have to pick your suspects and peanut an egg are probably the main ones to think about. But again, there was no evidence to avoid these foods anymore. That's completely changed. The best advice for the families to give to the teachers and your families now is to treat allergens like any other food. You're not worried about introducing cereal or rice cereal or or Apple or squash. Think about egg and peanut as being in those categories as well and any other allergens as well. Once it's in the diet, it's good to keep it in as a regular part of the diet.