What is a food allergy?
A food allergy is a reaction that takes place when the body's immune system reacts to the ingestion of a particular allergenic protein found in food. The immune system acts as though the protein is harmful to the body and triggers various symptoms, ranging from mild to severe. It is important to note that a food allergy is different than a food intolerance and should be treated appropriately, a common confusion for many, especially when it comes to dairy foods. Lactose intolerance does not have to mean dairy avoidance; whereas, for those with a milk allergy, dairy should be avoided due to the potential for an allergic reaction.
Just like a milk allergy, a peanut allergy is identified as a priority allergen by Health Canada. Peanut allergy is a significant health issue with no known treatment or cure. Individuals and caregivers who live with peanut allergy have to be cautious about the foods they consume and the environments they enter in order to avoid allergic reactions. Peanut allergy usually develops in infancy and persists throughout the duration of life. However, new evidenced-based guidelines have been released which suggest that introducing peanut into the diet during infancy can reduce the risk of developing peanut allergy.
New guidelines for the prevention of peanut allergy
On January 24th, 2019 the Canadian Pediatric Society (CPS) released a new position statement regarding the introduction of peanut and other allergenic foods to babies. These new guidelines follow the Addendum Guidelines for the Prevention of Peanut Allergy in the United States, released by the National Institute of Allergy and Infectious Diseases (NIAID) in 2017. Written by experts in the areas of allergies and infant feeding, including Medical Doctors (MD) and a Registered Dietitian (RD), the new position statement provides a review of the current evidence on practices for introducing allergenic foods to high risk infants. According to the statement released by CPS, infants at high risk of developing allergies are defined as those who have a personal history of allergic diseases (including eczema), or a first-degree relative with allergic disease (e.g. eczema, food allergies, allergic rhinitis, or asthma). It is important to note that the definition of "high-risk" is not currently agreed upon by all international organizations, and various studies have used different methods of classifying allergic risk in infants.
New recommendations as laid out by the CPS are largely influenced by the landmark 2015 Learning Early About Peanut Allergy (LEAP) study, which discovered that infants aged 4–11 months who were at high risk for peanut allergy decreased their risk of developing peanut allergy when exposed to peanut during these early months of life.
Putting it into practice
Following a review of the current evidence, the CPS emphasizes the following guidance for practice:
If the infant is at high risk for developing allergies, consider introducing age-appropriate, peanut-based solid foods at around 6 months of age, but not before 4 months of age. For this group, parents and caregivers are strongly advised to consult with the infant’s health care provider prior to feeding peanut. Allergy testing (i.e. peanut specific IgE blood tests or skin prick tests) should be considered to determine whether or not peanut-containing food should be introduced to the infant. This early introduction window of 4-6 months may decrease the risk of developing peanut allergy and is presented as a range, as it is important to follow cues regarding readiness for solid foods. An infant is ready for solid foods when they have good head and neck control, can sit with support, and begin to transition from a sucking reflex to swallowing (i.e. they do not push a spoon out of their mouth with their tongue). Other solid foods should be introduced prior to the introduction of peanut-based food to ensure the infant is developmentally ready.
For infants at no- or low-risk of food allergy (i.e. not falling under the high-risk classification described above), introduce age-appropriate, peanut-containing foods around 6 months of age. It is recommended that the introduction of peanut take place at home; however, an in-office supervised feeding can be done with a physician if preferred.
The importance of breastfeeding should be promoted and supported for infants up to 2 years and beyond, as it is associated with unique immunological and developmental benefits.
For introduction of all common allergenic foods (eggs, peanuts, cow's milk, tree nuts, fish, shellfish, wheat, and soy), be sure to introduce them one at a time to gauge reaction. If an infant appears to tolerate the common allergenic food, advise parents to offer this food to baby a few times a week to maintain tolerance.
Tips for home introduction of peanut-containing food
- Ensure child is healthy.
- Introduce peanut in home setting when caregiver can be with infant for 2 hours post-exposure.
- Stop feeding if signs and symptoms of allergic reaction present and call 9-1-1.
Recommended peanut preparation
Parents and caregivers are not advised to introduce peanut protein to infants via whole peanuts or peanut butter due to the risk of choking. Therefore, the recommended preparation method for peanut introduction is:
- Combine 2 tsp of peanut butter with 2–3 tsp of hot water. Stir until blended.
- Once mixture has cooled, place a small amount on the tip of a spoon and feed to infant.
- Wait 10 minutes.
- If no symptoms of allergic reaction are observed, continue to feed infant at their regular feeding rate.
For additional introductory peanut recipes, read Instructions for Parents and Caregivers on Feeding Peanut Protein to Infants from NIAID, or visit HealthLink BC's Reducing Risk of Food Allergy in Your Baby for more suggestions on recipe ideas to introduce common allergens to your baby.
Professional organization endorsement
Be advised that the recommendations for the timing of food introduction are not harmonized between all professional organizations. Allergy prevention guidelines typically recommend that the introduction of food to infants take place between 4-6 months. In contrast, world feeding guidelines currently recommend exclusive breastfeeding until 6 months of age and advise that complementary foods only begin to be introduced following this period of time.
The 2017 NIAID guidelines are officially supported by the Canadian Society of Allergy and Clinical Immunology (CSACI), the Academy of Nutrition and Dietetics, and now the Canadian Pediatric Society, as well as multiple other international organizations. Furthermore, Dr. Edmond Chan, the only Canadian member on the NIAID expert panel, who is the Head of the Division of Allergy and Immunology in the UBC Department of Pediatrics, and the Director of the Allergy Clinic at BC Children’s Hospital, recently stated, “Feeding peanut to children around six months is the best way to prevent an allergy to peanut.” Dr. Chan was one of the principal authors on the new CPS guidelines.
Currently, Health Canada and Dietitians of Canada have not formally endorsed the 2017 NIAID Addendum Guidelines or the new CPS position statement.
The release of these guidelines is yet another step forward in providing consistent guidance to parents around the prevention of food allergy. As these new guidelines represent a shift from previous advice reagrding the introduction of peanut in a child's diet, Food Allergy Canada and the CSACI have compiled an FAQs document addressing common questions and concerns.
By Britney Lentz, year 5 dietetic student, with Carmen Gorlick, RD
Updated March 2019
A Togias et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. (2017) Journal of Allergy and Clinical ImmunologyDOI: 10.1016/j.jaci.2016.10.010
Canadian Society of Allergy and Clinical Immunology (CSACI) & Food Allergy Canada.(2017)Early Infant Feeding Guidelines FAQs. Retrieved from http://csaci.ca/wp-content/uploads/2017/10/FAQs-for-early-infant-feeding-guidelines.pdf
Canadian Paediatric Society (2019). Timing of Introduction of Allergenic Solids for Infants at High Risk. Retrieved from https://www.cps.ca/en/documents/position/allergenic-solids
Dietitians of Canada. (2018) Facts on Peanut Allergies. Retrieved from http://www.unlockfood.ca/en/Articles/Food-allergies-intolerances/Peanut-Allergies-FAQs.aspx
Dietitians of Canada. (2017) Introduction of Allergenic Foods to Infants, especially Peanuts: Interim Guidance for Canadian Dietitians. Retrieved from https://www.dietitians.ca/Downloads/Members-Only/DC-Infant-Allergy-interim-January-2017.aspx
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Food Allergy Canada. (2017). New Guidelines for Introducing Peanut to Babies: What do they Mean? Retrieved from http://foodallergycanada.ca/resources/videos-presentations/#healthcare
Food Allergy Canada. (2017). Important Changes with the Introduction of Peanuts to Babies. Retrieved from http://foodallergycanada.ca/2017/01/important-changes-introduction-peanuts-babies/
Health Canada (2017). Peanuts- A priority food allergen. Retrieved from https://www.canada.ca/en/health-canada/services/food-nutrition/reports-publications/food-safety/peanuts-priority-food-allergen.html
HealthLinkBC (2017). Introducing Solid Foods to your Baby. Retrieved from https://www.healthlinkbc.ca/health-topics/te4473
HealthLinkBC (2018). Reducing Risk of Food Allergy in your Baby. Retrieved from https://www.healthlinkbc.ca/healthy-eating/reducing-baby-food-allergy-risk
National Institute of Allergy and Infectious Disease. (2017) NIH-Sponsored Expert Panel Issues Clinical Guidelines to Prevent Peanut Allergy. Retrieved from https://www.niaid.nih.gov/news-events/nih-sponsored-expert-panel-issues-clinical-guidelines-prevent-peanut-allergy
National Institute of Allergy and Infectious Disease. (2017). Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Summary for Parents and Caregivers. Retrieved from https://www.niaid.nih.gov/sites/default/files/peanut-allergy-prevention-guidelines-parent-summary.pdf
National Institute of Allergy and Infectious Disease. (2107). Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Summary for Clinicians. Retrieved from https://www.niaid.nih.gov/sites/default/files/peanut-allergy-prevention-guidelines-clinician-summary.pdf
National Institute of Allergy and Infectious Disease. (2017). Appendix D. Instructions for Home Feeding of Peanut protein for Infants at Low Risk of an Allergic Reaction to Peanut. Retrieved from https://www.niaid.nih.gov/sites/default/files/addendum_guidelines_peanut_appx_d.pdf
The University of British Columbia: Faculty of Medicine. (2017). The best way to prevent peanut allergies? Feeding your infant peanut-based foods early. Retrieved from https://www.med.ubc.ca/news/the-best-way-to-prevent-peanut-allergies-feeding-your-infant-peanut-early/