The American Academy of Allergy, Asthma & Immunology (AAAAI), American College of Allergy, Asthma & Immunology (ACAAI), and the Canadian Society for Allergy and Clinical Immunology (CSACI) have published a consensus statement and recommendations on nutritional interventions for the prevention of food allergy. The recommendations were published in a recent edition of the Journal of Allergy and Clinical Immunology: In Practice.

Dermatologic Conditions and Food Allergy Risk

While the AAAAI/ACAAI/CSACI guideline committee notes that there is currently no consensus on what qualifies an infant to be at high risk for food allergies, recent guidance recommends that clinicians consider eczema as a clinical characteristic predictive of food allergy in infants. 

Based on the available evidence, the guideline committee also suggests that an increased risk of food allergy exists in infants if they meet the following criteria: mild to moderate eczema; family history of atopy in either or both parents; or 1 known food allergy. 

Introducing Potentially Allergenic Foods

The guideline recommends infants should be introduced to peanut- and egg-containing products starting at 6 months of life but not before 4 months of life. Eggs should be cooked prior to consumption. Introduction of these foods should be considered for all infants and irrespective of relative risks of developing a peanut allergy. 

According to the writing panel, introduction to potentially allergenic peanut-containing foods should be done either in a supervised oral food challenge or “at home when the infant is developmentally ready for complementary food introduction, in accordance with the family’s cultural practice.” Regular ingestion of these products should be maintained once introduced.

The authors of the guideline suggest that screening for peanut allergy or office introduction is not required but should remain an option for families who prefer to not introduce these foods at the home.

For infants with a risk of food allergy, clinicians are advised to discuss that risk with families along with the benefits of early food introduction. In terms of testing for food allergies, clinicians are advised to discuss the overuse and misinterpretation of these tests prior to using them. Clinicians should also discuss with families that food specific immunoglobulin E (IgE) testing is not diagnostic in infants who have never ingested a potentially allergic food.

Delays in Introducing Potentially Allergenic Foods

In a subsequent recommendation, the guideline committee notes that there should be no deliberate delays in the introduction of other potential allergenic complementary foods, including soy, wheat, sesame, fish and shellfish, or tree nuts. Furthermore, the authors wrote that observational studies suggest there may be potential harms associated with delaying the introduction of those foods. 

Diet Diversity

Once complementary foods have been introduced into an infant’s diet at 6 months of age, the guideline notes the infant should be fed a diverse diet as a means of preventing food allergy. While no evidence from randomized controlled trials exist to support this weak recommendation, the guideline committee points to observational studies suggesting a diverse range of dietary choices could be helpful for food allergy prevention in infants.

Hydrolyzed Formula for Food Allergy Prevention

The guideline strongly recommends against routinely prescribing or recommending the use of hydrolyzed formula for the prevention of food allergy or the development of food sensitization. This recommendation was made because of the lack of available evidence supporting the use of hydrolyzed formula for the specific prevention of food allergy.

Maternal Recommendations

Mothers should not focus on excluding common allergens during pregnancy and lactation to prevent food allergy in infants, according to the guideline. The committee also wrote that they have no specific recommendation to support the use of any food or supplement for mothers as a means of preventing food allergy in infants, either in the prenatal period or during breastfeeding. This strong recommendation was also made based on the fact that little conclusive or consistent evidence exists to support the exclusion or inclusion of a food or supplement in the maternal diet for preventing infant food allergy.

Applying the Recommendations

According to the AAAAI/ACAAI/CSACI, the recommendations in the guideline are intended to be a reference for specialists caring for and managing children with food allergies. In addition, the recommendations can be used by “primary care providers who care for the potentially at-risk child; dieticians; governments, and policymakers; as well as patients and patient-advocacy groups.”

Reference

Fleischer DM, Chan ES, Venter C, et al. A consensus approach to the primary prevention of food allergy through nutrition: guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract. Published online November 26, 2020. doi:10.1016/j.jaip.2020.11.002