A January 23, 2019 article by Kelly Grant, writing for The Globe and Mail, comments on findings that “waiting years to feed babies foods that can trigger allergic reactions is not just out outdated advice, it increases the risk they’ll develop allergies and has contributed to a dramatic increase in the number of children who can’t safely eat food such as peanuts and eggs.” The updated advice from the Canadian Paediatric Society (CPS) reflects a significant change in thinking from their previous recommendations, issued in 2013, and “a seismic shift” from recommendations in place twenty years ago that recommended avoiding feeding peanuts to high-risk children under the age of three.

The author of the article interviewed Elissa Abrams, the president of CPS’s allergy section and the lead author of the new practice guidance, who said that “in the years since the group’s last official statement, ‘gold standard’ evidence has emerged showing that high-risk children who start eating peanuts and, to a lesser extent, cooked eggs, earlier can largely prevent the development of food allergies.” A landmark British trial published in 2015, the LEAP study, was significant in its findings that feeding high-risk babies pureed peanuts early and frequently reduced their risk of developing peanut allergies by as much as 80 per cent.

On January 24, 2019, the Canadian Paediatric Society issued a revised recommendation for the introduction of allergenic solids for infants. The Practice Point states:

Food allergy affects an estimated 2% to 10% of the population, with evidence of increasing prevalence over time. Preventing food allergy has become an important public health goal. Health Canada currently recommends breastfeeding infants exclusively until they are 6 months old, while acknowledging that in individual practice, signs of infant readiness may guide the introduction of complementary foods a few weeks earlier. There is emerging evidence that early food introduction, between 4 to 6 months of age, may have a role in preventing food allergy, particularly for egg and peanut, in high-risk infants. For infants at high risk for allergic disease, it is now recommended that commonly allergenic solids be introduced at around 6 months of age, but not before 4 months of age, and guided by the infant’s developmental readiness for food. Continued breastfeeding should be encouraged and supported because of its many health benefits.

The document discusses the change in recommendations. “In 2013, a Canadian Paediatric Society joint statement with the Canadian Society of Allergy and Clinical Immunology recommended exclusively breastfeeding infants at high risk for food allergy for their first 6 months, in keeping with World Health Organization recommendations to exclusively breastfeed infants for the first 6 months of life. Since 2013, however, more evidence has become available to suggest that introducing allergenic solids before an infant reaches 6 months of age may help prevent food allergy development, particularly for egg and peanut, in infants at high risk.”

The Practice Point document notes that “there is no current international consensus regarding how to define infants at high risk for developing food allergy. The 2013 CPS statement and other international guidelines defined an infant at high risk as having a first-degree relative with an allergic condition….[since then] the definition of ‘at-risk’ or ‘high-risk’ infants is becoming increasingly blurred….This practice point defines the infant at high risk as having a personal history of atopy, including eczema, or having a first-degree relative with atopy (e.g. eczema, food allergy, allergic rhinitis, or asthma).

The document includes the following evidence-based guidelines for practice:

• Infants considered to be at high risk for allergic disease have either a personal history of atopy or a first-degree relative with atopy.

• For high-risk infants, and based on developmental readiness, consider introducing common allergenic solids at around 6 months of age, but not before an infant is 4 months of age.

• For infants at no or low risk for food allergy, introducing complementary foods at about 6 months is recommended.

• Breastfeeding should be protected, promoted and supported for up to 2 years and beyond.

• Allergenic foods should be introduced one at a time, to gauge reaction, without unnecessary delay between each new food.

• If an infant appears to be tolerating a common allergenic food, advise parents to offer it a few times a week to maintain tolerance. If an adverse reaction is observed, advise parents to consult with a primary care provider about next steps.

• The texture or size of any complementary food should be age-appropriate to prevent choking. For young infants, smooth peanut butter can be diluted with water or mixed with a previously tolerated puréed fruit or vegetable, or with breast milk. For older infants, smooth peanut butter can be spread lightly on a piece of thin toast crust, or a peanut puff product could be offered.

Food Allergy Canada, in a response to the new recommendations, comments on the value of having a reliable source of guidance for families around how they can potentially help prevent food allergy in their children, while noting that there will be a need for education and public healthcare support to shift mindset in adopting the new recommendations, both in parents and in healthcare professionals. In particular, they draw attention to a survey of Canadian healthcare professionals, published last summer, that found a significant portion of family physicians recommended introduction of allergenic solids at age 1 or more.

The Canadian Society of Allergy and Clinical Immunology, in partnership with Food Allergy Canada, has produced helpful Early Infant Feeding Guidelines FAQs document, downloadable as a pdf at http://csaci.ca/wp-content/uploads/2017/10/FAQs-for-early-infant-feeding-guidelines.pdf to support parents in the introduction of peanuts and other potential food allergens into the infant diet.