Introducing allergens to your child/ for some it should be done earlier than you might think

 Starting solids can feel overwhelming. 

When you sort through all the overwhelming amount of information out there, there really aren’t a lot of hard and fast rules, but here are a couple.

1. Babies younger than one year should never have any raw honey

2. Have some common sense choking precautions. This means: no whole nuts, round hard things, etc

Really that’s it, so relax!

But is anything really that simple? 

There are actually a few considerations.

Some kids are eagerly watching every bite you take. They are willing you to share whatever you are munching on.

Others aren’t at all interested. They are not impressed by your acting skills as you make loud YUM noises over a spoonful of mushy peas.

Some families have lots of free time, love to cook  and want to make their own food, others are perfectly content to open some jars.

Some kids have lots of poop issues that start after the solids begin.

Some have a history of family allergies or severe eczema and understandably want to proceed carefully around allergens.

As you can see, no situation is exactly the same.

Some parents create lists, charts and flowsheets (you know who you are). This is especially common with first kids. Most of the time as siblings come along, the second (and subsequent)  babies simply get fed whatever else the family is eating, without paying too much attention.  Assuming that allergies aren’t a significant issue, those kids turn out just fine.

But there is a lot of buzz about introducing allergens that is worth paying attention to.

Peanuts are the food that are often the most associated with severe allergic reactions. Because of this, folks were quite cautious and often kept kids away from their first exposure until they were at least two or three-years-old.

It turns out that this caution was possibly exacerbating the problem. As more and more kids were identified as being allergic, in the mid 2000s, some scientists noted that kids in Israel were not following the same trajectory. What was fascinating was that these same kids were genetically very similar to Jewish populations scattered throughout the world. So why did kids in Israel have much lower rates of peanut allergies than their Western counterparts?

It is as simple as Bamba. It turns out that young kids in Israel were routinely exposed to a popular peanut based puff. This routine and early exposure seems to prevent many of the kids from ultimately becoming reactive to the nuts.

After examining this trend, new guidelines were established. Now, as opposed to delaying that initial introduction, it is suggested that the ideal age to introduce some of these tricky foods is between 4-6 months.

4 or 6 months? A note on the age for starting solids:

Understandably, there are a lot of opinions about the age for starting solids. Solid Starts, the very popular baby-led-weaning app, doesn’t recommend starting any true solids until 6 months. If you think about what makes sense evolutionarily, there’s probably some gray here. Cave people didn’t track their infants’ exact age, they just saw that they were watching the food they brought to their mouths attentively and reaching for it. It’s likely that at that point, they were given a bone to chew on or some other foods. When your child is sitting supported in your lap, watching you eat, and reaching for the food you bring to your mouth, as long as they are at least four months old, Dr. Ted and I think that they’re effectively ready to play with solids. ‘Play’ is the operative word here. This is about exploring. It is not about meeting their nutritional needs. Breastmilk and/or formula are all they need until 6 months.

Not everyone needs to pay such careful attention to the introduction of allergens.

Kids who have lovely buttery soft skin are unlikely to have any issues with foods.

But if your little one is one of the many who have dry patchy skin, any signs of asthma or family history of food allergies, it is really important to introduce things early in the effort to avoid allergies later.

Any time you are exposing your baby to ANY new food, I strongly suggest that you do it in the morning when you are in the position to keep a close eye on them for the next hour or so. Have them dressed in clothes that are easy to lift us so you can see if there are any rashes developing.

Recognizing Allergic Symptoms

What are allergic symptoms that are cause for alarm and need immediate attention?

These symptoms may begin within minutes to an hour after ingesting the food.

• Hives (these are not little red dots, but typically full body welts and large areas of red raised skin that will often have a white center and tend to move around the body)

• Breathing difficulties like excessive coughing or wheezing

• Vomiting

• Swelling of the lips or face

• Sudden fussiness

• Sudden dramatic sleepiness

What are symptoms that are NOT cause for alarm?

These are common reactions and the ones we get asked about the most. They are more often benign food sensitivities. 

• Rashy red cheeks that show up after eating and linger (they might show up quickly, but can last for hours and even days).

• Diaper rashes that are either red dots or large red rings.

• Mild changes in poop consistency or color in kids that are otherwise happy.

There are a million opinions about what to do with these benign reactions to food. Dr. Ted usually says to just power through, unless the face is so rashy that it’s breaking skin, then consider using a bunch of Vaseline. Nurse Judy will advise people to cut back a little on the extra berries that are so often the culprit. 

For the First Introduction of Peanuts

Before you start: if you have a known severe (anaphylactic) reaction to peanuts in the family, do not try peanuts on your own at home. Ask your pediatrician for testing first, or a referral to an allergist.

It is important to know that before having a food allergy reaction, a sensitive child must have been exposed to the food at least once before, or could also be sensitized through breast milk. It is the second time your child eats the food that the allergic symptoms happen.

• Prepare some peanut butter by thinning it out: You can mix it  with a few drops of warm water or breast milk. Make sure it’s natural, free of honey, and with no extra salt or sugar. There is also peanut powder as an option (more on this below).

• Rub a small amount of the thinned peanut butter on the inside of the infant's lip (not on their skin), or dip your finger and let them suck it off. 

• I used to recommend touching peanuts to skin, because indeed allergic babies would react. This seemed less scary at the time. It turns out that skin exposure to allergens might be part of what causes allergies. As such, if you have a rashy child, you should apply some Vaseline or other skin barrier around the mouth before feeding allergens. It seems weird (and tedious), but this simple fix may decrease the likelihood that allergies will develop.

•  If there is no reaction after a few minutes, feed the baby  ¼ teaspoon of the thinned peanut butter and observe for 30 minutes.

• If there is still no allergic reaction, give ½ teaspoon of smooth peanut butter/paste and observe for a further 30 minutes.

• If it is well tolerated, parents should continue to include peanut butter in their infant’s diet in gradually increasing amounts at least once or twice weekly, as it is important to continue to feed peanut to the infant as a part of a varied diet.  As a bonus, peanuts are a nice source of protein!

• If there is any mild or moderate allergic reaction (mentioned above) at any step, stop feeding peanuts to the infant and seek medical advice. I would work closely with your pediatrician or allergist  to make a plan moving forward.

Don’t hesitate to give a dose of cetirizine (Zyrtec) at the first sign of any symptoms. Benadryl is not quite as good in these situations because it can cause sleepiness which can potentially be harder to assess, and only lasts 4-6 hours, while cetirizine lasts 24 hours. 

Of course, If there is any difficulty breathing, call 911. Be assured that actual anaphylactic reactions in kids under a year are quite rare. 

Dr. Ted’s Tidbits:

The thought of giving your child anaphylactic shock is terrifying. A lot of parents will subsequently delay allergen introduction due to this fear. I’d encourage you not to wait, and here’s why. In order to have anaphylactic shock, the body releases a large amount of histamine in multiple organs. You can tell if your baby has a propensity to release large amounts of histamine: these kids almost always have very significant eczema. Their skin is like a big flag announcing, “hey, I’m allergic!” They also might have very reactive airways and are oftentimes wheezing. If your child has, as Nurse Judy says, buttery smooth skin, they’re highly unlikely to have anaphylaxis out of nowhere, and no, you don’t need to own an epi pen “just in case.”

Introducing Other Allergenic Foods

The most common food culprits are nuts, fish/shellfish, milk, eggs, wheat, and soy.

If you are nursing and eat some of the things on the list, it is possible that your baby will show some signs of fussiness and intolerance, but not always.

As noted above, there is a big difference between life-threatening allergies and the run-of-the-mill nuisance variety.

Milk allergies usually show up as blood in the poop. Dietary changes are needed in the first year, but this is not generally dangerous and virtually all babies grow out of it.

Think about how many of your adult friends have to carry an epi pen for milk, egg, or wheat allergies. Probably not many. If you’re trying to get the most bang for your buck with early allergen introduction, focus on nuts and shellfish. 

FPIES (food protein-induced enterocolitis syndrome)

This condition is VERY rare but worth knowing about.

Unlike most food allergies, symptoms of FPIES do not begin immediately after eating. Instead, it can take hours before severe symptoms begin.

Typical symptoms of FPIES include severe vomiting, diarrhea and dehydration two hours after eating. These symptoms can lead to other complications, including changes in blood pressure (although it’s rare you’re checking this at home) and body temperature, lethargy, and poor weight gain.The most common FPIES food triggers are cow’s milk, soy, rice and oats, but any food can cause FPIES symptoms. 

FPIES is commonly misdiagnosed as a severe stomach bug because the symptoms are so similar. 

However, most tummy bugs only last for a couple of days. When symptoms are lingering is when most doctors start looking more closely for possible causes. It is generally only after repeated ingestion of the trigger food — followed by severe symptoms hours later — that indicate FPIES may be the cause.

Treatment is generally avoiding the trigger foods. Fortunately most kids outgrow this by the time they are 3.

What about these new food allergen kits?

There are a lot of new products that aim to make allergen introduction easier, and more scientific, for parents. They are small and typically flavorless powders that are essentially freeze-dried proteins from typical allergenic foods. They make it easier to introduce allergens without needing to figure out the “how” (“how will I feed a small infant a shrimp cocktail?”). You can sprinkle the powder into breast milk or add it to any other food your baby already tolerates. They are proven and effective, but not all allergists think they’re worth the price (as of this writing). If you aren’t intimidated by figuring out how to feed the real deal, you can save your money and get the same results.

In Conclusion

Breathe. This all can feel very scary. There’s something very sinister about the idea of allergic reactions…this concept that the body can just flip a switch and attack itself, seemingly without warning. Luckily this is extraordinarily rare in infants. Using the latest data and studies on allergen introduction, you can hopefully avoid serious allergies later in life and train the body to accept everything in the diet. And for the majority of you without risk factors (no eczema, no asthma, no food allergies in parents), you should relax and feed your kid. You don’t need to focus on introducing allergens to young infants.

And before you know it they are driving!

Thanks to my models EJ and Sawyer