Interview transcript (edited for clarity):
Scott Sicherer, MD, FAAP:
Hello, my name is Scott Sicherer and I am 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 has been an incredible change in advice over the last 23 years. In 2000, the Committee on Nutrition released a clinical report that actually said that to prevent food allergies, a high-risk infant, that is, if there is a family history of allergy or a allergy in baby, should avoid milk until the age of 1 year. egg up to 2 years, peanut, seafood such as fish, up to 3 years. I mean, that meant the baby couldn’t have a birthday cake. You know that this was incredible advice based on a randomized trial and observational studies and that this information remained available for about 8 years. In 2008, the AAP Allergy Section and the Nutrition Committee got together and said “wait a minute, we’re seeing differences in the data coming from the field, we’re going to rescind this opinion.” So that was erased, although I think in a lot of people’s minds, they were still saying, “oh, you know, you’re prone to allergies, you shouldn’t eat peanuts, you shouldn’t have d ‘eggs’, things like that. So we fast forward to 2015, a study is published in the New England Journal of Medicine, they used a lot of observational data, it seemed that feeding babies peanuts and peanuts posed a choking hazard for babies, so we’re not talking about peanuts or peanut butter that pose a thick choking hazard, but infancy forms like smoothed out in applesauce, let’s say. So this study followed up on the idea that maybe your earlier introduction might help and they randomized the babies to get peanuts early, or to avoid them like they had been doing. And it turned out that there was a significant reduction in peanut allergy in babies who ingested it early. They looked at this between 4 and 11 months of age by starting the diet earlier. It may be better to do it even earlier for some ideas that come out later. But ultimately it gave us real-world evidence, in a great randomized trial, that this was a thing and maybe it was better to introduce the allergen early. This has led several other countries, including ours, to advise for early introduction of peanut in different scenarios. So this advice was also summarized in an AAP clinical report in 2019. That report gave, as part of its recommendation, advice from our National Institute of Allergy and Infectious Diseases (NIAID), which talked about babies who had a bad egg allergy or a bad egg allergy. Eczema would introduce peanuts very early into the diet, perhaps after a few tests. Children with eczema should probably also be given a peanut early, we’re talking about 4 to 6 months or around 6 months and people without risk factors perhaps shouldn’t delay introducing this peanut. So that was 2019, but things have changed again, and the more information there is, the more information there is that says, okay, you know, maybe like the peanut, there’s has evidence for egg, and there is no reason to suspect there are allergenic foods. So now we’re talking about a lot of allergens. Fish, shellfish, sesame, there are many allergens. So maybe an earlier introduction, around 6 months, not before 4 months, that kind of window, anything that can be introduced early could be protected. Part of the things I talked about in my presentation was that there are nuances here: Is it really necessary to pre-test people? Well, many countries advise not to do allergy testing, just let them add the food to their diet. There are questions about you know, how much? The studies had a fairly substantial quantity, some think that you need to consume the equivalent of 2 teaspoons of peanuts 2 to 3 times a week to have a real effect. But you know, there aren’t a lot of studies on this aspect. If we take the egg and the peanut, what about all the other foods and it becomes a practical problem. A baby cannot eat 15 different foods in large quantities. So you kind of have to pick your suspects and peanuts and eggs are probably the main ones to think about. But again, there was no longer any evidence to justify avoiding these foods. It’s completely changed. The best advice families can give to teachers and your families now is to treat allergens like any other food. You’re not afraid to introduce cereal or rice cereal, or apples or squash. Think of egg and peanut as also falling into these categories, along with any other allergens. Once it is in the diet, it is good to keep it as a regular part of the diet.
