Don’t wait on introducing new foods and especially new solids to your baby during the COVID-19 pandemic. Period.
An anecdotal trend I’ve been discussing with colleagues across the county is the worry parents have with interventions right now, especially when it comes to prevention efforts. Parents are hesitating on seeing their pediatrician for vaccines, they are hesitating to do routine health visits, and they hesitate to do things that feel risky. Because of new and unfolding data, our track record in giving pediatric advice for the last 15 years or so has created both confusion, and worry in parents, when it comes to solid food introduction to infants. This is especially true with foods that are known common allergens, like peanut or egg, fish or shellfish.
Outdated advice from the past has likely increased the number of children with life-threatening food allergies. From the year 2000 to about 2015, pediatricians like me recommended a delayed approach for certain foods to protect infants. Because of the erred approach, even as guidelines have changed for food introduction, parents have remained worried about introducing new foods for fear of a potential allergic reaction and the eventual need for a subsequent trip to the ER. The increased worry today is rooted in parents’ concern that an ER visit could incur a COVID-19 exposure. Reality is, most babies will NOT have any reaction to any food introduction, especially if done at 4 to 6 months of age. Further, even in the rare case of an IgE-mediated food allergy at first feeding, research shows the two most common signs of an allergic reaction for infants and toddlers are hives and vomiting, both of which often do not require a trip to the ER.
According to multiple pediatric allergists and pediatric ER physicians I have spoken with, there are numerous safeguards in place to ensure maximal safety and prevention against exposure to COVID-19 for every patient, staff member, and care provider that enters the hospital. It turns out that ER census and utilization is very low at the moment, due to stay-at-home, physical distancing orders, and the fear of seeking care in general. This further decreases the risk of exposure to any viral or infectious pathogens.
When it comes to food allergies in babies, the true risk to babies at large, may be the tendency to dial back or wait on food introduction. Babies are at increased risk for development of food allergies if they are not introduced to potential allergens during infancy. They are are at lower risk when introduced early.
I spend the majority of my time working to help parents and pediatricians recognize the huge opportunity we have to prevent food allergies because of new science around how we feed babies. My strong and passionate recommendation is to encourage early and diverse food introduction to infants at 4 to 6 months of age. Once an infant shows signs of readiness (sitting without support and with good head control, opens mouth when food presented, shows excitement, and no tongue thrust when the food is in their mouth), introduce common allergens (peanuts, fish, egg, sesame, wheat, etc) regularly like you introduce fruits and veggies, meats and cereals. And keep at it so as your baby grows up, and their immune system does too. Help your child grow up to be able to eat everything!
5 Reasons To Encourage Early, Diverse Food Introduction and Inclusion:
- Prevention is possible. Data from around the world, including the LEAP trial, the EAT study, and Venter food diversity study, show that prevention of food allergies is possible, especially with high-risk infants (eczema is biggest risk factor).1,2 The American Academy of Pediatrics and NIAID guidelines recommend early introduction of diverse foods including common allergens between the crucial 4-6 month window.3-5
- Delaying introduction increases risk. The Canadian CHILD study demonstrates that avoiding during the first year increased the risk of food-specific sensitization.6 In fact, infants who were not introduced peanut by 12 months had 4 times increased chance of developing a food allergy.6 If families waited until 18 months the risk was 7 times as high as those babies who got peanut in and continued to eat it through infancy.
- Allergic reactions in infancy and toddlerhood are rare, typically hives and vomiting. There was a recent Children’s Hospital study evaluating food reaction severity among a large pediatric population.7 Allergic reactions tend to get more severe as your baby gets older, so starting as early as possible is the safest way to feed potential allergens to your baby.7 “Severe (food allergic) reactions and mortality…are particularly low in infants,” with no food allergy deaths ever reported in infants under age 1 year.7 Before your baby turns 1 is the safest time to feed them allergens like peanut, egg, milk, shellfish, tree nuts, etc in efforts to avoid becoming sensitive. If your child has severe eczema, risks for food allergy are higher so talk with your pediatrician and/or a pediatric allergist about making a good plan for introduction and keeping all sorts of common allergens in the diet as your baby grows.
- Let’s enjoy feeding babies without such worry! Feeding babies is a beautiful, nearly spiritual experience. The introduction of solids can be a joy for both families and babies. As pediatricians, we need to begin to liberalize our approach to food introduction as joyful and healthful. And stop positioning food introduction in the framework of risk and fear. I want families to know that the more they introduce a wide variety of foods early in a child’s life, and keep that diverse diet all along, the better the prevention!
- Let babies learn first about food through their tummy, not their skin. About 70% of the immune system lives in the GI tract (mouth, esophagus, stomach, intestines) – the introduction of food should begin there, not elsewhere.8 This is especially during early, critical immune development. Research confirms the #1 risk for developing a food allergy is eczema (because the introduction of food first through the open skin in eczema tends to be sensitizing) therefore ensuring food introduction commences in the tummy will ensure those at highest risk avoid the increased likelihood of sensitizing events in infancy.9
Bibliography and references:
- Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-813. doi:10.1056/NEJMoa1414850
- Perkin MR, Logan K, Tseng A, et al. Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. N Engl J Med. 2016;374(18):1733-1743. doi:10.1056/NEJMoa1514210
- Venter C, Maslin K, Holloway JW, et al. Different measures of dietary diversity during infancy and the association with childhood food allergy in a UK birth cohort study. J Allergy Clin Immunol Pract. January 2020. doi:10.1016/j.jaip.2020.01.029
- Greer FR, Sicherer SH, Burks AW, COMMITTEE ON NUTRITION, SECTION ON ALLERGY AND IMMUNOLOGY. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods. Pediatrics. 2019;143(4). doi:10.1542/peds.2019-0281
- Togias A, Cooper SF, Acebal ML, 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. J Allergy Clin Immunol. 2017;139(1):29-44. doi:10.1016/j.jaci.2016.10.010
- Tran MM, Lefebvre DL, Dai D, et al. Timing of food introduction and development of food sensitization in a prospective birth cohort. Pediatr Allergy Immunol. 2017;28(5):471-477. doi:10.1111/pai.12739
- Capucilli P, Kennedy K, Alfaro MK, Spergel Z, Dorris S, Spergel J. Age differences in food reaction severity during oral food challenges in a large pediatric population. Journal of Allergy and Clinical Immunology. 2020;145(2):AB219. doi:10.1016/j.jaci.2019.12.161
- Vighi G, Marcucci F, Sensi L, Di Cara G, Frati F. Allergy and the gastrointestinal system. Clin Exp Immunol. 2008;153 Suppl 1:3-6. doi:10.1111/j.1365-2249.2008.03713.x
- 9. Martin PE, Eckert JK, Koplin JJ, et al. Which infants with eczema are at risk of food allergy? Results from a population-based cohort. Clin Exp Allergy. 2015;45(1):255-264. doi:10.1111/cea.12406
Kathy Wiseman says
Thank you Wendy. Very helpful
Do you have a good handout you give to parents on this topic?
Dr. Wendy Sue Swanson says
I do! We made it at Before Brands, where I’m the Chief Medical Officer:
I have a question–We’ve started introducing solids on the regular schedule and try to regularly include common allergen foods and thankfully have had no issues so far! I am concerned though about the resultant decline in breast milk consumption/production combined with the risk of him getting sick with COVID. To clarify I am worried about losing milk supply and not being able to provide him with antibodies and breast milk nutrition were he to get sick. This has not prevented us from continuing solids or for me to continue to try to keep up my supply but I am curious your thoughts on this situation and what you might say to these concerns. The question is should I be worried about this and if so what suggestions would you have. Thanks!!
Dr. Wendy Sue Swanson says
It’s natural to have a gradual transition from full liquid breastmilk diet to a mix during later infancy to a primarily solid food diet at 12 months of age. No data that COVID19 can be prevented from breastmilk….unfortunately….and the changes in volume just don’t likely make a meaningful difference when it comes to immune protection. So carry on, keep on progressing with feeding and ENJOY and congrats on doing an awesome job feeding so smartly with common allergens in the diet regularly early in life!!!