Last updated March 14, 2022

Primary Prevention of Food Allergy Through Nutrition

Recommendations 

1. Consider infants with severe eczema at the highest risk of developing food allergy. Consider infants with mild to moderate eczema, a family history of atopy in either or both parents, or infants with one known food allergy potentially at some increased risk of developing food allergy (or an additional food allergy). Be aware that food allergy often develops in infants who have no identifiable risk factors. There is no evidence to clearly support the younger sibling of a peanut-allergic child is at increased risk of developing peanut allergy, though such infants may be at risk of developing peanut allergy secondary to delayed introduction of peanut.  (B, M, )

(IIa-IV) 

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2. Introduce peanut-containing products to all infants, irrespective of their relative risk of developing peanut allergy, starting around 6 months of life, though not before 4 months of life. Introduction can occur at home when the infant is developmentally ready for complementary food introduction, in accordance with the family’s cultural practice, but not before the infant demonstrates developmental readiness with eating a few other common starter foods. While screening peanut skin or sIgE testing and/or in-office introduction is not required for early introduction, this remains an option to consider for families that prefer to not introduce peanut at home. This decision is preference-sensitive and should be made taking into account current evidence and family preferences. Strongly consider encouraging either home introduction, or offering a supervised oral food challenge for any positive skin prick test (SPT) or sIgE result. Once peanut is introduced, regular ingestion should be maintained.  (A, S, )

(Ia-III) 

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3. Introduce egg or egg-containing products to all infants, irrespective of their relative risk of developing allergy, around 6 months of life, though not before 4 months of life. Use only cooked forms of egg and avoid administering any raw, pasteurized egg-containing products. Introduction can occur at home when the infant is developmentally ready for complementary food introduction, in accordance with the family’s cultural practice, but not before the infant demonstrates developmental readiness with eating a few other common starter foods. While screening egg skin or sIgE testing and/or in-office introduction is not required prior to early cooked egg introduction, this remains an option to consider for families that prefer to not introduce egg at home. This decision is preference-sensitive and should be made taking into account current evidence and family preferences. Strongly consider encouraging home introduction, or offering a supervised oral food challenge for any positive SPT or sIgE result. Once egg is introduced, regular ingestion should be maintained.  (A, S, )

(Ia-III) 

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4. Do not deliberately delay the introduction of other potentially allergenic complementary foods (cow’s milk, soy, wheat, tree nuts, sesame, fish, shellfish) once introduction of complementary foods has commenced at around 6 months of life but not before 4 months. There may be potential harm in delaying the introduction of these foods based on past observational studies. There are no data showing harm in introducing these other allergenic foods within the first year of life, but also no data suggesting specific benefit. Prior to early introduction of these foods, screening skin or sIgE testing and/or in-office introduction is not required. However, the decision to screen or not is preference-sensitive and should be made by the clinician taking into account current evidence and family preferences. Strongly consider encouraging home introduction or offering a supervised oral food challenge for any positive SPT or sIgE result if screening is performed. Once introduced, regular ingestion should be maintained.  (, M, )

(A/B-Ib-IV) 

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5. Upon introducing complementary foods, infants should be fed a diverse diet, since this may help foster prevention of food allergy. There is observational evidence but not any RCTs supporting this recommendation, but this is balanced by no known harm in introducing a diverse range of foods. Future evidence may more conclusively demonstrate specific potential health benefits of diet diversity. In accordance with Recommendation 4, do not deliberately delay the introduction of other potentially allergenic complementary foods (cow’s milk, soy, wheat, tree nuts, sesame, fish, shellfish) once introduction of complementary foods has commenced at around 6 months of life, but not before 4 months.  (C, W, )
(IIb-III) 
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6. Do not routinely prescribe or recommend the use of any hydrolyzed formulas (HFs) for the specific prevention of food allergy or development of food sensitization.  (A, S, )

(Ia-IV) 

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7. We do NOT recommend maternal exclusion of common allergens during pregnancy and lactation as a means to prevent food allergy. We offer no recommendation to support any particular food or supplement in the maternal diet for the prevention of food allergy in the infant in either the prenatal period or while breast-feeding. While exclusive breastfeeding is universally recommended for all mothers, there is no specific association between exclusive breast-feeding and the primary prevention of any specific food allergy.  (, W, )

(B/C-Ia-IV) 

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Recommendation Grading

Overview

Title

Primary Prevention of Food Allergy Through Nutrition

Authoring Organizations

Publication Month/Year

November 1, 2020

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Adult, Child

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient

Intended Users

Dietician nutritionist, nurse, physician

Scope

Prevention

Diseases/Conditions (MeSH)

D000486 - Allergy and Immunology, D005502 - Food

Keywords

primary prevention, risk, screening, food allergy, egg allergy, peanut allergy, Hydrolyzed formula, Breast-feeding, Diet diversity, cost-effectiveness