Food Allergy and Your Kiddo

How to Feed Babies to Prevent Food Allergies: The Safety of "Early" Food Introduction

• Alice Hoyt, MD, and Pam Lestage, MBA • Season 5 • Episode 80

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This episode focuses on the importance of early introduction of allergenic foods in preventing food allergies in infants. Tune in to hear Dr. Hoyt discuss the LEAP and EAT studies, which illustrate how feeding babies common allergens early can significantly reduce their risk of developing allergies. You'll come away from the episode with a better understanding of:

• The rising rates of food allergies and changing recommendations
• The significance of early introduction
• The LEAP and EAT studies and their findings
• The safety of early introduction

And if you are a pediatric clinician, check out the Food Allergy Pediatric Hub, where you can learn more about food allergies with information specifically for pediatricians and other pediatric clinicians. 

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This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.

Speaker 1:

Hello and welcome to Food Allergy and your Kiddo. I am your host, dr Alice Hoyt, excited to be here to talk with you today about how to prevent food allergies. I've talked about this in the past, but there really is a lot of strong movement now towards really helping families not get into the food allergy pickle to start with, and so if you're listening to this episode and you're the parent of a kiddo with a food allergy, then you may have done what's called early introduction. That's what we're going to talk about today. Or maybe you didn't do early introduction, um. Or maybe you know somebody who just had a baby and is concerned about how to feed their baby Totally legit concern. Spoiler alert we have over-medicalized how we feed babies and so today's episode is all about how to feed babies to prevent food allergies. And, before we dive deep into this episode, any of our listeners who are pediatricians, pediatric nurse practitioners, physician's assistants if you serve families who have food allergies and you're interested in learning more about food allergies, then go over to foodallergypedshubhoitalergycom. I know it's a mouthful, we'll put a link in the show notes, but foodallergypedshubhoitalergycom and that's where you can sign up for this awesome weekly email where I break down a um, a food allergy article that I think is super powerful and helpful for my general pediatric colleagues. So go over to foodallergypeethubhoidallergycom to learn more.

Speaker 1:

Okay, now let's get into the show. And so really to kick off the episode, what really is early introduction? Is it safe? Early introduction is when we feed a baby a food, really earlier than six months. So the term early is somewhat relative to what the current recommendations are for food introduction. So what are those? Well, in 2000, the uptick in peanut allergy was first identified, and in response, the AAP said well, you know what? Let's have babies avoid commonly allergenic foods until their immune systems are ready for them. And so what that meant was having babies avoid cow's milk until they're one year old, having them avoid egg until they're two and having them avoid peanuts, tree nuts and fish until they're three years old. Now, unfortunately, we did not see a decrease in food allergy after that recommendation, but we actually saw the opposite. We saw an even larger increase than what we were already seeing. And so, in 2008, those recommendations were quietly softened because there was not good evidence that children, especially babies, should avoid these foods, should avoid these foods, and so fast forward until the LEAP study. If you're listening to this podcast, chances are you have heard of the LEAP study Learning Early About Peanut. That study was published in 2015 by Gideon Lack and what it very clearly demonstrated is that babies who are at risk of peanut allergy are less likely to develop peanut allergy if they are exposed to peanut early in life, and often. So what does that really mean? We're going to get into the LEAP study and its findings and another study that also looked at early introduction in babies. But really, before we move out of this segment of the show, wrapping up the timeline of food allergy, that is sort of the pathway in the world of feeding babies. Regarding foods, there's a whole other approach to feeding babies that we in developed countries we don't think a whole lot about anymore, and that's really just how. How do we feed babies safely?

Speaker 1:

When we look at recommendations from the World Health Organization, they have a very explicit recommendation that really nothing should go into that baby's mouth except breast milk via breastfeeding until that baby is six months of age, and I'll tell you that a lot of clinicians, when we hear a big organization give a very explicit recommendation, we certainly take pause and we consider that in our medical decision making. Now, should we only go off of what an organization says as a guideline? No ifs, ands or buts. No personalized medicine. No ifs, ands or buts. No personalized medicine. No, of course not. We should take these recommendations into our consideration whenever we are personalizing a treatment plan or a management plan for a family.

Speaker 1:

And so when we look at the World Health Organization and we look at their recommendations for exclusive breastfeeding until six months of age, for exclusive breastfeeding until six months of age, how is that recommendation applicable or less applicable to children in developed countries? Well, the World Health Organization is trying to serve especially the families in countries where they might not have great access to clean water, they might have high rates of HIV and other infectious diseases that, if the baby were to catch, could be devastating, could be fatal. And the World Health Organization is also really focused on areas of the world that don't have access to great nutrition, that can't necessarily go to the grocery store and have all these different baby food products. And so when we're looking at why is the World Health Organization's recommendation nothing in the mouth except for breast milk via breastfeeding it's because they're trying to keep those babies safe. And it does keep them safe. It does keep them safe against washing a baby bottle, even if, even if it's pumped breast milk. Washing a baby bottle with, or pump parts with parts that are with, water that is not clean, that could pass along a serious illness to that baby.

Speaker 1:

Um, or trying to wean a baby from breastfeeding too early or formula feeding too early. Like I said, they don't like anything other than breast milk via breastfeeding. Trying to wean babies too early and replacing breast milk with something that is nowhere near equal formula. Infant formula is developed to try to be as similar to breast milk as possible. But if we wean babies too early to something that is not equivalent to breast milk, then those babies can have serious nutritional deficiencies. So one of the one of the barriers I hear from some of my general pediatrician colleagues as to why they're not as aggressive in adopting early introduction recommendations is because there are still these nothing except breastfeeding until six months recommendations from big organizations like the World Health Organizations. But when we sit down and we really think about why does this organization have this recommendation? Then we can better tailor our recommendations to our patients based on our specific patient's medical needs and their specific social situations.

Speaker 1:

So now that we have talked more about sort of the, the history of when to feed babies. That's a very abbreviated history, by the way, um, but, but since we have kind of like a, a starting point of like, okay, before six months, some groups consider that early. Well, what does any of this have anything to do with food allergies? Well, as I talked about earlier, when that uptick was noted in peanut allergy in 2000, which, by the way, we still don't know why, why that uptick even occurred, but we noted the uptick. We made recommendations of oh well, let's have kids avoid the foods until their immune systems are ready for it, and then found out, wow, that was absolutely the complete opposite recommendation we need to give. And then, how did we really get good data on that? Because then, in 2015, we had the LEAP study. Well, the LEAP study was the good data, the beginning of the good data.

Speaker 1:

The story behind the LEAP study is really a lovely story. The primary investigator, gideon Lack, and for my non-science listeners, if you're wondering who the primary investigator is, like the senior investigator, that's going to be the person at the when, when you're reading the journal article, at the very end, the last name usually is a senior author. And then there's also the first author, who is the author who did a lot, of, a lot of work on the study and and was a absolutely a leader in the study, was a absolutely a leader in the study, um Gideon Lacks, the senior author of the LEAP study, learning early about peanut, and he recognized that leading up before, before he had done the LEAP study. The reason he the LEAP study came to be is because he saw that babies in Israel had food allergies but they didn't have a lot of peanut allergy. And he said well, why is this? Well, turns out, in Israel they had this little peanut puff, kind of like a Cheeto but made with like peanut. They had this peanut puff that little babies would gnaw on from a really early age. And so those little babies, four months, six months, one of their first like teething foods was these little peanut puffs. And he hypothesized well, maybe if the baby start chewing on peanut, they started ingesting peanut protein early in life, around four or six months of age maybe that helps protect them against peanut allergy. And so that's where the idea of the LEAP study learning early about peanut came about.

Speaker 1:

Was the research question really was does early and regular ingestion of peanut prevent the development of peanut allergies in babies who are at risk of peanut allergy. So then you're probably like well, who's at risk of peanut allergy? What does that mean? Well, they had done some other studies prior to the LEAP study that showed that kiddos who have severe eczema and kiddos or babies I should say babies um under the age of one who have severe eczema and or an egg allergy are at risk of developing a peanut allergy. So they enrolled babies with those criteria.

Speaker 1:

Some of those babies had positive skin prick tests a peanut and some of them had negative skin prick tests. Now, if they had a skin prick test that was five millimeters or greater so they had like a reasonable size skin prick test they were excluded from the study. But these were kiddos who had severe eczema and or egg allergy and either were or were not sensitized. I mean, either they had a low positive skin test or they didn't have a positive skin test at all. And these babies were stratified into one of two groups. They were either to strictly avoid peanut or they were to start consuming peanuts and what was. And they continued this until their fifth birthday, at which time they had a peanut challenge and were determined whether or not they were allergic to peanut. And then they even, in the LEAP-ON study, which was the subsequent study, they had the kids who were avoiding peanut stop eating peanut for a year and then challenged them after one year with peanut.

Speaker 1:

And so what happened? Well, spoiler alert, the kiddos, the babies, who were fed peanut early and often were significantly less likely to develop a peanut allergy significantly less likely to develop a peanut allergy. So when we look at the kiddos again high risk kiddos who had a negative skin test going into the study, and we look at the per protocol analysis, meaning the kiddos who were able to really follow the study methods, meaning they were eating peanut pretty regularly, then 0.4% of the kiddos who were eating peanut developed a peanut allergy, compared to 13.9% of kiddos who were avoiding peanut developed a peanut allergy. Of kiddos who were avoiding peanut developed a peanut allergy. When we look at the kiddos who had positive skin tests and we look at the kids who followed the protocol, meaning they were either eating peanut or strictly avoiding it, 0% of these kids with positive skin tests who were eating peanut developed a peanut allergy, whereas 34% of the kiddos who were avoiding peanut developed a peanut allergy. So pretty robust data.

Speaker 1:

Also, what should be noted is sort of my point number two. Point number one what really is early introduction and is it helpful? Early introduction is feeding a baby a commonly allergenic food before six months of age. Is it helpful? If you look at the LEAP study, it was very helpful for peanut. Other studies have come out suggesting and demonstrating that it is helpful for other foods such as egg. Um, but really my point number two is is this safe, right?

Speaker 1:

So I talked through the LEAP study and you might also be asking well, you know like how much, how much did they eat? These babies ate about six grams of peanut protein per week. So if, if you look on the back of a jar of peanut butter, most jars of peanut butter have six to seven grams of protein for every two tablespoons. So two tablespoons is one serving size of peanut butter usually and one serving has about six to seven grams of protein in it. So if you break that down, then these kiddos could have had like one teaspoon of peanut butter per day, because there's three teaspoons and one tablespoon, and two tablespoons would be six teaspoons. And if they ate six grams per week, then we're saying okay, well, maybe they, they, they had it every other day, something like that, right, but on average six grams per week.

Speaker 1:

Um, I mentioned another study that I'll talk briefly about, the eat study, which enrolled babies at three months of age. These babies were exclusively breastfed, and foods were introduced cow's milk first as the allergenic food, and then peanut egg, fish and sesame were introduced next, and they were randomized. The babies were randomized as to what was it peanut first, was it sesame first, whatever? That was randomized, and then were randomized as to what was it peanut first? Was it sesame first, whatever? That was randomized. And then the last we'd introduced was wheat, and it was introduced at around four months of age or so, and by five months of age though, so between three and five months old, all of those foods needed to be in the diet twice per week while still breastfeeding.

Speaker 1:

Now you're probably like, oh my gosh, like, first of all, it's a, it's a relatively new little baby here, right, like I mean, I remember when my littles were that little and, um, trying to just, you know, keep their diapers clean could be difficult at times, much less try to have all six of these foods twice per week in a five-month-old Difficult stuff sometimes, and that's exactly what the study showed. It showed like, wow, the feasibility of this. This is hard, like such robust early introduction is hard. But what this study also showed is that early introduction of peanut and egg are very helpful in preventing the development of peanut allergy and egg allergy respectively.

Speaker 1:

So these, the practice of introducing a food early and again I say early, I'm doing air quotes and that whole term early is based on sort of our current day thinking of well, everybody says not everybody. But you know, like World Health Organization says nothing except breastfeeding until six months. But so early really is relative in my opinion, and this is where I think we've really somewhat over-medicalized, um, how we feed babies. It's absolutely important that babies, especially in areas where there's not clean water, where it's going to be difficult to access good nutrition, as long as breastfeeding can happen, the better. Breast milk is absolutely a wonderful, like it's not magical. I mean God knew what he was doing, right, like that is what grows babies. So we don't want to undervalue breast milk at all. We also don't want to place such low bar for families regarding how to safely introduce foods while making sure your child has full access and is fully being fed the nutrition safely that they need Translation.

Speaker 1:

In many developed countries, we are able to introduce foods early to babies. We're able to do it safely because we value breast milk, we value formula as well, and we know that those need to be the primary sources of nutrition. That being said, we can also introduce what's commonly called complementary foods. In this case, what this show is about to prevent food allergies, but also because you know, when you're five month olds, looking at you and looking at what you're eating and is sitting up, holding her head up has really good trunk support you know like she's able to sit up on her own. She's like grabbing for your food. Yeah, it's time to give her some food. Now you want to do it. You don't want to give her a peanut. You know it's a choking hazard. You want to give her a texture that is safe for her, and I'll talk a little bit about, like, how to introduce peanut butter and such, because even peanut butter is way too tacky for a baby.

Speaker 1:

But the point being, or the point is, that foods can be introduced before six months of age and it absolutely helps prevent the development of food allergies, and that is food allergies is absolutely a problem in developed countries, and so when we're thinking about how to feed babies, we need to think about that because that is a problem for us in developed countries and so we need to be helping families prevent that. What about the safety? So here's sort of the third point, right. So we talked about sort of the timeline of food allergies and feeding babies and we talked about the safety. Or we talked about how this early introduction stuff came to be and what really is early introduction and you know sometimes being challenging the feasibility, right, especially if you're doing a lot of foods really early. But is it safe? In these studies there were no deaths.

Speaker 1:

Also, looking at the LEAP study, the learning early about peanut, the babies to get into that study, if they were going to eat peanut they needed, they had what's called a peanut challenge where they were fed peanut. Epinephrine was not needed for any of those babies and so we can really be as a pediatrician, as an allergist, I can feel very comfortable in advising families to introduce peanut early, as early as three to four months of age, and not say, oh, here's an EpiPen too, you might need this. It would be highly unlikely for that to happen. Could it happen? Yes, rarely do things happen right. Never say never right.

Speaker 1:

But when we're looking at these studies, and the LEAP study had kids who were at high risk of having peanut allergy and there were zero administrations of epinephrine for these baseline or entry study challenges. That is incredibly reassuring, not just to me as an allergist but to my general pediatrician colleagues. And it's really the pediatricians who are on the front lines of this stuff, colleagues, and it's really the pediatricians who are on the front lines of this stuff. And even in looking at the EAT study, epinephrine was administered to four participants twice in one participant on two separate occasions but for choking, so kind of a misunderstanding of what was happening and it was administered for choking was happening and and it was administered for choking. And then the other three. The other three administrations of epi occurred in the clinical trials unit during ingestion challenges.

Speaker 1:

So again, these are the in the EAT study was kiddos who were not necessarily at high risk, um, as opposed to the LEAP study which would, which were kiddos who were at high risk of having a peanut allergy. The other important thing to note there's you can look up the EAT study, you can look up the LEAP study, um, and when you find these studies. There's so much supplemental data and they've done a lot of other analyses to find interesting, interesting findings. Oh yeah, great use of language, dr Hoyt. But one of the very cool findings was actually that kids who had early introduction they slept a little bit longer. They got, on average, 16.6 minutes more sleep per night at six months of age. Look, I don't know how far away you are from having had a little infant, but 16 minutes of sleep like that's that's not nothing, that is something, um. But really more importantly here, this was all safe. There were no deaths. There was very limited epi. Breastfeeding also huge point here. Huge point the breastfeeding journey was not negatively impacted.

Speaker 1:

So by introducing foods early, that does not mean you're weaning a baby off of breast milk or even formula. It means you're introducing, you're incorporating, but the primary source of nutrition is still the breast milk. So that is, in a nutshell, bad joke. Early introduction, especially of peanut. Early introduction, to recap, is when foods are introduced, really before six months of age, they need to be done. Oh, I said I had mentioned this. When foods are introduced it needs to be done in a way that clearly is safe for baby. So baby has to be ready for early introduction head trunk control, baby's interested in food, bringing things to baby's mouth, and that all is typically happening around four months of age in many babies and ways that you can introduce foods early, like peanut butter. There are puffs for this stuff. Younger babies typically aren't ready for puffs. There's little powders, mix-ins, things like that.

Speaker 1:

We've had some some folks on the podcast talking about their early introduction products, and one of mine still my favorite is going to be taking peanut butter and mixing it with breast milk and feeding that to your baby. It is cheap, it is easy, um, but what? What is so nice is that there are there are options, um, and there's more options, um, coming out, which which is really great, um. So if you have a baby on the way, congratulations. Or if you have a little baby, congratulations.

Speaker 1:

I want to encourage you to talk with your pediatrician about early introduction and to look at the early introduction of commonly allergenic foods. It can get kind of hairy when you do have a kiddo who has a food allergy or if you yourself has a food allergy, and I definitely want to encourage you to talk with your allergist about how can you safely introduce food into your little baby, even with having an older baby, a bigger baby or you or your spouse having a food allergy. So that's the episode all about feeding your baby to help prevent food allergies. That's the episode. Thanks so much for tuning in. Of course I'm an allergist, but I'm not your allergist. So talk with your allergist about what you learned on this episode and visit us at foodallergyandyourkiddocom where you can submit your family's questions. God bless you and God bless your family.