Setting Expectations in Food Allergy Risk Reduction

Food allergy prevention lacks practice-changing data, yet there’s measures available which can help parents navigate pediatric risk reduction. There’s also common misconceptions physicians need to dispel as part of that discussion.

In an interview with MD Magazine® while at the American College of Allergy, Asthma & Immunology (ACAAI) 2019 Scientific Meeting in Houston, Whitney Morgan Block, MSN, CPNP, FNP-BC, president, chief executive officer, and co-founder of the National Allergy Center (NAC), and Teresa Neeno, MD, fellow NAC co-founder, discussed the truths and falsehoods surround food allergy prevention and risk reduction.

MD Mag: Are there viable means to prevent or reduce risk of food allergy development?

Neeno: There's not really good data on prevention of food allergy. I think in the past, we would say when babies were born, you know, avoid certain foods. And then, the studies came out that showed there's no really good data on avoiding foods for both the babies and the moms during pregnancy.

So it was like, okay we need to go back to how grandma used to feed—introduce foods to the babies when they're ready. So, when they can sit up and they have good head support, when they know what to do with the spoon as it's coming toward them—because that's a skill as they grow and develop—then feed them what's on the table. You know, mush it up, so it's not going to be a choking hazard.

So, I think that's really the best advice.

Block: So, when I was back in school—which wasn’t that long ago—we were taught, don't give peanuts until after a year, don't give egg and milk until like 2 years, don't give fish until 4 years. They were just kind of arbitrary numbers, and now we know that that's incorrect data.

But we need to make sure that, as we're telling patients this, that it's not their fault. They did not know—they were following instructions, and they were following the exact advice.

So, I get a lot of patients that come to me saying the first kid doesn't or does have food allergies, and they say, ‘Well what am I supposed to do with the next one to prevent them from having it?’ And I just need to reinforce that you didn't do anything to actually create or develop these food allergies in your kid. There's no data right now to suggest that whether you breastfeed, whether you formula feed, whether you do it until a year or 2 years, whether you ate a whole bunch of nuts and allergenic food in your diet, whether you didn't, there's nothing suggesting that we're actually triggering these allergies.

And there's a ton of parents that are totally caught off guard by it, because they don't have allergies themselves. What's the number—it's like 50%, or something like that. That's a crazy big number, of the kids that are developing food allergies that don't have parents with food allergies.

So they're really caught off guard about why this is happening, and I think the thing to consider is well, not really why it's happening—but what can you do about it now. And if you are pregnant or you're thinking about having another kid, is there anything that you can do to prevent that next one from having from having allergies.

And we know that there are some modifiable factors, like early introduction, and introducing foods between 4-6 months old—as soon as the kid is ready for solids. The only 2 rules are no chokeable foods ever, and no honey because of the botulism risk, until after a year.

But there there's a lot of products on the market, and I know they’re kind of controversial. But there's a lot of products on the market that make it easier, because it's not just a checkbox of ‘Okay, I gave my kid peanut. That’s a safe food and I never have to give it to them again.’ You actually have to incorporate it as part of your diet.

So we do a ton of food challenges at National Allergy Center, and one of the hardest things is once we actually say this kid is not allergic to this food, my instructions used to be incorporating the food as part of the diet. It's really hard though, because babies don't eat that much, and they wear as much food as they actually ingest.

So how do you actually get these foods routinely into a diet? And a lot of parents just kind of give up, and they say they try, but they go pretty much back to avoiding. And that's the life that they knew, they were told because of positive blood tests and skin tests that the kid is allergic, and so that was just kind of normal life. And it's easier to keep doing what you're doing instead of actually change and incorporate foods.

And so now I've changed my tune a little—instead of saying ‘Incorporate as part of your diet,’ I've give them specific instructions based on the LEAP study and say, ‘Okay, I want this particular food in the kid’s diet 2-3 times a week.’ That's the ultimate goal, and we know that the constant repetitive exposure is what's going to be kind of key to preventing those allergies.

So it's not just introduce the food, but keep it in the diet. And that's something that's really important for everybody to understand.

Neeno: The other thing to think about is, in babies especially, the studies show that it's the contact through the skin that causes the allergy, as opposed to ingestion. So, keeping the skin in good shape, keeping the barrier function working really well, is super important.