Infants < 1 Year with Food Allergy Can Safely Eat Low Doses of Causative Food

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A new study found infants under a year with a food allergy can safely consume low doses of causative foods.¹

Not only that, but the findings suggest parents should avoid eliminating causative foods in their infant’s diet since it may help them in the long run.

“The amount of food that can be consumed without triggering allergic symptoms can be confirmed when a patient passes the [low-dose oral food challenge],” wrote investigators, led by Mari Takei, from the department of allergy at NHO Sagamihara National Hospital in Japan. “This strategy also reduces the burden on guardians regarding allergic symptoms caused by contamination.”

It is generally advised that infants < 1-year-old with confirmed food allergies should avoid causative foods completely for a particular period. However, in Japan, the food allergy guidelines recommend low-dose oral food challenges for high-risk children to build up tolerance and avoid complete elimination of these causative foods.

The National Institute of Allergy and Infectious Disease recently recommended introducing peanuts early to babies for the same reason.² Although this is recommended, not a lot of data is available on the success of the safety of these low-dose oral food challenges.

A previous study suggested low-dose oral food challenges in infants pose a potential risk of life-threatening anaphylaxis.³ In that study, 94% of infants aged 4 – 6 months with sensitization to hen’s egg experienced allergic reactions, including anaphylaxis, when eating small doses of pasteurized whole eggs. Nevertheless, it is important to see what low-dose oral food challenges are safe and useful so infants can get early exposure and not have allergic reactions to that food later down the line.

Investigators sought to assess the safety and utility of low-dose oral food challenges in infants by retrospectively analyzing the clinical records of low-dose oral food challenges performed in infants under a year (median age: 10 – 11 months; 62% male) who were allergic to hen’s eggs, cow’s milk, or wheat between April 2014 and October 2017.¹ The challenge included approximately 1/25th–1/20th of the egg white from a heated whole hen's egg, 3 mL heated cow’s milk, and 2 g wheat udon noodles.

The team assessed for the safety outcome of low-dose oral food challenges, including induced symptoms and treatment required for positive results. Among infants allergic to eggs (n = 68), milk (n = 42), and wheat (n = 13), the positivity rates for the challenge were 7%, 24%, and 0%, respectively.

Infants consuming low doses of milk may have had a greater positivity rate than those consuming egg (P = .064) or wheat (P = .190), but the difference was not statistically significant. Additionally, infants who consumed eggs (P = .156) or milk (P = .125) on their own vs those who consumed the ingredients in a cake had no significant differences in positivity rates (egg: P = .272; milk: P = .834).

The study demonstrated low-dose oral food challenges were safe. The most common reaction was skin symptoms which were treated with oral antihistamines and did not result in anaphylaxis or adrenaline injections.

Infants who were challenged with eggs experienced generalized urticaria (60%) and emesis (40%). The reaction occurred after a median of 55 minutes.

Infants challenged with milk experienced skin symptoms (90%), mild respiratory symptoms (30%), and gastrointestinal symptoms (10%), and the reactions occurred about 30 minutes after eating.

Some of the participants coughed, including 4 infants allergic to eggs and 3 allergic to milk. One participant had 3 coughing episodes at different times and was administered β2 stimulant inhalation. No infants were wheezing or demonstrated poor oxygenation.

“[Low-dose oral food challenge] in infants may serve as a crucial initial step in managing food allergies, potentially leading to early tolerance acquisition in a stepwise [oral food challenge] process,” investigators wrote. “Further studies are needed to evaluate the prognosis of food allergies arising from early consumption of low doses of causative foods in infants with food allergies.”

References

1. ^{Takei, M, Yanagida, N, Sato, S, et al. Low-dose Oral Food Challenges. Wiley. 2024. https://doi.org/10.1111/pai.14258}
2. ^{NIH-sponsored expert panel issues clinical guidelines to prevent peanut allergy. National Institutes of Health. January 5, 2017. https://www.nih.gov/news-events/news-releases/nih-sponsored-expert-panel-issues-clinical-guidelines-prevent-peanut-allergy#:~:text=Guideline%202%20suggests%20that%20infants,the%20risk%20of%20peanut%20allergy. Accessed October 16, 2024.}
3. ^{Bellach J, Schwarz V, Ahrens B, et al. Randomized placebo-controlled trial of hen's egg consumption for primary prevention in infants. J Allergy Clin Immunol. 2017;139(5):1591-1599.e2. doi:10.1016/j.jaci.2016.06.045}