Providers Not Following Food Allergy Guidelines for Infants

Waheeda Samady, MD

Findings of a recent survey indicate most pediatric providers do not counsel families to wait at least 3 days between introducing new foods unless infants are at risk for developing a food allergy.

The results suggested current recommendations limit food diversity and could delay early peanut introduction, resulting in the possible need for a reevaluation of published food allergy guidelines.

Waheeda Samady, MD, and colleagues characterized pediatric practitioner recommendations for complementary food introduction and waiting periods between introducing new foods. Among those surveyed, 39% recommended waiting at least 3 days before introducing new foods, while for those at risk for developing food allergy, 66% recommended waiting.

Samady and the team designed a 23-item electronic survey on solid food introduction among infants. The survey was issued to members of the Illinois Chapter of the American Academy of Pediatrics and the national American Academy of Pediatrics. Survey participants were nonretired primary medical practitioners like pediatric or family medicine physicians, resident physicians, or nurse practitioners who provided pediatric care to infants 12 months old or younger.

The team’s main outcomes were recommendations on age of complementary food introduction and waiting periods between the introduction of new foods.

The final survey evaluation included 563 responses from a majority of pediatricians (80.6%; 95% CI, 77.2-83.7), followed by resident physicians (15.1%; 95% CI, 12.4-18.3), nurse practitioners (3.6%; 95% CI, 2.3-5.4), and family medicine practitioners (.7%; 95% CI, .3-1.9).

Nearly half of respondents (46.9%; 95% CI, 42.8-51) recommended infant cereal as the first food introduction. More than 200 practitioners (40.1%; 95% CI, 36.1-44.2) said there was no specific order recommendation.

Close to half (47.6%; 95% CI, 43.5-51.7) of participants recommended food be introduced for exclusively breastfed (EBF) infants at 6 months and 34.3% (95% CI, 30.5-38.3) recommended 6 months for non-EBF infants (P <.001). Fewer than 20% (17.9%; 95% CI, 15-21.3) recommended 5 months for EBF infants and 20.2% (95% CI, 17.1-23.8) recommended 5 months for non-EBF infants (P=.2). More than 30% (31.8%; 95% CI, 28.1- 35.8) recommended 4 months for EBF infants and 42.5% (95% CI, 38.4-46.6) recommended 4 months for non-EBF infants (P <.001).

The investigators reported 38.9% of participants (95% CI, 34.1-44.6) recommended waiting at least 3 days between food introduction, while 19.9% (95% CI, 16.8-23.4) suggested waiting 2 days and 27.4% (95% CI, 23.8-31.2) recommended waiting 1 day.

More than half of practitioners (60.4%; 95% CI, 56.3-64.3) believed the introduction of multiple new foods together was safe.

A majority of respondents (69.4%; 95% CI, 65.5-73.1) reported they would change their current recommendation if the infant was at risk of food allergy development, including if their older sibling suffered food allergy (68.7%; 95% CI, 64.8-72.4), moderate to severe eczema (66.4%; 95% CI, 62.4-70.2), and family history of food allergy (65.7%; 95% CI, 61.7-69.5).

The team found 41.7% (95% CI, 36.9-46.7) recommended waiting 3 days between food introduction among infants with food allergy risk factors. Only 24.6% of practitioners (95% CI, 20.5-29.1) suggested waiting more than 3 days.

Overall, the survey results demonstrated most practitioners recommended waiting 2 days or less between the introduction of new food and only 2 of 5 reported following the AAP and CDC recommendation of waiting 3-5 days between introducing new foods.

“The findings suggest that the current recommendation limits infant food diversity and may delay early peanut introduction,” the study investigators wrote. “Because the approach to food allergy prevention has changed, a reevaluation of published feeding guidelines may be necessary.”

The study, “Recommendations on Complementary Food Introduction Among Pediatric Practitioners,” was published online in JAMA Network Open.