Infectious Disease

‘Encourage, evaluate, educate’ to ensure early infant introduction to allergens

August 14, 2023

6 min read



James JM, et al. Food allergy prevention: Applying current guidelines and overcoming adoption barriers. Presented at: APA-AAI Annual Allergy, Asthma & Immunology CME Conference; July 27-30, 2023; Park City, Utah.

James reports being the president of Food Allergy Consulting and Education Services and a consultant for Food Allergy Research & Education and the Asthma and Allergy Foundation of America.


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Key takeaways:

  • Infants should try peanut between age 4 and 6 months.
  • Many parents and physicians alike are unaware of these guidelines.
  • Education, resources and collaboration can increase early introduction.

PARK CITY, Utah — Barriers may prevent physicians and caregivers alike from introducing allergens into infant diets to prevent food allergies, but these obstacles can be overcome, according to a presentation here.

“We want to let the babies eat,” John M. James, MD, president of Food Allergy Consulting and Education Services, said during his presentation at the Association of PAs in Allergy, Asthma and Immunology (APA-AAI) Annual Allergy, Asthma & Immunology CME Conference.

When working with families, physicians should create an environment where early introduction of peanuts and other allergens is normal. Image: Adobe Stock

Current guidelines

The Dietary Guidelines for Americans 2020-2025 recommends exclusive breastfeeding for the first 6 months with vitamin D supplementation as needed and continued breastfeeding through 1 year and beyond if desired. Complementary foods including allergens can be added at 6 months and when infants are developmentally ready.

“We want to make every bite count,” James said. “But we want to try to let them eat things that prevent the later food allergies, especially if they’re at risk.”

John M. James

According to the National Institute of Allergy and Infectious Diseases Addendum Guidelines for Peanut Allergy Prevention, infants who do not have any eczema or food allergy should be introduced to peanut products and various other foods, including other allergens, between ages 4 and 6 months when they are developmentally ready and in line with cultural and family preferences.

“Don’t delay,” James said.

These guidelines also say infants with mild to moderate eczema should be introduced to peanut products at age 6 months or when they are developmentally ready. When infants have severe eczema and/or an egg allergy, physicians should strongly consider an IgE blood test for peanut and/or a skin test.

If testing is negative, or less than 0.35 kU/L, peanut can be introduced between age 4 months and age 6 months at home or in the office without delay. If it is positive, or higher than 0.35 kU/L, the infant should be referred to an allergist immediately.

“You want to confirm the diagnosis with a food challenge, and then you want to get that early introduction going,” James said. “It’s a window of time you’re battling against.”

Guideline implementation

James cited the three E’s of early peanut introduction: encourage, evaluate and educate.

“Encourage parents to introduce infant-safe foods when the baby is ready, as early as 4 to 6 months,” James said.

These introductions should not interfere with breastfeeding, which also benefits infants, but they should still be early and often.

Physicians also should empathize with families who already are managing a peanut allergy at home.

“You may have another sibling, a 6-year-old or a parent who has peanut allergy,” James said. “They’re doing things at home to prevent accidental ingestion.”

Next, physicians should evaluate the small subset comprising approximately 5% of infants with severe eczema or an egg allergy, which are considered high-risk factors for developing peanut allergy.

“Consider skin tests or blood tests, and then referring them to an allergy specialist,” James said.

Physicians then should educate parents about readiness cues for when they can start introducing solid foods into their infants’ diets and how to introduce foods with peanut as well as other common food allergens safely and effectively.

“Share information about how to do that,” James said, including educational handouts discussing the benefits of a diverse, healthy diet as well as how to identify food allergy reactions in infants.

“You can talk about it all you want, but you’ve got to give them basic, easy-to-follow instructions,” he said. “It has got to be something they can take away.”

Despite the availability of these guidelines, James said, many medical providers still tell the families they serve to delay allergen introduction far beyond what is recommended.

“This happens. This is what we’re dealing with. They need to be made aware of the guidelines,” James said. “We need to be leading the charge.”

James called for organizations such as the NIAID, the American Academy of Pediatrics and APA-AAI to work together to promote early introduction and allergy prevention.

“It’s a team effort,” he said.

Barriers to early introduction

Although 93% of physicians were aware of the NIAID guidelines in a 2020 study, James said, only 64% partially implemented them, and only 30% fully implemented them.

“There’s an uncertainty about the guidelines and applying them,” James said. “Maybe the infant’s not going to be ready. They’re not developmentally ready.”

Parents also are uncertain when it comes to understanding and applying the guidelines, James said, with worries about skin or gastrointestinal reactions or actual allergy.

“Think about what’s in the media about peanut allergy. It’s everywhere,” he said. “It’s an uphill battle that we’re going against, but we have to attack it.”

According to James, 69% of parents would not consider introducing peanut to their infant before or around age 6 months. Also, approximately 40% would wait until after their infant was age 11 months before introducing peanut, tree nuts or seafood.

Practical problems involving convenience, cost and preparation in addition to the presence of other family members with a food allergy and infant refusal to eat foods due to taste or swallowing issues may inhibit early introduction as well.

Additionally, 51% of parents are unwilling to do a skin prick test and 56.8% are unwilling to do an oral food challenge before the infant is age 11 months.

“It takes time. It takes staff. It takes training. It’s not the easiest thing to do. But you’ve got to be committed to thinking about doing it or get them to an allergist who will do it, because it’s important,” James said.

“You don’t want to be doing all these things if the patient doesn’t have peanut allergy,” he continued. “You don’t want to put them on an oral immunotherapy if they don’t have peanut allergy. So, you’ve got to know sometimes. Do they really have it or not? That’s critical.”

James acknowledged the challenges that a busy staff faces in adding allergy screenings, testing and education to an already packed patient appointment too.

“When I was in practice, we were pushed to see more and more patients, and you had to be very efficient with your time,” he said. “It wasn’t always easy.”

Additional barriers may include lack of parental interest in early introduction, parental concerns about blood draws, concerns about legal liability, and insufficient insurance coverage or reimbursement.

“But it’s a battle that’s worth fighting for your patients, because you can prevent peanut allergy,” James said.

Practical tips

James advised physicians to increase education and training about the guidelines in their practices. He also recommended the use of practical aids among providers in the office.

“I can’t stress that enough,” James said. “Even little video clips can be used — 1 minute, 2 minutes — that you can show in a waiting room or on your website.”

Physicians also should take advantage of guides for clinical assessment, recommendations and in-office supervised feedings and food challenges. Collaboration with ancillary support providers such as nutritionists, psychologists, gastrointestinal specialists and allergists is essential as well.

When working with families, James continued, physicians should create an environment where early introduction of food allergens is normal.

“Start the conversation early,” he said, suggesting that physicians should discuss early introduction when the mother is still pregnant.

James emphasized access to care and education as well.

“Get them to the right providers along the way and provide resources, again, for education,” he said, including risks for anaphylaxis and plans for parents to follow if their infant has a reaction.

Finally, James said shared decision-making is essential in implementing early introduction, with a plan that is evidence-based and in line with the family’s personal values.

“It’s not a paternalistic thing. We’re not preaching to our patients. We’re not having a one-way street. There’s a continuum from a provider to the patient, back to the provider, using all the resources,” he said.

“We want to empower our families, give them confidence,” he continued. “We don’t want to give mixed messages. We want to give risk-benefits. We want to put everything on the table. It may take a while to do this, but it’s going to pay off in the end.”


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