How to Talk to Patients About Early Introduction
By Lil Mixins Editorial Staff
A Familiar Situation
When you enter the room, Ms Lester is playing with her 4 month old Joshua. Katherine is there too. She’s 5 by now, but school is closed today.
Joshua laughs through the exam and looks healthy. He is growing well and nothing strikes you as a concern. But Ms. Lester looks visibly nervous.
So you ask again, “any problems feeding? Does he seem like he’s adjusting to daycare?”
“Yes” she says, “It’s.... he’s eating great now.... But I’m scared of what’s next. He seems ready to eat solids. But I’m not ready to feed him. Katherine hasn’t outgrown her food allergies, which means Joshua is likely to have them too. I don’t think I can go through it again...waiting for the reactions and rushing to the ER…”
For all the casual certainty with which the new guidelines on Early Introduction were released, parents greet them with a mix of trepidation and disbelief.
“How come you said the exact opposite with my older child? Why should I trust you now? I thought babies were born with allergies? Are you saying it’s my fault that my kid has food allergies?”
That is a lot of confusion to address in a limited amount of time! But until Early Introduction becomes as normal as swaddling, you may have to take the time to walk your patients through it. There are a few key points to make.
And while there is so much to cover at the early well baby visits, this conversation could prevent a life-long condition.
Where To Start
1.Babies aren’t born with allergies.
Parents may remember that the infant’s immune system is very weak in the first couple months, which is why breastfeeding is encouraged and extra precaution is usually taken around relatives. Studies suggest that there is a “tolerance induction window“ between 4 and 6 months of age, where infants can be safely exposed to developmentally appropriate versions of common allergens, with limited risk of reaction. The LEAP and EAT study showed that beginning regular exposure in this window can dramatically reduce the risk of developing a food allergy.
One analogy that seems to work for parents is the idea of language and accents. Everyone intuitively understands that babies aren’t born with language, they learn it. They have also experienced how an accent learned in youth can be life-long, because it was imprinted at a specific point in a child’s development.
Using this analogy, some patients can better understand how there is a window to properly teach the immune system, just like the brain. And also like a language, repetition is important to proper learning.
2. The old guidance to avoid foods was a mistake and wasn’t based on clinical data
Parents will really struggle with the idea that a hunch was used to guide parents for nearly two decades -- a period that saw the fastest spike in food allergy. As much research has shown, however, an apology is the fastest way to get a patient to listen.
It may be a tough sell to some parents, but science changes over time as our methods improve, and our understanding improves along with it. A growing body of literature, and already existing evidence, shows that Early Introduction is our best bet at reducing food allergy rates.
3. The guidance for early introduction is based on the highest level of evidence.
The LEAP study was a randomized controlled study where infants at high risk of peanut allergy (as determined by an existing egg allergy or severe eczema) were assigned to either avoid or introduce peanut regularly. As a group, the infants who were fed peanuts, even those who skin tested as sensitized to peanut, showed an 80% reduction in the comparative rate of peanut allergy.
Studies don’t get better than this. The study was independently funded, used a large sample size, and showed statistically significant differences between the intervention and control in all stratified groups. Pretty much any hole or complaints that normally arise in study design were controlled for in this case.
4. Early introduction won’t prevent all food allergies, but it is your best chance of preventing one
It’s true that not every child in the LEAP study who started early introduction was saved from developing a peanut allergy. For many people, thinking about an 80% comparative risk reduction is difficult to weigh, and might seem pointless. Either an intervention works, or doesn’t work for their child. It’s binary and conclusive. You may have to ask a caregiver what they already know about early introduction and see if there is any hesitancy.
But in the end, it's important to impress upon the parent(s) that the evidence for Early Introduction is very strong, and an 80% chance is much better than the alternative.
5. There is no need to test for allergy or fear the first exposure unless the child is HIGH risk.
Because a baby is growing and changing, and because allergy testing has a lot of false positives, unnecessary testing can be more harmful than helpful. It helps to explain to a parent that the only true test of a food allergy is an oral food challenge, aka eating the food.
So even if you perform skin prick or SIgE testing, a food challenge will be necessary to rule a food allergy in or out. After a more visits, and perhaps a painful blood test for their baby, they will be right back at this moment.
For some parents, especially those with an older child who has food allergies, introducing allergens for the first time can be scary enough for them to simply avoid doing it. For those parents, the option of offering the first serving of peanut in the waiting room of the office may provide the necessary comfort.
6. Never feed a baby whole peanuts. Babies can choke on anything too chunky.
It's important to remind new parents - especially first-time parents - of the basics. The only safe ways to give a baby peanuts are to 1) use an infant peanut powder or 2) heat, thin, with water, and then cool peanut butter. This might sound obvious to you, but try to remember if you had knew what the words "choking hazard" before you became a parent or a doctor... probably not
7. There’s no need to space out new foods every 3 days.
Eating is supposed to be fun. Food, and meals, are the focal point of every human culture and every family. Food helps us celebrate our joys and nourishes and sustains us. Food should not be approached as a danger. The wide majority of infants will never develop a food allergy. Instead of thinking of food with fear, parents need to be encouraged to provide healthy, whole food meals with an emphasis on diversity of diet.
Feeding an infant blends of foods can foster a confident palate and to develop their “nutritional intelligence”. Perhaps the easiest way to think about this is that a baby should eat what their parents eat. Many parents don’t realize they can puree almost any adult meal into a smoothie like texture and feed it to their infant right from the beginning. Feeding a baby the same thing as its parents will also promote family meal times right from the beginning.
So tell the parents to go for it. If they love curries, pasta and veggies, or even beef stew, they can puree it and feed it to their little one.
8. Beginning solids does not mean give up on formula or breastfeeding.
It’s worth mentioning that in all the studies on early introduction, none showed a decrease in breastfeeding as a result of the introduction of solids. Some parents might be confused that “start solids” means “stop nursing”. It’s always good to remind parents that until age one, breastmilk or formula should be the primary source of nutrition. Solid food is for fun.
That’s a lot to cover in a short visit, and not all these points will need to be discussed with every family. But a clear conversation right at this high attention time point can ensure caregiver follow-through.
To see a real impact on food allergy rates in your practice, all parents to feed allergenic foods early and often. The key points above will cover Ms. Lester’s concerns and empower her to speak with her friends.
We have created some helpful handouts covering the same concepts, that you are welcome to print and use yourself or disseminate to your patients.
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And of course, you should share this article with a friend who might be interested.