By Lil Mixins Editorial Staff
A Familiar Situation
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? I thought babies were born with allergies? ”
Until Early Introduction becomes as normal as swaddling, you may have to take the time to walk your patients through it.
Where To Start
1. Babies aren’t born with allergies.
Caregivers may need help to understand why infants can be safely exposed to developmentally appropriate versions of common allergens between 4 and 6 months of age with limited risk of reaction.
One analogy that seems to work is a vaccine - babies get a vaccine before an illness arises, to prevent that illness. Understanding early introduction as a similar preventative measure can be helpful.
Many parents believe that food allergies are pre-determined from birth. Understanding that food allergies develop more often between 6 and 10 months of age can help early feeding appear correctly safe.
2. The old guidance to avoid foods wasn’t based on clinical data
Parents may struggle with the idea that the old thinking of avoidance was based on no clinical studies, and that this period saw the fastest spike in food allergy.
You can remind them that a thankfully is has now been studied and a growing body of literature, shows that Early Introduction is our best bet for reducing food allergy rates.
3. The guidance for early introduction is based on the highest level of evidence.
Parents may not understand study quality - small cohort studies versus a randomized controlled trial like the LEAP study.
Many parents understand when told that nearly 500 babies ate peanuts early and often and their outcomes were compared to 500 control infants who ate no peanut. With those numbers in mind, the 80% reduction in the comparative rate of peanut allergy is much more meaningful.
They may need help to understand that studies don’t get much 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.
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 prevented from developing a peanut allergy. For many people, thinking about an 80% comparative risk reduction is difficult to weigh. Either an intervention works, or doesn’t work for their child. It can be helpful to have them think about an 80% chance in the context of winning a game - would they play if they thought they could win 80% of the time?
5. There is no need to test for allergy or fear the first exposure unless the child is HIGH risk.
Many caregivers do not understand that allergy testing has a high false positive rate, and 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.
Even if their baby has a 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.
7. There’s no need to space out new foods every 3 days.
Eating is supposed to be fun. Food helps us celebrate our joys and nourishes and sustains us. Food should not be approached as a danger. Remind parents that the wide majority of infants will never develop a food allergy. Instead of thinking of food with fear, parents can look forward to providing healthy, whole food meals with an emphasis on diversity of diet.
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 smooth texture and feed it to their infant.
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.
We have created some helpful handouts covering the same concepts, that you are welcome to print and use yourself or disseminate to your patients.