Food allergy and the introduction of solid foods to infants: a consensus document

First Bites-Why, When, and What Solid Foods to Feed Infants

Humans are the only mammals who feed our young special complementary foods before weaning and we are the only primates that wean our young before they can forage independently. There appears to be a sensitive period in the first several months of life when infants readily accept a wide variety of tastes and this period overlaps with a critical window for oral tolerance. As a result, infants should be exposed to a wide variety of flavors while mother is pregnant, while mother is nursing and beginning at an early age. There also appears to be a sensitive period between 4 and 9 months when infants are most receptive to different food textures. There remains debate about when it is best to begin introducing solid foods into an infant's diet however, the available evidence suggests that provided the water and food supply are free of contamination, and the infant is provided adequate nutrition, there are no clear contraindications to feeding infants complementary foods at any age. There is emerging evidence that introduction of solid foods into an infant's diet by 4 months may increase their willingness to eat a variety of fruits and vegetables later in life, decrease their risk of having feeding problems later in life, and decrease their risk of developing food allergies, and the early introduction of solid foods into an infant's diet does not appear to increase their risk of obesity later in childhood.

Relationship between respiratory and food allergy and evaluation of preventive measures

Food allergy and respiratory allergy are two frequently associated diseases and with an increasing prevalence. Several reports show the presence of respiratory symptoms in patients with food allergy, while certain foods may be related to the development or exacerbation of allergic rhinitis and asthma. The present update focuses on this relationship, revealing a pathogenic and clinical association between food and respiratory allergy. This association is even more intense when the food hypersensitivity is persistent or starts in the early years of life. Food allergy usually precedes respiratory allergy and may be a risk factor for allergic rhinitis and asthma, becoming a relevant clinical marker for severe atopic asthma. Furthermore, the presence of co-existing asthma may enhance life-threatening symptoms occurring during a food allergic reaction. Recommendations for dietary restrictions during pregnancy and breastfeeding to prevent the development of respiratory allergy are controversial and not supported by consistent scientific data. Current recommendations from medical societies propose exclusive breastfeeding during the first four months of life, with the introduction of solid food in the fourth to the seventh month period of life. A delayed introduction of solid food after this period may increase the risk of developing subsequent allergic conditions. Further studies are encouraged to avoid unjustified recommendations involving useless dietary restrictions.

Timing of introduction of solid food and risk of allergic disease development: understanding the evidence

Strategies to prevent or reduce the risk of allergic diseases are needed. The time of exclusive breastfeeding and introduction of solid foods is a key factor that may influence the development of allergy. For this reason, the aim of this review was to examine the association between exposure to solid foods in the infant's diet and the development of allergic diseases in children. Classical prophylactic feeding guidelines recommended a delayed introduction of solids for the prevention of atopic diseases. Is it really true that a delayed introduction of solids (after the 4th or 6th month) is protective against the development of eczema, asthma, allergic rhinitis and food or inhalant sensitisation? In recent years, many authors have found that there is no statistically significant association between delayed introduction of solids and protection for the development of allergic diseases. Furthermore, late introduction of solid foods could be associated with increased risk of allergic sensitisation to foods, inhalant allergens and celiac disease in children. Tolerance may be driven by the contact of the mucosal immune system with the allergen at the right time of life; the protective effects seem to be enhanced by the practice of the breastfeeding at the same time when weaning is started. Therefore, recent guidelines propose a "window" approach for weaning practice starting at the 17th week and introducing almost all foods within the 27th week of life to reduce the risk of chronic diseases such as allergic ones and the celiac disease. Guidelines emphasize the role of breastfeeding during the weaning practice.

Individual and job-related variation in infant feeding practices among working mothers

OBJECTIVE

To document working mothers' infant feeding practices and delineate factors that may shape infant feeding.

METHODS

Cross-sectional data were obtained from a community sample of working women with 8-month old infants (n=199).

RESULTS

Nearly all working mothers used commercially prepared foods like infant cereals, fruits, and vegetables. Approximately one-fifth fed infants french fries, sweetened beverages, and sweetened desserts. Unhealthy infant feeding was elevated among unmarried mothers, those with less education, and those with a nonstandard work schedule.

CONCLUSIONS

Working mothers use commercially prepared foods for infant feeding. Socially disadvantaged working mothers' infant feeding may pose health and developmental risks.

Survey of physicians' approach to food allergy, Part 2: Allergens, diagnosis, treatment, and prevention

BACKGROUND

Food allergy (FA) practice varies widely.

OBJECTIVE

To report differences between allergists and nonallergists regarding diagnosis, treatment, and prevention of FA.

METHODS

A 2-page questionnaire was mailed to 3,000 allergists and 4,000 nonallergists. We previously published the findings on prevalence and manifestations. Herein, we report the findings on food allergens, diagnosis, treatment, and prevention.

RESULTS

Responses were received from 584 (19.5%) of the allergists and 77 (1.9%) of the nonallergists. Because of the nonallergists' low response rate, descriptive comparisons were made without emphasis on statistical significance. Allergists and nonallergists differed in their rankings of the 5 most common food allergens. Nonallergists differed markedly from allergists in the diagnostic methods, using more leukocytotoxic tests (10.9% vs 0.3%), specific IgG4 tests (33.8% vs 6.0%), and intradermal tests (40.0% vs 9.5%), but fewer percutaneous skin tests (44.7% vs 98.9%), specific IgE tests (73.4% vs 97.8%), and challenges (61.1% vs 87.6%). They also differed in their use of open, single-blind, and double-blind challenge tests. Allergists were more likely to rely on elimination of proven food allergens and less likely to use conventional elimination diets, rotation diets, and sublingual or subcutaneous hyposensitization. Allergists were more likely to recommend a diet regimen during pregnancy (76.7% vs 35.3%) and lactation (91.1% vs 72.9%), breastfeeding (93.6% vs 84.3%), hydrolysate formulas (83.5% vs 64.3%), and withholding solids until the age of 6 months (89.4% vs 70.0%).

CONCLUSION

Differences were noted between nonallergists and allergists regarding causes, diagnostic methods, treatment, and prevention of FA, indicating the need for more education in this area.

Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition

This position paper on complementary feeding summarizes evidence for health effects of complementary foods. It focuses on healthy infants in Europe. After reviewing current knowledge and practices, we have formulated these conclusions: Exclusive or full breast-feeding for about 6 months is a desirable goal. Complementary feeding (ie, solid foods and liquids other than breast milk or infant formula and follow-on formula) should not be introduced before 17 weeks and not later than 26 weeks. There is no convincing scientific evidence that avoidance or delayed introduction of potentially allergenic foods, such as fish and eggs, reduces allergies, either in infants considered at increased risk for the development of allergy or in those not considered to be at increased risk. During the complementary feeding period, >90% of the iron requirements of a breast-fed infant must be met by complementary foods, which should provide sufficient bioavailable iron. Cow's milk is a poor source of iron and should not be used as the main drink before 12 months, although small volumes may be added to complementary foods. It is prudent to avoid both early (<4 months) and late (>or=7 months) introduction of gluten, and to introduce gluten gradually while the infant is still breast-fed, inasmuch as this may reduce the risk of celiac disease, type 1 diabetes mellitus, and wheat allergy. Infants and young children receiving a vegetarian diet should receive a sufficient amount ( approximately 500 mL) of breast milk or formula and dairy products. Infants and young children should not be fed a vegan diet.