Complementary and Allergenic Food Introduction in Infants: An Umbrella Review

Essential elements for learning to eat: guidance to support families with infants and young children

Feeding infants and young children (IYC) is an emotional commitment for caregivers as they strive to achieve a sense of mastery, goodness, and accomplishment in providing nourishment for their children. Feeding practices are important during early childhood for lifelong health and well-being as behaviors related to healthy eating are established, and there is an interrelation between growth, gross/fine motor skills, and social-emotional behavior in shaping "learning to eat" for IYC. Mealtimes and feedings are opportunities for engagement with the family, formation of healthy habits, exposure to different foods, practicing eating skills, and learning to appreciate foods. The caregivers' role is pertinent as they influence and teach children "what" and "how" to eat and play a crucial role in supporting children's social, emotional, and cognitive development in relation to food and mealtimes. This mini review provides practical guidance for caregivers as their IYC "learn to eat." Caregiver behaviors have changed, particularly in the choice of feeding methods, requiring an update on complementary feeding advice. Healthcare providers can encourage positive feeding practices. Family mealtimes provide opportunities for (1) bonding, (2) practicing and refining gross/fine motor, cognitive, language, and social-emotional skills, (3) offering a variety of nutrient-dense, appropriate textured foods, and (4) reinforcing the central role of the caregiver in establishing healthy eating patterns, a positive relationship with food, and joyful eating experiences. Healthcare providers play a pivotal role in raising awareness among caregivers about the importance of their role in feeding their child(ren).

Diversity of complementary diet and early food allergy risk

INTRODUCTION

Diet diversity (DD) in infancy may be protective for early food allergy (FA) but there is limited knowledge about how DD incorporating consumption frequency influences FA risk.

METHODS

Three measures of DD were investigated in 2060 infants at 6 and/or at 9 months of age within the NorthPop Birth Cohort Study: a weighted DD score based on intake frequency, the number of introduced foods, and the number of introduced allergenic foods. In multivariable logistic regression models based on directed acyclic graphs, associations to parentally reported physician-diagnosed FA at age 9 and 18 months were estimated, including sensitivity and stratified analyses.

RESULTS

High weighted DD scores (24-31p) at age 9 months were associated with 61% decreased odds of FA at age 18 months [OR (95% CI) = 0.39 0.18-0.88] compared with infants with the lowest DD scores (0-17p). The association remained significant after exclusion of early FA cases. Having introduced 13-14 foods at age 9 months, independent of consumption frequency, was associated with 45% decreased odds of FA [OR (95% CI) = 0.55 (0.31-0.98)] compared to having introduced 0-10 foods. When stratifying, significantly reduced odds for FA were seen for children with eczema and for children with no FA history in the family. No association was seen between DD at age 6 months and FA at age 18 months.

CONCLUSION

A diverse diet at age 9 months may prevent FA at age 18 months. Our results underscore the need for additional investigations on the impact of consumption frequency in infancy.

EAACI guidelines on the management of IgE-mediated food allergy

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

Prospective associations of infant food exposures and appetitive traits with early childhood diet quality

BACKGROUND

Early-life food exposures may influence food preferences and receptivity, thereby impacting long-term diet quality. Infant exposure to discretionary foods may be more detrimental for infants with high food approach traits; conversely, early exposure to fruits and vegetables may be more important for those with high food avoidance traits. This study investigated associations of infant food exposures with early childhood diet quality and whether these associations are modified by infant appetitive traits.

METHODS

Data are from the Pregnancy Eating Attributes Study (PEAS) and Sprouts follow-up study, a prospective cohort assessed from the first trimester of pregnancy through early childhood. Birthing parents completed the Baby Eating Behavior Questionnaire assessing food-approach and food-avoidance appetitive traits at 6 months and food frequency questionnaires assessing infant age at introduction to and frequency of consuming food groups at ages 6 months, 1 year, and 2 years. At child ages 3.5 and 5 years, parents provided two 24-h dietary recalls, from which the Healthy Eating Index-2020 was calculated to measure diet quality. Structural equation models using maximum likelihood estimation examined associations of age at introduction to, and intake frequency of, fruit/vegetables and discretionary foods, and their interactions with food-approach and food-avoidance appetitive traits, on child diet quality at ages 3.5 & 5 years, controlling for income, education, and breastfeeding duration.

RESULTS

Higher childhood diet quality was associated with later infant age at introduction to discretionary foods, lower intake of discretionary foods at ages 1 and 2 years, and greater intake of fruits and vegetables at age 2 years. Childhood diet quality was not associated with infant age at introduction to fruits and vegetables. Intake of fruits and vegetables at age 1 year interacted with food avoidance traits, indicating that the association of fruit and vegetable intake with childhood diet quality was magnified by greater food avoidance.

CONCLUSIONS

Exposure to discretionary food in the first two years of life was consistently associated with lower diet quality in early childhood regardless of the strength of appetitive traits. Findings suggest that improving child diet quality may require stronger efforts to limit exposure to discretionary foods in infancy.

Prevalence and Determinants of Food Allergy in the Era of Early Allergen Introduction: The EarlyNuts Population-Based Study

BACKGROUND

Infant feeding guidelines in Australia changed in 2016 to recommend introducing common allergy-causing foods by age 1 year to prevent food allergy. Although most Australian infants now eat peanut and egg by age 6 months, some still develop food allergy despite the early introduction of allergens.

OBJECTIVES

To describe the prevalence of food allergy in a cohort recruited after introducing the nationwide allergy prevention recommendations; identify characteristics of infants who developed allergy despite early introduction of allergens; and estimate the causal effect of modifiable exposures on food allergy prevalence and whether this differed between infants who were introduced to allergens before or after age 6 months.

METHODS

We recruited a population-based sample of 12-month-old infants in Melbourne, Australia. Infants had skin prick tests to four foods and parents completed questionnaires. Infants with evidence of sensitization were offered oral food challenges. Prevalence estimates were adjusted using inverse probability weighting.

RESULTS

In a cohort of infants (n = 1,420) in which nearly all infants had been introduced to common allergens such as egg, milk, and peanut by age 1 year, the prevalence of food allergy remained high at 11.3% (95% CI, 9.6-13.4). Infants who developed food allergy despite introduction of the allergen by age 6 months were more likely to have Asian-born parents. Early-onset moderate or severe eczema was associated with an increased odds of food allergy irrespective of whether allergens were introduced before or after age 6 months. Among infants who were introduced to peanut at age 6 months or earlier, antibiotic use by age 6 months was associated with an increased odds of peanut allergy (adjusted odds ratio = 6.03; 95% CI, 1.15-31.60).

CONCLUSIONS

In a cohort in which early allergen introduction was common, the prevalence of food allergy remained high. Infants who developed food allergy despite introduction of the respective allergen by age 6 months were more likely to have had Asian parents and early-onset eczema. New interventions are needed for infants with a phenotype of food allergy that is not amenable to early allergen introduction.

Characteristics of childhood anaphylaxis in different age groups

BACKGROUND

Anaphylaxis is a severe systemic hypersensitivity reaction that usually has a rapid onset and can be fatal. Presentations of childhood anaphylaxis vary widely in accordance with the triggers and the patient's age, geographical region and dietary and lifestyle habits.

METHODS

The medical records of 177 paediatric patients diagnosed with anaphylaxis between January 2021 and January 2024, whose disease progression was monitored at a single tertiary care centre, were reviewed retrospectively.

RESULTS

The study included 177 patients diagnosed with anaphylaxis (107 males and 70 females with a median age of 48 months). The most common allergen responsible was food (53.7%). Egg allergy was the most common source of anaphylaxis, afflicting 35 patients (19.3%), while beta-lactam provoked the most common drug allergy, affecting 24 patients (13.6%). The most common organ involved was the skin (92.7%). When the patients were analysed by age group, there were more males in the infancy, preschool and school age groups, while there were more females in the adolescent group (p = 0.44). Food-induced anaphylaxis became less common with increasing age, whereas the rate of drug-induced anaphylaxis increased (p = 0.01 and p = 0.01, respectively). Cardiovascular system findings were observed more frequently in adolescents compared to other age groups (p = 0.003). Most cases stemming from a food allergy were mild, whereas most drug-induced cases were moderate or severe (p < 0.05). When severity was analysed by age group, mild cases in infants were more common than moderate to severe cases.

CONCLUSION

The aetiological and clinical manifestations of childhood anaphylaxis vary among different age groups.

Directed acyclic graph for epidemiological studies in childhood food allergy: Construction, user's guide, and application

Understanding modifiable prenatal and early life causal determinants of food allergy is important for the prevention of the disease. Randomized clinical trials studying environmental and dietary determinants of food allergy may not always be feasible. Identifying risk/protective factors for early-life food allergy often relies on observational studies, which may be affected by confounding bias. The directed acyclic graph (DAG) is a causal diagram useful to guide causal inference from observational epidemiological research. To date, research on food allergy has made little use of this promising method. We performed a literature review of existing evidence with a systematic search, synthesized 32 known risk/protective factors, and constructed a comprehensive DAG for early-life food allergy development. We present an easy-to-use online tool for researchers to re-construct, amend, and modify the DAG along with a user's guide to minimize confounding bias. We estimated that adjustment strategies in 57% of previous observational studies on modifiable factors of childhood food allergy could be improved if the researchers determined their adjustment sets by DAG. Future researchers who are interested in the causal inference of food allergy development in early life can apply the DAG to identify covariates that should and should not be controlled in observational studies.

Timing of complementary feeding for early childhood allergy prevention: An overview of systematic reviews

OBJECTIVE

To summarise and critically appraise systematic review (SR) evidence on the effects of timing of complementary feeding (CF) on the occurrence of allergic sensitisation and disease.

DESIGN

Overview of SRs. AMSTAR-2 and ROBIS were used to assess methodological quality and risk of bias (RoB) of SRs. RoB 2 Tool was used to assess RoB of primary randomised controlled trials (RCTs) (or extracted). The certainty of evidence (CoE) was assessed using GRADE. Findings were synthesised narratively.

DATA SOURCES

MEDLINE (via PubMed and Ovid), the Cochrane Library and Web of Science Core Collection (2010 to 27 February 2023).

ELIGIBILITY CRITERIA

SRs investigating the effects of timing of CF in infants or young children (0-3 years) on risk of developing food allergy (FA), allergic sensitisation, asthma, allergic rhinitis, atopic eczema and adverse events based on RCT evidence.

RESULTS

Eleven SRs were included. Only two SRs had low RoB; common issues were failure to report on funding of primary studies and failure to provide a list of excluded trials. Common limitations of included trials were lack of blinding of outcome assessment or detailed trial preregistration, and inadequate handling of high loss to follow up. Primary study overlap was very high for specific FA and slight to moderate for FA in general and other primary outcomes. Introducing specific foods (peanut, cooked egg) early probably reduces the risk of specific FA. Evidence for other allergic outcomes was mostly very uncertain and based on few primary studies. Trials varied regarding timing of CF, nature of complementary foods and population risk, which limited comparability between SRs.

CONCLUSIONS

For developing guidelines to support decision-making on the timing of CF as a preventive strategy, early introduction of specific foods (i.e. egg and peanut) seems promising and safe, whereas more extensive research is required regarding other allergic outcomes and potential adverse events.

Nutritional Considerations for the First Year of Life

Feeding during the first year of life is a dynamic process with unique questions, concerns, and milestones emerging at every step. This article will review a small selection of specific questions and concerns related to feeding in the first 12 months of infancy. The aim of this article is to inform and support pediatric providers and parents during this crucial developmental period. [Pediatr Ann. 2023;52(9):e316-e321.].