Why is Early Introduction to Allergenic Foods Important?

Prakash Chandran: We all know that children can be picky eaters, but how can the early introduction of foods affect the overall outcome of allergies? Today, we'll learn about the most common allergies, why more are developing and how to properly introduce food during childhood and infancy. We're going to talk about it today with Dr. Savannah Sommerhalder, a pediatric allergist at Aspire Allergy and Sinus.

This is a Achoo!, the podcast for people with allergies and sinus issues from Aspire Allergy and Sinus. I'm your host, Prakash Chandran. So Dr. Sommerhalder, really great to have you here today. This has been a topic that I've been excited to talk about because I have two little ones. I can remember the first time I gave my daughter eggs and she threw up everywhere. And so I've always kind of been wondering, you know, what is the right time to introduce these foods, when is it important to introduce them and just really a whole framework around that. So I'd love to get started by asking, you know, why is early introduction to allergenic foods so important?

Savannah Sommerhalder, MD: So these are all great questions. I'm also a mom, and so I think all of these things are just so important for parents to be aware of and to allow them a little bit more comfort when introducing foods. So, we now know this is relatively new information, but we've got new, data that tells us that delayed introduction of solid food, especially these highly allergenic foods, can actually increase the risk of food allergy development or even eczema. And so, early introduction, meaning around the age of four to six months of these highly allergenic foods could actually prevent those things from happening in infants and children. And so, that's the time that we recommend introducing those foods.

Prakash Chandran: Okay. That makes a lot of sense. So you're saying four to six months, that's the timeframe that you should typically start introducing the foods, right?

Savannah Sommerhalder, MD: Right. That's exactly right.

Prakash Chandran: Okay. And before we get into the dynamics of that, I've heard of this thing called the Top Nine. Can you tell us what those are?

Savannah Sommerhalder, MD: Yeah. So the top nine are the most highly allergenic foods that we have. So those include cows milk, eggs, soy, wheat, peanuts, tree nuts, fish, shellfish, and the newest one is sesame.

Prakash Chandran: Okay. Understood. And so, you know, I just want to get into the safety for introducing foods early. You know, I said at the intro, that moment that, you know, we just didn't know better. We gave our daughter eggs and she was throwing up everywhere. So that's obviously a really scary thing. So maybe talk a little bit about the safety of introducing these allergenic foods early and the right way to do it.

Savannah Sommerhalder, MD: Yeah. So I think the most important thing, and first thing to think about is are they developmentally ready to ingest whatever food you're introducing. So a peanut, you know, is a bit more unsafe or less safe than eggs. But around that four to six months timeframe, we want you to start introducing very small amounts of these allergenic foods, specifically in the beginning, eggs or peanut products. Giving a very small amount, just right on the tip of their tongue is perfect. Watch them for 10 to15 minutes. Make sure they don't have any sort of reaction. And then you can slowly give them higher volumes of the food after that. We do recommend only one allergenic food at a time, so every three to five days or so in that four to six months age range. Start with a little bit of scrambled eggs on their tongue. Wait about 10 to 15 minutes. Give them a little bit more. They do well, three to five days later, you can add a little yogurt or something with cows, milk protein in it and so forth and so on with those allergenic foods would be a great start.

Prakash Chandran: Okay, understood. And when you say these small amounts, you're just saying a very, very small amount. It can be like a spoonful even, right?

Savannah Sommerhalder, MD: Even less than that, yeah. Just a little tiny bit, like it fits on kind of the tip of your finger, a little thumb tack. Put that on their tongue, let them, you know, take a taste and go from there.

Prakash Chandran: Okay. And then do you continue that over time? You know, let's just talk about eggs, for example, let's say you give them a little bit of eggs, everything seems to be fine. Do you continue day over day or week over week? How do you recommend continuing, just to make sure that the protection is strong?

Savannah Sommerhalder, MD: Yeah, you certainly can do that. Three to five days a week is what's recommended for them to ingest bits of that protein. Certainly, for patients with atopic dermatitis or eczema, that's something that is definitely recommended specifically in that patient population.

Prakash Chandran: So you kind of talked about the order in which these foods should be introduced, maybe talk a little bit more, as it relates to the top nine, around how parents can think about the order of introduction.

Savannah Sommerhalder, MD: I think it all depends on the patient and the parents' comfort level. I guess, at that age, it would be the parents' comfort level and also the prevalence in the community of what they may be exposed to. So you certainly want to introduce the foods when they're in a safe place. We don't recommend, you know, sending them to daycare with a new allergenic food. We want you to introduce those things in the home.

Eggs are something that are frequently encountered in restaurants that parents may be eating, things like that. Same thing with cow's milk. Peanut is very prevalent in the community as well and so that may be one that should be one of the earlier of the nine to be introduced. And then after that, I think it's just based on the patient's diet. You know, all families and different cultures have different things that are used more commonly in their cooking, so those are the things that should be introduced first.

Prakash Chandran: Now, is there ever a case where the child should be a little bit more developed before introducing one of these allergenic foods? Like, you know, for example, you mentioned the four to six-month timeframe, but is there like one of these foods that really you should wait, for example, a year or older?

Savannah Sommerhalder, MD: So the old recommendation used to be--initially, it was wait until three years to introduce these allergenic foods. Then, it came down to one year. And again, the newest recommendation, which is a couple of years old now says that four to six-month range. We do want them to be developmentally capable of ingesting those foods. So we don't recommend giving, you know, a four-month old a peanut or a cashew because that would be a choking hazard. So it certainly needs to be in a medium that baby can tolerate.

With that being said, there are a couple of conditions or family histories that may warrant consult with their pediatrician or their allergist, which include moderate to severe eczema or if they have a family history, a close family history, like a sibling with a food allergy, they may want to be seen by their allergist first. And then the last one would be if they have any other known food allergies. We would want them probably to be seen first, potentially tested first before they introduced those things.

Prakash Chandran: Yeah, I was just going to ask if you should still introduce potential allergenic food if, you know, for example, another child or someone in the family also has a food allergy.

Savannah Sommerhalder, MD: Yeah, it's definitely not, you know, a certainty that a sibling is going to have a food allergy just because another one does, but it does put them at a little bit of a higher risk. And a lot of times we see some anxiety or nerves associated with that, which is completely reasonable and understandable. And so being seen by an allergist is certainly a reasonable option before introduction of allergenic foods for patients who have siblings who are also food allergic.

Prakash Chandran: Okay. So let's say a parent starts to slowly introduce their child to one of these top nine allergenic foods, what does a reaction to that food look like? What should parents look out for and how quickly does it happen?

Savannah Sommerhalder, MD: Yeah. So at this age, at the four to six months age, by far most common reaction that we see will be a skin manifestation and a GI manifestation, so that will look like typically hives and or vomiting. Those are the two most common. That doesn't mean there can't be other systems involved too. Some patients will have sudden onset of nasal congestion, eye watering, sneezing. Sometimes they'll have lung involvement, meaning like wheezing, coughing, things like that. Those are the most common that we see and usually the first to present themselves, which typically will happen in the first 30 minutes usually if a patient's going to have a reaction to a food. It can be a couple hours later, but usually we see it in the first30 minutes.

Prakash Chandran: And how long typically does that reaction last?

Savannah Sommerhalder, MD: It depends actually. That certainly ranges from patient to patient. I will say that recognizing it early is very important and addressing it early, treating them if necessary.

Prakash Chandran: Okay. And so you said, you know, the two of the most common manifestations were either something on the skin or vomiting. So when we talk about treatment, what exactly does that look like?

Savannah Sommerhalder, MD: So if it's a first time introduction, which can happen, you can have a reaction on the first ingestion of let's say peanut in which case you probably will not be equipped with an epi pen, which we know, is one of the first line medications. Having on hand Benadryl, Zyrtec, one of those anti-histamines is certainly an option if that's all that you have. And then, reaching out for further assistance, 911, would be the next step.

Prakash Chandran: Okay. I understand. And so would you recommend, if you are going to start making the introduction of some of these allergenic foods to a four to six-month-old, you know, having like, for example, the infant Benadryl nearby just in case?

Savannah Sommerhalder, MD: You know, as a mom, I would say yes, because there are a lot of nerves that come with introducing these foods, especially if you ever family history. So I do not think it's a bad idea to have them on hand. Most of the population, most babies will do just fine and not need anything. But as a mom, my answer is yes.

Prakash Chandran: Absolutely.

Savannah Sommerhalder, MD: So we'll go with that.

Prakash Chandran: Yeah. For sure. Now, look, in talking about this, you know, I, myself, am asking, like, is it it to introduce some of these, you know, foods that could potentially cause a severe reaction. I know there's obviously risk to anything, like what is the real benefit of doing that versus waiting? And I know that you said there could be increased food allergy in the future or even more extreme cases of eczema, but maybe talk a little bit about the data that you're seeing and why this is so important.

Savannah Sommerhalder, MD: We absolutely have great evidence and great data that tells us delaying introduction of these allergenic foods can and likely will, if you're in that population, increasing the likelihood of you having an allergy. Introducing them early, we know that is proven that it reduces the incidence of having a food allergy and like you mentioned to eczema. And so it seems like a pretty clear cut answer based on evidence what to do, which is to introduce early.

Anxiety, fear, nerves, all of those things come into play, but if we're doing what's best for our child, it's really, you know, buckling down and offering those foods early as long as, again, we don't have any of those other coexisting things going on, sibling with food allergies, moderate to severe eczema, history of other food allergies themselves.

Prakash Chandran: Yeah. And I know you've covered that before, but I just really wanted to drive the point home of why it's so important. You know, I think one of the other things I wanted to ask is if let's say there's like a mild reaction, maybe like a small skin rash after giving your child one of these foods, what does that mean? Does that mean you should keep trying? Does that mean you should, you know, tell your pediatrician? Talk a little bit about.

Savannah Sommerhalder, MD: Yeah. If it's localized, perioral-like redness, things like that, I'm not too concerned about it. It's not likely to progress into something systemic or involving other systems in their body. So if they eat, let's say like a strawberry, and they get redness just around their mouth, it doesn't move anywhere else, I feel pretty comfortable with that. That's likely just kind of a contact reaction from the fruit juices, the acidity, things like that. It's when it becomes some other system in their body or a full body. So, you know, if they eat something and they get hives on their face, their chest, their legs or if they vomit, things like that. But if it just stays localized around the mouth, I'm not too worried about that and I want them to keep eating it.

Prakash Chandran: So, if it does kind of, you know, express itself all over the body, you don't recommend continuing to give it to them. I imagine that you would just tell your pediatrician, "Hey, I think my child might have a reaction to this specific type of food" and then figure out a plan from there. Is that correct?

Savannah Sommerhalder, MD: Absolutely. Absolutely. Agreed.

Prakash Chandran: Okay. Another question I wanted to ask is, you know, does eating allergenic foods during pregnancy reduce the risk for food allergies in the baby?

Savannah Sommerhalder, MD: We don't know the answer to that. Some studies tell us yes, and some studies tell us that it doesn't make a difference. We do know that it doesn't hurt the baby for you to eat allergenic foods. It doesn't increase the risk of them having allergies if the mom's ingesting them. So in summary, with that information, we want moms to have a free and open diet, not restricting any of those allergens.

Prakash Chandran: Okay. And, you know, one of the last questions that I wanted to ask is just around food allergies in general. It seems like in my research that more people are developing them and I'm not exactly sure why that is. So is that something you can speak to?

Savannah Sommerhalder, MD: Yeah. A lot of the reason we think that more children are developing food allergies is because of the avoidance that we're practicing. And like I said previously, recommendations were, you know, to hold off on these allergenic foods until the age of five, until the age of three, because of that, we think we're developing more allergies.

In a lot of other countries where peanut for example, are integrated into the diet very early, we're seeing less peanut allergy there. And so this is part of the reason that we started really delving into and studying early introduction, and we've had great outcomes.

Prakash Chandran: Okay. Amazing. So just as we close, I just wanted to structure a good recommendation or path forward for parents that either have children between the ages of four to six months, or they're about to have a child. What is a good structure plan around how they can start introducing these top nine foods to their children?

Savannah Sommerhalder, MD: Yeah. If you've got a baby with, you know, no other health conditions, introduce those foods between four and six months. Make sure they're age appropriate for whatever food they're actually going to be ingesting. You know, free of choking hazards and things like that, sufficient neck control, they're able to sit and support themselves, those things are important to think about. But as long as the baby's there and developmentally ready, introducing those foods between four and six months is safe. We encourage it in order to decrease the likelihood of those allergies.

Prakash Chandran: Okay. Fantastic. And then final thing that I always like to ask is, you know, you have a lot of experience as a pediatric allergist. I'm sure that you've seen a lot of children. What is just one thing that you know to be true that you wish just more parents knew before they cameto see you?

Savannah Sommerhalder, MD: Testing for food allergens that have never previously been a problem is not recommended. There are a lot of physicians out there that will do kind of broad food allergy testing. And the patients come to me with these results that sometimes are uninterpretable. Sometimes we're seeing a lot of false positives, which can be really confusing for families.

So if you go to your pediatrician, looking for testing before you're introducing foods, we don't recommend that generally. And the reason again is high rate of false positives, which can cause the family to be fearful of introducing those foods, delaying introduction further and, again, increasing the likelihood that they're going to develop an allergy with that delay.

Prakash Chandran: Well, Dr. Sommerhalder, that's really great advice and certainly something that I will take with me. Thank you so much for your time today.

Savannah Sommerhalder, MD: You're welcome.

Prakash Chandran: That was Dr. Savannah Sommerhalder, a pediatric allergist at Aspire Allergy and Sinus. You can visit aspireallergy.com to learn more. This has been Achoo!, the podcast for people with allergies and sinus issues from Aspire Allergy and Sinus. I'm your host, Prakash Chandran. Thankyou so much for joining us, and we'll talk next time.

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