Safely Introducing Eggs, Peanuts in Infants 4 to 6 Months of Age

In this podcast, John Harrington, MD, speaks with Angela Hogan, MD, about the importance of safely introducing eggs and peanuts in infants aged 4 to 6 months to help reduce their risk for developing a peanut allergy later in life, including how much and how often parents/ guardians should offer the foods to children. 

Additional Resource:

• Du Toit G, Roberts G, Sayre PH, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-13. doi:10.1056/NEJMoa1414850

For more pediatric nutrition content, visit the Resource Center. 

John W. Harrington, MD, is the vice president of quality, safety, and clinical integration and division director of General Academic Pediatrics at Children’s Hospital of The King’s Daughters (Norfolk, VA).

Angela Duff Hogan, MD, is a professor of pediatrics at Eastern Virginia Medical School and an allergist/ immunologist at Children's Hospital of the Kings Daughters and Children's Specialty Group (Norfolk, VA). 

TRANSCRTIPTION:

Moderator: Hello everyone. And welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant 360 a multidisciplinary medical information network. It is well known that peanut and egg allergies are common in young children and have significant negative impacts on their quality of life. Here to speak with us today about infant nutrition is Dr John Harrington, vice president of quality safety and clinical integration and division director in general academic pediatrics at Children's Hospital of the King's Daughters in Norfolk, Virginia, with his guest, Dr Angela Hogan. Let's listen in.

Dr John Harrington: This podcast is really based on the fact that 8% of all children have an allergy to some type of food. And we wanted to bring you an expert in that, but one of the two predominant foods that kids are allergic to are peanuts and eggs. And so, therefore, a lot of this will be based on that, but we'll also touch upon a few other things and here to join us is Angela Hogan.

Dr Angela Hogan: Hi, I'm Angela Hogan. I am a professor of pediatrics at Eastern Virginia Medical School and Children's Hospital of the King's Daughters and also in practice with Children's Specialty Group. I currently am on several national committees that work toward the safety of children and the health of children. I am a fellow of the American Academy of Pediatrics, and also a fellow of the American College of Allergy Asthma and Immunology, and fellow of the American Academy of Allergy Asthma and Immunology. My areas of interest and focus have been predominantly on asthma, food allergy, and allergy prevention. And I'm also an active member of the AAP planning committee for the national curriculum for the national NCE.

Dr John Harrington: I was going to just sort off with where did all this start? I thought kids shouldn't be allergic to things early on. Historically speaking kids just ate what their parents ate, and maybe you can line that up for us and then find out how things have sort of progressed to today where we have actually recommendations from our allergist and for primary prevention of allergies.

Dr Angela Hogan: Yes. So that's very true that we've seen a changing pattern of food allergies over time. If you go back into the sixties and seventies, most families introduce foods sort of would almost appear haphazard now to their children. It was based on oftentimes what foods they had available, or one of the things that families did is they would just feed the baby from the table as kind of a sign of love or whatever other resources were available.

And then we sort of medicalized food allergy introduction, and somewhere in the late nineties, it was considered that early introduction of certain high-risk foods actually might be what was contributing to the development of food allergies. So in 2000, there were some guidelines that came out from the American Academy of Pediatrics and several of the colleges and academies of allergy institutions. And they basically said that there was a sweet spot, a time period when you should introduce foods if you wanted to reduce the risk of allergy.

And so those guidelines actually said that eggs shouldn't be introduced until the age of two and that peanuts and tree nuts shouldn't be introduced until the age of three. And that milk products shouldn't be introduced until 12 months. And what actually happened is we saw even more food allergies develop. And because of that, there was a study that was instrumental in sort of reversing our thinking. And probably most of you have heard of that study that was called the LEAP study.

And the LEAP study stood for learning early about peanut allergy. And in that particular study, they took high-risk infants who were infants, who had eczema and egg allergy. And they divided them into two groups. And one group said you're not going to get to have peanuts until you're five years old. And the second group, they screened them for early peanut allergy. And if they didn't have it, they said, you're going to eat peanuts until you're five years old. And that interval was three times a week.

And so when they looked at both of those groups at the age of five, what they found is that there was 86% less peanut allergy in the infants who got an early introduction and began to eat it regularly. And so from that, we changed our guidelines completely in this country. And in 2017, we said, hey, we want to introduce peanuts early in high-risk infants. And again, high-risk infants at that time were infants who either had egg allergies or severe eczema. But since that time we've seen some evolution of those guidelines. And now there are new recommendations that exist for families with, in terms of introduction now of both peanut and egg.

Dr John Harrington: So, I mean, that is the gist of it. And so where did this four months to six months come from? Was that just because of the LEAP study did it that way, or is it because there's a specific timing for that? How did that come about?

Dr Angela Hogan: The four to six months did come from the LEAP study and the LEAP study initially started to feed babies four to six months those more solid foods because that seemed to be a time when we felt like infants were developmentally ready. And the current guidelines as they exist now say that all infants should have the introduction of eggs and peanuts around six months. And it can be as early as four months. But again, the key here is are they developmentally ready.

Dr John Harrington: I had a question about premature babies and stuff like that. So if a premature infant, if they're developmentally ready at say five months or six months, they should just introduce at that time.

Dr Angela Hogan: Yes. And there are different forms of the foods that you can feed that certainly adapt to what the child is developmentally ready for, but just like the introduction of any food in pediatrics, you know, want to make sure that the child can sit upright, that when you put the food into their mouth and spoon it, that they're appropriately able to swallow it and not tongue it out or choke. That's an important part of their early feeding process. So the child has to be ready to do that before you introduce those proteins.

We also know that when we look at foods from an allergen standpoint, egg allergy is happening really early and probably infants that become sensitized to eggs are probably becoming sensitized somewhere between three and six months of life. So it's really important that we get the egg in the diet early so that we potentially can keep seeing that allergen level over and over again so that we don't go on to develop a food allergy. We think peanut allergy probably happens somewhere between four and seven months for most infants. So again, if we can introduce the food and have it repetitively seen by the immune system so that it becomes tolerizing is important around that six-month window, also.

Dr John Harrington: Here's a question that I seem to always get from parents that I fed my child scrambled eggs, and they had a rash or they got a rash from it, or they got some sort of reaction to it. I know they talk about baked eggs or eggs that are cooked or whatever, but a lot of parents ask about the egg whites versus the yolks versus all these different things. So what's your sort of overarching thing way of talking about egg introduction?

Dr Angela Hogan: So the current recommendations are to introduce egg in a heated form, but not necessarily baked egg. You could do bake egg, but you run the risk potentially that there may be some child who can tolerate bake egg but might not be able to tolerate scrambled egg. So the current recommendations are actually to introduce egg protein. So we usually recommend keeping it simple, like doing a little bit of a scrambled egg and breaking it down to smaller pieces. I think an equally important part is that this just isn't a one-time introduction. And sometimes I'll have families that I see in my clinic who will say, well, I did introduce egg at six months and they tolerated it and I haven't given any more. Or I put a little dollop of peanut butter on their tongue and they were perfectly fine, but no, I haven't gone on to feed it.

What we know for the immune system. It's really important not only that we introduce these proteins early, but that we have continued exposure at regular intervals so that the immune system continues to maintain that tolerizing state so that those foods are tolerated.

So to get back to your question specifically about egg, it's really not the amount of egg. They don't have to be able to feed a whole egg. You could do a little bit of a boiled egg, you could do a scrambled egg and then just break it down to a much smaller amount so that the baby is able to eat it. It could be mixed into a baby food. You could theoretically even do baked powder, a baked egg powder that you could stir like into a protein drink. You could stir that over into a baby food. And that would be an easy way to get egg into the diet. Most kids don't really like the texture of baked things very early on. Four to six months, it's really hard to get a child to want to eat a muffin or a cookie. That's just not a texture that they're used to. So that can become a part of their regular egg diet that they're going to have. But usually they don't tolerate that very well until about seven or eight months.

Dr John Harrington: One of the things that we find with parents is doing something on a regular basis is not always the easiest thing, right? So I guess from that standpoint, I know the peanut introduction is supposed to be, at least the study was three times a week, I think, or something like that, that they give a certain amount, seven grams or some other number of peanut or peanut-like thing. And then I always thought I was just taking peanut butter on your finger and sticking it in your kid's mouth and stuff. I wondered if that was a way to do it as well, but I know that peanut butter can get sticky and cause some choking. And what's your sort of preferred way of telling parents how to give peanut protein?

Dr Angela Hogan: So coming back again, just to your point there, I think that initially, we over-structured how much protein it had to be and how often. And I think we've really understood now from real-life experiences of how families really feed their children. That it's really not the amount that we're feeding. It's just really more the consistency of feeding. And so I think for egg, it probably should be at least once a week or so, and probably for peanut a couple times a week, but we do have some kids who like it so much and they eat it every day and there is no too much that you can do.

And actually, there are some really good studies that show even early introduction of egg and peanut, it doesn't influence breastfeeding outcomes. Parents continue to breastfeed without any problems. If they're a breastfeeding mom, you certainly would hate to think that we bumped somebody for breastfeeding or that we made them wean early because of food introduction. And what's been shown for egg and peanut, that it doesn't affect continued breastfeeding for those families that want to.

But your question about peanut is there are multiple different forms of peanut. And in the younger kids, it's probably easiest to do peanut powder or peanut flour, which are both products that right now are on the shelf, oftentimes right beside the peanut butter, or you can get them over in the specialty section of the store where people might have powders and proteins that they're stirring into smoothies. Those kinds of products are very helpful and useful to stir into a baby food or a baby cereal for the introduction of those foods. And then as they get more and more feeding skills, seven or eight or nine months, then you could move more towards potential peanut in the form of a teething biscuit. And they actually also make pouches now like apple sauce and peanut butter. And certainly, those kinds of things are easy ways to get peanut protein into the diet also.

And then additionally, there is this food that we affectionately called Bamba, which are peanut puffs Bamba actually is a brand that was what the initial studies were done with. But now there are peanut puffs that are on multiple different manufacturers' labels that actually are peanut protein that are in a Cheeto. And so it's not necessarily a choking hazard because they dissolve very easily, but probably textually, most kids are not interested in those until probably eight or nine months. But that can be an additional source of continuing peanut protein in the diet after you've introduced it.

Dr John Harrington: That's very interesting. So are there any contraindications to introducing peanut or egg early and doing it at home? If a child had severe eczema, would maybe you want to do that here in an allergist's office, or maybe you want to have an EpiPen ready in case they have a real problem with it or something? Are there any things like that that you would ever sort of say, hey, you might not want to do that. I haven't heard of anything, but I just wondered if you had any, I guess, anecdotal things that occurred related to the introduction of peanut and egg.

Dr Angela Hogan: This is really is wheres start to kind of split hairs based on what camp you're with, but in reality, what the new guidelines or consensus document says is that it is for all infants, irrespective of whatever their allergy status is. Now the reasons potentially to do it in the office or to send them to an allergist would be, if you don't think the family's going to do it and they need help, or they need to have it demonstrated to them that it is safe because the critical thing is that we do need to get an early introduction in, and sometimes families are afraid. Maybe they have a previous child that has an allergy, or maybe the parents have allergies, or maybe everything they've read on the internet says that they should delay introduction. And so I think that in those kids, it may be worthwhile to have them seen.

I think it's really important to use Australia as an example here. Australia has a different type of healthcare system where oftentimes they implement guidelines and because of their type of medicine, they're able to get them across a large population very quickly. And what we know in the Australian data, and they have gone back and looked at early introduction, they have done it across the population and they have had no fatalities whatsoever with home introduction of egg and peanut to all infants across their population. Now that doesn't mean they haven't had allergic reactions. And there are some kids who do have allergic reactions, but we know that allergic reactions in infants are much less severe across the board when we compare them to older kids.

And so if you did have a child at introduction who had a rash or had something that you weren't clear whether or not it was an allergic reaction, then I recommend get your phone out and take pictures and then contact your primary care provider and discuss with them what you saw. And potentially if there's a concern that this might have been an allergic reaction, then that's the important time to send them in a timely manner, over to an allergist that can evaluate them to either say, hey, I think it's okay. Let's go ahead and introduce the food in the office to make sure it's safe. Or in fact, if they have determined it's a food allergy, then to give them an auto-injectable epinephrine device. I don't think any child at any form needs to have auto-injectable epinephrine available at home for early introduction.

Dr John Harrington: I really like that advice in terms of the thing because so many parents tell me that their child got a rash from the introduction of the food. And I think that gets into so many other issues. I'm like just take a picture of it and hold onto that or send it to me or bring it to me when you have your visit or your sick visit. Because a lot of times it's just like a little maybe contact dermatitis or some other thing. And it might not even be, or maybe unrelated. There are some kids that get viral urticaria and stuff like that. And you're sort of like, well, you had a virus at the same time. Maybe that was it and stuff.

Dr Angela Hogan: And then there are so many kids that rash just to rash. So they seem to rash to everything. Yeah.

Dr John Harrington: One of the things that I was thinking about, is what if a parent or sibling has an allergy to the food that they're trying to give? Is there any sort of advice for that? If the sibling should be at a different table, the parent should let the other parent do it if they're allergic. I mean, are there any other things like that, that sort of crop up that you would give advice about?

Dr Angela Hogan: Yeah. So first of all, in terms of so many families come with the notion that if they had another child who had a particular food allergy, not only do they think the next child is going to have a food allergy, but the specific food even is, oh, my older child had an egg allergy, therefore, my new baby potentially is going to have an egg allergy. And the only food allergy there has ever been established a possible genetic link at all to is peanut. Not for any of the other foods per se has there been any genetic link. And some of that's even been called into question more recently.

Maybe the development of peanut allergy and a subsequent sibling is because of the delayed introduction because the family is already so afraid that, oh my gosh, we've already got a peanut-allergic child. We're not going to introduce peanuts or they're totally hesitant because they're afraid they're going to potentially contaminate the other child. Then they don't introduce peanuts. And they may be sadly helping to create the next child, having a peanut allergy because of delayed introduction.

When there's already a food allergy in the home, I usually just try to get practical tips on what they might be able to do. First of all, again, emphasizing as much as you're afraid to do this, we need to do it. And if you can't do it, we'll do it in the office. But sometimes I'll have parents set up like the play yard and have them put the high chair in the middle of it and say, okay, you're going to feed the baby in the high chair. And you've established a perimeter around the toddler and say, no, no, we're not going to go and bother the baby while the baby is sitting in the high chair in the middle of the play yard, or I'll say, let's introduce the food to the baby while the other child is taking a nap, or let's introduce the food to the baby at grandmother's house or something.

And I try to work through all of the questions they fire at me one after another of different circumstances that they might be worried about having an allergic reaction in the other child. And then I remind them again, even the child with the known peanut allergy in order to have a peanut reaction, the protein's got to get inside. So simply opening the jar of peanut butter or peanut powder that you're stirring into the baby food does not necessarily make the other child no matter what their age in the home at risk for a peanut reaction as long as the peanut protein doesn't get inside of the allergic child.

Dr John Harrington: I'll just jump off of this for a second. But in terms of waiting in between foods that if a child, if you want to start a new food and they used to say three days or five days, I remember reading in some of the older books and stuff. It said three to five days between each new food, just to make sure they're not allergic to it. Is that just total garbage or is that something that you, what do you usually say?

Dr Angela Hogan: So again, there's no great evidence-based medicine to support any of these time intervals. They're sort of all what we were taught when we were learning how to be primary care providers. And when I was learning, it was five years. And so I really don't think there's a magical window here. It does make logical sense that you wouldn't necessarily want to introduce six foods all in one meal so that if there were a weird rash, you'd be like, I don't know which one of the six foods it was, but you certainly could layer foods. You know that you've done this food for a day or two. And then you add another food to that food. I think it tends to make sense.

I certainly follow the recommendations of my child's pediatrician on what foods to introduce when and specifically do you do cereals first? Do you do yellow vegetables first? I think your pediatrician has learned what they're comfortable with, but there is no magic interval of time. At least immunologically that food should not be introduced or introduced within. All we know is that early introduction is important for eggs and peanuts, but has not been demonstrated for other foods. And the current recommendation from the American Academy of Pediatrics is that all foods should be introduced theoretically by 12 months or at least the highly allergenic foods. So that means fish and shellfish we're going ahead and introducing around 12 months also. But beyond that, I don't think there are magic schemes or patterns or ways that we should be feeding foods other than what they're interested in and what's developmentally appropriate. What are your thoughts about food introduction? What do you tell your patients?

Dr John Harrington: I actually say one to three days in between a new food. And I mean, I still sort of gravitate towards that because I think it's hard for a parent to go like, okay, has it been three full days or five full days since I last introduced a new food? So I think it's just one of those things where they usually buy sometimes jars. What do you say about jar food versus your own cooked food or anything like that? Do you have any sort of saying, can they add stuff to their cooked food? Sometimes they're adding spices or they're adding other stuff to what they eat from their table. So is there any other things that you say, should it just be that food or should there be spices added in or things like that? Because a lot of parents kind of, oh, I made the mashed potatoes with milk and other things and added a few spices. So are there other things that you feel that you should not do or do, or?

Dr Angela Hogan: Actually as an allergist and from an immunological standpoint, I don't restrict and tell them certainly culturally, if they're used to putting a little bit of cinnamon, let's say in their food and their child has tolerated cinnamon without a problem and they want to continue to add those spices. I don't really have a limitation. And in terms of homemade's best versus jar foods, I think having been a mom of three children, you do what you have at the moment. You can do it. And certainly, when I can make my own food, I felt really proud and happy of myself that day. But when I didn't have time for it, then baby bananas in the jar is what you got and you got good baby bananas that way too. So I think whatever we are able to do as parents is good, as long as we are meeting our nutritional needs for our child.

Dr John Harrington: Is there something to be said about the dose-response? If a kid has a little bit of a reaction to that, but you gave them a lot of it. Is it something that maybe if you gave them a little, they wouldn't have had a reaction? Are there any dose-response issues related to allergies?

Dr Angela Hogan: So once you have an established allergy, clearly there is a dose-response. And we know that there are some individuals who a little bit, may only give them a minor allergic reaction, but a whole lot may result in a more severe reaction called anaphylaxis. And there are some kids who do have food allergies that are developing that sometimes in the setting with an allergist, we might start to introduce incremental amounts and increase it up over time.

I think when we're talking about just general feeding, we just want to do an adequate dose and it really doesn't matter that you start with a small amount and work forward with that. If you have a child that you're not suspecting of having a food allergy, then you should just feed them the food. And if you do have a child that you think has a food allergy, then you shouldn't feed them any of the food until you have that sorted out and make sure that they are not at risk for having the more severe anaphylactic reaction.

And then in the context of the practice with your allergist, then you all can determine what would be an appropriate dose if any, moving forward. Sometimes there's something called OIT, which is oral immunotherapy, that some children will undergo where they will have small amounts of the food. And it'll be built up over time and increase to help develop either their tolerance or desensitization to that food. And that's a whole different subject, but we would never want to do that concept by ourselves at home if we thought your child was allergic to a food, then you'd want to be evaluated to determine if we need auto-injectable epinephrine or not. So the safest thing is to avoid the food completely until you know.

Dr John Harrington:

So what would be, maybe to finish up a little bit on this, what kind of maybe three top recommendations would you make to either pediatricians or to parents, I don't know which one, in terms of improving our ability to get kids less allergic to these peanuts and eggs and even shellfish?

Dr Angela Hogan:

So I think first of all, I think breastfeeding is still an important thing that we can do to be proactive and give our child the best opportunity. Immunologically. There are so many good things that are contained in breast milk that may also help induce oral tolerance to foods. Then I think if the child is developmentally ready around six months, or maybe even as soon as four months, if they're ready to eat foods at that time, we should consider the early introduction of both eggs and peanuts. And again, we're talking peanut protein and we would want to use safe forms of both egg and peanut protein. And then I think equally important, you can't just introduce it. You got to keep it in the diet with consistency as we move forward because it's those repetitive viewings of those proteins to our immune system that actually help maintain tolerance as we move forward.

Dr John Harrington: That's great. Dr. Hogan, I've learned a lot and also will be able to sort do better for my patients. Thank you for bringing that to us today because I think there are a lot of pediatricians out there that probably would benefit from the education, like I have. Anyway, thank you very much for your time.

Dr Angela Hogan: Thank you.

Dr John Harrington: And we will probably be listening to this over and over again to make sure we got all the things that we were supposed to. Thanks a lot, Dr. Hogan.

Dr Angela Hogan: Thank you.