Can we continue to recommend early allergenic food introduction during a pandemic?

By Dr. Elissa M. Abrams and Dr. Edmond S. Chan, Canadian Paediatric Society Allergy Section

In light of the COVID-19 pandemic, there is an unparalleled need to keep children out of the emergency department (ED) and hospital. As a result, a common question is whether families whose infants are at risk of allergy should proceed with early introduction of allergenic solids.

Yes: Even during a pandemic, the CPS continues to recommend that if infants are at high risk of food allergy (due to eczema, other food allergy, or an immediate family history of allergies), allergenic solids should be introduced early—around 6 months, but not before 4 months of age (1).

Allergenic solids should be introduced one at a time, in an age-appropriate way, and without unnecessary delay between solids. If the food is well tolerated, recommend that parents offer it to the infant a few times a week to maintain tolerance. This approach has been proven in the LEAP randomized trial to reduce the risk of peanut allergy in high-risk infants by over 80% (2).

While it’s critical to keep infants out of the ED, the risk of a severe allergic reaction on first ingestion of an allergen in infancy is extremely low. There has never been a death due to first ingestion of an allergenic food in infancy. Large observational studies and randomized controlled trials have found early introduction of allergenic foods such as peanut to be safe, with low rates of reactions (approximately 2%) that are mild, and exclusively skin reactions (2-4). None of the reactions required epinephrine and none were life-threatening. Based on these studies, we can estimate the risk of a life-threatening anaphylactic reaction to be much lower than 2%. With this very low risk of severe reaction, it’s extremely unlikely that an infant would need to be taken to an ED after first ingestion.

While many other practice recommendations are changing because of COVID-19, we can continue to recommend early introduction of allergenic foods for at-risk infants, since the benefit (large reduction in food allergy) clearly outweighs the risk (extremely small risk of severe reaction at first ingestion). As new information becomes available, and if circumstances change, this post will be updated as required.

For more information: Timing of introduction of allergenic solids for infants at high risk

Information for parents: Feeding your baby in the first year

References

1. Canadian Paediatric Society. (Principal authors: Abrams EM, Hildebrand KJ, Blair B, Chan ES). Timing of introduction of allergenic solids for infants at high risk. Paediatr Child Heal. 2019;24:66–7.
2. Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015 Feb;372(9):803–13.
3. Perkin MR, Logan K, Tseng A, Raji B, Ayis S, Peacock J, et al. Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. N Engl J Med. 2016 May;374(18):1733–43.
4.  Koplin JJ, Peters RL, Dharmage SC, Gurrin L, Tang MLK, Ponsonby A-L, et al. Understanding the feasibility and implications of implementing early peanut introduction for prevention of peanut allergy. J Allergy Clin Immunol. 2016 Oct;138(4):1131-1141.e2.

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