Food Allergy Awareness: Prevention is Worth a Pound

Food allergies are a significant public health issue and May is Food Allergy Awareness Month. As COVID has proven over the last couple of years, health inequality is also an urgent issue – and this applies to those with food allergies. Estimates, based on self-reported data, suggest that up to 8% of children and around 10% of adults in the U.S. may have a food allergy. Food allergies result in an unequal burden for families living in lower socioeconomic situations.? Preventing food allergies is essential to reducing future suffering, financial burdens and to improving health equity among Americans. According to the experts, preventing future cases of peanut allergies can be significantly reduced through early infant feeding, if current guidelines are followed.??

The latest recommendations for infant feeding have the potential to prevent most future cases of peanut allergies if they are followed. | Image: Shutterstock??

In addition to preventing tens of thousands of new peanut allergies each year, early introduction has the potential to reduce healthcare costs, encourage consumption of nutrient-dense foods and ensure the gap in health equity does not grow wider. Estimates are that the economic cost of managing a food allergy averages $4,184 per child annually (Gupta R. H., 2013). This is a huge issue for all families with food allergies, but especially those who are already struggling economically (Warren, 2021). Out-of-pocket medical expenses, expensive allergen-safe foods and lost wages due to sick-care and lost opportunities amount to a greater percentage of the budgets of low-income families and have a disproportionate impact on their lives. Having food allergies can also result in further limiting access to affordable, nutrient-rich foods including eggs, cow’s milk and peanut butter, the top three food allergies among children. These compounding issues of narrowing access and affordability ultimately make food allergies an issue of health equity and nutrition security.??

Living with food allergies also has a significant psychosocial cost, resulting in a lower quality of life and disproportionately affecting mothers (Feng, 2019). When one person in the household has food allergies, everyone else is affected too. Families may choose to forgo typical social activities, including sleepovers, camps, birthday parties, dining out and even some family events. Sometimes, parents and caregivers choose to stop working in order to homeschool because they find it so difficult to juggle both work outside the home and food allergy management.?

Prevention is Evidence-Based Practice?

While there remains no cure, we do have a proven method of prevention for peanut allergy. As a result of the groundbreaking Learning Early About Peanut allergy (LEAP) Study, experts now recommend the introduction of peanut foods as early as four to six months of age (Du Toit, 2015) (NIAID-Sponsored Expert Panel, 2017). Powerfully, LEAP demonstrated up to an 86% reduction in development of peanut allergies in high-risk infants when early introduction practices were applied.?

While the evidence strongly supports the introduction of peanut foods to prevent peanut allergies and no evidence shows that dietary avoidance of allergens in infancy prevents food allergies, changing behavior can be slow. Entrenched beliefs based on the 2000 recommendation by the American Academy of Pediatrics (AAP) to avoid allergens in infancy did not shift after those guidelines were rescinded in 2008. Moreover, although the AAP and the 2020-2025 Dietary Guidelines for Americans are aligned with NIAID Guidelines recommending the early introduction of peanut foods which were published in 2017 (and go further encouraging all allergens in the first year), parents and professionals alike have not yet fully embraced early introduction.??

While there remains no cure, we do have a proven method of prevention for peanut allergy. As a result of the groundbreaking Learning Early About Peanut allergy (LEAP) Study, experts now recommend the introduction of peanut foods as early as four to six months of age. | Image: Shutterstock?

According to a 2020 survey of 946 U.S. allergists, less than two-thirds were fully implementing the NIAID guidelines for the prevention of peanut allergies (Johnson J, 2020). And a survey of 3,062 caregivers of children seven months to three and a half years of age revealed that just 13.3% reported being aware of the latest guidelines for feeding babies peanut foods and 17.6% reported feeding their babies peanut foods by seven months of age (Samady W, 2022). However, when caregivers were asked about the safety of introducing peanut foods in infancy nearly half believed it was beneficial for preventing peanut allergies (Zaslavsky J, 2022) .?

Changing the Standard of Care?

To make a dent in the numbers of children who go on to develop peanut allergies in future generations, we must change the standard of care for early infant feeding of potentially allergenic foods and underscore the urgency for early introduction during this critical life stage. New parents need healthcare professionals to provide them with specific direction to introduce infant-safe peanut foods and other allergens in a timely manner consistent with their risk. Those with severe eczema and/or existing egg allergy are at highest risk for peanut allergy and may benefit most from earlier introduction, starting at around four months, while all other infants should begin eating peanut foods starting around six months after they’ve started eating a few other foods.??

Once successfully introduced, peanut foods should remain part of the diet. | Image: Shutterstock?

Once successfully introduced, peanut foods should remain a regular part of the diet, as the evidence for early introduction methods support timing to be both early and often. Other allergens can also be introduced after six months of age and, aside from peanut, evidence is strongest for the early introduction of egg to protect against egg allergy. Whether or not introducing other commonly allergenic foods prevents allergy to those foods is still unknown; however, we do know that it is safe to introduce these other foods and that they are nutritious. In addition, there has been research associating a more diverse diet in infancy with lower rates of allergy (Venter, 2020). Pediatricians, nurses at all levels, registered dietitians and others who regularly work with families, pregnant women and infants and children can – and should – empower parents to confidently feed their babies commonly allergenic foods early and often.?

Public Health Intervention: Opportunities Within the WIC Program?

As a public health issue for the approximately four million babies born in the U.S. each year, preventing peanut allergy for tens of thousands of underserved families can be enhanced through the WIC program. According to the WIC website, approximately half of the nation’s infants participate in the WIC program, relying on WIC for a healthy start to life. However, the WIC food package does not currently offer peanut foods for those participants under 12 months old, presenting a significant barrier to the implementation of these guidelines. As the lead federal agency charged with safeguarding the health and well-being of at-risk pregnant and breastfeeding women and their children in the U.S., WIC has a unique opportunity to champion the nationwide adoption of early introduction of peanut foods to reduce the risk of peanut allergy and therefore prevent furthering nutrition insecurity for this already at-risk population. As the WIC food packages open for public comment and revision this year, careful consideration should be made to how preventing food allergy through early infant feeding of infant-safe peanut foods and other commonly allergenic foods can be included.?

The Role of Registered Dietitian Nutritionists in Prevention of Food Allergies?

Registered dietitian nutritionists are natural advocates for improving nutritious food options for all. As experts, we know the importance of nutrition in early life, and preventing food allergies plays a key role in healthy infant feeding. Research shows, and expert guidelines recommend, feeding babies commonly allergenic foods, in particular peanut and egg, starting between four and six months of age can help reduce the risk of developing food allergies. Implementing the infant feeding guidelines means helping to prevent food allergy and increasing options for nutrient-dense foods for a lifetime. This is a cause we can all help move forward by sharing the latest recommendations with our clients and patients, families and friends, colleagues and our wider audiences.??

My call to action for you is to help spread the word to your sphere of influence When the WIC food package proposed rule is published by USDA, speak out in the public comments. Let the leadership at WIC know that they should add peanut butter to the package along with appropriate education for caregivers. Proactively prevent peanut allergies and help close the health equity gap for this population.?

To learn more about ways to help with this important issue, check out an article from me about the Five Key Points for RDNs here.??

REFERENCES

Du Toit, G. R. (2015). Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New Eng J Medicine, 803-813.

Feng, C. a. (2019). Beyond Avoidance: the Psychosocual Impact of Food Allergies. Clin Reviews in Allergy & Immunol, 74-82.

Gupta, R. H. (2013). The Economic Impact of Childhood Food Allergy in the United States. JAMA Pediatrics, 1026-1031.

Johnson J, G. R. (2020). Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI. J Allergy Clin Immunol: In Practice, 875-883.

NIAID-Sponsored Expert Panel. (2017). Addendum Guidelines for the Prevention of Peanut Allergy in the United States. Retrieved from National Institute of Allergy and Infectious Diseases: https://www.niaid.nih.gov/sites/default/files/addendum-peanut-allergy-prevention- guidelines.pdf

Samady W, W. C. (2022). Current Peanut Introduction Practices amongst a Large, Representative Sample of US Households. J Allergy Clin Immunol: In Practice, AB39.

Zaslavsky J, S. W. (2022). US Caregiver Beliefs, Attitudes, and Considerations of Early Introduction of Peanut. J Allergy Clin Immunol, AB38.

Warren, C. T. (2021). Advancing Food Allergy Through Epidemiology: Understanding and Addressing Disparities in Food Allergy Management and Outcomes. J Allergy Clin Immunol Pract, 110-118.

Venter, C., M. K. (2020). Different Measures of Diet Diversity During Infancy and the Association with Childhood Food Allergy in a UK Birth Cohort Study.?The Journal of Allergy and Clinical Immunology: In Practice.?8 (6), pp. 2017-2026.?