Dietary interventions to prevent atopic disease: Updated recommendations
Scott H.Sicherer, M.D., FAAP and Frank R.Greer, M.D., FAAP
AAP Clinical Report
Recommendations for allergy prevention through early infant dietary intervention continue
An updated AAP clinical report from the Committee on Nutrition and Section on Allergy
and Immunology provides some new recommendations based on reviews of expert guidelines,
systematic reviews, meta-analyses and studies published since the AAP’s 2008 report
The updated report, The Effects of Early Nutritional Interventions on the Development of Atopic Disease
in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding,
Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods, is available at https://doi.org/10.1542/peds.2019-0281 and will be published in the April issue of Pediatrics.
Evolution of recommendations
In 2000, an AAP policy suggested that the approach to allergy prevention in infants
at high risk of allergy based on family history of atopic disease could include use
of hydrolyzed infant formulas; maternal avoidance of peanut and other allergenic foods;
and delayed introduction of milk, egg, peanut, nuts and fish beyond age 1 year. Those
recommendations were based on limited data. Over the subsequent eight years, mounting
evidence suggested that delaying introduction of allergens was notpreventive.
The 2008 clinical report replaced the prior recommendations with more tentative comments
about the impact of hydrolyzed formulas and made no recommendations on restricting
food allergens in the maternal diet during pregnancy or lactation. The report presented
a comprehensive review of the infant diet including breastfeeding and the timing of
introduction of solid foods on outcomes of numerous atopic conditions, including asthma,
atopic dermatitis and food allergy. Since then, accumulating evidence has further
informed the field, resulting in the following new conclusions and recommendations.
Maternal dietary restrictions
There is lack of evidence to suggest maternal dietary restrictions during pregnancy
or lactation reduce the risk of atopic disease. The report notes that one systematic
review found that a maternal diet rich in fruits, vegetables, fish and foods containing
vitamin D and Mediterranean dietary patterns were associated with lower rates of atopic
disease in children.
The table below summarizes the evidence on the role of breastfeeding on atopic disease
and the impact of hydrolyzed formula if breastfeeding cannot be accomplished. A beneficial
impact of breastfeeding is evident. Several conclusions differ from ones presented
in 2008, due to new studies and meta-analyses incorporating them. Among them are:
Any duration of breastfeeding beyond three to four months protects against wheezing
in the first two years.
Some evidence reveals that longer duration of any breastfeeding protects against asthma even beyond age 5 years.
Early introduction of peanut
One significant change in the recommendations involves the timing of peanut introduction.
While the new clinical report still concludes that there is no evidence that delaying
introduction of allergens beyond 4 to 6 months of age prevents atopic disease, there
is evidence to support early introduction of infant-safe forms of peanut.
The AAP endorsed a report from a National Institute of Allergy and Infectious Diseases
expert panel that made recommendations heavily based on the Learning Early About Peanut
(LEAP) allergy trial and other studies (http://bit.ly/2CPqfki).
Those recommendations focus on a high-risk population — infants with severe atopic
dermatitis and/or egg allergy — who are advised to introduce infant-safe forms of
peanut as early as 4-6 months, in specified amounts, with consideration of pre-testing
to rule out allergy. The guidelines recommend that infants with mild to moderate eczema
be introduced to infant-safe peanut-containing foods as early as 6 months of age,
and those without food allergy or risk factors do so when age appropriate and depending
on family preferences, i.e., after 6 months of age if exclusively breastfeeding.
The theory is that eczematous skin can be a portal of exposure that triggers allergic
responses; in contrast, oral exposure induces tolerance. Hence, delayed peanut ingestion
may result, for these infants, in increasing risks of sensitization with time. Additional
details about early introduction of peanut are available at http://bit.ly/2UFB5Cq and in the clinical report.
More data are needed to understand the impact of the timing of introduction of other
foods such as egg on food allergy outcomes as limited evidence is less clear compared
Drs. Sicherer and Greer are the lead authors of the clinical report. Dr. Sicherer
is a former chair of the Section on Allergy and Immunology Executive Committee, and
Dr. Greer is a former chair of the Committee on Nutrition.