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A solid start: enjoying food while avoiding allergens

Allergy guidelines have been revised. How does this affect infant feeding?

Starting solids can be a confusing time for new parents, with the barrage of information available online offering conflicting advice. Allergies and intolerances are on a dramatic incline, and research in this area in recent years has led to the revision of infant feeding and allergy prevention recommendations in 2016 by the Australasian Society of Clinical Immunology and Allergy (ASCIA). The cause of the increase in food allergy is unknown, and thus these guidelines are pertinent to all families, not just those with a known family history.

Food allergy is an immune-mediated response to ingestion and can result in swelling of lips, face and eyes; hives or welts; eczema or rash; abdominal pain; vomiting or tingling in the mouth; and may or may not occur prior to anaphylaxis.

More than 90 per cent of food allergens are from the following foods: cow’s milk, egg, peanut, tree nut, wheat, soy, sesame, fish and shellfish. However, any food may cause an allergic reaction.

Food allergy in Australia is now being seen in 10 per cent of children under 1 year of age, 4-8 per cent of children under 5 years, and 2 per cent of adults. Diagnosis of food allergy must be done under the professional guidance of an allergist or immunologist via skin prick or RAST testing and oral food challenges.

Following feeding guidelines for happy feasting: Zoe Hutchinson.

Following feeding guidelines for happy feasting: Zoe Hutchinson.

The benefits of breastfeeding on both baby and mother are well documented. However, in recent years, the evidence for a protective and preventive effect on the development of food allergy has been low. The results from the recent LEAP study and STEP trial, among others, have highlighted the benefit of introducing high-risk allergenic foods (particularly peanuts) early, and of the food remaining in the infant’s diet. This is especially true for those at higher risk of developing a food allergy.

As a result, the revision of the infant feeding guidelines by ASCIA stipulates first and foremost that solids should be introduced when an infant is developmentally ready at about 6 months of age, but not before 4 months of age.

Signs of developmental readiness include: adequate postural support, good head control, reaching for food, and opening the mouth when food is offered on a spoon.

Iron-rich foods should be introduced first, with high allergen risk foods such as cooked eggs, wheat, fish and nuts in a suitable form. Introduction should not be delayed and allergenic foods should be offered within the first year of life.

Previously recommended face smearing of food prior to ingestion can produce skin irritation without gut involvement and vice versa, and as such is now not recommended to exclude allergy.

In high-risk families, that is, those with a family history of allergy, parents may wish to seek guidance from a paediatrician conjointly with a paediatric Accredited Practising Dietitian (APD), particularly if feeding has already been a concern, including faltering growth. If foods need to be excluded from the maternal or infant’s diet, an assessment by a paediatric APD will ensure both mother and baby are consuming a nutritionally complete intake so both are thriving.

Evidence gathered since 2010 has seen the infant feeding guidelines change to become more in line with preventive measures for the development of allergies for all infants.

The 2016 ASCIA revised infant feeding guidelines are a useful resource. Among their key points are:

  • Breastfeeding should be encouraged where possible and for as long as possible before and during the commencement of solids.
  • Alternatively, formula is to be utilised as sole source of nutrition. Cow’s milk or alternatives are not recommended, due to the lack of nutritional composition, prior to 12 months of age.
  • Solids should be introduced at about 6 months of age when an infant displays signs of developmental readiness, but not before 4 months of age.
  • Iron-rich foods are encouraged first (red meat, iron-fortified cereal, eggs, legumes, green leafy vegetables).
  • No need to delay high allergen risk foods.
  • Cow/soy milk can be used in cooking prior to 12 months.
  • Do not introduce raw egg.
  • If an infant has faltering growth, poor feeding and strong family history of allergy/intolerance, review by a paediatric APD is strongly recommended.

Zoe Hutchinson is a paediatric dietitian and founder of Little Sprouts Nutrition


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