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Introducing highly allergenic foods to infants and children

David M Fleischer, MD
Section Editor
Scott H Sicherer, MD, FAAAAI
Deputy Editor
Elizabeth TePas, MD, MS


Studies support the existence of a critical time early in infancy during which the genetically predisposed atopic infant is at higher risk for developing allergic sensitization [1]. Thus, dietary interventions in the first years of life have been analyzed for their effects on the prevalence of allergic disease including food allergy [2]. Both American and European expert committee guidelines recommend that solid food be introduced between four to six months of age in all infants [3-6]. Recommendations regarding when to introduce highly allergenic foods, particularly in high-risk infants, have shifted over time.

Introduction of highly allergenic foods is discussed here. The general approach to introduction of solid foods during infancy is reviewed in greater detail separately, as is use of formula in high-risk infants. (See "Introducing solid foods and vitamin and mineral supplementation during infancy" and "Introducing formula to infants at risk for allergic disease".)

Other aspects of the primary prevention of allergic disease are also discussed in greater detail separately. (See "Primary prevention of allergic disease: Maternal diet in pregnancy and lactation" and "The impact of breastfeeding on the development of allergic disease".)


While any food has the potential to cause allergy, certain foods are more common triggers of significant acute allergic reactions due to various factors. The most common food allergens in children in the United States and many other countries include cow’s milk (CM), hen’s egg, soy, wheat, peanut, tree nuts, and seafood (shellfish and fish). (See "Pathogenesis of food allergy", section on 'Factors influencing sensitization or tolerance' and "History and physical examination in the patient with possible food allergy", section on 'Common culprit foods' and "Food allergy in children: Prevalence, natural history, and monitoring for resolution", section on 'Prevalence of childhood food allergy' and "Food allergens: Overview of clinical features and cross-reactivity".)


Infants and young children with a family history of atopy are at high risk for developing allergic disease, and those with a personal history of atopy are also at increased risk of developing other atopic diseases including food allergies. The American Academy of Pediatrics (AAP) had previously suggested in 2000 that the introduction of certain highly allergenic foods be delayed further in high-risk children: cow's milk (CM) until age one year; eggs until age two years; and peanuts, tree nuts, and fish until age three years [7]. This recommendation was based upon early studies that suggested that delayed introduction of solid foods might help prevent some allergic diseases, particularly atopic dermatitis (AD) [8-10]. (See "Introducing formula to infants at risk for allergic disease", section on 'Infants at high risk for developing allergy'.)


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Literature review current through: Sep 2016. | This topic last updated: Aug 16, 2016.
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  1. Zeiger RS. Food allergen avoidance in the prevention of food allergy in infants and children. Pediatrics 2003; 111:1662.
  2. Pali-Schöll I, Renz H, Jensen-Jarolim E. Update on allergies in pregnancy, lactation, and early childhood. J Allergy Clin Immunol 2009; 123:1012.
  3. Greer FR, Sicherer SH, Burks AW, et al. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics 2008; 121:183.
  4. Muraro A, Dreborg S, Halken S, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol 2004; 15:291.
  5. Grimshaw KE, Allen K, Edwards CA, et al. Infant feeding and allergy prevention: a review of current knowledge and recommendations. A EuroPrevall state of the art paper. Allergy 2009; 64:1407.
  6. Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract 2013; 1:29.
  7. American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346.
  8. Fergusson DM, Horwood LJ, Beautrais AL, et al. Eczema and infant diet. Clin Allergy 1981; 11:325.
  9. Fergusson DM, Horwood LJ, Shannon FT. Early solid feeding and recurrent childhood eczema: a 10-year longitudinal study. Pediatrics 1990; 86:541.
  10. Fergusson DM, Horwood LJ, Shannon FT. Asthma and infant diet. Arch Dis Child 1983; 58:48.
  11. Sicherer SH, Burks AW. Maternal and infant diets for prevention of allergic diseases: understanding menu changes in 2008. J Allergy Clin Immunol 2008; 122:29.
  12. Agostoni C, Decsi T, Fewtrell M, et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46:99.
  13. Høst A, Halken S, Muraro A, et al. Dietary prevention of allergic diseases in infants and small children. Pediatr Allergy Immunol 2008; 19:1.
  14. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372:803.
  15. Du Toit G, Sayre PH, Roberts G, et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med 2016; 374:1435.
  16. Palmer DJ, Metcalfe J, Makrides M, et al. Early regular egg exposure in infants with eczema: A randomized controlled trial. J Allergy Clin Immunol 2013; 132:387.
  17. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008; 122:984.
  18. Zutavern A, von Mutius E, Harris J, et al. The introduction of solids in relation to asthma and eczema. Arch Dis Child 2004; 89:303.
  19. Zutavern A, Brockow I, Schaaf B, et al. Timing of solid food introduction in relation to eczema, asthma, allergic rhinitis, and food and inhalant sensitization at the age of 6 years: results from the prospective birth cohort study LISA. Pediatrics 2008; 121:e44.
  20. Snijders BE, Thijs C, van Ree R, van den Brandt PA. Age at first introduction of cow milk products and other food products in relation to infant atopic manifestations in the first 2 years of life: the KOALA Birth Cohort Study. Pediatrics 2008; 122:e115.
  21. Poole JA, Barriga K, Leung DY, et al. Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics 2006; 117:2175.
  22. Nwaru BI, Erkkola M, Ahonen S, et al. Age at the introduction of solid foods during the first year and allergic sensitization at age 5 years. Pediatrics 2010; 125:50.
  23. Koplin JJ, Osborne NJ, Wake M, et al. Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol 2010; 126:807.
  24. Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow's milk protein is protective against IgE-mediated cow's milk protein allergy. J Allergy Clin Immunol 2010; 126:77.
  25. Tromp II, Kiefte-de Jong JC, Lebon A, et al. The introduction of allergenic foods and the development of reported wheezing and eczema in childhood: the Generation R study. Arch Pediatr Adolesc Med 2011; 165:933.
  26. Joseph CL, Ownby DR, Havstad SL, et al. Early complementary feeding and risk of food sensitization in a birth cohort. J Allergy Clin Immunol 2011; 127:1203.
  27. Grimshaw KE, Maskell J, Oliver EM, et al. Introduction of complementary foods and the relationship to food allergy. Pediatrics 2013; 132:e1529.
  28. Luccioli S, Zhang Y, Verrill L, et al. Infant feeding practices and reported food allergies at 6 years of age. Pediatrics 2014; 134 Suppl 1:S21.
  29. Roduit C, Frei R, Depner M, et al. Increased food diversity in the first year of life is inversely associated with allergic diseases. J Allergy Clin Immunol 2014; 133:1056.
  30. Perkin MR, Logan K, Tseng A, et al. Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. N Engl J Med 2016; 374:1733.
  31. Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998; 102:e6.
  32. Consensus Communication on Early Peanut Introduction and the Prevention of Peanut Allergy in High-Risk Infants. http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Announcements/Consensus-Communication-Final-6-1-15.pdf (Accessed on June 02, 2015).