Weaning, feeding & food allergies
Practical considerations on food allergies for parents who are weaning their babies, from specialist paediatric dietitian Lucy Upton of the @ChildrensDietitian
Over the last 5- 10 years there have been huge advancements in research surrounding food allergy, particularly when it comes to prevention. Driven by increasing rates of food allergy in babies and children – with estimates of between 5-7% of children diagnosed with a food allergy by 2 years of age – studies such as LEAP and EAT have helped drive a shift of weaning practice recommendations surrounding food allergen introduction in support of prevention! Frustratingly for parents however, this is an area of weaning advice where guidance has changed a number of times over the past 20 years and it’s therefore perhaps understandable that a recent study of parents (by Your Baby Club) found that nearly half of parents (49%) remain worried about allergic reactions during weaning.
In practice as a Paediatric Dietitian, and through www.thechildrensdietitian.co.uk, I see first-hand the challenges, anxiety and worry food allergy management imparts on parents – including implications for children’s diet & feeding down the line. So, whilst the topic of food allergy, weaning and feeding extends far beyond a single blog article, I’ve tried to summarise three key areas for consideration on the topic of weaning, feeding & food allergies.
Introduction of allergenic foods during complementary feeding
- Cow’s milk
- Foods that contain gluten, including wheat, barley & rye
- Tree nuts e.g. almond, pistachio, hazelnut, macadamia, pecan, cashew, brazil
When should these be introduced during weaning?
For most babies – current UK department of health advice recommends that children are introduced to solids around 6 months of age (once developmentally ready.). With this in mind, once your baby has started weaning and got to grips with their first weaning foods such as vegetables, fruit, starchy foods and/or iron rich foods, you can begin to proactively incorporate the foods above into their diet without delay.
For babies who would be considered higher risk of developing food allergy research suggests there may be benefits to proactive earlier introduction of these foods from as early as 4 months of age – especially egg and peanut. Babies at higher risk of developing food allergy include;
- Babies who already have a known food allergy (never feed your baby a food they are known to be allergic to)
- Babies with eczema, particularly those with early onset and/or more severe eczema
If your baby falls into one of these higher risk groups, I encourage parents to proactively try to discuss with a health professional such as GP, Health Visitor, Paediatrician or Dietitian about the when and how to introduce these foods. Whilst these babies are higher risk of reaction, they are also likely to benefit most from proactive early introduction.
- Be sure to introduce one allergen at a time – never give two or more new allergens to your baby one day
- Ensure your baby is well and not recovering from illness. If baby has eczema, aim for skin to be well managed/under control (see further points below)
- Start with a small amount and build up gradually e.g. ¼ of a teaspoon, increasing slowly over the next few days. Waiting for 2-3 days after an initial introduction may also be beneficial to ensure there is no evidence of delayed reaction
- Ensure the food is appropriately prepared safely for baby e.g. peanuts, tree-nuts and seeds should be well ground or a smooth butter or paste (loosened with warm water/milk), egg should include the yolk & white
- Consider offering the food earlier on in the day e.g. in the morning to allow you time to monitor for any signs of reaction during the day
- If you baby refuses the food initially don’t despair! Try again another day, or consider mixing it into a food already tolerated and accepted. Do not force feed – allow baby to go at their own pace
- Consider the best way of supporting your baby to consume the allergenic food – often parents find that a puree or mashed foods initially are easier for guaranteeing consumption of the allergen, compared to baby-led style finger food – but this depends on your baby’s skills and progress with eating
- Once you’ve successfully introduced an allergenic food it’s important to keep giving it to your baby regularly – particularly egg and peanut. This may be easier for some foods such as wheat which is in a number of foods, but for options like egg and peanut aim to incorporate in baby’s diet at least once per week, but ideally up to 2 or 3 times per week.
It can be helpful before introducing allergens to familiarise yourself with the common signs of a food allergy which can be found here
Key take home points
There is no benefit to delaying introduction of allergenic foods during weaning. In fact, delaying introduction past 12 months of age has been found to potentially increase your child’s risk of developing an allergy. Seek support early if your child fits in the higher risk groups above.
Whether your baby has a known food allergy, is at risk of food allergy or neither, it is not uncommon for many parents to find themselves approaching weaning very cautiously – especially if it is their first weaning experience, or there have been early feeding challenges with baby. Whilst it can definitely feel daunting moving through the weaning journey, I find many parents (particularly those of babies with food allergy) fall into the trap of thinking all new foods, whether that be fruit, vegetables, protein rich foods or carbohydrates, need to be introduced one at a time over 2-3 days (or even longer) or get stuck offering foods considered as safe or preferred. In reality, however, this means that achieving dietary diversity including introduction of a wide range of foods, textures, taste & experiences (all key factors during weaning) can really start to be impacted.
Aside from the implications on supporting baby to be familiar and accepting of a balanced varied diet, recent research has also highlighted that encouraging dietary diversity e.g. offering lots of different foods into baby’s diet once weaning alongside food allergen introduction helps to support a reduction in overall food allergy risk.
With this in mind, I always encourage parents (unless otherwise recommended by a child’s medical team or clinically required) to enjoy exploring and introducing baby to a wide variety of foods, tastes, combinations and suitable textures as they progress through weaning each week – of course taking into account that those common allergenic foods should be foods introduced individually or more cautiously for some children.
Approaching weaning and feeding with positivity, patience and pragmatism, whilst challenging at times, is also key from a parental perspective. Enjoyment of mealtimes together, including communicating positively and responsively with you baby has such an important role in developing a happy mealtime & feeding environment too.
Protecting delicate skin, eczema & allergy considerations
Weaning can be a very messy experience and as a Dietitian I encourage this for a variety of reasons – Tidy Tot’s guide to Sensory Weaning is helpful here for ideas on how to get messy and keep the mess under control! However, aside from just coping with mess, the act of getting messy can throw up a number of concerns for parents who have babies with delicate skin, eczema and/or those who already have food allergies.
Some common questions or queries I often discuss with parents are summarised below:
- Many babies have sensitive or delicate skin (even more so if they have eczema), this means that contact with some foods directly during weaning can cause localised redness or irritation (contact dermatitis/reaction) during or after consumption – particularly around the face and hands. This reaction is not food allergy, but often interpreted to be so. Foods that typically cause these symptoms include those which are acidic and/or high in histamine – with common culprits including (but not limited to) tomato, kiwi, strawberries and acidic fruits. You can help protect a baby’s skin from such reactions by applying a barrier cream or emollient moisturiser before feeding
- Rubbing food on your baby’s skin before offering orally/to eat is not encouraged as a way of predicting possible food allergy (although I still hear this doing the rounds a lot!). Whilst it is understandable to want to explore a safer way of ‘testing the waters’ for potential food allergy – this approach is not evidence based or clearly proven to have any predictive value for food allergy diagnosis. For higher risk babies (see next) – especially those with eczema this practice may also have a counterproductive effect
- As summarised above, babies with eczema particularly those who experience early onset presentation (in the first few months of life) and/or moderate to severe severity are a group known to be at elevated risk of food allergy. But why eczema? Allergy research has highlighted the significance of eczema in the ‘dual allergy exposure hypothesis’. In short, this identifies that babies can become sensitised to allergens (including food proteins) via cutaneous (skin) contact and exposure, rather than and/or prior to consumption of these food particles first via the digestive system.
For babies with a compromised skin barrier e.g. broken or damaged skin associated with eczema, it is therefore so important to consider:
- Seeking help early from your GP to get on top of eczema management early
- Keeping on top of emollient and cream regimens to support maintenance, protection and/or healing of their skin (ideally prior to weaning and during weaning too)
- Aiming to have eczema well controlled prior to any introduction of common food allergens during weaning (see above)
- Seeking support if eczema symptoms or flares appear to be associated with certain triggers such as food, and/or are not responding to treatment
- Consider whether their skin needs protecting at mealtimes to continue to allow your baby to get messy, but with some extra protection for their skin – particularly if sore, infected or itchy (scratching can be a distraction at mealtimes)
Further information on weaning and food allergies can be found at www.allergyuk.org
More expert advice and tips on weaning can be found from Lucy at www.thechildrensdietitian.co.uk. It’s also important to make clear that this blog does not serve to replace or substitute any individualised medical advice, and content is based on research and guidelines available at the time of writing – 23rd June 2020