By: Sharon M. Donovan, PhD, RD, Professor, Department of Food Science and Human Nutrition University of Illinois, Urbana
Food allergy has become an increasingly recognized global health concern. Defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food (1), the disease impacts health and quality of life for sufferers and their caregivers (2). A new Report entitled “Finding a Path to Safety in Food Allergy: Assessment of the Global Burden, Causes, Prevention, Management, and Public Policy” was recently released by The National Academies of Sciences, Engineering and Medicine (available at www.nationalacademies.org/FoodAllergies). The report evaluated the scientific evidence on the prevalence, origins, diagnosis, prevention, and management of food allergy and makes recommendations to bring about a safe environment for those with food allergy.
The prevalence of food allergy is reported to be in the range of 1-10% of the population (3-6). Studies of self-reported allergy typically overestimate prevalence (12 % when compared with studies that for the allergy itself (7). A serious misconception about food allergy diagnostics relates to equating a “positive test” by a serum food-specific IgE (sIgE) blood test or skin prick test (SPT) to having an allergy to the tested food. Therefore, the committee recommends that a medically-supervised oral food challenge (OFC) be used to confirm allergy or tolerance.
Although many foods have been noted to cause allergic reactions, it is clear that cow’s milk, hen’s egg, peanut, tree nuts, and seafood are responsible for most of the serious allergic reactions (1,8). For many years, parents have been instructed to avoid introducing these potential allergenic foods in high-risk infants. However, a series of recent studies have challenged this recommendation. The LEAP (Learning Early About Peanut Allergy) study conducted in the UK studied infants who were at high risk for peanut, defined by early-onset eczema or coexistent egg allergy. Half of the parents were told to avoid peanut containing foods in their child’s diet until age 5, whereas the other half of the infants consumed a peanut-containing snack with 3 or more meals per week (~ 6 g peanut protein/week). Of the children who avoided peanut, 17% developed peanut allergy by the age of 5 years, whereas, only 3% of the children who were randomized to eating the peanut snack developed allergy by age 5 (9). These findings have led a number of professional organizations (10) and the National institute of Allergy and Infection Disease (11) to recommend “……that children with severe eczema, egg allergy, or both have peanut introduced as early as 4-6 months of life, after assessment by a trained allergy specialist. For children with mild-to-moderate eczema, peanut can be introduced at 6 months, without the need for specialist evaluation. For children with no eczema, peanut can be introduced in accordance with family and cultural preferences, without the need for specialist evaluation”.
What about other allergens? There are on-going clinical trials evaluating early introduction of egg, cow milk and wheat, therefore definitive evidence will soon be available. However, in the meantime, the report concludes that “limited evidence …suggests that delaying the introduction of egg, cow milk and wheat to decrease risk of those food allergies has no benefits” and discusses a potential benefit of introducing these foods in the first year of life when the infant is developmentally ready, around 6 months but not before 4 months of age, including for those at high risk of allergy. Nevertheless, any parent of a food-allergic child or expectant mothers with a family history of food allergy, should consult with the pediatrician or allergist before initiating any dietary changes.
“Note: The author is responsible for the content of this article, which does not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine, their committees, or convening bodies.”
- Boyce JA, Assa’ad A, Burks AW, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126:1105-18.
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- Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics 2011; 128:e9-17.
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- Sicherer SH, Munoz-Furlong A, Godbold JH, Sampson HA. US prevalence of self-reported peanut, tree nut, and sesame allergy: 11-year follow-up. J Allergy Clin Immunol 2010; 125:1322-6.
- Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: a meta-analysis. J.Allergy Clin Immunol. 2007; 120:638-46.
- Sicherer SH. Epidemiology of food allergy. J Allergy Clin Immunol 2011; 127:594-602.
- Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372:803-13.
- Fleischer DM, et al. Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants. J Allergy Clin Immunol. 2015;136:258-61.
- Togias A, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139:29-44.