An average of two percent of the population under age five develops an egg allergy. However, most children outgrow their egg allergy by late childhood.
Despite the allergenicity of foods such as eggs, experts do not encourage avoiding these foods when introducing solids to infants. According to the 2016 National Academies of Science, Engineering, & Medicine food allergy report, there may be “benefits of introducing allergenic foods in the first year of life to infants when a child is developmentally ready: around 6 months of age, and not before 4 months.” This is based on studies showing a possible decrease in the development of food allergies when food allergens are introduced at 4 to 6 months of age. This advice is consistent with recommendations from the American Academy of Pediatrics.
Previous recommendations for infant feeding included
guidance to avoid early introduction of eggs and allergenic foods in the diet
for both the infant1 and mother.2 However, science has
advanced, and early life feeding recommendations are rapidly changing. The 2020 Dietary Guidelines Advisory
Committee evaluated evidence for complementary feeding, and allergy experts
chimed in with the latest scientific evidence.3 Current research
indicates infants should have a diverse diet during the first year of life,
including allergenic foods, especially peanut and egg, in an age-appropriate
LATEST RECOMMENDATIONS FOR EARLY INTRODUCTION
According to a recent systematic review conducted for the
USDA and the Department of Health and Human Services Pregnancy and Birth to 24
months project, “…there is evidence to suggest that introducing allergenic
foods in the first year of life (>4 months) does not increase risk of food
allergy or atopic dermatitis but may prevent peanut and egg allergy…Moderate
evidence suggests that introducing egg in the first year of life (>4 months)
may reduce the risk of food allergy to egg.”4 This conclusion aligns
with the American Academy of Pediatrics’ Clinical Report on early nutritional
interventions, which states, “There is no evidence that delaying the
introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4
to 6 months prevents atopic disease.”5
A recent analysis of the Enquiring About Tolerance (EAT) randomized controlled trial found “early introduction
was effective in preventing the development of food allergy in specific groups
of infants at high risk of developing food allergy…Of equal importance was that
early introduction of allergenic foods into the diets of the non-high-risk
infants was not associated with any increased risk of food allergy.”6
High risk infants in this study were
identifed as those with visible eczema at enrollment and infants with food
sensitization (IgE antibodies present to one or more of the six allergenic
foods). In this secondary analysis,
early introduction of egg reduced the risk of allergy for both infants sensitized
to egg and for those who had moderate to severe eczema at enrollment. Food Allegy Research and Education (FARE) has also commented on this new study, and suggests,
“Guidance on early egg introduction is likely to evolve as more evidence
BAKED EGGS ARE TOLERATED BY MANY CHILDREN WITH EGG
In the U.S., approximately 1% of all children, and about 12%
of children with food allergies are allergic to eggs.7 Egg allergies
are considered to have a high rate of resolution in childhood, with
approximately 50% of children with egg allergy reaching tolerance between the
ages of 2-9 years.8,9
Of significant interest, it has been observed that
approximately 70% of children with egg allergy can tolerate extensively baked
egg in foods like muffins or cakes (as opposed to lightly cooked eggs like
scrambled or French toast).9-11 Several studies have suggested that
introduction of baked egg in the diet of children who can tolerate these foods
may help hasten resolution of allergy,9-11 with some data showing frequent ingestion
increases the likelihood of tolerance compared to infrequent ingestion.12
Although these are promising observations, many of these
recent studies lack adequate control groups, limiting conclusions of the impact
of extensively baked egg on allergy progression or development of tolerance.11
So, while more research is needed to better understand the role of baked eggs
to potentially alter the course of egg allergy, “…inclusion of egg and milk in
its baked form may also have other benefits.
It is reasonable to expect that liberation of the diet may boost
nutrition, improve the child and family’s quality of life and reduce family
anxiety, however, no studies have specifically investigated this.”11
Importantly, caregivers of children with egg allergy should consult the child’s
physician before introducing extensively baked egg into the child’s diet.
ADDITIONAL BENEFITS OF EARLY INTRODUCTION
Early introduction of eggs into an infant’s diet has the added benefit that eggs provide various amounts of all nutrients listed by the American Academy of Pediatrics as essential for brain growth.13 Eggs additionally provide 252 mcg of lutein + zeaxanthin, carotenoids with emerging evidence linking to brain development and health.14,15 As a nutrient-rich food that is a good or excellent source of eight essential nutrients, including choline, incorporation of eggs into the diet early may not only reduce the risk of food allergy to egg, but also serve as an important food to support brain development.
Obbagy, J.E., et al., Complementary feeding and food allergy, atopic dermatitis/eczema, asthma, and allergic rhinitis: a systematic review. Am J Clin Nutr, 2019. 109(Supplement_7): p. 890s-934s.
Greer, F.R., S.H. Sicherer, and A.W. Burks, 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. Pediatrics, 2019. 143(4).
Perkin, M.R., et al., Efficacy of the Enquiring About Tolerance (EAT) study among infants at high risk of developing food allergy. J Allergy Clin Immunol, 2019. 144(6): p. 1606-1614.e2.
Gupta, R.S., et al., The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States. Pediatrics, 2018.
Sicherer, S.H. and H.A. Sampson, Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol, 2018. 141(1): p. 41-58.
Savage, J., S. Sicherer, and R. Wood, The Natural History of Food Allergy. J Allergy Clin Immunol Pract, 2016. 4(2): p. 196-203; quiz 204.
Nowak-Wegrzyn, A. and A. Fiocchi, Rare, medium, or well done? The effect of heating and food matrix on food protein allergenicity. Curr Opin Allergy Clin Immunol, 2009. 9(3): p. 234-7.
Dang, T.D., R.L. Peters, and K.J. Allen, Debates in allergy medicine: baked egg and milk do not accelerate tolerance to egg and milk. World Allergy Organ J, 2016. 9: p. 2.
Peters, R.L., et al., The natural history and clinical predictors of egg allergy in the first 2 years of life: a prospective, population-based cohort study. J Allergy Clin Immunol, 2014. 133(2): p. 485-91.
Schwarzenberg, S.J. and M.K. Georgieff, Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics, 2018. 141(2).
Egg Nutrition Center partnered with Jessica Ivey, RDN, LDN to write this blog
Some parents are excited to introduce their
baby to solid foods, while others find the process nerve-racking. No matter
where they fall on the spectrum, this is an important milestone for baby and
can be a fun family experience.
Most babies are ready for complementary foods
around 6 months of age. According to the American Academy of Pediatrics, there
is not enough information to suggest which foods should be introduced first and
in what order, but rather, it’s best to introduce a wide variety of single
ingredient foods in any order.1 Different foods contain different
nutrients, so a more varied diet will be more nutritionally complete. Also,
food and flavor preferences are established early, so exposing infants to many
different textures and flavors from an early age can help establish lifelong
healthy eating patterns.
Previously parents were told to wait to
introduce allergenic foods to their infants, especially if there was a family
history of food
allergies. But groundbreaking research2,3 has found that early introduction of potential
allergens, including eggs, to an infant around 6 months of age helps to reduce
the likelihood of developing an allergy to that food.
When considering first foods, parents should choose
nutrient-rich foods with essential nutrients for growth and development. Eggs
are a good or excellent source of eight essential nutrients, including choline
and lutein, nutrients that are important for brain development, learning, and
memory. Plus, eggs have all of the nutrients that the American Academy of
Pediatrics lists as key nutrients that support neurodevelopment – which are
protein, zinc, iron, choline, folate, iodine, vitamins A, D, B6 and B12, and
long-chain polyunsaturated fatty acids.4
There are several ways to incorporate eggs
into an infant’s diet. Here are some ideas to consider:
Hard-cooked egg yolk mashed on a spoon or once baby is ready, mashed egg yolk spread on a piece of toast cut into sticks that the baby can pick up.
If parents are having trouble getting their child to try new foods, remember that many babies and toddlers need to be exposed to the same foods multiple times before accepting them. Encourage parents to keep offering nutrient-dense foods, like eggs, and eat nutritious foods themselves! Babies and toddlers are more likely to try foods that they see their peers, siblings, and parents eating.
DiMaggio D, et al. Updates in Infant Nutrition. Pediatr Rev, 2017. 38(10): p. 456.
LEAPing Past Food Allergies: How and When to Introduce Potential Allergens
Reported food allergies have been on the rise for the last decade. Groundbreaking findings from research led to new guidelines recommending early introduction of peanut foods in infancy to reduce the risk of peanut allergies. But what about other allergens such as egg, milk, and fish? Join internationally recognized researcher and pediatric allergist, Dr. Gideon Lack, and food allergy expert, Sherry Coleman Collins, MS, RDN, to review the latest science and feeding recommendations for reducing the risk of food allergies.
After attending this webinar, the attendee will be able to:
• Describe the latest science and feeding recommendations for reducing the risk of food allergies. • Utilize the latest research to guide patients and clients on when and how to introduce common allergens, including peanuts, eggs, and others. • Incorporate the latest National Institute of Allergy and Infectious Disease (NIAID) and American Academy of Pediatrics (AAP) guidelines on infant feeding practice into their patient and client education and counseling.
This webinar has been approved for: 1.0 CEU 1.0 AAPA Category 1 CME*
*This activity has been reviewed by the AAPA Review Panel and is compliant with AAPA CME Criteria. This activity is designated for 1 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.
A child’s risk of developing some
of the most common food allergies, including egg allergy, can be reduced by up
to 80% through early and sustained allergen introduction
Egg allergy affects 2% of children
and along with milk and peanut, make up 80% of childhood food allergic
The new research on food allergy
prevention offers two key takeaways for parents: 1) Start introducing allergens
early and 2) Keep going
As a board-certified allergist, I see firsthand how families struggle with food allergies. Thankfully, recent landmark studies have shown that a child’s risk of developing some of the most common food allergies, including egg allergy, can be significantly reduced through early and frequent exposure to certain allergenic foods starting at 4-6 months of age. For example, the PETIT (Two-Step Egg Introductionfor Allergy Prevention in Infants with Eczema) Study showed that in young infants exposed to eggs there was a 79% reduction in the overall rate of egg allergy.1
Top Allergens Affecting Children
Food allergies are on the rise and now more
than 1 in 10 suffer from a food allergy in the US. Although more than 170 foods have been
identified as triggers of food allergy, the FDA classifies 8 foods/food groups
as major food allergens: milk, egg, peanut, tree nuts, shellfish, fish, wheat
Egg allergy affects 2% of children and along
with milk and peanut, makes up 80% of childhood food allergic reactions. Egg
allergy typically presents in the child’s first year of life and ~50% of
children do not “outgrow” (or become tolerant to) their egg allergy, but if
they do, it may not happen until as late as their teenage years.2,3
New Research on Food Allergy Prevention
The science on food allergy prevention has
changed, and the American Academy of Pediatrics, National Institute of Health,
and other national organizations have all come out with new recommendations
about early and sustained allergen introduction. Here’s a quick summary of the
new research on food allergy prevention and how parents can now help prevent
common food allergies including an egg allergy.
LEAP Study: Reference 4
EAT Study: Reference 5
PETIT Study: Reference 1
However, introducing allergens can be hard to
do. In fact, in the EAT study5, only half of study participants
could achieve the study protocol, indicating that early and sustained
introduction was difficult at such a young age. I’ve seen this both in my
clinical and personal experience. When my son David was 5 months old, I realized
how frustrating and time consuming early and sustained allergen introduction
was, especially when most of what I offered him to eat ended up on the kitchen
floor or on his bib….not in his mouth.
5 Key Lessons for Preventing Food Allergies
As an allergist and mom, there are 5 key
lessons that I believe every parent needs to know about reducing the risk of
food allergies in their baby:
Start Introducing Early, Don’t Delay: Guidelines recommend starting as early as 4-6 months because there is a specific window within which our immune systems develop either a positive or negative response to certain food proteins.
Only Introduce When It’s Best For Baby: Parents should introduce allergens for the first time only when: 1) Baby is healthy and 2) An adult can monitor for any signs of a reaction for at least 2 hours.
Sustaining Frequent Exposure is Necessary: A baby’s immune system needs time and repeated oral exposure to develop a positive response to foods. Recent landmark studies exposed infants to allergenic foods 2-7 times/week for 3-6+ months.
Be Persistent: Babies can be picky eaters at 4-6 months of age and it’s hard to get them to consistently eat enough. In one of the recent studies, more than 50% of parents weren’t able to stick with an early allergen introduction protocol and therefore did not necessarily see a decrease in food allergy.
Breastfeeding + Early Introduction: While breastfeeding can be beneficial, it has not been proven that moms can prevent allergies by eating allergenic foods and exposing the baby through breast milk. It’s important for babies to get additional exposure.
While early introduction is possible to do yourself, many parents struggle to consistently feed allergenic foods as a regular part of their infant’s diet. For some helpful tips on early allergen introduction, visit this link.
For additional information on food allergen
labeling visit the FDA website second on food allergens.6
Katie Marks-Cogan, M.D. is board certified in Allergy/Immunology and Internal Medicine, and treats both pediatric and adult patients. She received her M.D. with honors from the University of Maryland School of Medicine and completed her residency in Internal Medicine at Northwestern and fellowship in Allergy/Immunology at the prestigious University of Pennsylvania and Children’s Hospital of Pennsylvania (CHOP). She currently works in private practice and is a member of the scientific advisory board for Ready, Set, Food!
Natsume O, Kabashima S, Nakazato J, et al. Two-step egg introduction for prevention of egg allergy in high-risk infants with eczema (PETIT): a randomised, double-blind, placebo-controlled trial. Lancet. 2017 Jan 21;389(10066):276-286.
Gupta RS, Springston EE, Warrier MR, et al. The Prevalence, Severity, and Distribution of Childhood Food Allergy in the United States. Pediatrics Jul2011, 128 (1) e9-e17.
Egg Allergy. American College of Allergy, Asthma, and Immunology. Version current 3 December 2019 Internet: https:// acaai.org/allergies/types-allergies/food-allergy/types-food-allergy/egg-aller- gy. Published 2014. Accessed July 24, 2019.
DuToit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015
Perkin MR, Logan K, Marrs T, et al. Enquiring About Tolerance (EAT) study: Feasibility of an early allergenic food introduction regimen. J Allergy Clin Immunol. 2016 May;137(5):1477-1486.
Featured article in the Fall 2018 Issue of Nutrition Close-Up; written by Diana K. Rice, RD, LD
What infants eat in their first few months of life is critical. Around six months old, breast milk and formula are no longer sufficient to meet an infant’s increasing nutritional needs. In particular, the nutrients needed for cognitive development including iron, zinc, choline and docosahexaenoic acid (DHA) must start to come from solid foods.1 We also now know that early exposure to common allergens including eggs and peanuts can actually help decrease the development of problematic food allergies.2