Allergies and how to introduce foods to your infant

This post was written by Mark T Adams, MD, FAAP, PPG – Pediatrics, Warsaw.

Over the past 10 years, I’ve noticed that many of my patients are asking

about food allergies, peanuts in particular. This comes as no surprise, as more than 3 million kids under the age of 18 have been diagnosed with food allergies.

How do you know if your child or teenager has a food allergy?

Simply put, a food allergy happens when the body reacts to “harmless” proteins found in many foods. The reactions can occur shortly after, or within several hours of when the food was eaten. Most reactions are mild to moderate, and don’t result in a visit to a medical provider. It’s the rare, but life-threatening reactions, referred to as anaphylaxis, that cause parents and medical providers to worry so much about food allergies.

Some parents will bring a photo at the office visit. This is a great way to show your medical provider your child’s rash or reaction. Some reactions can be confused with a food allergy. For example, food poisoning can cause flu-like symptoms with vomiting and diarrhea, but is caused by bacteria in the contaminated food that’s been eaten. Caffeine in soda and candy can cause shaking and jitteriness. Energy drinks are notorious for causing the “shakes”. Citrus, like lemons, limes and orange juice, can cause skin irritation, especially after sun exposure. Acidic foods made with tomato products can also cause skin irritation. Even diarrhea can be caused by a sugar overload to the gut, which we see with many juices.

The American Academy of Pediatrics (AAP) recommends no juice for infants under 1 year. Intolerance to the lactose in milk and other food products is a food sensitivity, not an allergy. Infants under one year of age are the most affected, but 80% grow out of lactose intolerance as they get older. Food additives, preservatives and dyes added to foods may cause some reactions, but children are rarely allergic to that food. 

What are the most common food allergies?

There have been more than 150 different foods associated with food allergies, usually mild. According to the AAP, there are eight types of foods that are the most likely to cause a food allergy. These are:

  • Milk
  • Eggs
  • Peanuts
  • Soy
  • Wheat
  • Nuts from trees (i.e. walnuts, pistachios, cashews)
  • Fish (tuna, salmon, cod)
  • Shellfish (shrimp, lobster)

The top three for children are usually milk, eggs and peanuts. For teenagers and adults, it is usually peanuts, tree nuts and seafood.

What are the symptoms associated with a food allergy?

When your body’s immune system is overreacting to certain foods, there are multiple body systems that can be affected. The food reactions can vary from person to person, and the same person can react differently each time there is a reaction. Here are some of the food reactions (Note: Depending on severity, know that there are reactions that require calling 911 for assistance.)

Skin problems (most common type of reaction)

  • Hives: red itchy bumps that come and go and appear in different sizes
  • Eczema: dry patches on the face and extremities that itch
  • Swelling of the face, lips, tongue. Itchy, watery eyes.

Most of the skin issues are not severe, and can often be treated with an over-the-counter antihistamine or call to your primary care provider. If the skin problem results in eczema, it can become a chronic condition and sometimes a dermatologist may be needed. Individually, skin problems are not cause for immediate alarm. If, however, the condition continues to worsen, and more symptoms occur, there may be reason to seek immediate medical help. Start by calling your medical provider. Remember, kids with eczema are more likely to experience more severe reactions.

Breathing problems

  • Coughing
  • Wheezing
  • Throat tightening

Food allergies can also lead to breathing problems. Breathing problems can be as mild as a stuffy nose and sneezing, but can change suddenly into coughing, wheezing or throat tightening and shortness of breath. If this happens, call 911 immediately. Please keep in mind, if your child has asthma these reactions can be even more severe and require immediate medical attention.

Stomach symptoms

  • Mild nausea
  • Vomiting
  • Diarrhea

While not life-threatening, these certainly do warrant a call to your physician.

Circulation problems

  • Pale skin with some sweating
  • Light-headed, fainting from low blood pressure

These symptoms can occur independently or in combination with others. When several of these conditions occur at the same time, the reaction may be more severe and may create a more emergent situation. Anaphylaxis (shortness of breath, fainting, loss of consciousness) can start with a mild reaction, but suddenly turn into a life-threatening situation. Call 911!

How is a food allergy diagnosed?

If you suspect a food allergy, start with a visit to your provider. Be prepared to give a good history about your child’s reactions. Document all of the symptoms your child has had. Make sure you know how often the reaction happens and the time it takes between eating that food and the onset of the symptoms. Make sure you’ve questioned other family members about food allergies, asthma or eczema. Your provider may refer you to an allergist for skin testing and explore the need for an epinephrine pen.

How do I treat or prevent a food allergy?

There really is no medical therapy that can prevent or treat food allergies. Avoidance is the only way. But there are some new options and ideas for prevention of food allergies. Several children’s hospitals in the Midwest have peanut desensitization programs. I have a handful of patients that have enrolled and had successful results.

Do children grow out of food allergies?

The good news is, yes! Most kids outgrow these allergies. Nearly 80% of the egg, milk, soy and wheat allergies are gone by 5 years old. Peanut allergies are more persistent and those children have more severe reactions. Only 20% will outgrow their allergy.

How should I introduce these foods to my infant?

The new guidelines by the American Academy of Pediatrics recommend introducing foods by 4-6 months. New research confirms early introduction to the most common allergy causing foods, by 4-6 months, is helpful in actually reducing the risk of allergies to those foods. So, don’t wait!

There is no medical evidence that introducing foods in any particular order is an advantage to your infant. However, over the years I’ve used the same schedule and had good results:

First, introduce single-grain cereals. Use boxed rice, oat and then barley cereal. (Though, in my experience, most infants don’t like barley.) Put the cereal in a bowl and make it thin like ketchup by mixing it with breast milk or formula. Feed it to the child with a spoon. Never give the cereal in a bottle unless, your provider recommends it for reflux. Start it at breakfast for three days. If you don’t notice a rash, vomiting or diarrhea, then you can give it at dinner, too. Gradually increase the amount and thickness. Now you know your infant can tolerate this food, and it is time to try another one. Move on to oat cereal for three days. Note: Never give food before bedtime. It does not help your baby sleep through the night.

After the 3 days of giving rice and 3 days of giving oat cereal, it’s time to start green vegetables (which most babies don’t like), followed by yellow/orange (which they usually like).

Next, introduce fruits (which they really like), and finally meats. I do not recommend baby meats (the ones you buy in a jar). I recommend you give your infant all the meats that you eat – ground beef, ground turkey, chicken and deli meats. Avoid hot dogs or meat sticks, as they are a choking risk hazard. If you can squish the puréed or soft food that you eat between two fingers, your infant can gum it. No teeth needed!

Start with the new food at lunchtime. After three days, if there are no reactions, you can give that food at dinner or any time, even with a new food. Below is a good schedule for you to follow:

Sample Schedule

Beginning at 4 to 4.5 months

Give these foods at lunchtime, if possible. It’s better to know if your infant will have a reaction in the afternoon as opposed to the evening.

Day 1: Green vegetable 1 (i.e. peas)
Day 2: Green vegetable 1 (Same vegetable as day 1)
Day 3: Green vegetable 1 (Same vegetable as day 1)
If no reactions, start giving peas at dinnertime.

Start new food
Day 4: Green vegetable 2 (i.e. broccoli)
Day 5: Green vegetable 2 (Same vegetable as day 4)
Day 6: Green vegetable 2(Same vegetable as day 4)
If no reactions, give it at dinner with/without peas

Start new food
Day 7: Green vegetable 3 (i.e. green beans)
Day 8: (Same vegetable as day 7)
Day 9: (Same vegetable as day 7)
If no reaction, give at dinner with/without peas, broccoli

Start new food
Day 10: Yellow/orange vegetable (i.e. carrots)
Day 11: Yellow/orange vegetable (same as day 10)
Day 12: Yellow/orange vegetable (same as day 10)
If no reaction, give at dinner with/without green vegetables

Start new food
Day 13, 14, 15: Yellow/orange vegetable (example squash)
If no reaction, give at dinner with/without any of the above

Start new food
Day 16,17,18: Yellow/orange vegetable (sweet potatoes)
If no reaction, give at dinner with/without any of the above

Start new food
Day 19, 20, 21: Fruit (banana)
If no reaction, give at breakfast with cereal and dinner with/without any of the above

Start new food
Day 22, 23, 24: Fruit (pears)
If no reaction, give at breakfast with cereal and dinner with/without any of the above

Start new food
Day 25, 26, 27: Fruit (peaches)

If no reaction, give at breakfast with cereal and dinner with/without any of the above

After 27 days and no food reactions we are almost ready to start ... peanut butter. That’s right! However, do not start peanut butter without discussing with your provider first. They will look for risk factors for an allergic reaction. Some infants may need to undergo testing first.

Learn more

If you have questions or concerns, always be sure to contact your primary care provider or pediatrician. For more information on food allergies, visit foodallergy.org.

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