If you are the parent, grandparent or caregiver of an infant, then this is big news! After more than a decade, the American Academy of Allergy, Asthma and Immunology (AAAAI) released new infant feeding guidelines in early 2013. The new guidelines make specific, definitive, evidence-based recommendations that change how we feed babies in some big ways! 
Feeding guidelines are based on just a few concerns: the potential to cause food allergies, the risk of choking, and the physical ability of the child to safely eat food (development of head and neck control, loss of the so-called extrusion reflex, and so on).
Allergies have long been a major concern, and previous guidelines (issued in 2000) were driven by the fear of causing food allergy by introducing food too early in life. But interestingly, between 2000 and 2010, the incidence of food allergy actually increased significantly as these guidelines were implemented. As a result, scientists and allergy specialists have rewritten the recommendations based on new data about food allergies.
Here are the new recommendations:
- Exclusive breastfeeding is recommended for at least the first 4 months, preferably 6 months of life.
- If breastfeeding isn't an option, and you need to use formula, consider this: most babies do fine with regular, milk-based formulas (like Similac Advance® or Enfamil Lipil®). But, if your baby is at high risk for allergies, there may be an advantage to using a "partially hydrolyzed formula," in which the milk protein is partly broken down (such as Gerber® Good Start®, Similac Total Comfort® or Enfamil GentleEase®), for allergy prevention.
- You can begin to introduce "complementary foods" at 4 to 6 months of age.
- Begin with single-ingredient foods, usually rice or oat cereal, and introduce a new food every three to five days (to see if there is any sign of a reaction to each food).
- You can move from the rice or oat cereal to yellow/orange vegetables (like sweet potatoes, squash or carrots), fruits (like apple, pear or banana), green vegetables and finally to age-appropriate staged foods with meats.
- Once a few of these typical complementary foods have been introduced, and there are no problems, it is OK to introduce highly allergenic foods (like peanut butter, egg, soy, wheat or fish). More on this topic below.
- It is safe to give cows' milk to infants, as long as it is an ingredient in other foods (like baked goods or other dairy products, such as yogurt and cheese). You should not give whole milk to a child as a drink until 1 year of age. (Incidentally, this recommendation has nothing to do with allergy, but with other things, like iron deficiency and kidney function.)
Now some more details.
Why is it best to breastfeed exclusively, when possible, for 4 to 6 months? There are many benefits to the baby, but specifically, with regard to allergy, breastfeeding does the following:
- Decreases the incidence of atopic dermatitis (also called eczema)
- Decreases the incidence of wheezing in children younger than 4 years of age
- Decreases the incidence of cows' milk allergy
Physicians have traditionally recommended "avoidance diets" to pregnant or nursing moms if there is high risk of allergy. For example, a doctor might have suggested that a pregnant or nursing mom avoid milk to prevent a milk allergy in the baby. However, evidence now shows that avoidance diets do not work, so they are no longer recommended. The only possible exception is peanut allergy, where there is conflicting evidence. Some studies show a benefit, others actually show an increase in peanut allergy with an avoidance diet – so more research is needed on peanut allergy.
When you do introduce highly allergenic foods to your baby, it is recommended that you give the initial taste at home (rather than at day care or at a restaurant). A reaction can occur even with the first known ingestion, although there have not been any fatal reactions documented with first ingestion. If there is no reaction, you can gradually increase the amount given. Allow three to five days between new foods.
It is no longer recommended to delay the introduction of acidic fruits, like berries, tomatoes or citrus. These foods can cause redness or hives around the mouth or at other areas of skin contact, but this is not an allergic reaction. It is due to skin irritation from the acid. These fruits can be introduced with the other complementary foods at 4 to 6 months.
Although it is not addressed in the guidelines, since it is not an allergy-related issue, there is one important guideline that hasn't changed: you should never give honey to a child under one year of age due to the risk of a disease called botulism.
Finally, you should see your primary care provider, who may refer you to an allergist, if your baby has:
- Moderate to severe atopic dermatitis (eczema) despite treatment, as this could be a sign of food allergy
- An immediate allergic reaction to a particular food
- A sibling with a peanut allergy (as there is a seven percent risk of peanut allergy in each sibling)
In summary, the newly released guidelines from the AAAAI reflect a growing body of evidence that early introduction of highly allergenic foods can actually decrease the risk of food allergy. This means that we don't have to stress as much over what we give our babies to eat. Just follow the simple guidelines above and remember: breastfeed at least 4 to 6 months if you can, start introducing foods at 4 to 6 months, give a few days between new foods, avoid choking hazards, and don't give whole milk as a drink untill age 1 year. As you introduce new foods to your baby, enjoy the adventure using these updated recommendations!
Source: Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol: In Practice 2013; 1:29-36.
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