CME review article

This feature is supported by an unrestricted educational grant from AstraZeneca LP

Food allergy and the introduction of solid foods

to infants: a consensus document
Alessandro Fiocchi, MD*; Amal Assa’ad, MD†; and Sami Bahna, MD‡; for the Adverse Reactions to
Foods Committee of the American College of Allergy, Asthma and Immunology§

Objective: To make recommendations based on a critical review of the evidence for the timing of the introduction of solid
foods and its possible role in the development of food allergy.
Data Sources: MEDLINE searches using the following search algorithm: [weaning AND infant AND allergy]/[food allergy
AND sensitization]/[dietary prevention AND food allergy OR allergens]/[Jan 1980-Feb 2006].
Study Selection: Using the authors’ clinical experience and research expertise, 52 studies were retrieved that satisfied the
following conditions: English language, journal impact factor above 1 or scientific society, expert, or institutional publication,
and appraisable using the World Health Organization categories of evidence.
Results: Available information suggests that early introduction can increase the risk of food allergy, that avoidance of solids
can prevent the development of specific food allergies, that some foods are more allergenic than others, and that some food
allergies are more persistent than others.
Conclusions: Pediatricians and allergists should cautiously individualize the introduction of solids into the infants’ diet. With
assessed risk of allergy, the optimal age for the introduction of selected supplemental foods should be 6 months, dairy products
12 months, hen’s egg 24 months, and peanut, tree nuts, fish, and seafood at least 36 months. For all infants, complementary
feeding can be introduced from the sixth month, and egg, peanut, tree nuts, fish, and seafood introduction require caution. Foods
should be introduced one at a time in small amounts. Mixed foods containing various food allergens should not be given unless
tolerance to every ingredient has been assessed.
Ann Allergy Asthma Immunol. 2006;97:10–21.

Off-label disclosure: Drs Fiocchi, Assa’ad, and Bahna have indicated that this article does not include the discussion of unapproved/investigative use of a
commercial product/device.
Financial disclosure: Drs Fiocchi, Assa’ad, and Bahna have indicated that in the last 12 months they have not had any financial relationship, affiliation, or
arrangement with any corporate sponsors or commercial entities that provide financial support, education grants, honoraria, or research support or
involvement as a consultant, speaker’s bureau member, or major stock shareholder whose products are prominently featured either in this article or with the
groups who provide general financial support for this CME program.
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INTRODUCTION plementary foods for the primary prevention of allergic dis-

Whereas parents and pediatricians can be in no doubt regard- ease in at-risk infants,1,2 the same degree of confidence
ing the avoidance of cow’s milk and dairy products as com- cannot be shared regarding the introduction of the child to a
solid diet, for which no evidence- or consensus-based guid-
* University of Milan Medical School, Milan, Italy. ance is available. To compound the problem, there is no
† Division of Allergy and Immunology, Cincinnati Children’s Hospital Med- standard schedule for weaning infants who are healthy or at
ical Center, Cincinnati, Ohio. risk for allergy. According to The Concise Oxford Dictionary,3
‡ Allergy and Immunology Section, Louisiana State University Health Sci-
ences Center, Shreveport, Louisiana. weaning is defined as follows: “To accustom an infant or other
§ The members of the Adverse Reactions to Foods Committee are Staffan young mammal to food other than milk.” The World Health
Ahlstedt, Mercedes Amado, Wesley Burks, William Hark, Sherry Hubbard, Organization (WHO)4 gives the term weaning a more restricted
Luis Matos, Jennifer Maloney, Binita Mandal, Michael Norvell, James
Pollowitz, Mary Catherine Tobin, Diane Wagner, and Brian Wilson.
sense to indicate the complete cessation of breastfeeding, but the
Received for publication May 1, 2006. phrase “introduction of complementary feeding” is increasingly
Accepted for publication in revised form June 12, 2006. used. This describes the process starting when breast milk alone

10 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ceases to meet the infant’s nutritional requirements and when and pasteurized milk are deemed acceptable starting at the age of
other foods and liquids are needed along with, or in lieu of, 12 months.
breast milk.5 The introduction of solid foods, however defined, The UK Department of Health has issued qualified advice
remains linked to breastfeeding duration and is also determined for the weaning diet18: “The majority of infants should not be
by adverse reactions. This may explain why “the introduction of given solid food before 4 months,” “cow’s milk should not be
solid foods” is not an optimal end point for the focus of research. used as a main drink before one year,” and “first weaning
In the present consensus document, we aim to provide literature- foods should be nonwheat cereals and pureed fruit and veg-
based recommendations on the introduction of solid foods to etables.” HealthCanada has published nutritional guidelines
infants’ diets as relates to the development of allergy. For this for healthy infants from birth to the second year of life.19
purpose, a MEDLINE search was performed using the following These recommendations provide information on, among
search algorithm: [weaning and infant and allergy]/[food allergy other topics, the transition to solid foods. A joint document
and sensitization]/[dietary prevention and food allergy or aller-
from several government agencies and scientific societies,
gens]/[January 1980 –February 2006].
this statement represents a consensus view based (whenever
INTRODUCTION OF SOLID FOODS possible) on scientific evidence. Throughout, the Canadian
The American Academy of Pediatrics (AAP) recommends recommendations strive to distinguish between evidence-
exclusive breastfeeding for at least 6 month, followed by the based and lay-practice advice.20
gradual introduction of solid foods in the second half of the In the United States, the AAP recommendations for infants
first year and continued breastfeeding for up to 12 months or and young children have remained substantially unchanged
as long as is mutually desired thereafter.6 Similar indications during the past 4 decades. Exclusive breastfeeding for the
are recommended by UNICEF,7 and the WHO Expert Con- first 4 to 6 months of life, the introduction of solid foods at 4
sultation recommends exclusive breastfeeding for 6 months, to 6 months of age, the desirability of prolonging nursing to
followed by the introduction of complementary foods while the first birthday and beyond, and infant formula use during
breastfeeding is continued.8 –10 An evidence-based consensus the first year of life for infants who are not breastfed remain
has been reached that 6 months of exclusive breastfeeding is the backbone of this regimen.21 The AAP recommends intro-
optimal for infant and mother health,11 but few controlled ducing single-ingredient complementary foods one at a time
trials support the view that introducing solid foods before 17 during a trial lasting several days.22 All these documents, and
weeks of age is harmful in developed countries,12 and the the European Academy of Allergy and Clinical Immunology
main perceived risk is that the early introduction of comple- and AAP consensus-based guidelines regarding weaning in
mentary foods may shorten breastfeeding duration.13 A large allergic children,23,24 state that the early introduction of solid
systematic review14 did not find evidence either in support of foods can be associated with the induction of food allergy.
or against a departure from the WHO recommendations. In
developed countries, it has been hypothesized recently that
energy requirements are not fulfilled by exclusive breastfeed- WHICH SOLID FOODS? FACTORS RELEVANT TO
ing, suggesting that the introduction of complementary feed- INTRODUCTION
ing may be necessary before 6 months of age.15 After 6 The rationale for the timing of the introduction of solid foods
months of age, however, there is general agreement that it should be based on 4 main considerations: (1) the selected foods
becomes increasingly difficult for breastfed infants to meet should provide sufficient energy, protein, and micronutrients in
all their nutritional needs from human milk alone,4 and most balanced and appropriate-for-age supply to meet the child’s
infants are by then developmentally ready for other foods.16 growing nutritional needs (nutritional); (2) foods should be hy-
gienically stored and prepared (toxicologic); (3) foods should be
INTRODUCTION OF INDIVIDUAL FOODS supplied in response to the child’s signals of appetite and satiety
Cultural approaches to food in general (and to baby feeding in and should be compatible with and promote the development of
particular) are the main obstacles against listing suitable solid specific developmental stages vis-à-vis food and feeding skills
foods in an introduction schedule acceptable to all families, even (behavioral); and (4) foods should be appropriate for current
in the social context of a single nation. Dietary Guidelines for immune development by avoiding exposure of the child to an
Children and Adolescents in Australia17 recommends “puréed
increased likelihood of sensitization with known allergenic
foods” at 6 to 7 months of age, eg, gluten-free cereals (such as
foods (immunoallergologic).
rice) as start-up foods, followed by vegetable (eg, carrot) and
fruit (eg, apple and banana) purées, mashed potatoes, and well- Whereas nutritional and toxicologic considerations may be
cooked puréed liver and meat. Well-cooked fish, minced liver more relevant to the developing world and behavioral con-
and meat, and mashed cooked vegetables and fruit are suggested siderations are compatible with current parenting and wean-
for 8- to 12-month-old children. Raw fruit and vegetables, such ing skills in developed countries, we focus herein on immu-
as banana, melon, and tomato in chopped form, are considered noallergologic considerations in the belief that the timing of
suitable at this age, as are egg yolk, cereals such as wheat and the introduction of complementary feeding should be predi-
oats, bread, pasta, cheese, custard, and yogurt. Other table foods cated mainly on immunoallergologic considerations.

VOLUME 97, JULY, 2006 11

IMMUNOLOGIC ASPECTS OF THE of the fact that it is impossible to exclude that the parents of
INTRODUCTION OF SOLID FOODS infants without early onset of allergic disease may have
In the course of evolution, environmental pressure has selected followed the delayed introduction advice for other reasons,
for a mucosal immune system capable of sophisticated adaptive such as a family history of disease or socioeconomic factors,
responses to handle these challenges. Oral tolerance is a com- these methods seem open to criticism. Similar considerations
plex phenomenon25,26 and basically depends on apoptosis when may be applied to other noninterventional studies.35
intestinal antigen exposure is excessive and on anergy and A good example of the effects of the introduction of solid
induction of immune deviation at lower antigen doses.27 Thus, foods early in life is sesame allergy. In Israel, food allergy
from a theoretical point of view, overexposure to food allergens prevalence was found to be 1.7%, with sesame as the third most
and avoidance of exposure during vulnerable periods can result common food causing sensitization after egg and cow’s milk.
in tolerance. The best strategy depends on the answers to 4 Furthermore, sesame was second only to cow’s milk as a leading
crucial questions: (1) Can the early introduction of solid foods cause of anaphylaxis. This may be due to the increasing use of
cause food allergy? (2) Can the avoidance of solid foods prevent sesame-containing products among infants in Israel, suggesting
the development of food allergy? (3) Are some foods more that food allergy “is a matter of geography after all.”36
allergenic than others? (4) Are some food allergies more persis-
tent than others? In this review, we propose that the rationale for DOES THE DELAYED INTRODUCTION OF SOLID
the scheduled introduction of solid foods be based on the issues FOODS PREVENT THE DEVELOPMENT OF FOOD
that these questions raise. ALLERGY?
Since the 1980s, prophylaxis of atopic disease has been
DOES THE EARLY INTRODUCTION OF SOLID attempted by intervention in the form of specific food item
FOODS CAUSE FOOD ALLERGY? elimination from the early diet. In a study37 that reported on
Noninterventional studies have found that the introduction of the effects of late vs early introduction of fish and lemon on
solid foods before the fourth month of life increases the risk of allergic sensitization, at 3 years of follow-up, data showed
developing atopic dermatitis until the age of 10 years.28 Cow’s that late exposure to solid foods can postpone but not prevent
milk formula supplementation before milk letdown has also allergy to these foods. The results of another study38 suggest
been linked to the development of cow’s milk allergy.29 that total solid food elimination for the first 6 months of life
To evaluate the relationship between the early introduction is prophylactic in children at risk for atopy by family history.
of solid foods and infant health during the first 2 years of life, In a case-controlled epidemiologic study,39 the early intro-
a prospective observational study30 evaluated the effect of duction of cereals has been associated with grass-triggered
different timing of the introduction of foods on weight, gas- asthma, a conclusion that needs confirmation owing to the
trointestinal diseases, respiratory illness, nappy rash, and retrospective data presented.
eczema up to 24 months of age. Infants given solid foods at Many prospective studies have addressed the possibility of
an early age (⬍8 vs 8 –12 weeks) showed a significant food allergy prevention by dietary intervention. Clinical re-
increase in respiratory illness at 14 to 26 weeks of age and search from Canada,40 – 42 Belgium,43,44 the United States,45,46
persistent cough at 14 to 26 and 27 to 39 weeks of age. The England,47– 49 Sweden,50,51 Denmark,52 and Germany53 sug-
incidence of eczema was also increased in infants who re- gests that the avoidance of cow’s milk proteins can reduce
ceived solid foods at 8 to 12 weeks of age.30 However, the sensitization to milk. Recent systematic review of this evi-
magnitude of these differences was not high, and the authors dence indicates that dietary prevention of allergy by avoid-
recommend “a more relaxed approach to early feeding.” ance of food allergens in early life is effective.1,54,55
A prospective, randomized, well-controlled study31 of pre-
term infants followed up to 18 months of age and a prospec- WHICH FOODS ARE “ALLERGENIC”?
tive study32 of unselected full-term infants followed up to the “The ability of a given food to elicit specific IgE sensitization
age of 17 years concurred that introducing solid foods after 6 and to cause allergic reactions in a given population” varies
months of exclusive breastfeeding lowered asthma and ec- according to the characteristics of the food and of the population
zema risks later in childhood. Conversely, the late introduc- in which it is consumed.56 Data from European surveys57,58
tion of egg has been reported to increase the risk of atopic indicate that the most allergenic solid foods are egg, fish, sea-
eczema and wheezing in preschoolers in a cohort of prospec- food, peanut, soybean, and tree nuts. In the Swedish adult
tively selected infants.33 However, because of the retrospec- population, among patients reporting symptoms of “food intol-
tive evaluation of this particular item, the authors’ conclusion erance,” 26% developed elevated IgE levels in response to egg
that “. . . results do not support the guidelines for the preven- white, peanut, soybean, milk, fish, and wheat.59 In France, the
tion of asthma and allergy in general populations, stating that most frequent allergenic foods are fruits from the Rosaceae
the introduction of solids should be delayed for at least 4 – 6 family (apple, cherry, and peach; 14%), followed by vegetables
months” does not exclude reverse causality as the result of (9%); milk (8%); crustaceans (8%); shellfish (7%); the latex–
design bias. In a different birth cohort study of 2,612 two- cross-reactive avocado, kiwifruit, banana, and chestnut (5%);
year-olds, reverse causation was excluded by stratifying the hen’s egg (4%); tree nuts (3%); and peanut (1%).60 In a study of
sample for symptom onset before 6 months of age.34 In view Danish 3-year-olds, 0.6% reacted to cow’s milk, 1.6% to hen’s

12 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

egg, and 0.2% to peanut.61 In Germany, foods often implicated proteins cannot be recommended on the basis of cross-reac-
in food allergy include nuts and fruits (77.6%), vegetables tivity, which is considered low between Leguminosae.90
(54.4%), wheat flour (14.9%), milk (4.5%), and egg (2.9%).62 It Tree Nuts
has been reported that shellfish constitutes the primary cause of
Allergic reactions to tree nuts can be life threatening. Some nut
food allergy in adults in some areas of the United States.63
allergens have been identified and characterized, and some of
Consequently, the implicated foods have been designated for
their IgE-reactive epitopes have been described.91,92 Allergens
explicit labeling in the case of processed food products.64 – 66 In
such as lipid transfer proteins, profilins, and members of the Bet
this section, we focus first on the foods that trigger the more
v 1–related family are considered panallergens. Others, such as
severe reactions and then continue to the foods that are likely to
legumins, vicilins, and 2S albumins, represent major seed stor-
cause persistent allergies. age protein constituents of the nuts.93 Cross-reactions frequently
Hen’s Egg occur among hazelnut, walnut, cashew, almond, chestnut, Brazil
Exquisitely small amounts of egg allergen have been reported nut, pine nut, macadamia nut, and pistachio nut (and even
to trigger reactions after inhalation in adults67,68 and chil- coconut). Thus, avoidance of all kernels is recommended to
dren.69,70 Patients allergic to egg can experience reactions to patients responsive to a single nut.94 The roasting of hazelnuts
fowl. Chicken serum albumin (␣-livetin) has been implicated may reduce their allergenicity.95
in the bird-egg syndrome. However, IgE reactivity to chicken Seafood
albumin was reduced by 88% after heating at 90°C for 30 The causes of seafood allergenicity are of a chemicophysical
minutes.71 Thus, it seems that homogenized, rather than fresh, nature. Codfish includes one of the most heat-stable major
poultry products should be preferred in introducing the infant allergens, Gad c 1, which not only withstands cooking but
to these nutritionally useful animal proteins. also becomes airborne in steam without undergoing denatur-
Peanut ation.96 It is also resistant to chemical detergents97 and is
Peanut allergy has increased in prevalence,72–74 but the mag- minimally affected by various cooking methods when protein
nitude of the rise remains to be ascertained.75 Whether this is bands at sodium dodecyl sulfate–polyacrylamide gel electro-
linked to increased peanut consumption, ubiquitous peanut- phoresis are compared with raw and cooked codfish.98 The
containing nonfood products,76,77 consuming peanuts while major allergens responsible for cross-reactivity among dis-
breastfeeding,78 or other factors is also unclear. An intriguing tinct species of fish and amphibians are parvalbumins, and
observation is that peanut allergy is rare in China,79 where the major shellfish allergen has been identified as tropomy-
consumption of the legume is not different from that in the osin.99 These allergens are responsible for cross-reactions
United States. Although the frequency of atopic disease is between mites and snails100,101 and among insects, shrimps,
generally lower in China, preparation methods differ. In and cockroaches.102 In the literature, reports of extensive
China, peanut is boiled or fried, whereas it is dry roasted in clinical cross-reactivity between fish species are common.103
the United States. Roasting seems to enhance the allergenic- Fresh Fruits and Vegetables
ity of peanut.80,81 Another relatively thermostable allergen Plant food panallergens are so sensitive to heat that they
belonging to the Leguminosae family is soybean. Its behavior cannot be reliably preserved in reagents for skin testing.104
can be modified by technological treatments,82 but the effects For this reason, they are conceived of as a nonoffending food
of cooking on these proteins are not uniformly interpreted.83,84 and are, therefore, introduced early in the weaning process.
One study85 found remarkably thermostable antigenicity us- However, early exposure may result in allergy, and reactions
ing home technology, with cooking at 100°C for 2 hours to kiwifruit are increasing with its popularity among chil-
decreasing IgE binding to soy proteins, whereas cooking at dren.105 A heat-treated homogenized kiwifruit preparation
80°C to 120°C for 60 minutes did not. In another study, was tolerated by children with challenge-confirmed allergy to
however, cooking at 80°C to 120°C for 60 minutes decreased fresh kiwifruit.106 Industrial treatment in this case may be
IgE binding.86 To our knowledge, no in vivo study has eval- sufficient but perhaps not necessary, given the lability of fruit
uated the effects of cooking soy proteins, and neither have allergens, to destroy kiwifruit allergenicity.
large studies been performed on soybean proteins. Soy hy- Cross-reactivities between different types of fruits may be
drolysates have had the same scant attention.87 Legumes different in children and adults.107–109 Despite this possibility,
exhibit an extensive degree of cross-sensitization, which does patients allergic to raw fruits and vegetables do not generally
not always translate into clinical reactivity. Up to 94% of skin react to the cooked food. The fact that some vegetables (such
prick tests have yielded false-positive results for soybean,88,89 as potatoes) are always consumed cooked can account for
and sensitization to carob seeds does not translate to cross- this, despite the known allergenicity of solanaceous pro-
reactivity in children allergic to peanut.90 These observations teins.110,111 A notable exception to the suitability of cooked
have important clinical correlates; for example, carob may be greens is celery. This plant (in both its root vegetable and
acceptable as an additive in processed foods, antiregurgita- aerial stem varieties) retained its allergenicity after cooking at
tion formulas, and weaning formulas because avoidance of its 110°C for 15 minutes.112

VOLUME 97, JULY, 2006 13

Cereals with prognosis of food allergy, although these associations are
A Western diet staple, wheat, is responsible for causing food not consistent among studies.135–137
allergies in children and has been linked to food-dependent, To indicate the persistence of food allergies to solid foods,
exercise-induced anaphylaxis in recent years.113 Sensitization an estimate of the persistence of allergies can be drawn from
patterns show a great degree of individual variation, and the the duration of food allergy. For example, 50% of children
presence of IgE to purified ␻-5 gliadin in children was highly lose their cow’s milk allergy by 1 year of age.138 In a limited
predictive of immediate clinical symptoms on oral wheat sample of children with egg allergy (median age, 17 months),
challenge in one study.114 Most of these allergens seem to be tolerance reached 44% of cases at 21⁄2 years of age.139 Other
heat stable, and most symptoms can be related to the inges- studies found that 31% to 51% of children allergic to egg
tion of bakery products. Thus, it seems that the relatively long overcame the problem.140 However, it is difficult to compare
baking time and high temperature do not suppress the aller- the results of earlier studies because of widely varying study
genicity of wheat proteins.115 Because celiac disease is far designs. A more recent study141 found persistence of egg
more frequent than wheat allergy, at least in certain countries, allergy in 50% of the patients at 35 months of follow-up. This
the timing of the introduction of wheat is generally more means that half the children allergic to egg will tolerate the
often dictated by the latter than the former.116 In Western food when they are 4 to 41⁄2 years old.141 The proportion of
countries, the frequency of allergic reactions to rice does not tolerant children was 66% after 5 years. Thus, egg allergy
reach 1% of atopic patients,117,118 and anaphylaxis to rice in persistence should be considered 3 times greater than cow’s
children has been described only occasionally.119,120 In con- milk allergy persistence.
trast, rice is an important allergen in Asia, where a hypoal- Peanut allergy was once considered to be a lifelong condi-
lergenic rice has been marketed with clinical success.121 tion,142 but peanut-allergic infants sometimes outgrow their al-
lergy.143–146 Taking the results of the various studies together, it
Meat seems that approximately 20% of young children outgrow pea-
Beef represents a special case in that exposure to bovine nut allergy.147 In rare cases, patients may become susceptible
serum albumin, the major beef allergen, is more likely to have again to these allergens, but further studies are needed to clarify
occurred before the introduction of solid foods through milk this point.148,149 Thus, it is not possible to establish an average
supplementation. Cooking can alter the reactivity of beef,122 duration of peanut allergy. Similarly, fish allergy is usually a
and homogenized and freeze-dried beef baby food prepara- long-lasting condition, and reports of recovery are rare,150 with
tions lose their ability to elicit a positive skin prick test possible resensitization.151 However, no study has evaluated the
reaction.123,124 In children allergic to beef, lamb and turkey natural history of fish allergy in infants, and fish should also be
have been proposed as substitute sources of animal protein,125 regarded as causing persistent allergies.
but little is known about their allergenicity. Lamb is not as Whereas it is known that peanut, tree nut, fish, and seafood
hypoallergenic as is often believed, as bovine and ovine allergies are mostly persistent conditions, little is known about
serum albumins share 552 of their 607 amino acid sequenc- the natural history of allergy to staples such as fruits, vegetables,
es126,127 and are close enough biochemical relatives for cross- cereals, and meat. Because young children with milk (or egg)
reactivity, as demonstrated by means of serologic analysis in allergy likely have other food allergies, it is often recommended
beef-allergic children.128 that major food allergens, such as peanuts, tree nuts, fish, and
These and other data indicate a wide cross-sensitization shellfish, be avoided until the child is at least 3 years of age.53
potential between the meats of different and related animal Although this recommendation seems reasonable, there is no
species. Tropomyosin129 and bovine IgG130 have also been evidence to demonstrate that an avoidance strategy will be
indicated as cross-reactive allergens in patients allergic to successful in preventing future allergy.
beef and other meats. The use of alternative meats in beef- An important observation is that older children152 and
allergic children, therefore, must be carefully evaluated for adults153 lose their reactivity to foods if the responsible food
the individual patient, and no meat should be presumed to be allergen is identified and strictly eliminated from the diet.154
“hypoallergenic.” Well-cooked beef131 can be recommended Relevantly, the severity of the initial reaction does not seem
in weaning for its reduced allergenicity. to correlate with the likelihood of clinical reactivity loss, but
the degree of compliance with the allergen avoidance diet and
the food responsible for the reaction affect the outcome.
WHICH FOOD ALLERGIES ARE LIKELY TO BE Thus, it seems a good precaution to introduce weaning foods
MORE PERSISTENT? later during infancy in children at risk of persistent allergy.
In designing a solid food introduction diet for the infant, not only
should the risk of sensitization to any food be taken into account, OPTIMAL TIMING OF SOLID FOODS
but the risk of developing persistent allergies should be evalu- Although it would be difficult to propose an optimal feeding
ated on a case-by-case basis. In general, there is a relationship schedule for infants in general, studies measuring the effect
between symptom severity after ingestion and the likelihood of of dietary intervention in children at risk of food allergy may
outgrowing the problem.132,133 Other factors, such as specific IgE circumstantially provide practical suggestions. Two issues
antibody level and age at diagnosis,134 have also been associated should be considered in introducing individual foods: (1)

14 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

avoiding interference with any prescribed dietary interven- Table 2. Timing of the Introduction of Foods in Children at Risk for
tion, such as special formula, and (2) evaluating the effects of Allergy
delayed solid food introduction on allergic sensitization and Age at introduction, mo
atopic disease. The definition of allergy risk, however, was Recommendation
AAP24 ESPACI-ESPGHAN25
not universal in all the studies. Some studies considered as “at
risk” children with atopic parent(s) or relatives, whereas Breastfeeding ⱕ12 ⱕ4–6
others used predictors such as cord blood IgE levels and Solid foods ⱖ6 ⱖ5
specific questionnaires (Table 1). Hypoallergenic diet 6 NA
Dairy products 12 NA
In all these studies, schedules recommend the introduction
Egg 24 NA
of solid foods between the ages of 4 and 6 months for at-risk Peanut, tree nuts 36 NA
children (similar to that for children who are not candidates Fish 36 NA
for intervention). The timing of the introduction of specific
foods varies widely, but most researchers consider it prudent Abbreviations: AAP, American Academy of Pediatrics; ESPACI-ES-
PGHAN, European Society of Pediatric Allergy and Clinical Immu-
to introduce hen’s eggs between 9 and 12 months of age and
nology–European Society of Pediatric Gastroenterology, Hepatology,
fish, peanut, and nuts after the age of 12 months. However, and Nutrition; NA, not applicable.
such recommendations are not evidence based. The effect of
the late introduction of solid foods on sensitization is not
reported for specific foods. EVIDENCE-BASED TIMING OF THE
The 2000 AAP Committee on Nutrition23 and the 1999 Eu- INTRODUCTION OF SOLID FOODS
ropean Society of Pediatric Allergy and Clinical Immunology Currently, evidence as to an optimal time for the introduction
together with the European Society of Pediatric Gastroenterol- of any individual solid food in the infant’s diet is lacking, and
ogy, Hepatology, and Nutrition (ESPACI-ESPGHAN)24 recom- it may be better to think in terms of individual schedules
mendations for the prevention of food allergy concur that solid toward which broad categories of patients may be addressed
foods should be introduced between 5 and 6 months of age in on an experimental basis. This would also be in keeping with
infants with a family history of allergy (Table 2). The guidelines the etymologic meaning of the verb to wean (from Old
differ only in that the AAP specifies several solid food classes English wenian, to accustom3). Optimizing introduction
and the ESPACI-ESPGHAN document indicates optimal breast- schedules characterizes the allergist’s earliest intervention to
feeding duration and avoidance of generic supplementary food influence the process of tolerance induction beyond milk and
before the fifth month of life. The American College of Allergy, dairy products. Because this is geared toward reducing the
Asthma and Immunology food allergy 2006 practice parame- incidence or delaying the onset of allergic symptoms, this
ter155 recommends “avoidance of solids at a young age” for area is in need of practice guidelines based on special epide-
primary prevention of food allergy. miologic and clinical studies.

Table 1. Evaluation of Allergic Risk and Timing of the Introduction of Solid Foods and Single Specific Foods in Studies on the Prevention of
Food Allergy
Age introduced, mo
Source Risk factor for atopy Specific IgE
Solids Egg Nuts Fish
Chandra et al 40
ⱖ1 first-degree relative Yes NA NA NA NA
Chandra et al41 ⱖ1 first-degree relative Yes ⬎6 18 36 18
Vandenplas et al43 ⱖ2 first-degree relatives No (yes to egg on 5th day) ⬎4 (apple) ⬎6 NA ⬎6
Zeiger et al45 1 parent (SPT/RAST) Yes ⬎6 24 24 24
Zeiger et al46 ⱖ1 parent No ⬎6 24 36 36
Arshad et al47 2 first-degree relatives or 1 first-degree relative Yes ? (wheat 10 mo) 11 ⬎12 ⬎12
and CB IgE ⬎0.5 kU/L
Hide et al48 2 first-degree relatives or 1 first-degree relative Yes ? ⬎9 ⬎9 ⬎9
and CB IgE ⬎0.5 kU/L
Hide et al49 2 first-degree relatives or 1 first-degree relative Yes ? ⬎9 ⬎9 ⬎9
and CB IgE ⬎0.5 kU/L
Oldaeus et al51 2 first-degree relatives or 1 first-degree relative Yes ⬎4 ⬎12 ? ⬎12
and CB IgE ⬎0.5 kU/L
Halken et al52 Both parents or 1 first-degree relative and CB IgE Yes ⬎4 ? ? ?
⬎0.5 kU/L
Von Berg et al53 1 first-degree relative with allergy according to a No Left to the mother ⬎12 ⬎12 ⬎12
questionnaire
Abbreviations: CB, cord blood; RAST, radioallergosorbent test; SPT, skin prick test.

VOLUME 97, JULY, 2006 15

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144. Zimmerman B, Urch B. Peanut allergy: children who lose the E-mail: [email protected]

Objectives: After reading this article, participants should be able to demonstrate an increased understanding of their knowledge of allergy/asthma/
immunology clinical treatment and how this new information can be applied to their own practices.
Participants: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge in the
field of allergy/asthma/immunology.
Credits: ACAAI designates each Annals CME Review Article for a maximum of 2 category 1 credits toward the AMA Physician’s Recognition Award. Each
physician should claim only those credits that he/she actually spent in the activity. The American College of Allergy, Asthma and Immunology is accredited
by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

20 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

CME Examination
1–7, Fiocchi A. 2006;97:10 –21.
CME Test Questions e. the late introduction of egg increases the risk of
atopic eczema
1. What is the optimal age of introduction of solid foods 4. All the following are subject to the Food and Drug
according to the American Academy of Pediatrics Administration allergenic foods requirements except
recommendations? a. crustacean
a. 3 months b. shellfish
b. 4 months c. celery
c. 5 months d. wheat
d. 6 months e. soybeans
e. “soon after the cessation of breastfeeding” 5. Which of the following foods can be introduced
2. Which is the optimal age of introduction of egg in freely in infants’ diets because of low allergenicity?
children at no allergic risk according to the National a. fish
Institutes of Health guidelines? b. seafood
a. 6 months c. egg
b. 8 months d. rice
c. 10 months e. none of the predicted
d. 12 months 6. Half the infants allergic to egg will tolerate the food
e. none of the above when they are
3. All of the following have been reported in noninter- a. 2 years old
ventional studies about the effects of the early intro- b. 3 years old
duction of solid foods except c. 4 years old
a. the introduction of solid foods before 4 months of d. 5 years old
age correlates with the risk of atopic dermatitis e. none of the above
b. solid foods before 1 month of age are associated 7. The average duration of fish allergy is
with perineal rash and atopic dermatitis a. 2 years
c. solid foods at an early age are associated with an b. 5 years
increased incidence of eczema c. 10 years
d. introducing solid foods after 6 months of exclu- d. lifelong
sive breastfeeding reduces asthma and eczema e. none of the above
risks later in childhood Answers found on page 77.

VOLUME 97, JULY, 2006 21