Food Allergy Resources

AAP Retracts Previous Diet Recommendations for Mothers and Children

April 2008

Food for Thought: Preventing Food Allergies

By Beth Puliti

In a move that surprised families of food-allergic children and the medical providers who care for them, the American Academy of Pediatrics (AAP) started the New Year off with new feeding guidelines that reversed prior recommendations.

Earlier restrictions on moms' and babies' diets from the 2000 AAP guidelines—namely avoiding select foods during pregnancy, using soy formula or postponing solid foods beyond six months—were revised and replaced with updated advice. In fact, the only unaffected suggestion was to continue breastfeeding, as it aids in the prevention of allergies.

As expected, the new policy statement has "generated much interest among families of food allergic children and medical providers," mainly because key areas of the policy depart from previous recommendations that offered stricter guidelines when introducing allergenic foods, said Todd D Green, M.D., assistant professor of Pediatrics, Allergy and Immunology at the Children's Hospital of Pittsburgh.

In 2000, the AAP's feeding guidelines recommended that breastfeeding mothers of infants at high risk for developing allergy should avoid cow's milk, egg, fish, peanuts and tree nuts. If they couldn't breastfeed, it was recommended they use a hypoallergenic formula as an alternative to breastfeeding. Parents were also instructed that solid foods should not be introduced into the diet of high-risk infants until 6 months of age, with dairy products deferred until 1 year, eggs until 2 years, and peanuts, nuts and fish until 3 years of age.

These recommendations from 2000 understandably triggered anxiety among pregnant and breastfeeding mothers. Parents also felt guilty when children developed allergies despite their efforts to keep risky food at bay by avoiding the recommended foods.

New Recommendations For "At-risk" Children

The AAP policy released in January was written after finding that delaying the introduction of solid foods as previously recommended did not lead to fewer food allergies among children at risk for developing allergies based on family history.

"This new policy allows parents not to feel guilty because there is just not enough evidence to support avoidance as a preventive measure," explained Roger Friedman, M.D., clinical professor of Allergy, Immunology, and Pediatrics at Nationwide Children's Hospital in Columbus, Ohio. "This doesn't mean you shouldn't avoid certain foods if advised by your child's physician; it just means that there isn't a reason to recommend it universally."

The new guidelines only recommend that solid foods not be introduced before 4 to 6 months. It also suggests that there is too little evidence to support that diet manipulation among pregnant or breastfeeding moms can cause or prevent a child's allergy.

The policy addresses the following major points.

1. There is not enough evidence that maternal dietary restrictions during pregnancy play a significant role in preventing atopic disease in babies. An atopic condition is one that includes asthma, allergic rhinitis (also known as hay fever), food allergies or eczema. There is also a lack of evidence that avoidance of allergy-causing foods during breastfeeding prevents atopic disease, with the possible exception of eczema, but more data is needed on this.
   
   
2. For high-risk babies (those with parents or sibling that has any allergic disease), there is evidence that exclusive breastfeeding for at least four months in comparison to intact cow's milk-based formulas (such as Similac® or Enfamil®) decreases incidence of eczema and cow's milk allergy in the first two years of life.
   
   
3. There is evidence that exclusive breastfeeding for at least 3 months protects against wheezing in early life, but an effect on the prevention of asthma in children greater than 6 years is not convincing.
   
   
4. For high-risk infants (those with parent or sibling with allergic disease) who are not breastfed, there is modest evidence that eczema may be delayed or prevented by the use of extensively hydrolyzed formulas (such as Alimentum®, Nutramigen® or Pregestimil®) or partially hydrolyzed formulas (for example, Good Start® is partially hydrolyzed whey; Gentlease® is partially hydrolyzed casein) in comparison to cow's milk-based intact formulas. Extensively hydrolyzed formulas may be more effective in the prevention of atopic disease. More research is needed to see if these benefits extend into later childhood and adolescence. The use of amino acid-based formulas (such as Neocate® or Elecare®) has not been studied for the prevention of allergic disease.
   
   
5. There is NO evidence for the use of soy for the prevention of allergy.
   
   
6. Solid foods should not be introduced before 4 to 6 months. Delaying the introduction of solids past 6 months shows no evidence of a protective benefit—regardless of type of formula used or breastfeeding. This includes solids that are thought to be highly allergenic.
   
   
7. After 4 to 6 months of age, there is not enough data to support dietary intervention (restriction).
   
   
8. More studies are needed to document long-term effects of dietary restrictions to prevent atopic disease—especially in children older than four, and adults.

For Babies and Children with an Allergic Disease

It is important to note that the information in the new policy does NOT apply to babies and children who already have an atopic disease (including eczema and asthma). It is meant to provide guidelines for children who are not yet diagnosed with an atopic disorder. Therefore, the term "high risk" refers to any child with a parent or sibling who has an allergic condition, not the child himself.

For Breastfed Babies

Unfortunately, the new policy also does not address breastfeeding babies who react because they are already atopic. For those who already have an atopic child, these recommendations will apply to any future children as they would be considered high risk.

While the recommendations do not address the entire food allergy population, the current shortage of good data is understandable, Dr. Green noted.

"These are difficult studies to perform, requiring many families willing to go to great efforts over long periods of time," he explained, and underscored the strengths of the report—specifically its acknowledgement of the complication of preventing food allergies.

"It acknowledges the need for more evidence while emphasizing what we do know. And hopefully it will serve to spur more interest and research in this area," he said.

For more information on the AAP's new infant feeding guidelines, please visit: www.aap.org.

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