This is a picture of my daughter when she was seven months old. I buckled her into her highchair with a pile of puffs in front of her and served my 3 year old a peanut butter sandwich. Then I turned my back. It was just enough time for my baby to grab the table cloth, pull her brother’s plate across the table, and get her hands and mouth on a piece of sticky, gooey, peanut butter sandwich. She was quite pleased with herself as you can see. I posted the picture to my facebook page with the comment, “What would the AAP say?” I was actually referring to the act of leaving her unattended long enough to get her hands on a food that was a little too advanced for her and posed a choking risk. However, the comments that my friends left centered on the risks and benefits of early peanut exposure and allergies.
The literature and the AAP recommendations have gone back and forth on early exposure of infants to allergenic foods. When I was in medical school, we recommended avoidance of foods like peanuts, tree nuts and eggs. When I was in residency, the AAP formally rescinded this recommendation citing too little evidence to support it. At this point, small observational studies started to appear showing decreased rates of severe allergy with early exposure to allergenic foods but none of them were strong enough to provide a clear answer. As a result, different pediatricians were giving different advice.
Last week the New England Journal of Medicine published one of the largest studies looking at the effects of early exposure to peanuts on the development of peanut allergy. 600 babies between the ages of 4 and 11 months were enrolled in the study. All of the kids who participated in the study had either severe eczema (a skin condition associated with food allergy) or confirmed egg allergy or both, indicating a predilection for food allergies in these individuals. A small group of participants had mild hypersensitivity to peanuts at the beginning of the study. The babies were randomly assigned either to avoid peanuts entirely until they were five years old or to receive peanut products in their diets regularly until they were five years old. After five years, every child in the study was fed peanut butter and monitored for signs of allergic reaction. The results? The kids who were exposed to peanuts for the first five years of life had significantly lower rates of peanut allergy than the kids who avoided peanuts completely. This was also true for the kids who showed mild hypersensitivity to peanuts at the beginning of the study.
Like any good study, this paper has people asking a lot of questions. What does this mean for babies who are at high risk for peanut allergy? What does it mean for kids without eczema or food allergies? How in the world to you expose babies to peanut products that are not choking hazards?
This article has had a huge impact on the discussion of when to introduce peanuts but it is by no means the last word on the subject. The study only included kids at high risk for peanut allergy so it is difficult to say with certainty if kids at low risk would respond in a similar pattern. Kids with mild reaction to peanuts at the beginning of the study were included, but those with a severe reaction to peanuts did not participate. Moreover, the study only looked at peanut exposure and peanut allergy. It did not evaluate other highly allergenic foods like seafood, tree nuts and wheat. And while the study has good data, early introduction did not work for everyone. Nine of the kids assigned to the peanut eating group withdrew from the study because they began to develop allergy symptoms.
For kids with a history of food allergies, eczema or a concerning family history, decisions about allergenic food introduction need to be made in conjunction with a physician who knows them well. In my family, we do not have a significant history of food allergies. I introduced peanut products to my two older children before they were a year old. After reading this study, I will still plan to introduce peanut products to my youngest before she turns one, perhaps with a little more confidence.
And how do you introduce peanuts to babies? The study used Bamba snacks, which are apparently quite popular in Israel. They are corn puffs that are coated in peanut butter and dried. Out of curiosity, I ordered some. They are crunchy and taste like peanut butter. For the purposes of the study, the snacks were softened into a paste for babies who could not tolerate the crunchy texture. I thought my youngest might get to try Bamba snacks in a month or two but with the way my big kids are scarfing them down, they may not give her a chance.
*Disclaimer: The people who make Bamba snacks do not know who I am. I am not endorsing their product and I am not getting paid to tell you that my kids think their snacks taste good.