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Article: When to Introduce Solid Foods
Written by: Mark Gettleman, M.D., F.A.A.P.
First I apologize for my writing absence. I just got inundated by lifes trials and tribulations. I will make a concerted effort to update this column at least once per month. Now on with the latest installment:
There is considerable confusion on when to introduce solid foods, especially highly allergic foods like peanuts, eggs, and fish. Most pediatricians have recommended waiting till after 1 year of age. In 2000, the AAP released a policy statement saying that children at high risk should avoid dairy till after 1 year old, eggs till 2 years and peanuts, tree nuts and fish till after 3 years.
The problem is there is an ever growing body of evidence that these foods can not only be introduced earlier, but they should be in order to decrease allergies. There is a window theory that says if you introduce the foods too early (<4 m/o) OR too late (unsure of exact time) you will increase allergic diseases later in life. These allergic diseases include: Food allergies, Eczema (Atopic Dermatitis), Hay Fever (Allergic Rhinitis), wheezing, and Asthma. This same theory has been applied to allergies for exposure to other allergens. Children growing up on farms (with lots of allergens and other germs) have less asthma than suburban kids in a much cleaner environment.
In December 2008 the AAP released another policy statement saying that although solids should not be introduced before 4-6 months of age, there is no current convincing evidence that delaying their introduction has a significantly protective effect. This includes foods considered to be highly allergic, such as fish, eggs, and foods containing peanut protein. So why the switch from the 2000 statement? First of all, a comprehensive one 5 year study showed that delaying introduction of peanut protein to 2 or 3 years of age did not decrease the rate of allergies at all.
The best study, however, to demonstrate why feeding early makes sense is a study done by Du Toit, et al in the Journal of clinical immunology, nov 2008. They looked at 5615 kids in Israel and 5171 kids in the United Kingdom, all of Jewish descent to assure a similar genetic makeup. The Israeli kids ate peanuts earlier and in larger quantities than the English. (Median monthly consumption in Israel from 8-14 months is 7.1 g vs. 0 g). The Israeli kids had a 10 fold lower rate of peanut allergies than the UK kids (0.17% vs. 1.85%).
Another paper just published in the January 2010 issue of Pediatrics by Bright, Et al. was a Finnish prospective cohort study. Its conclusion is that late introduction of solid foods was associated with increased risk of allergic sensitization to food and inhalant allergens. Most interestingly the study also showed a significant increase allergic risk by delaying fish past 8.2 month and eggs past 10.5.
Here are some conclusions from a few other studies:
- Pediatrics July 2008; Snijders, et al: Delay introduction of cow milk and other foods was associated with higher risk eczema (a type of skin allergy)
- Pediatric allergy Immunology, Feb. 2008; Prescott, et al: Tolerance to food allergies appears to be driven by regular, early exposure to these proteins during a critical early “window” of development.
- Acta pediar. May 2009; Wennergrad: Elimination of food allergens during pregnancy and infancy failed to prevent food allergy. Instead several studies indicate early introduction of foods like fish and peanuts may be beneficial. Conclusions: early introduction rather than avoidance may be better strategy for the prevention of food allergy. (This was a meta analysis)
- Pediatrics Feb. 2006; Zutavern : Cohort study- no evidence to support delayed introduction of solids beyond 6 months of age to prevent Atopic disease.
- Archive of Childhood Diseases 2004; Zutavern: late egg introduction increased eczema and wheezing.
The fact remains that allergies (including food allergies) are increasing an alarming rate. (20 years ago we had never heard of “peanut free zones”). According to the Center for Disease Control (CDC) in 2007, approximately 3 million children under age 18 (3.9% of the population or almost 4 out of every 100) were reported to have a food allergies. The prevalence of peanut allergies has doubled in the 5 years from 1997 to 2002 (Journal of Allergy & Clinical Immunology Dec. 2003.) Maybe it’s time to do something to stop this. Shouldn’t we pay attention to the studies which indicated we need to start feeding solids earlier? We are so afraid of committing an act which harms our children so we delay feeding certain foods, but we may be causing more harm with our omission. I say let them eat!