Introducing peanut into your baby’s diet – and how to keep it in!

As a parent approaching or commencing complementary feeding (weaning) with your baby, it can often feel like there’s a lot of information to take in, make sense of and then actually follow. Amongst decisions about when to start, what foods to start with and the approach you wish to take, there are also daunting and anxiety-provoking topics.  One of which is introducing common allergenic foods such as peanut to your baby during weaning.  Not only is this a topic where it can be easy to find conflicting information, a recent study of parents by Your Baby Club found that nearly half of parents (49%) were worried about allergic reactions during weaning.

Background to allergy advice

Over the past two decades, there has also been a complete U-turn in the advice given regarding allergy prevention in children.  About 20 years ago, recommendations were very different (which is why it’s understandable that even now it’s easy to get confused!), with the UK’s Chief Medical officer & COT committee recommending that atopic mothers (those with a history of eczema, asthma, hay fever or food allergy) avoid peanut consumption during pregnancy and breastfeeding, and subsequently avoided or delayed introduction to peanuts in their baby during weaning. 

High-risk babies, who were considered those with eczema or another food allergy, were also advised to delay peanut introduction until after 3 years of age. Interestingly, in the years following this recommendation, the prevalence of peanut allergy increased to the point of reporting some of the highest recorded rates of peanut allergy in school-age children (4-5years). We also know that the prevalence of peanut allergy has almost doubled over the past 10 years – specifically within countries where advice was in place recommending avoidance of peanut during pregnancy, breastfeeding, the introduction of solids and in the diet within early years.

Following this, researchers set out to delve deeper into allergy prevention, and measures that could prevent the development of peanut allergy in children.  An interesting observation was made in countries (or populations) such as those in Israel who introduced peanut products e.g. BambaTM during weaning.  These groups had significantly lower levels of peanut allergy than populations with dissimilar weaning practices with peanut, such as the UK.  This observation then helped fuel ground-breaking research including two key studies which took place in the UK, looking into the early introduction of peanuts (LEAP) and common food allergens (EAT) and food allergy prevention in breastfed babies.  

These key studies are:

• LEAP study (Learning Early About Peanuts)
• EAT study (Enquiring About Tolerance)

You can read much more about each of the studies via their studies above, but to summarise, these studies have found:

• In high-risk infants (those with severe eczema and/or egg allergy), introduction of peanut during complementary feeding (weaning) and regular peanut consumption that begins in infancy, may help prevent the development of food allergy (e.g. protected against peanut allergy)
• For the very small percentage of infants who were already allergic to peanut, only mild reactions were observed during the introduction in infancy.  No severe reactions were reported in either study
• Introducing peanuts during the first year of life is safe, and did not affect parameters such as growth, nutritional status or breastfeeding rates. 
• They may be key windows of opportunity for allergen introduction – babies may benefit from egg first, then peanut.

The combined results of these studies have led to the development of some evidence-based guidance for parents about introducing allergenic foods such as peanut during weaning, which we’ve summarised next.

Current advice on the introduction of peanut (and allergic foods) during weaning:

With a focus solely on the topic of the introduction of allergenic foods, such as peanut, during complementary feeding, the take-home messages and guidance for parents are:

• Avoid delaying the introduction of allergenic foods (e.g. peanut) past 12 months of age – deliberate avoidance or exclusion from your baby’s diet may actually increase the risk of developing food allergy.  I like to describe this to parents as ‘not leaving the door open for food allergy’.
• For most babies who are at low risk of food allergy, common allergenic foods such as peanut should not be differentiated from the introduction of other solid foods and can be introduced from around 6 months of age (in line with current WHO & DOH guidelines) alongside other foods such as vegetables, fruit, starchy foods, cereals and iron-rich foods
• High-risk babies (who are categorised as below) may benefit from earlier and proactive introduction to peanut (and egg) from around 4-6 months age when they are developmentally ready* (not before 17 weeks of age) and with the support of a health professional

*Note: for babies who do set out early – offering these foods as purees instead of a baby-led finger-based food approach is often more developmentally appropriate, but also helps better ensure the goal e.g. actual consumption of the allergenic food

HIGH RISK INFANTS:

• Babies already diagnosed food allergy e.g. milk, egg 

and/or

• Babies with eczema – especially if this is more severe e.g. requires daily steroid creams and/or was early onset (in first months of life)

Whilst this latter group are evidently at higher risk of developing an allergy, they are also the group who would be considered to benefit most from this prevention advice. Families with babies who fall into this high-risk group should discuss their individual care with their GP or another health professional if they are concerned**.  

**It’s important to remember that the window of opportunity for introduction is, however, relatively small, and the risk of delaying introduction until receiving specialist input or testing in this group of babies needs to be balanced up by parents carefully, taking advice as required.

How do I introduce my baby to peanut?                                                   

• Avoid offering peanut butter directly off a spoon as the texture can be difficult for a baby to manage and may present an increased choking risk
• Choose a smooth 100% peanut butter with no added salt or sugar wherever possible.  Avoid chunky or crunchy options as these can present a choking risk

NOTE: BABIES & CHILDREN <5YEARS OF AGE SHOULD NEVER BE GIVEN WHOLE NUTS DUE TO CHOKING RISK.

Practical guidance for on the day

1. Be sure to introduce one allergen at a time – never more than one new allergen to your baby in one day.  Foods already accepted and tolerated within your baby’s diet can continue to be offered.
2. Ensure your baby is well and not recovering from illness before starting.
3. If your baby has eczema, aim for skin to be well managed and under control/stable (seek support early from your GP for any babies with eczema, how can forward onto specialist services such as Dermatology as required)
4. Start with a small amount and build up the amount gradually e.g. ¼ of a teaspoon, increasing slowly over the next few days such as ¼ tsp – ½ tsp etc.  Allow 3-4 days of introduction of one allergenic food before considering introduction of another.
5. Consider offering the food earlier on in the day e.g. in the morning to allow you time to monitor for any signs of reaction during the day
6. If your baby refuses the food initially, don’t despair!  Try again another day, or consider mixing it into a food already tolerated and accepted, or offer in a different way.  Do not force feed – allow baby to go at their own pace.
7. Consider the best way of supporting your baby to consume the allergenic food – often parents find that a puree or mashed foods initially are easier for guaranteeing consumption of the allergen, compared to baby-led style finger food – but this depends on your baby’s skills and progress with eating
8. If you think your baby might be having an allergic reaction or symptoms you must stop and seek medical advice.  Remember that severe reactions are very rare.
9. It can be helpful before introducing allergens such as peanut to familiarise yourself with the common signs of a food allergy which can be found here.

Once I’ve successfully introduced peanut, is that it?

The short answer here is no!  To support your baby’s immune system to maintain tolerance to peanut protein, it’s recommended (particularly in the high-risk group) that you keep giving it to your baby regularly. It’s recommended that, where possible, babies and children have ~2g peanut protein 2-3 x per week:

2g peanut protein = 1 heaped teaspoon smooth peanut butter /  20g or two-thirds of a bag of BambaTM 

On top of the suggestions above, you can consider;

• Mixing peanut butter into porridge, cereals, yoghurt, mashed sweet potato, fruit, smoothies or bakes such as flapjack
• Spreading peanut butter onto toast, bread, muffins, pancakes or apples
• Mixing well-ground peanuts into stews, curry, cereals, homemade granola, yoghurt or cream cheese
• Incorporating peanuts into simple recipes for family meals is also a fabulous way to maintain exposure.

TAKE HOME MESSAGE: give early & often

Don’t delay in commencing discussions with your GP, Dietitian and/or allergy team if you want to address your individual concerns regarding your baby.

If you would like more personalised advice about introducing allergens to your child, please don’t hesitate to get in touch to see how I can help you.