The best way to prevent food allergies is to introduce the most common allergenic foods to babies early in life, as research evidence for peanut and egg has shown. Even during the current COVID-19 pandemic, the benefits of allergy prevention outweigh the very small risk of a severe reaction.
As clinicians and researchers in the field of allergy and infant nutrition, we are worried that COVID-19 may lead parents to delay the introduction of allergens to their babies. Parents may not feel comfortable taking their baby to an emergency room because of potential exposure to COVID-19, so they don’t want to risk a severe allergic reaction requiring a hospital visit.
The most recent Canadian recommendations continue to apply during the COVID-19 pandemic. The recommendations encourage parents to introduce allergenic foods to babies as soon as they start eating solids around six months, but not before four months of age. This applies to lower-risk infants as well, but is especially important for babies who are at higher risk of allergy due to eczema, other food allergies or an immediate family history of an allergic condition.
Many parents may be wondering if they should hold off on introducing allergens to their baby because of COVID-19. The answer is no. Despite the pandemic and some families trying to avoid the risk of an emergency room visit, introducing allergens to babies without delay is recommended. The risk of a severe allergic reaction when eating a new food for the first time is extremely low— well below two per cent.
Delaying the introduction might put children at higher risk of allergies. If not introduced in infancy, the risk of an allergic reaction as a child gets older is increased, so it’s better to introduce early and not delay. There is evidence that in higher-risk infants, peanut introduction during infancy reduces the risk of peanut allergy by up to 80 per cent.
It’s very unlikely that infants will react so severely to a new food that they will need an emergency trip to the hospital. To put it further into perspective, food allergies affect around two per cent to 10 per cent of Canadians, so even most older children will not have an allergic reaction to foods. The chance of a severe allergic reaction such as anaphylaxis is much less than two per cent, even in higher risk infants.
In the unlikely event that infants have a severe reaction and need to go to the emergency room, the risk of acquiring COVID-19 is also extremely low when proper infection control measures are adhered to. The risk of an infant dying from COVID-19 in the unlikely event that it is acquired while visiting the emergency room is even more remote since children have milder disease symptoms.
In Canada, the most common allergens are cow’s milk, eggs, peanuts and tree nuts, sesame seeds, fish and shellfish, soy and wheat. Puréed foods, smooth nut butters diluted with breast milk or formula, or ground nuts mixed in purées are great ways for parents to introduce allergens safely in non-choking form for babies.
It’s important that the allergen be introduced orally, meaning that the infant eats the food. We don’t recommend rubbing it on the skin or lips to test for an allergic reaction as that may cause irritation that could be misinterpreted as allergy.
Parents can introduce these foods one at a time, always in an age-appropriate way for their baby, and without delays between the introduction of new foods. Allergic reactions usually appear very quickly, so parents can gauge reaction within a couple of hours following the meal.
Allergic reactions in infants will usually affect the skin (hives, itchiness, rash), gastrointestinal tract (vomiting, diarrhea) or respiratory system (wheezing). Parents should monitor the signs closely and take pictures of skin reactions as they seek advice from their family doctor. If there is a reaction, the food should be avoided until parents have consulted their health-care team, and decided on the next best steps to take.
Once an allergen has been introduced safely, it is very important to keep offering and serving it to the baby a few times a week to maintain tolerance. Aiming to include these allergens in the regular family diet is a practical way for parents to offer it often to baby.
The benefit of preventing the development of food allergy (which can affect the quality of life of the whole family for many years) is far greater in our professional opinion than the very small risk of experiencing a life-threatening allergic reaction and potentially exposing infants to COVID-19.
Maude Perreault is a registered dietitian and research associate at McMaster University. Edmond S. Chan is a pediatric allergist, head & clinical associate professor at the Division of Allergy & Immunology in the Department of Pediatrics, Faculty of Medicine and an Investigator at BC Children's Hospital Research Institute at the University of British Columbia. Elissa M. Abrams is an assistant professor in the Department of Pediatrics, Section of Allergy and Clinical Immunology at the University of Manitoba and Johns Hopkins University.