PEN eNews 10(8) August 2020

Knowledge Creation Peer review Reviews Knowledge Translations

The Introduction of Common Allergic Foods in High Risk Infants - What is the Latest?

The Question

Among infants with parental history of allergy, does delaying the introduction of common allergenic foods until after four months of age decrease the incidence of allergy?

The Recommendation

In light of emerging evidence, recently published guidelines recommend that early (four to six months) allergenic solid introduction may prevent peanut and egg allergy in infants at high risk. Some evidence also supports the early introduction of wheat and cow’s milk products to prevent allergy.

In particular, among infants older than four months with a parental history of allergy there is no evidence to suggest that delaying the introduction of any solid foods or potentially allergenic solid foods (including peanuts, tree nuts, eggs, fish and crustacean shellfish, soy and wheat) after six months of age can decrease the risk for atopic disease (i.e. food allergy, eczema, asthma and/or atopic sensitization).

There is moderate evidence to support that early introduction (between four and six months) of egg and peanut may reduce the risk of egg and peanut allergy in high risk children. Guidelines from pediatric allergy organizations support early introduction peanut-containing products into the diets of high risk infants in countries where peanut allergy is prevalent.

Evidence Summary

A 2016 systematic review and meta-analysis of studies published up to March 2016 evaluating the timing of allergenic food introduction to infants and the risk of developing allergic or autoimmune disease reported with moderate certainty that peanut introduction between four and 11 months was associated with a lower risk of peanut allergy, and egg introduction at four to six months was associated with lower risk of egg allergy compared to later egg introduction. There was no significant difference in the risk of cow’s milk allergy in infants introduced cow’s milk earlier or later. There were no significant associations between the timing of allergenic foods introduction and the development of allergic rhinitis, wheeze or eczema.

A 2014 systematic review of 74 studies published up to September 2012 (involving 2,2502 children) examining proven food allergy prevention (not other atopic conditions seen in isolation such as eczema and asthma) stated that delaying the introduction of solid foods “later than the recommended weaning age” did not seem to be protective against the development of food allergy in any children irrespective of atopic heredity.

Grade of Evidence B

Remarks

There is no international consensus on what constitutes infants at high risk for food allergy. Typically, a high risk infant has a personal history of atopy (including eczema) or has a first-degree relative with atopy (e.g. food allergy, eczema, asthma or allergic rhinitis).

To see the full practice question, including references, click here.

Looking for more information on this topic? See the Allergic Disease - High Risk Infant Knowledge Pathway for practice questions on infant allergy risk and:

maternal atopy versus paternal atopy
parental history of allergy and maternal avoidance of common allergenic foods during pregnancy
parental history of allergy and impact of breastfeeding
infant feeding formulas.

COVID-19

Lisa Doerr's Surprising Findings - Fermented foods and COVID-19

Although I’ve seen a number of nutrition studies published in the wake of COVID-19 (see the ones we’re tracking here), I was surprised to see a headline suggesting that populations who regularly consumed fermented vegetables had lower COVID-19 mortality rates than those who did not (1). Intrigued, I sourced the original article (2), wondering if I should add sauerkraut and kimchi making to my list of new pandemic-inspired hobbies.

The authors hypothesized that the consumption of fermented foods would be related to COVID-19 mortality due to their antioxidant content and effect on a person’s microbiome. Information from the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database was cross-referenced against COVID-19 mortality data reported by the John Hopkins Coronavirus Resource Center, using demographic information obtained from EuroStat to control for confounders (gross domestic product, population density, unemployment rate, percentage population >64 years, percentage population with obesity). In their discussion, the authors conceded that food intake is unlikely to be a major factor in COVID-19-related mortality, but they reminded us that this doesn’t mean it has no effect at all. They found that the risk of death from COVID-19 decreased by 35.4% (95%CI, 11.4% to 35.5%) for every gram increase in average national consumption of fermented vegetables per day. No other type of fermented food (pickled vegetables, fermented sour milk, yogurt or probiotic milk) was significantly related to COVID-19 mortality, nor was any other confounding variable.

This study has a few limitations (e.g. exclusion of non-European countries, inability to determine cause and effect). Most notably, similar to many COVID-19 articles, it is a preprint and hasn’t yet been peer reviewed (a problem previously noted by the PEN Team in April’s Editorial). In fact, there is a disclaimer on the article that states that the study should not yet be used to guide clinical practice (or your new pandemic hobbies) for this reason. However, this doesn’t mean that it’s a bad article - it just means that there may be flaws that are not immediately apparent and that we should continue to look for confirming evidence. The study serves as a reminder that we must delve deeper than a headline to understand the true relevance of an article to practice, no matter how salacious the headline appears to be. Luckily, that’s what dietitians are trained for.

To learn more about how to critically appraise an article, you can find our resources here!

Lisa Doerr, RD MScFN

PEN Evidence Analyst

References

Robertson S. Study links fermented vegetable consumption to low COVID-19 mortality. News-Medical. 2020 July 8. Available from: https://www.news-medical.net/news/20200708/Study-links-fermented-vegetable-consumption-to-low-COVID-19-mortality.aspx
Fonseca S, Rivas I, Romaguera D, Quijal M, Czarlewski W, Vidal A, et al. Association between consumption of fermented vegetables and COVID-19 mortality at a country level in Europe. MedRxiv [Preprint]. 2020 July 7. Preprint ahead of peer review. doi: 10.1101/2020.07.06.20147025. Available from: https://www.medrxiv.org/content/10.1101/2020.07.06.20147025v1

COVID-19

why i use PEN^® Content alerts

Does your clinical practice always reflect best practice and evidence? If you said no, you are not alone. Many health care professionals do not provide care that is recommended or that is based on the latest research (1). Information overload, inaccessibility (1) and lack of awareness of new information (2) are just some reasons for this evidence-to-practice gap.

A Cochrane review evaluated the effects of automatic reminders for health care professionals on both processes of care (related to the health care practitioner’s practice) and outcomes of care (related to the health care condition) and found that reminders improved professional practices by 7% (1). They concluded that reminder interventions can improve care in many settings under different conditions.

This study made me think about the monthly dietetic practice reminders I receive. On the last day of each month, I receive an email alerting me to new and updated content in the PEN^® System. Called PEN^® Content Alerts, this Alert is customized to information that is most relevant to my areas of practice. For example, this past month, I was alerted to this resource: Learn How to Eat Mindfully with the ‘Eat—Mojis’. Without the Alert, I would not have been aware of this new (and on-trend) nutrition resource.

In previous alerts, I learned about the Microbiota Background, the Genetically Modified Organisms (GMO) Background and more! Whether it is a handout, a resource, a practice question, a general backgrounder or a Trending Topic, these Alerts have served as practice inspiration to maintain and enhance my nutrition knowledge in this ever-evolving field of nutrition.

If you haven’t already done so, sign up for PEN Content Alerts (instructions are here), a feature available to those with individual PEN^® System access. Once you receive your alert, grab a cup of tea, your computer or tablet, and continue to close the evidence to practice gap in your practice.

References:

Cochrane. The effect of automatically generated reminders delivered to providers on paper on professional practice. This version published: 2012; Review content assessed as up-to-date: July 18, 2012. Available from: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0050327/
Bauer J. Closing the Evidence to Practice Gap. PEN eNews 4(2). August 2014. Available from: https://www.pennutrition.com/enews.aspx?id=29#276

Written by:
Kristyn Hall MSc, RD

Adapted from a November 2016 PEN eNews article

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PEN eNews 10(8) August 2020

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