Introducing the Top 8 Allergens to Infants

Written by Rachel Rothman, MS, RD, CLEC

A frequent question I encounter in my practice and in my Introduction to Solids classes, is how to introduce foods that may be allergenic to babies.  The last 15 years have brought significant attention to allergens, and most parents are now keenly aware of the risks.  However, a drumbeat of new research published on the causes of allergies and allergy prevention has brought new strategies to light and debunked old myths. Until 2008, the American Association of Pediatrics recommended that parents delay exposing infants to certain allergens until after one year of age. The guideline changed because after a review of research and patient outcomes, there was no evidence for waiting. I help many moms and dads make sense of this new world, as they are understandably cautious about what this all means for their child.

 

What are the top 8?

The “top eight allergens” are: cow’s milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat.  These foods are associated with the eight most common food allergies, though it is possible for an allergy to occur with any food. 

So when can I introduce these foods?

Most pediatricians will tell you that you can begin to introduce these foods soon after starting solids. I usually recommend starting solids with foods not on the top 8 list, and getting 1-2 months of solids before introducing any of these more common allergens, just to note whether baby has any reactions to other foods.  That might mean you begin to offer the 'top 8' foods around 7-9 months of age.  And if your child is at a higher risk for food allergies, consult with your pediatrician.

When offering one of the top 8 allergens, it will be easiest if you only introduce one at a time, and that you observe and note any changes in baby in the first minutes, hours, or days.  If all goes well, wait a few days before offering another new food so you’ll be able to isolate any food that may be causing an issue.  If you’re concerned that something seems different, consult your pediatrician.

Let’s break down each of the allergens and discuss some ways to introduce:

Cow’s milk: Most of us have heard, no cow’s milk before one year of age.  This refers to the fact that cow’s milk should not be a replacement for breast milk or formula before the first year.  Why?  Cow’s milk has different nutrient properties than breast milk/ formula, primarily a higher proportion of protein and lower amount of fats and carbohydrates, including some differences in vitamins and minerals.  Breast milk contains the perfect proportion of all nutrients.  Cow’s milk should not be used as a replacement for breastmilk or formula. But, cow’s milk can be used in recipes, like soups, baked goods, or other foods before the first year.  Some families choose not to introduce cow’s milk, which is fine too.  This is a hot topic, so stay tuned for a post dedicated to the dairy debate!

Eggs:  Eggs are a staple in my house for my daughter, my husband, and myself.   It was previously thought to hold off on egg whites before one year of age, but like the recommendations for allergens, most pediatricians say you can introduce whole egg soon after starting solids- just be sure the egg is thoroughly cooked!  I love eggs as a finger food- they are so nutritious, and easy for baby to pick up and eat relatively early on.  Making an egg and vegetable scramble or frittata is a great way to include vegetables in baby’s breakfast as well.

Two-ingredient egg and banana pancakes: easy for baby to eat!
 

Peanuts and Tree nuts:  These are among the most highly allergenic foods, so be sure to monitor for reactions when introducing peanuts and tree nuts.  Keep in mind that whole nuts are a choking hazard for children until about 4 years of age.  When introducing nuts, try spreading a thin amount of nut butter on a piece of bread, mixing a bit of peanut butter into oatmeal or putting a very small amount of nut butter on a spoon (too large of a scoop can be a choking hazard, as well).  If your baby loves peanut butter as much as mine did, she’ll be well on her way to learning how to use a spoon!

Fish: Fish is great food for babies because of all of the nutrient benefits- just be sure fish is thoroughly cooked. Fatty fish is an excellent source of omega-3 fatty acids (specifically DHA) which baby needs for brain growth, especially under 2 years of age.  You will want to choose a fish type that is lower in mercury (some fish to avoid include King mackerel, marlin, orange roughy, shark, swordfish, tilefish, ahi tuna, and bigeye tuna).  The EPA has this great guide which lists the mercury content and sustainability level of many types of seafood. Flaked salmon can be a great finger food (or even mashed with avocado or sweet potato), or try making crab cakes or tilapia cakes.

A bit of flaked salmon, sautéed zucchini rounds and potato wedges – a perfect dinner for a 9 month old!
 

Soy: Some pediatricians do recommend waiting to introduce soy until baby is tolerating other foods.  If your baby has already been diagnosed with a soy allergy, you will want to speak with your pediatrician on it’s introduction, and keep in mind many packaged foods contain soy-based ingredients.  Baked or sautéed tofu can be a great finger food, or try adding tofu into lasagna in place of ricotta cheese.  You may want to wait until baby is about 9 or so months of age before introducing soy.

Wheat: Research and opinions are mixed on the introduction of wheat.  Many pediatricians recommend waiting on introducing wheat until other grains have been introduced (like oats, rice, or barley) to see if baby has any reaction to grains.  Wheat does contain gluten, and some babies might have a gluten intolerance or sensitivity, but note this will be different than a true wheat allergy. 

And again, always follow your pediatrician’s recommendations and speak with your pediatrician if food allergies run in your family, as the recommendations may be different.  Families of babies that have a history of an allergic condition, including a food allergy, asthma, allergic rhinitis or eczema, should absolutely speak with their pediatrician before offering any of these foods. 

Want to learn more about introducing solid food to your little one?  Join me at the San Diego Breastfeeding Center for my next introduction to solids class on January 28th at 10:00-11:30am. Learn more here

Rachel Rothman, MS, RD, CLEC is a mom, pediatric dietitian, and instructor at the San Diego Breastfeeding Center.  Rachel specializes in working with children and families.  She lives in San Diego with her husband, Ben, and daughter, Sydney.  You can contact Rachel here.

References:

Introduction of Solids and Allergic Reactions. (2009, December 7). Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Introduction-of-Solid-Foods-and-Allergic-Reactions.aspx

Fliescher, D. M. (2013, January 28). Early introduction of allergenic foods may prevent food allergy in children. Retrieved from https://www.aappublications.org/

Greer, F. R., Sicherer, S. H., & Burks, A. W. (2008, January). Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Retrieved from http://pediatrics.aappublications.org/content/121/1/183

How to Help Your Little One Feel Full with Solids

This post is by Rachel Rothman, MS, RD, and is the second post of a three-part series about introducing solids to your little one.  Rachel is a mom to a toddler and a pediatric dietitian. Rachel is the instructor of "Toddler Nutrition" and “Introduction to Solids” classes at the San Diego Breastfeeding Center. Join us for the next Toddler Nutrition class on October 29th at 10:00am.  More information and registration can be found here.

In my previous post, I addressed a parent’s responsibilities for the “when” (setting meal time) and the “what” (the food to be served) of feeding.  This approach is generally referred to as the feeding relationship: Parents are responsible for the “what, when, and where of feeding; children are responsible for the how much and whether of eating” [1].   The relationship is between parent and child, and between the child and the food they eat.  Now that we’ve established the parent’s responsibilities, we can move to the child’s responsibilities – whether to eat, and how much to eat.  

By controlling the WHAT, parents introduce foods, and should be actively monitoring how children respond. Getting started is fairly simple: you offer the food, and your child decides how much and WHETHER they want to eat it.  Yep, that’s it.  

However, this will surely bring a challenge (and for some, the harder obstacle to overcome) to be okay with how much and whether your child accepts the food.  

 

Start Small

When introducing solids to your little ones, starting small is essential to help him learn to physically accept solid food and learn to taste, chew, and swallow effectively.  If you choose to start by offering purees, offer a small amount of a pureed food to your little one.  If the child opens his/her mouth toward the spoon, help guide the food into his/her mouth.  If the child turns away from the spoon, trust his/her instincts that he/she does not want that food or is simply not ready.   If you choose to use the baby led weaning approach, start by placing food in front of your child on his/her high chair tray or the table. Trust that your baby knows what he/she needs.  And keep in mind, especially when starting out, breast milk or a breastmilk substitute will make up the majority of your little one’s calories and nutrition until he/she is close to a year old.  Your job is to help them learn how to eat.  You are letting them know they can choose how much and whether they would like to eat.  

When you move beyond purees and toward more complex foods, offered more frequently, this approach can, and often will, get more challenging.   As your child gets older and enters toddlerhood less of his/her nutrition may come from breast milk or a breastmilk substitute.  However, this is when it is more important than ever to keep in mind your child’s ability to self regulate.  As you offer more food at a given meal, you’ll be looking for signs that your child feels hungry.  That feeling (rather than a specific amount of food) helps your child to learn appropriate eating habits.

 

Experiencing Hunger and Feeling Full

Allow your child to experience the physical and cognitive effects of being hungry before eating - his/her young body’s regulatory reflexes come from feeling hungry and then knowing when he/she full.  

Research shows that children who are taught in this manner develop positive food attitudes, interest in eating a variety of foods, an intuitive sense of how much to eat, and long term skills for healthy eating and meal planning.[2]

There are a few things you can do to encourage your child to feel hungry and full, such as only offering a meal or snack every 2-3 hours (allow your child to feel hunger and sensation of fullness) and only offering water in between meals (rather than juice or sugary beverages).  

Eat Meals Together

Sit and have meals with your child, as time allows, and eat the same foods as they eat.  Not only will you be in a better position to monitor your baby’s preferences, but you can encourage her choices and ease her frustrations through words and sounds.  When your child tries a new food or enjoys an old favorite, you can show him that his choices matter to you.  Another benefit is cognitive: take the opportunity to teach your child the names of the foods he’s eating!

Lots of Exposure to the Same Foods

Keep in mind it can take up to 20 exposures of a new food before a child accepts it.  This is true when introducing solids to an infant as well as more complex foods to a toddler.  Before you rule out a food and dismiss your child as disliking it, keep offering it.  Chances are, after enough exposures, your child may have a change of heart.   While some degree of pickiness is normal, if you feel concerned with your child’s feeding habits, consult your pediatrician or a registered dietitian.

With the principles above, you’ll be on your way to raising a healthy eater!  Stay tuned for our next post, “Age-appropriate portions”.  If you’d like to keep exploring this topic with us, we’d love to see you in our next  Introduction to Solids class.

[1] Satter, Ellen M.,  Child of Mine: Feeding With Love and Good Sense, Bull Publishing Company; Revised edition (March 1, 2000) http://www.amazon.com/Child-Mine-Feeding-Revised-Updated/dp/0923521518

[2] Satter, “Eating Competence: Definition and Evidence for the Satter Eating Competence Model” Journal of Nutrition Education and Behavior ● Volume 39, Number 5S, September/October 2007  http://www.ellynsatterinstitute.org/cms-assets/documents/101150-596171.ecdefandev.pdf

Rachel Rothman, MS, RD is a mom, pediatric dietitian, and instructor at the San Diego Breastfeeding Center.  She lives in San Diego with her husband, Ben, and daughter, Sydney.  You can contact Rachel here.

Two Things More Important than Portion Sizes when Offering Solids to Infants

Join Rachel Rothman, MS, RD in our three-part blog series to learn more about introducing solids to your little one.  Rachel is a pediatric dietitian and the instructor of our Introduction to Solids classes here at the SDBFC. 

Introduction to Solids, Serving Sizes, Feeding Relationship

When babies are 4-6 months of age, many moms start thinking about how much solid food kids should eat.  It’s easy to get caught up in a race toward the “starting solids” milestone, but what comes next?  Many parents wonder, now that their little one has started eating solid foods, how much is enough?  Am I making him/her overeat?  Am I wasting food? Am I teaching poor habits? 

What might reassure you is that as long as your selections contain a balance of protein, carbohydrate, fats and vitamins and minerals, measuring “servings” of food consumed may not necessarily be the best way to ensure your baby’s success at adopting a solid diet.  

First, take a step back. Renowned feeding expert Ellyn Satter, MS, RDN, MSSW gives parents the helpful suggestion of a “division of responsibility.”  Parents are responsible for the “what, when, and where of feeding; children are responsible for the how much and whether of eating” (Satter).   Babies have the innate ability to self regulate.  They will let you know when they want more, such as opening their mouths when food is offered.  Conversely, will let you know when they are full, such as turning away from the spoon and sealing their lips tightly.  

Rather than a fixed “serving” - offer food to your child, but look for signs that they are full.  With that in mind, you have two things in your control: when is mealtime, and what are you serving.

When is mealtime?  

A general idea of how many meals you should offer each day depends on the age of your child:

Once you have an idea of when those mealtimes and snack times fit into your baby’s wake and sleep schedule, you’ll want to establish some strategies for how much to offer at each serving.  Start small: when first introducing solids, 1-2 teaspoons is enough for your little one.  And remember, up to one year of age breast milk or formula will continue to make up the majority of your baby’s calorie intake.  

Next, think about the overall composition of the meal:

Thinking about the composition of meals, know that all babies are different and some may progress through textures more quickly (or more slowly) than others. That’s okay.  As discussed above, you can only control the what and when.  Your child is in control of the how much and whether.

This process is bigger than serving size.  You’re trying not merely to nourish your little one; but to introduce your little one to a variety of new foods, textures, flavors, and nutrients.  This diversity is part of a journey you’re on, together with your young child, to ensure their healthy relationship with food.  These approaches will help your child to develop the tools to succeed when making food decisions on his/her own.

Stay tuned for my next post: “How To Help Your Little One Feel Full” to learn more about introducing new foods to your child.

Top Tips for Introducing Solids to Your Baby

Written by Rachel Rothman, MS, RD

At your baby’s four-month visit, your pediatrician may have talked to you about starting your baby on solid foods and probably recommended to start between 4-6 months.  It’s usually recommended that baby can start solids when he/she is sitting up mainly on his/her own, has a pincer grasp, seems interested in food, and opens his/her mouth when food is offered.  As a pediatric dietitian, I get asked many questions about infant nutrition and starting baby on solid foods.  

(Note - many pediatricians may suggest it’s okay to start a baby on solids as early as 4 months, but it is important to note that the American Academy of Pediatrics’ statement on breastfeeding is as follows: Exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.)

Here are just a few of the things to keep in mind when your baby is ready for solid foods: 

1. At the beginning it’s still just for fun.  Your baby will still be getting most of his nutrients from breast milk or formula, so your goal should be to help him learn these new feeding behaviors.  Eating should be a fun experience, and not stressful.  If you begin feeding solid food and your baby has a hard time with it – she’s gagging or fussy  - wait and try again at a later time.  You will not do any damage by waiting a bit.  
2. Consider some key nutrients and focus on variety.  Key nutrients for babies and toddlers include vitamins A, C, and D, iron, total fat and omega-3 fats, and calcium.  Each of these nutrients serves a specific purpose within the body; around 6 months of age, babies require these in other forms, above what is in breast milk or formula.  Don’t be afraid to be creative with the foods you are offering to meet baby’s needs for these nutrients.  Infant cereal may be what your grandmother recommends, and it’s no slouch – its high iron content is helpful.  However, variety is important for teaching your little one to appreciate different food tastes and textures, so try purees of spinach, beans or lentils.   To help baby intake of additional omega 3 fatty acids, try adding chia seeds, ground flax or ground walnuts to purees.
3. Some foods should be avoided at the beginning.  A few foods you will want to avoid until baby is 12 months include honey (because of the risk of botulism), cow’s milk (it contains too much protein), and small solids (small chunks of raw vegetables, grapes, sausages, whole nuts and seeds can all be choking hazards).  Allergens are another consideration.  Recommendations about the foods to avoid (in order to minimize risk from allergic reactions) have changed over the years.  A 2008 review of research by the AAP concluded that the top 8 allergenic foods (cow’s milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat) need not be avoided unless you have a family history of food allergies.  In that case, it is best to speak with your pediatrician before proceeding.
4. Serving sizes are small.  I hear a lot from parents that their baby is not eating enough.  But how much is enough?  A typical serving size when starting solids is 1-2 tablespoons of a puree or soft food - it’s a small amount.   And you will want to start by offering one to two meals per day.  Remember, baby will still be getting a good portion of her nutrition from breastmilk or formula until age one.  As baby gets older the serving size will increase, after 12 months the amount of food per meal should be around ¾ to 1 cup.
5. Division of Responsibility.  Renowned feeding expert, Ellyn Satter, gives parents the helpful suggestion of division of responsibility.  Parents are responsible for the “what, when, and where of feeding; children are responsible for the how much and whether of eating” (Satter).  Do not force your child to eat more or stop eating if you feel they have had too much.  Babies have the amazing ability to self regulate (many of us adults have long since lost this ability). Eating is a behavior that does need to be learned, but does not need to be rewarded.
6. Milk feedings first.  Ashley Treadwell, IBCLC at the San Diego Breastfeeding Center offers these tips for protecting your mill supply when starting solids. "When it comes to maintaining your milk supply, this can be one of the most important rules to follow when offering your baby solids.  Be sure that baby is always offered the breast first, and then solids.  If baby is filling up on solids, she may not remove as much milk from the breast as she needs.  Over time, milk left in the breast tells your body to stop producing as much which will decrease your milk supply.  If you are sure that baby is taking all the milk he/she needs from the breast prior to offering him solids, you will help to maintain your supply to meet your baby’s needs."

When feeding baby don’t forget about mom and dad.   All too often I see mom and dad focused so much on baby’s health and wellness that the parents’ health and wellness falls by the way side.  Remember to practice good nutrition for yourself, this will not only help you to feel better, but to set a good example for your child.  Healthy and happy mom and dad lead toward a healthy and happy baby!

Want to learn more about starting baby on solids? 

Join me at the San Diego Breast Feeding Center on June 17th from 10-11:30 am for a class on introducing solids.  More information can be found here.