Prevention of Non-peanut Food Allergies

  • Elissa M. Abrams
  • Edmond S. ChanEmail author
Food Allergy (E Kim, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Food Allergy


Purpose of Review

The purpose of this review article is to discuss the recent literature around methods of prevention of food allergies other than peanut allergy.

Recent Findings

While the most robust data to date exists for peanut, there are emerging studies suggesting a beneficial effect to early introduction of cooked egg, and cow’s milk as well. While the literature is sparse for other allergens such as tree nuts, finned fish, and shellfish, the mechanism of sensitization is thought to be the same and no study to date has demonstrated a harm with allergenic introduction in the 4–6 months of age window (nor has there been level 1 evidence of benefit to delay of such allergens). This strategy is safe, and pre-emptive testing is not required prior to allergenic solid introduction.


All allergenic solids should be introduced at around 6, but not before 4, months of age in infants at high risk.


Food allergy Allergy prevention Food introduction Complementary feeding Eczema Primary prevention Pediatric allergic disease 


Compliance with Ethical Standards

Conflict of Interest

EMA received an unrestricted educational grant from Novartis and is a member of the scientific advisory board for Food Allergy Canada. ESC has received research support from DBV Technologies, has been a member of advisory boards for Pfizer, Pediapharm, Leo Pharma, and Kaleo, is a member of the scientific advisory board for Food Allergy Canada, and was an expert panel and coordinating committee member of the National Institute of Allergy and Infectious Diseases (NIAID)-sponsored Guidelines for Peanut Allergy Prevention.

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Chafen JJS, Newberry SJ, Riedl MA, Bravata DM, Maglione M, Suttorp MJ, et al. Diagnosing and managing common food allergies: a systematic review. JAMA. 2010;303:1848–56.PubMedGoogle Scholar
  2. 2.
    Jackson KD, Howie LD, Akinbami LJ. Trends in allergic conditions among children: United States. NCHS Data Brief. 1997-2011;2013:1–8.Google Scholar
  3. 3.
    •• Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372:803–13. First randomized controlled trial to support early peanut introduction as a means of allergy prevention. PubMedPubMedCentralGoogle Scholar
  4. 4.
    •• Togias A, Cooper SF, Acebal ML, Assa’ad A, Baker JRJ, Beck LA, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139:29–44. Current NIAID guideline on the prevention of peanut allergy. PubMedPubMedCentralGoogle Scholar
  5. 5.
    Abrams EM, Sicherer SH. Diagnosis and management of food allergy. CMAJ. 2016;188:1087–93.PubMedPubMedCentralGoogle Scholar
  6. 6.
    • Lack G. Update on risk factors for food allergy. J Allergy Clin Immunol. 2012;129:1187–97. Excellent review article on food allergy risk factors. PubMedGoogle Scholar
  7. 7.
    Irvine AD, McLean WHI, Leung DYM. Filaggrin mutations associated with skin and allergic diseases. N Engl J Med. 2011;365:1315–27.PubMedGoogle Scholar
  8. 8.
    van den Oord RAHM, Sheikh A. Filaggrin gene defects and risk of developing allergic sensitisation and allergic disorders: systematic review and meta-analysis. BMJ. 2009;339:b2433.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Venkataraman D, Soto-Ramirez N, Kurukulaaratchy RJ, Holloway JW, Karmaus W, Ewart SL, et al. Filaggrin loss-of-function mutations are associated with food allergy in childhood and adolescence. J Allergy Clin Immunol. 2014;134:876–882.e4.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy in childhood. N Engl J Med. 2003;348:977–85.PubMedGoogle Scholar
  11. 11.
    Koplin JJ, Osborne NJ, Wake M, Martin PE, Gurrin LC, Robinson MN, et al. Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol. 2010;126:807–13.PubMedGoogle Scholar
  12. 12.
    •• Natsume O, Kabashima S, Nakazato J, Yamamoto-Hanada K, Narita M, Kondo M, et al. Two-step egg introduction for prevention of egg allergy in high-risk infants with eczema (PETIT): a randomised, double-blind, placebo-controlled trial. Lancet (London, England). 2017;389:276–86. Randomized controlled trial supporting early cooked egg introduction as a means of allergy prevention. Google Scholar
  13. 13.
    Wei-Liang Tan J, Valerio C, Barnes EH, Turner PJ, Van Asperen PA, Kakakios AM, et al. A randomized trial of egg introduction from 4 months of age in infants at risk for egg allergy. J Allergy Clin Immunol. 2017;139:1621–1628.e8.PubMedGoogle Scholar
  14. 14.
    Bellach J, Schwarz V, Ahrens B, Trendelenburg V, Aksunger O, Kalb B, et al. Randomized placebo-controlled trial of hen’s egg consumption for primary prevention in infants. J Allergy Clin Immunol. 2017;139:1591–1599.e2.PubMedGoogle Scholar
  15. 15.
    Palmer DJ, Metcalfe J, Makrides M, Gold MS, Quinn P, West CE, et al. Early regular egg exposure in infants with eczema: a randomized controlled trial. J Allergy Clin Immunol. 2013;132:387–92.e1.PubMedGoogle Scholar
  16. 16.
    Palmer DJ, Sullivan TR, Gold MS, Prescott SL, Makrides M. Randomized controlled trial of early regular egg intake to prevent egg allergy. J Allergy Clin Immunol. 2017;139:1600–1607.e2.PubMedGoogle Scholar
  17. 17.
    •• Ierodiakonou D, Garcia-Larsen V, Logan A, Groome A, Cunha S, Chivinge J, et al. Timing of allergenic food introduction to the infant diet and risk of allergic or autoimmune disease: a systematic review and meta-analysis. JAMA. 2016;316:1181–92. Meta-analysis on the benefit of early egg and peanut introduction as a means of food allergy prevention. PubMedGoogle Scholar
  18. 18.
    Katz Y, Rajuan N, Goldberg MR, Eisenberg E, Heyman E, Cohen A, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126:77–82.e1.PubMedGoogle Scholar
  19. 19.
    Onizawa Y, Noguchi E, Okada M, Sumazaki R, Hayashi D. The association of the delayed introduction of cow’s milk with IgE-mediated cow’s milk allergies. J Allergy Clin Immunol Pract. 2016;4:481–488.e2.PubMedGoogle Scholar
  20. 20.
    Peters RL, Koplin JJ, Dharmage SC, MLK T, VL MW, Gurrin LC, et al. Early exposure to cow’s milk protein is associated with a reduced risk of cow’s milk allergic outcomes. J Allergy Clin Immunol Pract. 2018;7:462–470.e1.PubMedGoogle Scholar
  21. 21.
    Abrams EM, Greenhawt M, Fleischer DM, Chan ES. Early solid food introduction: role in food allergy prevention and implications for breastfeeding. J Pediatr. 2017;184:13–8.PubMedGoogle Scholar
  22. 22.
    Poole JA, Barriga K, Leung DYM, Hoffman M, Eisenbarth GS, Rewers M, et al. Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics. 2006;117:2175–82.PubMedGoogle Scholar
  23. 23.
    •• Perkin MR, Logan K, Tseng A, Raji B, Ayis S, Peacock J, et al. Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016;374:1733–43. Only randomized controlled trial to examine early introduction of multiple allergenic solids in infancy. PubMedGoogle Scholar
  24. 24.
    BSACI: Preventing food allergy in higher risk infants: guidance for healthcare professionals [Internet]. [cited 2019 Mar 24]. Available from: Accessed 25 Sep 2019.
  25. 25.
    Joshi PA, Smith J, Vale S, Campbell DE. The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines. Med J Aust. 2019;210:89–93.PubMedGoogle Scholar
  26. 26.
    Abrams EM, Hildebrand KJ, Blair B, Chan ES. Timing of introduction of allergenic solids for infants at high risk. Paediatr Child Health. 2019;24:66–7.Google Scholar
  27. 27.
    van der Valk JPM, Dubois AEJ, Gerth van Wijk R, Wichers HJ, de Jong NW. Systematic review on cashew nut allergy. Allergy. 2014;69:692–8.PubMedGoogle Scholar
  28. 28.
    Abrams EM, Becker AB. Oral food challenge outcomes in a pediatric tertiary care center. Allergy, Asthma Clin Immunol 2017;13.Google Scholar
  29. 29.
    Crealey M, Alamin S, Tormey V, Moylett E. Clinical presentation of cashew nut allergy in a paediatric cohort attending an allergy clinic in the West of Ireland. Ir J Med Sci. 2019;188:219–22.PubMedGoogle Scholar
  30. 30.
    Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol. 2010;125.PubMedGoogle Scholar
  31. 31.
    McWilliam V, Peters R, Tang MLK, Dharmage S, Ponsonby A-L, Gurrin L, et al. Patterns of tree nut sensitization and allergy in the first 6 years of life in a population-based cohort. J Allergy Clin Immunol. 2019;143:644–650.e5.PubMedGoogle Scholar
  32. 32.
    Chan ES, Cummings C. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian Society of Allergy and Clinical Immunology. Paediatr Child Health. 2013;18:545–54.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Fleischer DM, Spergel JM, Assa’ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract. 2013;1:29–36.PubMedGoogle Scholar
  34. 34.
    Asai Y, Eslami A, van Ginkel CD, Akhabir L, Wan M, Yin D, et al. Canadian genome-wide association study and meta-analysis confirm HLA as a risk factor for peanut allergy independent of asthma. J Allergy Clin Immunol [Internet]. 2018;141:1513–6 Available from: Accessed 25 Sep 2019.PubMedGoogle Scholar
  35. 35.
    Asai Y, Eslami A, van Ginkel CD, Akhabir L, Wan M, Ellis G, et al. Genome-wide association study and meta-analysis in multiple populations identifies new loci for peanut allergy and establishes C11orf30/EMSY as a genetic risk factor for food allergy. J Allergy Clin Immunol. 2017;141:991–1001.PubMedGoogle Scholar
  36. 36.
    Martin PE, Eckert JK, Koplin JJ, Lowe AJ, Gurrin LC, Dharmage SC, et al. Which infants with eczema are at risk of food allergy? Results from a population-based cohort. Clin Exp Allergy. 2015;45:255–64.PubMedGoogle Scholar
  37. 37.
    Tsakok T, Marrs T, Mohsin M, Baron S, du Toit G, Till S, et al. Does atopic dermatitis cause food allergy? A systematic review. J Allergy Clin Immunol. 2016;137:1071–8.PubMedGoogle Scholar
  38. 38.
    Netting MJ, Campbell DE, Koplin JJ, Beck KM, McWilliam V, Dharmage SC, et al. An Australian consensus on infant feeding guidelines to prevent food allergy: outcomes from the Australian infant feeding summit. J Allergy Clin Immunol Pract. 2017;5:1617–24.PubMedGoogle Scholar
  39. 39.
    Turner PJ, Campbell DE. Implementing primary prevention for peanut allergy at a population level. JAMA. 2017;317:1111–2.PubMedGoogle Scholar
  40. 40.
    Koplin JJ, Peters RL, Dharmage SC, Gurrin L, Tang MLK, Ponsonby A-L, et al. Understanding the feasibility and implications of implementing early peanut introduction for prevention of peanut allergy. J Allergy Clin Immunol. 2016;138:1131–1141.e2.PubMedGoogle Scholar
  41. 41.
    Abrams EM, Soller L, Singer AG, Fleischer DM, Greenhawt M, Chan ES. Comparison of practice patterns among Canadian allergists before and after NIAID guideline recommendations. J Allergy Clin Immunol Pract. 2019Google Scholar
  42. 42.
    Shaker M, Stukus D, Chan ES, Fleischer DM, Spergel JM, Greenhawt M. “To screen or not to screen”: comparing the health and economic benefits of early peanut introduction strategies in five countries. Allergy. 2018;73:1707–14.PubMedGoogle Scholar
  43. 43.
    Hildebrand KJ, Abrams EM, Vander Leek TK, Upton JEM, Mack DP, Kirste L, et al. Primum non nocere-first do no harm. And then feed peanut. Allergy, Asthma Clin Immunol. 2017;13:7.Google Scholar
  44. 44.
    Boyce JA, Assa’ad A, Burks AW, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126:S1–58.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Maloney JM, Rudengren M, Ahlstedt S, Bock SA, Sampson HA. The use of serum-specific IgE measurements for the diagnosis of peanut, tree nut, and seed allergy. J Allergy Clin Immunol. 2008;122:145–51.PubMedGoogle Scholar
  46. 46.
    Couch C, Franxman T, Greenhawt M. Characteristics of tree nut challenges in tree nut allergic and tree nut sensitized individuals. Ann Allergy Asthma Immunol. 2017;118:591–596.e3.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Fleischer DM, Bock SA, Spears GC, Wilson CG, Miyazawa NK, Gleason MC, et al. Oral food challenges in children with a diagnosis of food allergy. J Pediatr. 2011;158:578–583.e1.PubMedGoogle Scholar
  48. 48.
    Choosing Wisely: Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy. Accessed 25 Sep 2019.
  49. 49.
    Zutavern A, Brockow I, Schaaf B, von Berg A, Diez U, Borte M, et al. Timing of solid food introduction in relation to eczema, asthma, allergic rhinitis, and food and inhalant sensitization at the age of 6 years: results from the prospective birth cohort study LISA. Pediatrics. 2008;121:e44–52.PubMedGoogle Scholar
  50. 50.
    Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane database Syst Rev. 2006; (PMID: 17054180);CD003664.Google Scholar
  51. 51.
    Boyle RJ, Ierodiakonou D, Khan T, Chivinge J, Robinson Z, Geoghegan N, et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ. 2016;352:i974.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Netting MJ, Campbell DE, Koplin JJ. An Australian consensus on infant feeding guidelines to prevent food allergy: outcomes from the Australian infant feeding summit. J Allergy Clin Immunol Pract. 2017;5:1617–24.PubMedGoogle Scholar
  53. 53.
    Koplin JJ, Suaini NHA, Vuillermin P, Ellis JA, Panjari M, Ponsonby A-L, et al. Polymorphisms affecting vitamin D-binding protein modify the relationship between serum vitamin D (25[OH]D3) and food allergy. J Allergy Clin Immunol. 2016;137:500–506.e4.PubMedGoogle Scholar
  54. 54.
    Allen KJ, Koplin JJ, Ponsonby A-L, Gurrin LC, Wake M, Vuillermin P, et al. Vitamin D insufficiency is associated with challenge-proven food allergy in infants. J Allergy Clin Immunol. 2013;131:1109–16 1116.e1–6.PubMedGoogle Scholar
  55. 55.
    Joseph CLM, Ownby DR, Havstad SL, Woodcroft KJ, Wegienka G, MacKechnie H, et al. Early complementary feeding and risk of food sensitization in a birth cohort. J Allergy Clin Immunol. 2011;127:1203–10.e5.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Nwaru BI, Erkkola M, Ahonen S, Kaila M, Haapala A-M, Kronberg-Kippila C, et al. Age at the introduction of solid foods during the first year and allergic sensitization at age 5 years. Pediatrics. 2010;125:50–9.PubMedGoogle Scholar
  57. 57.
    Simpson EL, Chalmers JR, Hanifin JM, Thomas KS, Cork MJ, McLean WHI, et al. Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol. 2014;134:818–23.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Horimukai K, Morita K, Narita M, Kondo M, Kitazawa H, Nozaki M, et al. Application of moisturizer to neonates prevents development of atopic dermatitis. J Allergy Clin Immunol. 2014;134:824–830.e6.PubMedGoogle Scholar
  59. 59.
    Lowe AJ, Su JC, Allen KJ, Abramson MJ, Cranswick N, Robertson CF, et al. A randomized trial of a barrier lipid replacement strategy for the prevention of atopic dermatitis and allergic sensitization: the PEBBLES pilot study. Br J Dermatol England. 2018;178:e19–21.Google Scholar
  60. 60.
    Lodrup Carlsen KC, Rehbinder EM, Skjerven HO, Carlsen MH, Fatnes TA, Fugelli P, et al. Preventing Atopic Dermatitis and ALLergies in Children-the PreventADALL study. Allergy. Denmark. 2018;73:2063–70.PubMedGoogle Scholar
  61. 61.
    Mullins RJ, Clark S, Camargo CAJ. Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin D-anaphylaxis hypothesis. Ann Allergy Asthma Immunol. 2009;103:488–95.PubMedGoogle Scholar
  62. 62.
    Vassallo MF, Banerji A, Rudders SA, Clark S, Camargo CAJ. Season of birth and food-induced anaphylaxis in Boston. Allergy. 2010;65:1492–3.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Molloy J, Koplin JJ, Allen KJ, Tang MLK, Collier F, Carlin JB, et al. Vitamin D insufficiency in the first 6 months of infancy and challenge-proven IgE-mediated food allergy at 1 year of age: a case-cohort study. Allergy. 2017;72:1222–31.PubMedGoogle Scholar

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Authors and Affiliations

  1. 1.Division of Allergy and Immunology, Department of Pediatrics, Faculty of MedicineUniversity of British ColumbiaVancouverCanada
  2. 2.Division of Pediatrics, Section of Allergy and Clinical ImmunologyUniversity of ManitobaWinnipegCanada
  3. 3.BC Children’s Hospital Research InstituteVancouverCanada

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