Weaning beyond peanut – part 1

Carina Venter and Rosan Meyerbaby-watermelon

The previous blog focused on the introduction of peanut in infants following the release of the NIAID guidelines. In the next two blogs blog, we would like to discuss the introduction of solid foods further.

Weaning: Points to take into account when introducing solid foods for ALL babies 

1. Importance of exposure to different tastes/flavor 

We have shown in some of our studies that avoiding milk from a baby’s diet with cow’s milk allergy, can lead to reduced likelihood of eating milk based foods even at 10 years of age. On the other hand, tastes and flavors that infants are exposed to, positively affect their preferences of those foods later in life. Infants are very good in distinguishing between different flavors and the more often they get exposure to a particular taste/flavor the more likely they are to eat that particular food – some foods needs to be given at least 15 times before the infant will happily eat it. The weaning period is therefore an ideal time to set the foundations for good eating habits.

2. Importance of exposure to different textures

Infants should be introduced to a variety of textures in early life ranging from purees, mashed, dissolvable and fingers foods. They should ideally tolerate the textures of family meals by 12 months, though some foods such as meat will need to be cut in smaller pieces.  Studies show that those infants, who have not eaten lumpy textures by 10 months of age, are more likely to develop faddy eating behavior in later childhood. Some mothers may prefer to do baby led weaning in which case you will offer your baby (age appropriate) foods that are soft-cooked and cut or mashed into small easily manageable pieces. This normally means that you will skip the phase of giving thin and runny purées and feeding your baby with a spoon. However, in terms of peanut, we suggest that you follow the recipes suggested by NIAID, included in our previous blog to prevent the risk of choking.

3. Importance of a varied or diverse diet 

A varied diet during infancy plays three important roles.

  • The more varied the foods introduced during the first few months of weaning, the less likely children are to have faddy eating behavior when they are toddlers.
  • A more varied diet will also positively influence nutrient intake.
  • Most importantly however, a more diverse diet, i.e. a diet with a large variety of different foods in the first year of life is also associated with the prevention of allergic disease, possibly via an effect on the infant’s microbiome.

4. Food preparation 

Food preparation and the use of home-made vs. commercial foods have recently been highlighted to play a possible role in the development of allergic disease. Commercial foods are sterile, the anti-oxidant content may be less than that of home-made foods and the variety can be reduced compared to home-cooked foods. This does however not mean that commercial baby foods cause food allergies, and home-cooking using lots of sugar and salt won’t benefit your baby either! Our common sense advice is: Cook/bake foods suitable for babies when you can, mash a banana or grate an apple when you can and use commercial foods in times when you are travelling or not at home.

See our next blog for guidance on introduction of other allergens.

Feeding your baby peanuts – Q&A

baby-eating
The new guidelines on “early” introduction of peanuts have received much attention in the past few days. For full background information and specific details, please read the guideline document. The information contained in this blog will serve as a practical guide for parents on introducing peanuts into the infants diet.

Weaning or introducing solid foods into your baby’s diet is meant to be a time of enjoyment, but with so much focus on allergen introduction, we risk “medicalizing” a process that should be part of normal development. I was very pleased to be invited as a member of the Expert Panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, to develop clinical guidelines on peanut allergy prevention.

The guidelines divide infants into 3 risk groups (guidelines 1, 2 and 3) and issued the following advice:

Group 1: Infants with severe eczema, egg allergy or both.

  • Check with your doctor before introducing peanuts at home.
  • Your doctor may recommend that your baby undergo allergy testing, followed by supervised peanut introduction if needed, before you introduce peanuts regularly at home.
  • Once you start giving peanut at home, it is recommended to give 2 g of peanut protein, 3 times per week.

Group 2: Infants with mild to moderate eczema.

  • Your doctor can tell you what “mild to moderate” eczema means and if it is safe for you to introduce peanut into you baby’s diet.
  • For this group of infant, the new guidelines suggest to start giving peanut around 6 months of age, after other solid foods have been tried.
  • Peanuts should be given based on the family’s eating preferences and given regularly to your baby.

Group 3: Infants with no eczema or food allergies

  • Start weaning your baby when developmentally ready.
  • Once a few foods are introduced, start giving your baby some peanut-containing foods.
  • Continue with regular peanut intake, based on the foods that your family likes and regularly eats.peanut-and-strawberries

Common questions:

  1. I thought peanuts can cause choking in children under 5 years of age, can I give it to my baby?

Yes – that is true – whole, shelled peanuts and lumps of peanut butter should not be given to children under 5 years of age due to the risk of choking; this is pretty much a recommendation all across the world. The new NIH guidelines recommend that you give your baby peanut puffs (e.g., Bamba), smooth peanut butter mixed with hot water and then cooled down, peanut flour, or peanut powder.

  1. Why 2g peanut protein, 3 times per week?

The amount of peanut used in the LEAP study was based on the median monthly consumption of 7.1 g peanut protein in Israeli children where peanut allergy prevalence is relatively low.

  1. What does 2 g of peanut look like, or is it actually 2 g of peanut protein?

It is 2 g of peanut protein. The NIH guidelines lists the following options for giving 2 g of peanut protein:

  • 17 g Bamba (another peanut puff that is very similar to Bamba is called Cheeky Monkey)
  • 9-10 g peanut butter depending on the brand
  • 8 g of ground peanuts
  • 4 g defatted peanut flour (e.g., defatted peanut flour from the Golden Peanut company) or peanut butter powder (e.g., PB2 powder or PB fit)
  1. I don’t have kitchen scales…does that matter?spoons

No – these amounts do not have to be that exact.

  • 17 g of peanut puffs is about 2/3 of a bag of Bamba.
  • 9-10 g peanut butter is either two level measured teaspoons or a “round full” teaspoon (Picture courtesy of myself and George Du Toit – the one and only LEAP first author)
  • 8 g of ground peanuts is 2 1/2 level measured teaspoons
  • 4 g of peanut flour or peanut butter powder is 2 level measured teaspoons
  1. What if my baby is sick and won’t eat, or if they are full and have not eaten the full portion?

We just do not know if smaller amounts or less frequent feeds will be as protective against the development of peanut allergy. However, according to LEAP authors, some of the babies got ill (as babies do) and some did not actually finish every feed, though most did. The main thing is to be as consistent as possible with regular peanut intake, even if your baby does not eat the full dose.

  1. What if my baby/child loves the peanut puffs and want to eat more?

peanut-puffsYes! Some babies are good eaters and love peanut flavor. Eating more is allowed; I also think that older children (peanut was given up to age of 5 years in LEAP) may not be happy if you remove the bag of Bamba once 2/3 of the bag is eaten. In the LEAP study, the median amount of peanut protein in the consumption group was 7.7 g (interquartile range, 6.7 to 8.8).

  1. I don’t think my baby will eat the peanut-containing foods in the NIH guidelines; is there anything else I can try?

I would say first try different options of the foods listed in the NIH guidelines. Peanut powder mixed with mango puree tastes very differently from diluted peanut butter mixed with baby rice or carrot puree. You could also try to crush the Bamba, dissolve it in water, and mix it into the baby’s pureed foods.
During the development of the NIH guidelines, we looked at other options, such as peanut-containing breakfast cereal or peanut containing candy (chocolate) and found that either the portion sizes would be too large (e.g., up to 6 cups of cereal) or the fat, sugar or salt content would be unsuitable for young children. If you are adventurous in the kitchen, try to bake low-sugar peanut cookies/biscuits – 1 cookie contains about 0.8 g of peanut protein, which means 2-3 cookies should give around 2 g of protein or cook peanut soup!

Any dietitian (irrespective of their knowledge of food allergy) can help you to find out what the peanut protein content of a food is by calculating it from the label (if peanut is the only ingredient) or from information obtained from the manufacturer. I am sure they will be happy to help ensure that you use foods that are culturally accepted and favorites of the family!

  1. Which solid foods are best to start with?

In terms of introduction of solid foods, just use the usual weaning advice as suggested by the country in which you live. In most situations, this will be vegetable or fruit purees or infant fortified cereal-rice/oat.

  1. Does it HAVE to be 4 months or 6 months?

I have mentioned in my introduction that weaning is part of normal development, and babies may be ready for solid foods at different ages; look out for developmental cues when starting to introduce solid foods – there is no need to set a clock to remind you that your baby is exactly 4 months of age! I absolutely love this fact sheet produced by colleagues of mine at the Infant and Toddler Forum.peanut-butter-sandwich

Some more easy recipes for peanut introduction in the first few years of life

 

The final knock out question:

My older child is peanut-allergic, I am not sure if it is safe to eat peanut around him?

This is a discussion that you have to have with your baby’s doctor, as many factors will determine how to approach the situation.

These guidelines address preventing peanut allergy and do not apply to anyone with diagnosed peanut allergy. Peanuts should not be given to those with peanut allergy – always follow your doctors advice.

Should all babies follow the NIAID guidelines for peanut intake – see my quick repose to this question 

How much fruit/vegetable puree or yogurt should be added to the peanut butter, peanut flour/powder or “Bamba-like” sticks/puffs?

Milk Allergies in Kids: Why You Should Actively Encourage Children With Milk Allergies To Have a Varied Intake of Tastes and Textures

It is known that young children with food allergies often exhibit ‘faddy’ or picking eating behaviour. In some presentations of food allergies, such as Eosinophilic Esophagitis, this may even present as a more severe form of faddy eating, referred to as feeding dysfunction.

I have often wondered if food exclusion diets during infancy still affect food intake years later, even into later childhood or adulthood. In 2012, I obtained UK funding for a PhD student to research the effect of cow’s milk avoidance in the first year of life on food choices up to a decade after any possible signs of cow’s milk allergy have resolved. The Food Allergy and Intolerance Research (FAIR) Cohort on the Isle of Wight were nearing 10/11 years of age and were ideal to perform such a study.

Kate Maslin RD led this research as part of her PhD and published the results earlier this year: Cows’ milk exclusion diet during infancy: Is there a long-term effect on children’s eating behaviour and food preferences?  She also set up collaborations with the team across the waters in Southampton who recruited a birth cohort (Prevalence in Food Allergy – PIFA) as part of the Europrevall study, and these children were nearing 5/6 years of age.

Kate showed that children who avoided cow’s milk for more than 4 months in the first year of life, rated their “liking” for dairy foods such as butter, cream, chocolate, full-fat milk and ice cream significantly lower than those who never avoided milk products. This was nearly a decade after the FAIR children outgrew any possible signs of milk allergy and up to 5 years after the PIFA children outgrew signs of a milk allergy.

What have I learned from this paper?

This paper has emphasised the importance of a dietetic consultation, focussing beyond just which foods should be avoided. Furthermore, I have realized that during dietary consultation the importance of focusing on suitable alternatives as well as what can be eaten is extremely important.

Looking at the particular foods the children did not “like” according the paper – butter, cream, chocolate, full-fat milk and ice cream – one cannot help question how often children ate any of the suitable milk-free alternatives based on soy, coconut, hemp, small amounts of rice and nut beverages (if tolerated) during the period of milk avoidance. If so, whether using these products would have prevented this long-term effect of less “liking”.

I therefore now spend significantly more time during consultations discussing suitable alternatives and ensuring the client’s diet is varied in terms of tastes and textures. Once the child outgrows their milk allergy, I stress the importance of introducing milk-containing foods as much as possible. This requires, in my opinion, very clear practical advice and at least one-two follow-up appointments with in RD.

Which questions still needs to be answered?

One of the questions our research team on the Isle of Wight particularly wanted to answer was if any particular formula(s) used for the diagnosis and management of cow’s milk allergy had a more profound effect on food intake than others. We unfortunately did not have the statistical power in each group to fully address this question.

Carina Venter PhD RD

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