Medical Examiner

Your Kids Don’t Need Training Wheels for Peanuts

Products that promise to safely introduce children to certain foods are a waste of money. Here’s what you really need to know about allergens.

Toddler eating a peanut butter sandwich.
Photo illustration by Slate. Photo by Thinkstock.

The first time you give your baby peanut butter can be a stressful experience: What if they have a life-threatening food allergy that you never even knew about? How should you, as a parent, balance this fear with the emerging theory that early exposure to such allergy-inducing foods might be the best choice for your baby in the long run? When did peanut butter and jelly get so stressful?

These fears are understandable: The incidence of potentially life-threatening childhood food allergies has risen dramatically since the mid-1990s. Meanwhile, the recommendations for when and how to introduce allergenic foods have been in flux. Previous recommendations included delaying some of the most common allergenic foods—cow’s milk was delayed until 1 year of age, eggs until age 2, and peanuts and shellfish until age 3. In 2008, though, the American Academy of Pediatrics reversed previous guidelines, releasing a report stating that there is no current convincing evidence that delaying solid foods beyond 4 to 6 months of age, including foods considered to be highly allergenic, such as fish, eggs, and peanuts, has a significant protective effect on the development of food allergies. The shift in guidelines hasn’t translated to clarity and confidence for parents and caregivers, at least for the time being—one recent study in Annals of Allergy, Asthma and Immunology, for example, found that there is low willingness and awareness for early allergenic solid food recommendations among new and expecting caregivers.

Amid the confusion, a series of products have emerged to help take the guesswork out of feeding children safely. Spoonful One, for example, bills itself as “a science-inspired daily food blend designed to help a child’s immune system get to know and stay accustomed to the foods responsible for 90% of food allergies.” It comes in stir-in packets at $80 for a kit, or $70 per month if purchased via subscription service. Another product, Hello Peanut, claims it is based in “ground breaking medical research,” and is the “first-ever system created specifically for introducing peanuts to infants.” It comes in stir-in packets that increase the dose of peanut protein over seven consecutive days. Inspired Start, the first “designed to introduce 8 common allergens,” carries similar claims of being science-based, and comes in ready-to-feed pouches with 1 gram of one allergenic protein per pouch.

These companies all cite three main studies on food allergies in kids as their backup. The landmark 2015 LEAP (Learning Early About Peanut) trial demonstrated that infants at high-risk for developing peanut allergy who consumed peanut protein when they were between 4 to 6 months of age had lower subsequent development of the allergy. The 2016 LEAP-ON study showed that of the children in the LEAP trial, regular consumption of peanuts until 60 months of age was associated with a reduced prevalence of peanut allergy, even after avoiding peanuts for one full year between 60 and 72 months. And the 2016 EAT (Enquiring About Tolerance) study found that introduction of six allergenic proteins before 6 months of age is not associated with increased risk of food allergies.

These studies are just the start, but they suggest a potential path for slowing the alarming rise in childhood food allergies. What they don’t do is offer direct support for the kind of dose-specific products the aforementioned companies offer. Although Spoonful One, Inspired Start, and Hello Peanut come with reassurance and ease-of-use, the science is still very much in early stages. “We don’t yet have direct evidence that commercial products marketed to introduce common food allergens are beneficial,” Dr. Supinda Bunyavanich, associate professor and allergist/immunologist at the Icahn School of Medicine at Mount Sinai, tells Slate.

For one thing, as Bunyavanich notes, “[t]he amount of food allergen protein in these products is low compared to those used in the randomized trials.” The LEAP trial used a dose of 2 grams of peanut protein three times a week, says Dr. David Stukus, assistant professor of pediatrics in allergy/immunology at Nationwide Children’s Hospital. “We have no idea whether the same effect would have occurred with 2 grams once a week, or 1 gram six times a week,” he said

The LEAP study also only applies to children at high-risk of a peanut allergy, said Dr. Steven Taylor, co-founder and co-director of the food allergy research and resource program at University of Nebraska–Lincoln. “[W]e know that there is a potentially sizeable benefit for [high-risk] babies to the early introduction of peanut,” he said. “But I would urge caution to avoid the temptation to immediately expand the advice to parents beyond the science to include all infants and especially to include all foods.”

The National Institute of Allergy and Infectious Diseases provides detailed instructions on how to introduce peanuts to kids’ diets for parents. Similar dosage guidelines for other foods that commonly cause allergies can’t be found because the data just isn’t available yet. Trials similar to LEAP have been done with egg, but “have led to inconsistent results,” and researchers have not yet found reasons for the inconsistencies, Taylor tells Slate. “A few trials have been done with milk and all have failed to prevent milk allergy development,” he adds. Beyond peanut, milk, and egg, other highly allergenic foods have not been subjected to clinical trials, he said.

There are still a lot of TBDs when it comes to the perfect way to introduce new foods. One thing is clear when it comes to childhood food allergies, though—the lack of clarity can make some parents anxious. “I felt this was better and safer than just giving him a taste of the food since I [won’t] know how much he actually ate that way,” wrote one parent in an Amazon review for Inspired Start. “This way I have a more exact amount that he is eating allowing me to ensure he has had enough of an exposure and I can just take the pouch to the ER with me in the event of a reaction.”

That’s an understandable way to navigate the uncertainty, but it’s important to be clear that there are many acceptable ways to introduce your kid to allergens without needing to buy dose-specific food packages. “These products are not necessary at all,” he says, adding that some caregivers may find them more convenient than preparing these foods from scratch. “Parents should not feel like they need to use these products or that they are doing something wrong if they choose to just feed their children normal age appropriate food instead.”

The packets are also pricey. Bunyavanich notes that “[t]he cost of commercial powder and puree products is also many fold higher than the cost of buying the component foods directly.” For some parents, the ease of a stir-in packet compared to preparing a peanut butter puree or another soft, age-appropriate allergen-containing food may be worth the premium—Hello Peanut and Spoonful One each cost about two dollars per serving. And the convenience of Inspired Start’s ready-to-serve purees is certainly attractive—but at 77 cents per ounce, it comes in at over twice the price tag of ready-to-eat puree pouches not marketed for allergen introduction.

None of this suggests that the research and the products aren’t all working off the same information and moving in the same direction. But to assess these specific products’ efficacy, you’d need to collect clear and specific data on the products themselves. A randomized, blinded, placebo-controlled nationwide study in over 700 healthy infants conducted by researchers at Northwestern University Feinberg School of Medicine, with funding support provided by Spoonful One’s maker, Before Brands, found that the product is safe and well-tolerated, with no allergic reactions in more than 8,800 feedings. But that doesn’t quite provide evidence to support the company’s claim that it helps “protect babies from developing a future food allergy and support immune health.” According to a press release, though, “studies are underway to assess the effect of this supplement on immunologic responses to the allergenic proteins and the longer-term incidence of food allergy.”

The absence of precise recommendations, the risks, and the fact that it’s your child all collide to create a hard, emotionally charged problem. Given the current facts on the ground, it seems that the best way to think of these food products is that they are safe, but by no means necessary. If you’re nervous about introducing a food, the best choice might be to consult your doctor. “Pediatricians are typically at the front lines of counseling parents on food introduction, and organizations such as the AAP currently recommend that pediatricians advise parents to introduce a wide variety of foods,” Bunyavanich says. But it could take years before the precision some parents crave will become a data-driven reality, and “these data are not going to appear quickly,” Taylor says. As Stukus suggests, “We need to do our best to not make feeding our infants a medical procedure.”