KEYWORDS
Food allergy, early introduction, racial differences, peanut, milk, egg
To the Editor:
Food allergy (FA) impacts 8% of children in the US,1with the prevalence varying by race and highest rates among Black
children.2 However, it is unclear what factors may
underlie racial differences in prevalence. Differences in timing of food
allergen introduction by race may influence FA development and disease
manifestation. Following a reversal of the 2000 guidelines in 2008
advising not to delay the introduction of highly allergenic foods to
infants, the NIAID released the Addendum Guidelines for the Prevention
of Peanut Allergy in the United States in 2017 (PPA guidelines). The
guidelines encourage peanut allergy risk assessment for infants and
introduction of peanut products into an infant’s diet around 4-6 months
of age for those at high risk.3
In the Enquiring About Tolerance (EAT) study, non-White participants had
higher rates of FA and were less likely to adhere to the early
introduction feeding protocol.4 Racial differences in
the timing of food allergen introduction have yet to be extensively
studied. Therefore, this study aims to identify potential racial
differences in the timing of peanut, milk, and egg introduction among
children with parent-reported allergies to these foods while also
exploring predictors of earlier or later food allergen introduction
during infancy.
Black and White children ≤12 years old with an allergist-diagnosed
IgE-mediated FA were enrolled into the Food Allergy Outcomes Related to
White and African American Racial Differences cohort (FORWARD), a
multi-site, prospective cohort study. Study sites included: Ann &
Robert H. Lurie Hospital of Chicago (Chicago, IL), Rush University
Medical Center (Chicago, IL), Cincinnati Children’s Hospital Medical
Center (Cincinnati OH), and Children’s National Hospital (Washington,
D.C.). Parents/caregivers of study participants completed an intake
survey that assessed demographics (child age, gender, race/ethnicity,
parent/caregiver highest level of education, household income) and FA
characteristics (current parent-reported FA(s), type of FA(s), if/when
each reported food allergen was introduced, etc.). Among children whose
parent/caregiver reported feeding specific allergenic foods, chi-squared
tests assessed associations by race concerning the age (≤ 6 months, 6-11
months, ≥11 months) at which children with specific food allergies
(i.e., milk, egg, and/or peanut) were first introduced to that specific
food. Multiple logistic regression analyses assessed determinants of
earlier or later allergen introduction, including race, age of
introduction of allergens, household income, and parent/caregiver
educational attainment. Analyses were stratified by childbirth year to
examine correlations between PPA Guideline implementation and timing of
reported allergen introduction.
A total of 632 children (234 Black and 398 White; mean [SD]
age=6.0[3.7]) were included in the analyses (Table 1). Only 5.3%
of peanut-allergic Black children ≤ 6 months of age and 58.9% at ≥11
months were introduced to peanut, compared to peanut-allergic White
children (13.8% and 31.8%) respectively, (Black vs. White p<
0.001) (Table 2). Peanut products were never introduced to 29.8% of
peanut-allergic Black children compared to 35.2% of peanut-allergic
White children. Milk products were introduced to 24.5% of milk-allergic
Black children ≤ 6 months of age and 45.3% at ≥11 months, compared to
milk-allergic White children (42.3% and 17.5%) respectively, (Black
vs. White p<0.001). However, 20.8% of milk-allergic Black
children were never introduced to milk products compared to 16.5% of
their White peers. Egg introduction was delayed among egg-allergic
Black children (5.8% ≤ 6 months and 42.3% at ≥11 months), compared to
egg-allergic White children (19.2% and 31.2%) respectively,
p<0.001. Egg was never introduced before 12 months of age in
36.5% of egg-allergic Black children compared to 21.9% of egg-allergic
White children.
After adjusting for participant demographics and FAs characteristics,
White children with peanut allergy were more likely introduced to
peanuts (Odds Ratio (OR) 3.6, 95% Confidence Interval (CI) 1.5-9.8),
milk (OR 2.9, CI 1.2-7.2), and egg (OR 3.1, CI 1.3-9.0) at ≤ 6 months,
compared to Black children (Table 3 ). Delay of introduction (11
months of age) was less likely among White children for peanuts (OR 0.2,
CI 0.1-0.4), egg (OR 0.4, CI 0.2-0.8), and milk (OR 0.2, CI 0.1-0.4)
compared to Black children. Examining early introduction by birth year,
there was no significant difference by race in introduction of peanut
products at ≤ 6 months of age between 2008-2014 (Appendix eFigure 1a).
White children born 2017-2019 were less likely to delay (>
11 months of age) introducing peanuts compared to their Black peers
(Race and Birth year Interaction P<.05) (Appendix eFigure 2a).
This study is the first to explore racial differences in food allergen
feeding practices during infancy. The observed differences in
introduction timing of peanut, milk and egg in this study relate to what
is known about the growing burden of and increased prevalence of FAs
among Black children.1,5,6 Nearly 89% of Black
children with peanut allergy were not introduced to peanuts early or
never introduced peanuts compared to 67% of White children with peanut
allergy. It is unclear if decisions to withhold or delay peanut feeding
were due to varying clinician recommendations, parental fears of
introducing allergens, or high allergic sensitization to peanut, but it
is possible that differences in knowledge regarding the safety and
effectiveness of early allergen introduction for prevention varies. A
recent study surveying parents/caregivers of children with FA found that
while caregiver knowledge about pediatric food allergies is generally
suboptimal, misperceptions were more frequently reported among
racial/ethnic minority respondents and those reporting lower household
income.7
White children with peanut allergy in our study were more often
introduced to peanut products at recommended ages compared to Black
children with peanut allergy born between 2017-2019 during which time
PPA Guideline implementation occurred. Our study reports similar
findings to a study conducted among a predominantly White population
describing challenges with parent/caregiver adherence to the PPA
Guidelines and delayed peanut product introduction ( >11
months of age).8 However, our findings suggest
possible racial disparities where the most vulnerable may have received
inadequate support to adhere to PPA Guideline-recommended practices.
This study has several limitations. Recall bias is possible, as
parents/caregivers were asked to report feeding practices that occurred
at various time points in the past. Selection bias is also possible,
however the completion rate among eligible respondents in the study was
very high, >95%. Finally, the case definitions applied for
peanut, milk and egg allergy relied fully on caregiver-report, which may
result in false positive cases.
Our study demonstrates that Black children were less likely introduced
to food allergens early compared to White children. This underscores the
need to better characterize racial differences, by examining if barriers
and facilitators exist to “early” introduction of allergen foods to
infants, which may inform culturally specific strategies to educate
families on the benefits of early introduction of common food allergens.
Additionally, it is necessary to explore how physician recommendations
for early introduction of food allergens influence parents’ decision to
introduce foods. Finally, the fact that many parents/caregivers in this
cohort of FA patients nevertheless report introducing allergenic
proteins “early” –including peanut—suggests that further work is
needed to better characterize the dietary exposures of diverse samples
of allergic and non-allergic patients. Such work has the potential to
inform ongoing intervention studies that seek to determine not only the
ideal timing of allergenic protein introduction during early childhood,
but also support targeted interventions to reduce FAs in diverse
pediatric populations, as well as optimize dosing, frequency,
preparation, and dietary patterns for FA prevention.
Audrey Brewer, MD MPH 1; Jialing Jiang, BA2; Christopher M. Warren, PhD 2;
Hemant P. Sharma, MD MHS 3; Mary C. Tobin, MD4; Amal Assa’ad, MD 5; Ruchi S.
Gupta, MD MPH 1,2* on behalf of the FORWARD
Team
1. Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago,
Illinois, United States
2. Northwestern University Feinberg School of Medicine, Chicago,
Illinois, United States
3. Children’s National Hospital, Washington, District of Columbia,
United States
4. Rush University Medical Center, Chicago, Illinois, United States
5. Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,
United States