Practical advice to help families introduce allergens early, safely and confidently…

There is strong evidence that introducing allergenic foods early in an infant’s life reduces the risk of developing food allergy. Infant feeding practices in Australia have shifted markedly over the past decade in response to updated guidelines that reflect the importance of this. Despite this, overall rates of food allergy in Australia have not declined significantly.

While awareness has improved, many families still find the process overwhelming and confusing. Misinformation and fear-based messages on social media may contribute to hesitation and delayed introduction. Parents of infants perceived to be high risk may be particularly cautious, despite these infants being among those who benefit most from early exposure. Additionally, even in cases where allergens are introduced early, ongoing exposure is not always maintained, which may contribute to the plateau in allergy rates.

Here are practical ways to support families through this process and help reduce the likelihood of serious food allergy later in childhood.

When to start solids and allergens

The Australian Society of Clinical Immunology and Allergy (ASCIA) advises introducing solids when the infant is developmentally ready at around six months of age, but not before four months.

Developmental readiness includes:

• sitting with minimal support,
• loss of the tongue thrust reflex
• and showing interest in food.

Once these signs are present, families should introduce a variety of solid foods starting with iron-rich foods while continuing breastfeeding if the infant is breastfed.

It’s important not to delay introducing allergenic foods, even if the infant has eczema or a family history of food allergy.

Practice tip: Discourage unnecessary delay. Eczema or a family history of food allergy alone is not a reason to see an allergist before introducing allergens.

What to introduce

There is no specific order for introducing foods. A practical approach is to start with foods the family commonly eats and then introduce any remaining common allergenic foods. The aim is to have all common allergens introduced by the time the child turns one.

Egg

Offer well-cooked scrambled egg or hard-boiled egg (white and yolk mashed together). Avoid raw or lightly cooked egg in the first 12 months of life, due to both its higher allergenicity compared to well cooked egg, and risk of salmonella.

Wheat

Suitable forms include Weet-Bix or risoni pasta, mixed into purée if required.

Cow’s milk (dairy)

Introduce fresh cow’s milk or yoghurt. Do not assume tolerance if the infant is formula-fed with a cow’s milk based formula, as whilst it’s uncommon, some infants tolerate processed formula but react to fresh cow’s milk. Likewise, infants who had formula in early life but not for several months may still develop an allergy. In these cases, cow’s milk or yoghurt should still be reintroduced cautiously.

Soy

Use fresh soy milk, soy yoghurt or tofu. As it is the protein component that contains the allergen, products with minimal soy protein (such as soy sauce) are not suitable for testing.

Peanut

Introduce as smooth peanut butter, thinned or mixed into puree. Peanut is a legume, not a nut, and is unrelated to tree nuts or sesame (which is a seed). Peanut, tree nuts and sesame should all be introduced separately.

Tree nuts

Introduce each tree nut individually, as tolerance to one tree nut does not imply tolerance to others. However, some tree nut allergies commonly occur together, specifically cashew with pistachio and walnut with pecan. For this reason, if a reaction occurs with one of these pairs, the other nut shouldn’t be introduced.

Tree nuts include almond, cashew or pistachio, hazelnut, walnut or pecan, macadamia, and Brazil nut. Almond butter is readily available in supermarkets, but other tree nuts usually need to be purchased whole and blended or crushed into a very fine nut meal or powder.

Sesame

Introduce using hummus which contains tahini (crushed sesame seeds), or as tahini alone which is best mixed into a purée as it can have a bitter taste.

Fish and shellfish

Introduce a few types of fish where possible (e.g. salmon, tuna, white fish), as well as shellfish such as prawns.

How to introduce allergens safely at home

Allergen introduction can be undertaken at home using a slow, cautious, graded approach, and by giving only one new allergen at a time. In this way, if allergic reactions occur, they will generally be on the milder spectrum, and the food that is responsible will be easier to identify.

Choose the right time

Only introduce new foods when the infant is well. Acute viral illness can cause hives that are misattributed to food, and reactions can be more severe if a child is unwell. A mild runny nose alone (no fever, no cough) is usually acceptable if the child is otherwise well.

Plan for a two-hour observation window

Symptoms of IgE-mediated reactions, such as hives, swelling or vomiting, generally start to occur within 15 minutes of ingestion; however, plan for a two-hour observation window, as symptoms may appear at any time within this period.

Introduce one new food at a time

Parents can mix the allergen into a previously tolerated food (for example, finely crushed nuts mixed into purée), but only one new food should be introduced at a time so any reaction can be clearly identified.

While commercial allergen introduction packs can be convenient, they still need to be used with caution. Some products do not clearly state protein content and may suggest relatively large first doses. If families wish to use them, advise the same graded approach used with supermarket foods: start small, build gradually, and continue offering tolerated foods regularly. In addition, advise them to check which allergens are included, as some packs may not contain all recommended allergens that need to be tested.

Protect the skin

Allergen exposure on the skin can cause contact reactions, particularly during baby-led weaning when infants feed themselves and food is likely to be smeared on the face. These reactions can be difficult to distinguish from IgE-mediated food allergy, which may create uncertainty about whether the food should be continued.

To minimise skin contact:

• Place allergenic food directly into the infant’s mouth
• Avoid rubbing food on the skin or lips
• Wipe away spills promptly
• A barrier cream on the lower face can help in infants prone to contact reactions, such as those with eczema.

Ensure eczema, especially on the face, is well controlled before introducing allergens.

Start small and build over five days

For solids, begin with ⅛ teaspoon and double daily (¼, ½, 1, then 2 teaspoons). For liquids such as milk, start at 1 mL and double each day until a serving size is reached (see below). Very small amounts may not provoke a reaction in allergic infants.

Ongoing exposure

This is very important to maintain tolerance. Once an allergen is tolerated, it should remain in the diet. Aim for a serve at least once per week in age-appropriate amounts. Examples include half to one whole cooked egg; a pouch of yoghurt or 150–200 mL of cow’s and soy milk for dairy and soy; a slice of bread, 1–2 Weet-Bix, or about half a cup of pasta for wheat; and 1–2 teaspoons of peanut or tree nut butters, or tahini, for ongoing exposure.

Lack of regular exposure after initial introduction may increase the risk of developing allergy later in childhood.

Practice tip: During routine infant checks, ask not only whether allergens have been introduced, but whether they are still being eaten regularly to help maintain tolerance.

Key takeaways

• Early introduction of common allergens around six months (not before four months) reduces food allergy risk and should not be delayed, even in infants with eczema.
• Use a graded approach at home: start with very small amounts, introduce one food at a time and observe for two hours.
• Ongoing ingestion (at least weekly) is essential to maintain tolerance after successful introduction.

Resources

Several useful resources are available to support families with clear, step-by-step guidance. These include:

• This one-page guide from the Royal Children’s Hospital Melbourne
• This practical take-home handout from the Australasian Society of Clinical Immunology and Allergy (ASCIA).
• Nip Allergies in the Bub offers accessible information for both healthcare professionals and parents.