To Screen Or Not To Screen? Allergy Screening For Babies with Severe Eczema
Some medical organizations' guidelines require allergy screening for babies with severe eczema, before they're introduced to foods like peanut, egg, and milk. But waiting too long for a screening could put them at greater risk for a food allergy. Here's what parents need to know about allergy screening for babies with severe eczema.
If your baby has severe eczema, they’re at the highest risk for developing allergies to foods like peanut, egg, and milk. Introducing your baby to these foods early and often, starting as early as 4 months of age, can help reduce their risk of developing an allergy to these foods.
However, some leading medical organizations, including the NIH and NIAID, require allergy screening before introducing high-risk babies to these foods.
Today, we’ll break down what parents need to know about food allergy screening for eczema babies:
Only some U.S. guidelines require food allergy screening. Guidelines from Canada, Australia, and the UK in addition to recent USDA Guidelines don’t require screening.
Waiting for a screening may put your child at a greater risk for developing food allergies. Because of the current shortage of allergists, the average wait time to see an allergist can be more than 60 days, and during that time, your baby may miss a critical window for prevention. As Dr. Michael R. Perkin, Dr. Scott Sicherer and other medical professionals have stated:
“Reactions at initial introduction are, in their majority, mild and the addition of a screening step may pose a barrier to or delay early peanut introduction.”
It is important to note -- For all other babies (those without severe eczema), early allergen introduction is consistently recommended by leading health organizations.
Introducing allergy-causing foods to babies under 1 year of age is safe, including for babies at high risk.
What is food allergy screening?
When a baby is screened (or tested) for a food allergy, a board-certified allergist uses a skin prick test or an oral food challenge. The food challenge is more reliable than the skin prick test.
In the skin prick test, a baby is given a small amount of a possible food allergen under the skin, and the allergist checks if they develop red bumps (a sign of a possible allergy).
In the oral food challenge, a baby is fed small, gradually increasing amounts of a food that might cause an allergic reaction, and the allergist closely watches for symptoms of a reaction.
Only some U.S. guidelines require food allergy screening.
Clinical guidelines on food allergy prevention don’t all agree about screening for babies with severe eczema (babies at the highest risk for food allergies). However, it is important to note that for all other babies (those without severe eczema and/or an existing allergy) early allergen introduction is recommended and is consistent with leading health organizations starting at 4-6 months of age.
For all other babies (those without severe eczema), early allergen introduction is consistently recommended by leading health organizations.
Notably, the only major clinical guidelines that require screening are from American health organizations. Guidelines from medical organizations in Canada, Australia, and the United Kingdom don’t require screening.
And even among U.S. guidelines, some insist on screening for babies with severe eczema, but others don’t.
These organizations require or strongly recommend screening:
But the USDA's new dietary guidelines for children under 2 don't require screening before introducing peanut and egg to high-risk babies.
Here’s a summary of when each set of guidelines recommends introducing common allergy-causing foods.
Waiting for a screening may put your child at a greater risk for developing food allergies.
Early introduction is key.
Landmark clinical studies (LEAP, EAT, PETIT) show that delaying the introduction of common allergy-causing foods (peanut, egg, milk) increases babies' risk for an allergy to these foods.
Instead, the studies show that introducing these foods to your baby early and often, starting as early as 4-6 months of age, can help reduce your baby's risk for developing an allergy to these foods by up to 80%.
This is because around this age, babies enter a critical immune window where introducing these foods helps babies build up a tolerance to them.
These studies prompted the development of all the clinical guidelines, which recommend early introduction of allergy-causing foods for all babies.
But if your baby has severe eczema, waiting for a screening may put your child at a greater risk for developing food allergies---they might miss the critical immune window.
In the LEAP study, which focused on babies at high risk for peanut allergies, around 9% of the enrolled babies had to be excluded from the study because they likely already had a peanut allergy before the study began. This means that they weren’t introduced to peanut early enough for prevention.
In addition, recent research suggests that the screening guidelines put babies with severe eczema at risk for delaying allergen introduction and therefore, increasing their already high risk of developing food allergies. As stated in the European Journal of Allergy & Clinical Immunology study, “A no-screening approach for Early Peanut Introduction (EPI) has superior health and economic benefits in terms of number of peanut allergy cases prevented.”
“A no-screening approach for Early Peanut Introduction (EPI) has superior health and economic benefits in terms of number of peanut allergy cases prevented.”
This further emphasizes the need to start introduction of allergy-causing foods early -- the earlier the better.
Guidelines recommend the earliest introduction for severe eczema babies.
Also, take a look back at the guidelines that require screening. Most of them (NIH, AAAAI, NIAID, AAP) recommend that babies at high risk for peanut allergies be introduced to peanut at 4-6 months of age.
That's earlier than when these guidelines recommend babies at moderate to lower risk for peanut allergies be introduced to peanut (around 6 months of age for moderate-risk babies, and before 1 year of age for lower-risk babies).
Due to the long wait for food allergy screening, though, it's likely that many high-risk babies will miss the prime introduction window that the guidelines recommend.
There's a shortage of allergists, so screening wait times are long.
In the U.S., there's a shortage of qualified allergists available to screen your baby. Out of 700,000 total practicing doctors, there are only about 5,000 to 6,000 board-certified allergists.
This means wait times to see an allergist can be long. According to a University of San Francisco study, the average wait time to see an allergist is 60 days.
If you live in a rural area, it can be even harder to find an allergist, so your wait time for screening may be even longer.
Because of the shortage of allergists and average wait time, your baby might end up missing the critical immune window for food allergy prevention, and be at a greater risk for developing a food allergy.
Introducing allergy-causing foods to babies is safe.
Thanks to studies, we also know that before age 1 is the safest time to introduce your baby to allergy-causing foods, even if your baby is at high risk. The LEAP, EAT, and PETIT studies, which introduced peanut, egg, and milk to babies early and often, show that feeding your baby these foods before they turn one is safe and effective for preventing food allergies.
Also, a study by Dr. Jonathan Spergel and others found that severe allergic reactions are least common in babies under age 1, and that food allergies did not cause any deaths under the age of 1. The older a child was, the greater the chances that they would develop a severe reaction.
As Dr. Spergel reports, "Babies have the fewest severe allergic reactions of any age group, with the severity of allergic reactions increasing as the child gets older.” (Read more about Dr. Spergel’s study here.)
Several leading doctors also don’t recommend waiting for allergy screening before introducing allergy-causing foods, since early introduction is safe. As Dr. Michael R. Perkin, Dr. Scott Sicherer and other medical professionals have stated , “The [NIAID] panels’ recommendation reflects a conservative approach aiming at reducing the possibility of severe reactions on first introduction. However, no other guideline so far produced [prior to January 2017] is recommending testing for any food (including peanut) before first introduction as reactions at initial introduction are, in their majority, mild and the addition of a screening step may pose a barrier to or delay early peanut introduction. It is hoped that physician and parent surveys will be conducted in the next few years that will offer answers to this guideline discrepancy and will allow for appropriate adjustments."
To screen or not to screen?
We want to help parents of babies with severe eczema make informed decisions about introducing their baby to allergy-causing foods.
Although several sets of U.S. guidelines recommend that high-risk babies get screened for allergies before starting early introduction, landmark studies have shown that early introduction, starting as early as 4 months of age, is safe and effective for babies at all risk levels.
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