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Australasian Society of Clinical Immunology and AllergyAllergy and Immunology2026intermediate

ASCIA Guideline: Infant Feeding for Food Allergy Prevention.

Published by Australasian Society of Clinical Immunology and Allergy (ASCIA) · GRADE

16Recommendations
53References
1Tables

Summary

AI-generated

This clinical practice guideline from the Australasian Society of Clinical Immunology and Allergy (ASCIA) provides 16 updated recommendations on infant feeding for the prevention of IgE-mediated food allergies. Key recommendations include introducing solid foods around 6 months of age (and not before 4 months) when developmentally ready, followed shortly by introducing well-cooked egg and age-appropriate peanut. Other common food allergens in the family diet should be introduced in the first year of life and offered weekly once introduced. Standard cow's milk-based formulas are preferred if breastfeeding is not possible, while hydrolyzed, soy-based, or alternative protein formulas are not recommended for allergy prevention. Additionally, mild perioral rashes should not be misidentified as allergic reactions, and testing food on the skin is discouraged.

Infant feedingFood allergy preventionPeanut introductionEgg introductionComplementary feedingAllergy preventionASCIA

Key Takeaways

  • 1
    Introduce solid foods when the infant shows signs of developmental readiness, usually around 6 months and not before 4 months of age.
  • 2
    Include well-cooked egg and age-appropriate peanut soon after starting solid foods, regardless of personal or family allergy risk status.
  • 3
    Introduce other common food allergens in the first year of life, prioritizing foods from the family diet, and offering only one new allergen per meal.
  • 4
    Continue to offer introduced food allergens at least once a week to maintain tolerance.
  • 5
    Maternal dietary restriction during breastfeeding is not recommended for food allergy prevention.
  • 6
    Hydrolyzed, soy-based, or alternative protein formulas are not recommended for food allergy prevention.
  • 7
    A mild perioral rash without other symptoms is likely contact irritation, not a systemic allergic reaction; parents should apply barrier cream and retry.
  • 8
    Do not smear food on the skin to test for allergy, as it can cause irritation and increase the risk of allergic sensitization.

What's New in This Version

Key changes from the 2016 ASCIA guideline include: specific recommendations regarding the timing of peanut and egg introduction soon after solids start; a new recommendation regarding perioral rashes to prevent unnecessary food elimination and support primary healthcare providers; updated guidance on the frequency of offering common food allergens (at least once a week); and clarification that infant formulas (hydrolyzed, soy, alternative proteins) are not recommended for allergy prevention.

Key Recommendations

3.1 Timing of Introduction of Complementary Foods

  • Recommendation 1

    Solid food introduction is recommended when the infant is showing signs of developmental readiness. This is usually around 6 months of age and not before 4 months of age.

    Moderate certainty of evidenceEvidence: ModerateComplementary Feeding

3.2 Introduction of Common Food Allergens

  • Recommendation 2

    When introducing new common food allergens, only introduce one new allergen at the same meal. This allows the trigger food to be more easily identified if there is an allergic reaction.

    Expert consensus (95% consensus in Round 2)Evidence: Expert consensusDietary Guidance / Food Allergen Introduction
  • Recommendation 3

    Well cooked egg should be included in the infant's diet soon after the infant has started solid foods.

    High certainty evidence (for decreased risk of egg allergy); recommendation based on balance of benefits and harmsEvidence: ModerateDietary Guidance / Food Allergen Introduction
  • Recommendation 4

    Peanut, in an age-appropriate form such as smooth peanut butter, finely ground peanut or peanut flour, should be included in the infant's diet soon after the infant has started solid foods.

    High certainty evidence (for decreased risk of peanut allergy); recommendation based on balance of benefits and harmsEvidence: ModerateDietary Guidance / Food Allergen Introduction
  • Recommendation 5

    Parents or carers should introduce other common food allergens in the first year of life, prioritising foods included in the family's usual diet. This includes cow's milk, wheat, tree nuts (such as cashew and walnut), sesame, soy, fish and shellfish.

    Weak/Limited evidenceEvidence: Very lowDietary Guidance / Food Allergen Introduction
  • Recommendation 6

    If there is an allergy to a specific food, other common food allergens should still be introduced into the infant's diet.

    Expert consensus (92% consensus in Round 1)Evidence: Expert consensusDietary Guidance / Food Allergen Introduction
  • Recommendation 7

    A mild perioral rash (redness or contact urticaria) which appears during or immediately after food consumption, without any other symptoms of allergy, may not be a sign of an allergic reaction. Parents and carers should be encouraged to try the food again. If more generalised symptoms develop upon subsequent consumption, parents or carers should seek specialist medical advice before re-trialling that food.

    Expert consensus (83% consensus in Round 1)Evidence: Expert consensusClinical Management / Guidance
  • Recommendation 8

    Food should not be smeared onto the skin to test if an infant is allergic, as food can cause irritation and/or redness/contact reactions, which does not indicate an allergy to the food. Furthermore, frequent skin contact to food allergens without consumption may be a risk factor for allergic sensitisation.

    Expert consensus (83% consensus in Round 1)Evidence: Expert consensusAvoidance of Harm

3.3 Ongoing Feeding of Common Food Allergens Once Introduced

  • Recommendation 9

    Once a common food allergen has been introduced, unless the infant has an allergic reaction to the food, the food should continue to be offered to the infant at least once a week.

    Expert consensus (96% consensus in Round 2)Evidence: Expert consensusOngoing Feeding / Dietary Maintenance
  • Recommendation 10

    Once introduced, if there are no signs of an allergic reaction, egg should continue to be offered to the infant at least once a week.

    Expert consensus (91% consensus in Round 2)Evidence: Expert consensusOngoing Feeding / Dietary Maintenance
  • Recommendation 11

    Once introduced, if there are no signs of an allergic reaction, peanut should continue to be offered to the infant at least once a week.

    Expert consensus (91% consensus in Round 2)Evidence: Expert consensusOngoing Feeding / Dietary Maintenance

3.4 Breastfeeding and Breastmilk Substitutes

  • Recommendation 12

    It is not necessary to remove common food allergens from the diet of breastfeeding mothers to prevent food allergy.

    Expert consensus (83% consensus in Round 1)Evidence: Expert consensusMaternal Dietary Guidance
  • Recommendation 13

    Hydrolysed (partially and extensively) infant formula is not recommended for the prevention of food allergy.

    Recommendation based on lack of consistent convincing evidenceEvidence: Very lowFormula Feeding Guidance
  • Recommendation 14

    Soy-based infant formula is not recommended for the prevention of food allergy.

    Recommendation based on lack of evidenceEvidence: Very lowFormula Feeding Guidance
  • Recommendation 15

    Due to a lack of evidence, infant formula based on alternative proteins is not recommended for food allergy prevention. This includes infant formula based on goat milk, sheep milk, rice, oat, pea or coconut protein.

    None of these formulas studied in the context of allergy preventionEvidence: Very lowFormula Feeding Guidance
  • Recommendation 16

    In healthy breastfed infants, transient supplementary feeding in the first week of life with cow's milk-based formula should be avoided, unless it is required for a medical reason or regular use is anticipated.

    Weak/Limited evidenceEvidence: Very lowBreastfeeding Support / Formula Feeding Avoidance

Scope & Objectives

Clinical Topic

Infant Feeding for Food Allergy Prevention

Objectives

To provide updated recommendations specifically in relation to infant feeding for food allergy prevention, specifically addressing the use of infant formulas, timing of complementary feeding, timing of introduction of common food allergens, and frequency of inclusion of common food allergens.

Target Patient Population

All infants, including those considered at increased risk of developing a food allergy, such as infants with allergic conditions (e.g., atopic dermatitis or pre-existing food allergies), infants with siblings or parents with allergic conditions and infants born in Australia to recently migrated parents, especially from Asian countries.

Target Providers

Primary healthcare providersChild health nursesDietitiansPharmacistsGeneral practitionersPaediatricians

Patient Criteria & Setting

Therapeutic Area

Allergy and Immunology

Guideline Scope

PreventionDietary Guidance

Inclusion Criteria

  • All infants
  • Infants with increased risk of food allergy (e.g., atopic dermatitis, pre-existing food allergy, or family history of allergic conditions)

Exclusion Criteria

  • Diagnosis of food allergy
  • Management of food allergy
  • Allergy prevention measures not related to infant feeding

Care Settings

Primary CareOutpatientCommunity Health

Special Populations

Infants with eczemaInfants with family history of allergyInfants of recently migrated parents

Evidence Grading

System: GRADE

Evidence Distribution

3Moderate
5Very low
8Expert consensus

Evidence Levels

HighDetermined by systematic reviews of high-quality randomized controlled trials (RCTs). Evidence of high quality.
ModerateDetermined by GRADE assessment in included systematic reviews (e.g., from RCTs with some limitations or strong observational studies).
Very lowDetermined by systematic reviews with high risk of bias, very small sample sizes, or inconsistent/unconvincing results.
Expert consensusDetermined by a formal Delphi consensus process when published evidence was lacking.

Recommendation Strength

Evidence-basedDerived from published scientific evidence evaluated via the AGREE II framework and systematic reviews.
Expert consensusDeveloped through a formal two-round Delphi panel process requiring at least 75% consensus among experts when evidence is lacking.

Safety & Contraindications

Contraindications

  • Transient supplementary feeding with cow's milk-based formula in the first week of life for healthy breastfed infants (unless medically indicated)
  • Commercial allergen introduction products containing several food allergens in the same serving
  • Hydrolysed, soy-based, or alternative protein infant formulas for allergy prevention
  • Smearing food onto the skin to test for allergy
  • Maternal dietary restriction of food allergens during breastfeeding

Monitoring Guidance

Monitor the adherence to infant feeding practices, the timing of introduction of allergenic foods, and the prevalence of food allergy in the population. Parents should monitor for signs of systemic allergic reactions upon food introduction, while distinguishing them from local perioral rashes.

Authors & Contributors

S. L. ValeM. J. NettingC. J. HornungJ. SmithI. RocheV. McWilliamK. HollinsheadC. SouthA. YoungK. RueterK. P. PerrettD. J. PalmerP. JoshiD. E. CampbellJ. J. KoplinL. S. Ford

Guideline Features

Based on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

intermediate

Learning Paths

PediatricsAllergy & ImmunologyInfant NutritionPrimary CareDieteticsFood Allergy Prevention