Food Introduction & Allergen Tracker

When should I start my baby on solids?

Between 4 and 6 months when your baby shows developmental readiness. AAP, NHS Start4Life, and WHO converge on this window. Earlier than 17 weeks too early; waiting past 26 weeks doesn’t protect against allergy and may increase iron deficiency.

What are the three NHS readiness signs?

1. Sits up and holds head steady (with support is fine).
2. Coordinates eyes, hands, mouth — looks at food, picks it up, gets it to mouth themselves.
3. Can swallow food rather than push it back out with tongue thrust.

ALL THREE present = ready. Common false signs: chewing fists, watching you eat, waking at night more, demanding bigger feeds — these are NOT readiness signs.

What are the 9 priority allergens?

• Peanut
• Tree nuts (almond, cashew, walnut, hazelnut, etc.)
• Egg
• Cow’s milk dairy
• Wheat
• Soy
• Sesame
• Fish (salmon, cod, tuna)
• Shellfish (prawns, crab, lobster)

Introduce all 9 between 4-6 and 12 months. Maintain regular intake (2-3 times/week each) for ongoing tolerance — sporadic exposure can lose tolerance.

How do I introduce peanut safely?

1. Use SMOOTH peanut butter mixed into familiar food (yoghurt, oatmeal, purée) or Bamba puffs.
2. NEVER whole peanuts or large blobs of stiff peanut butter — choking hazard.
3. Tiny smear on lip first; wait 10 minutes.
4. If no reaction, give teaspoon-sized portion.
5. Give in first half of day so any reactions show during waking hours.
6. HIGH-RISK INFANTS (severe eczema OR existing egg allergy): NIAID recommends allergist evaluation BEFORE first introduction.
7. Once tolerated, aim for ~2 g peanut protein, 2-3 times/week, for ongoing tolerance.

Why early allergen introduction?

The LEAP trial (Du Toit, NEJM 2015): 640 high-risk infants randomised to early peanut vs avoidance — early intro produced an 86% relative risk reduction in peanut allergy at age 5. The EAT trial (Perkin, NEJM 2016) extended this to six allergens. The 2017 NIAID Addendum Guidelines and 2021 EAACI consensus now recommend introducing peanut and other priority allergens between 4-6 months. Delaying past 6 months no longer has a protective rationale.

What's a normal reaction vs allergy?

• Mild reaction (common, usually self-limits): few hives around mouth, mild perioral redness, one or two vomits.
• Severe reaction (anaphylaxis — 999 EMERGENCY): hives spreading beyond mouth, lip/tongue/face swelling, repetitive vomiting, cough or wheeze, voice change, lethargy, pallor, blue lips.

Mild reactions still prompt a call to GP and allergy referral before further introductions of that food. NEVER avoid all common allergens after a single mild reaction.

What foods are absolute 'no's?

• Honey — until 12 months (infant botulism risk).
• Salt / stock cubes — under 12 months kidneys can’t handle (> 1 g/day).
• Sugar — first year about palate development; no added sugar.
• Whole nuts — choking hazard until ~5 years (use nut butters thinned).
• Raw / undercooked eggs without British Lion mark.
• Raw shellfish, undercooked meat.
• Unpasteurised cheese until 12 months.
• Large fish high in mercury (shark, swordfish, marlin).
• Oily fish max 2 portions/week.
• Rice milk under 4-5 years (arsenic levels).

What are the choking hazards?

• Whole nuts (any age).
• Whole grapes / cherry tomatoes (always QUARTER LENGTHWAYS).
• Large chunks of raw apple, carrot (steam or grate when starting).
• Sausages / hot dogs (slice lengthways then halve).
• Popcorn, hard sweets, chewing gum, marshmallows, lollipops.
• Fish with bones.

Learn paediatric first aid — gagging vs choking look very different and are managed differently.

Gagging vs choking — the difference

• Gagging: NORMAL and PROTECTIVE. Baby coughs, may go red, leans forward, pushes food out. NOISY. Don’t interfere — let them handle it. The gag reflex is much further forward in babies than adults, so they gag more.
• Choking: BLOCKED airway. SILENT or weak squeaky cough, can’t cry, going blue. EMERGENCY. Back blows + chest thrusts for under-1; back blows + abdominal thrusts for over-1. 999 if you can’t clear.

Different scenarios — common situations

Scenario 1: 5-month-old, severe eczema, parents have peanut allergy

High-risk infant. NIAID recommends allergist evaluation BEFORE first peanut introduction. Other allergens can be introduced per standard guidance.

Scenario 2: 6-month-old happily eating, hasn’t had peanut yet

Time to introduce. Smooth peanut butter mixed into yoghurt or porridge. Small smear first, wait 10 min, then teaspoon-sized portion. Once tolerated, regular 2-3 times/week.

Scenario 3: Baby develops hives around the mouth after egg

Mild reaction. Pause egg. GP review and allergy clinic referral. Don’t avoid all allergens — continue introducing the others. Egg is often successfully reintroduced under specialist guidance.

Scenario 4: Toddler gagging during baby-led weaning

Normal. Don’t interfere if they’re coughing/red but breathing. Stay close, stay calm. If silent and blue = choking emergency.

Scenario 5: 9-month-old not interested in solids

Common phase. Keep offering without pressure. Continue milk feeds. Different textures / temperatures. Mealtime in social context. Refer to HV / GP if persistent food aversion or growth concern.

Care guidance — weaning well

• Iron-rich foods early (red meat, lentils, fortified cereal).
• Combine plant iron with vitamin C for absorption.
• Avoid giving milk with iron-rich meals.
• One new food at a time in early days (3-5 day rule for non-allergens).
• Allergens introduced and MAINTAINED 2-3 times/week.
• Family meals when possible.
• Pre-cut high-risk choking foods properly.
• Always supervise eating.
• Continue breastmilk / formula as main calorie source until 12 months.
• Vitamin D drops for breastfed and combo-fed babies.

Sources

• Du Toit G, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy (LEAP). N Engl J Med 2015.
• Perkin MR, et al. Randomized trial of introduction of allergenic foods (EAT). N Engl J Med 2016.
• Togias A, et al. Addendum guidelines for the prevention of peanut allergy in the United States. NIAID Sponsored Expert Panel. 2017.
• EAACI. Position paper on the prevention of food allergy. 2021.
• Daniels L, et al. BLISS Study: Outcomes of baby-led weaning. Pediatrics 2018.
• NHS Start4Life. Your baby’s first solid foods.
• Greer FR, et al. AAP. The Effects of Early Nutritional Interventions on the Development of Atopic Disease. Pediatrics 2019.