ABSTRACT
Background
The Australasian Society of Clinical Immunology and Allergy (ASCIA) Guideline: Infant Feeding for Food Allergy Prevention is an update of the 2016 ASCIA guideline. This updated guideline provides recommendations specifically in relation to infant feeding for food allergy prevention.
Methods
A review of the guideline began in 2024, informed by a systematic evidence review process and using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) framework. Where evidence was lacking, a formal Delphi process was used to develop recommendations based on expert consensus. An Expert Writing Group comprising representation from ASCIA, the National Allergy Council, Allergy & Anaphylaxis Australia the National Allergy Centre of Excellence and the Centre for Food Allergy Research was established. Key stakeholder meetings were held.
Results
A systematic review of evidence resulted in 16 recommendations: eight based on published evidence; eight based on expert consensus. ASCIA recommends: In Australia and New Zealand, infants should be introduced to solid foods when they are showing signs of developmental readiness. This is usually around 6 months and not before 4 months of age. Soon after infants have started solid foods, well cooked egg and appropriate forms of peanut are included in the infant's diet. Other common food allergens included in the family diet should be offered to the infant. Once introduced, common food allergens should be offered around once a week. Breastfeeding is encouraged, with no maternal dietary modifications. Breastmilk substitutes based on hydrolysed milk protein, soy or other proteins are not recommended for allergy prevention. Mild perioral rashes which appear around food consumption (redness or contact urticaria with no other symptoms of allergy) may not be a sign of an allergic reaction, and the food should be offered again.
Conclusion
Key changes from the 2016 ASCIA guideline include specific recommendations regarding the timing of peanut and egg introduction, alongside a recommendation regarding perioral rashes to support primary healthcare providers. These guidelines require ongoing review and updating as new evidence emerges.
The 2025 Australasian Society of Clinical Immunology and Allergy (ASCIA) Guideline: Infant Feeding for Food Allergy Prevention supersedes the 2016 ASCIA guideline. Key changes include specific recommendations about the timing of egg and peanut introduction to the infant's diet, alongside a recommendation regarding perioral rashes to support primary healthcare providers.
1. Introduction
1.1. Background
The Australasian Society of Clinical Immunology and Allergy (ASCIA), as the peak medical body for allergy and immunology in Australia and New Zealand, has provided guidance to health professionals and parents about infant feeding relevant to the prevention of IgE‐mediated food allergy since 2005 [1].
ASCIA infant feeding guidance has evolved over time in response to changing evidence [2, 3]. Since 2016, randomised controlled trials (RCTs) and meta‐analyses have indicated that deliberate, timely introduction and continued inclusion of common food allergens, particularly peanut and egg, in the infant diet reduces the risk of developing IgE‐mediated allergies to these foods [4].
This guideline incorporates new evidence related to infant feeding and food allergy prevention using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) framework [5]. Where current evidence is lacking, recommendations are based on expert consensus developed using a Delphi panel process.
This guideline addresses the following in the context of food allergy prevention:
Use of infant formulas.
Timing of complementary feeding.
Timing of introduction of common food allergens.
Frequency of inclusion of common food allergens.
This guideline supports, but does not address:
Breastfeeding: Exclusive breastfeeding is recommended until around 6 months when solid foods are introduced. Breastfeeding should be continued while introducing appropriate solid foods and until 12 months of age and beyond, for as long as the mother and child desire [6].
Role of a varied, diverse diet consistent with the Australian National Health and Medical Research Council (NHMRC) dietary guidelines [7].
Recommendations for food allergy prevention not related to infant feeding. These are addressed in a separate ASCIA document.
This guideline does not address the diagnosis and management of food allergy.
1.2. Who Does the Feeding Guidance Apply to?
This guideline is aimed at 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 [8, 9] (Box 1).
BOX 1. Definitions.
Infant: Up to 1 year of age.
Complementary feeding (used interchangeably with ‘introduction of solid foods’): The process of introducing foods and liquids alongside breastfeeding (or infant formula if applicable) when breastmilk (or infant formula) no longer meets the nutritional requirements of infants [10].
Common food allergens: In Australia, the common food allergens include milk, egg, peanut, tree nuts, wheat, soy, sesame, fish and shellfish.
Developmental readiness: Signs of readiness to eat solid foods that appear in most infants from 4 to 6 months of age include being able to sit supported and hold their head steady; swallow food, rather than spit it back out; coordinate eyes, hands and mouth so they can look at the food, open their mouth ready to receive the food; and show interest in parents or caregivers eating [11].
Responsive feeding: Parents or caregivers observing and responding to their infant's feeding cues, offering food and drink without coercion [12].
Safe food practices: Feeding children under 4 years of age only food that they are capable of chewing and swallowing with ease and supervision while they are eating. Foods to be avoided include hard foods such as nuts (whole or pieces), raw vegetables and whole grapes [13]. Other foods which have a risk of bacterial contamination should also be avoided in infancy, such as raw eggs and honey [6].
Timely introduction: The introduction of common allergy causing food within the timeframe stipulated in the recommendation.
2. Methods
ASCIA published guidelines for infant feeding and allergy prevention in 2016. In 2020, minor updates were made to include reference to the Nip allergies in the Bub program, which is a National Allergy Council public health program to support food allergy prevention [14], and for consistency with other ASCIA resources. A review of the guidelines began in 2024, informed by a systematic evidence review process and use of the AGREE II tool to underpin guideline development. Where evidence was lacking, a Delphi process was used to develop recommendations based on expert consensus.
2.1. Stakeholder Involvement
Stakeholder meetings were held to define the scope and review process:
An initial stakeholder meeting was held in August 2023. Representatives from ASCIA, the National Allergy Council (NAC), Allergy & Anaphylaxis Australia (A&AA), the National Allergy Centre of Excellence (NACE) and the Centre for Food Allergy Research (CFAR) discussed how NACE/CFAR would conduct the evidence synthesis to underpin the guideline update. It was agreed the evidence review and guideline update would focus on recommendations related to inclusion of common food allergens in the infant diet for food allergy prevention, as this was the key area where new high‐quality evidence had been published since 2016.
NAC, ASCIA, A&AA, NACE and CFAR hosted a joint in‐person meeting in March 2024. Key representatives from these organisations participated. Results of the evidence review were presented by CFAR/NACE. Recommendations were drafted where sufficient evidence was available, and statements for the Delphi panel were drafted where expert consensus was required.
Following the in‐person meeting, an Expert Writing Group was established to finalise the guideline, comprising representation from ASCIA, NAC, A&AA, NACE and CFAR.
2.2. Evidence Review
2.2.1. Timing of Complementary Feeding and Introduction to Common Food Allergens
A systematic approach to identify relevant evidence, including two overviews of systematic reviews conducted in collaboration with national and international research partners, was utilised by CFAR and NACE researchers. The aims of these systematic reviews and their methods for identifying and selecting evidence have been published [15, 16] and are described in the following two paragraphs. Additional targeted searching in February 2024 aimed to identify any relevant evidence not covered in these overviews.
An overview of reviews examining systematic review evidence on the short and long‐term health outcomes (including food allergy) of the timing of introduction of complementary foods including common food allergens was conducted by Soriano et al. [15]. The authors searched MEDLINE (via Ovid), Embase, Cochrane Database of Systematic Reviews, PubMed and reference lists of included studies. This overview included 32 systematic reviews examining RCT and/or observational studies. Methodological quality and risk of bias of the included reviews were appraised using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2 tool) [17] and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) [18] assessments were performed.
To examine the more targeted question of the effects of timing of complementary feeding on the occurrence of allergic sensitisation and disease, Kuper et al. conducted an overview of reviews [16]. This overview included 11 systematic reviews examining 48 RCTs. Methodological quality and risk of bias of the included reviews were appraised using the AMSTAR 2 and Risk of Bias in Systematic Reviews (ROBIS) [19] tools [16, 20]. For each relevant primary outcome, risk of bias using the Cochrane RoB 2.0 tool [21] and certainty of evidence according to the GRADE approach were extracted from the systematic review or assessed by the overview authors as required.
2.2.2. Breastmilk Substitutes (Infant Formula)
Previous ASCIA guidelines included specific recommendations about use of infant formulas, including partially hydrolysed formula in the context of allergy prevention. Whilst these recommendations have not changed from the previous version of the guidelines, we have included reference to more recent systematic review evidence where this was available to support the recommendations in this guideline.
The impact of transient use of cow's milk formula in the first week of life has emerged as a new issue [10] and was included in the evidence review to support the recommendation included in this guideline.
2.3. Formulation of Recommendations and Consensus Statements
At the in‐person stakeholder meeting, the scope of the guideline was confirmed, and recommendations were drafted where sufficient evidence was available.
Where evidence was lacking, recommendations for a Delphi panel process were proposed. A total of 26 participants from the in‐person meeting held in March 2024 were invited to participate in the Delphi Panel; 23 participated in Round 1 and 24 participated in Round 2. Eight recommendations were included in the Delphi process and two Delphi panel rounds were undertaken to achieve at least 75% consensus for each recommendation.
2.4. Procedure for Updating Guidelines
This guideline is due to be updated in July 2028 or earlier if new evidence emerges requiring the guideline to be reviewed. Updates will be informed by living evidence surveillance and synthesis conducted by CFAR and the NACE [22].
2.5. Guideline Implementation
To identify sources of infant feeding and allergy prevention information and to assess interpretation of proposed recommendations, the NAC conducted 11 focus groups in July and August 2024. Healthcare professionals (child health nurses, dietitians and pharmacists) participated in two focus groups. Nine focus groups were conducted with parents: five with parents with a family history of allergy and four with parents who had no family history of allergy. Two focus groups specifically recruited parents with Asian ethnicity, and one focus group was specifically for fathers. Approval to conduct the focus groups was provided by the University of Western Australia Human Research Ethics Committee (2024/ET000377). Thematic analysis using NVivo Software was undertaken by two members of the research team, and the findings will support implementation of these guidelines.
3. Recommendations
3.1. Timing of Introduction of Complementary Foods
These recommendations intend to provide guidance about when to introduce any complementary foods.
3.1.1. 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.
3.1.1.1. Reason for Recommendation
National infant feeding guidelines in Australia and New Zealand recommend that solid foods should be introduced at around 6 months of age [6, 23].
An overview of reviews [15] found moderate certainty evidence that there is no association between timing of introduction of complementary foods and the development of food allergy. This is consistent with the findings of four previous systematic reviews [24, 25, 26, 27]. There is also no evidence that introduction of common food allergens prior to 4 months, compared with introduction at 4–6 months, is associated with lower rates of allergy to these foods. There is some evidence that introduction of complementary foods before 4 months of age may increase the risk of obesity [15, 28] and be associated with a higher rate of infection [29].
3.1.1.2. Strength of Recommendation
Moderate certainty of evidence, based on GRADE assessment in included systematic reviews [15, 27].
3.1.1.3. Practical Implications
Solid food introduction should begin when an infant is developmentally ready. Like other developmental milestones, this occurs within a range of ages and parents should be responsive to their infant's feeding cues. Most infants are ready to start solid foods between 5 and 7 months [30].
3.2. Introduction of Common Food Allergens
These recommendations intend to provide guidance about the timing and method of introduction of common food allergens in an infant's diet to promote tolerance to these foods. Once an infant has started solid foods, food allergens should be included as part of their diet.
Specific recommendations are made for egg and peanut as there are sufficient levels of evidence. The optimal timing of introduction of cow's milk, wheat, soy and tree nuts is not known. Because of this knowledge gap, specific recommendations for these foods (except not delaying introduction) are not made.
Recommendations 6–8 address questions regarding the introduction of common food allergens that are regularly asked by carers and healthcare providers of infants in whom there is already concern for allergy to a particular food or particular concern for food allergy in general.
3.2.1. 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.
3.2.1.1. Reason for Recommendation
This will allow the specific food allergen to be identified if an allergic reaction occurs.
3.2.1.2. Strength of Recommendation
Expert consensus.
3.2.1.3. Practical Implications
Commercial allergen introduction products containing several food allergens in the same serve are not recommended.
3.2.2. Recommendation 3
Well cooked egg should be included in the infant's diet soon after the infant has started solid foods.
3.2.2.1. Reason for Recommendation
The most recent systematic review of this topic identified is the 2023 review by Scarpone et al. [4, 16]. The findings, described below, are consistent with previous systematic reviews but include higher certainty of evidence with the addition of data from newly published RCTs [31, 32].
A meta‐analysis of 9 trials (4811 participants) reported that earlier introduction of egg between 3 and 6 months of age, compared with later introduction, was associated with a decreased risk of egg allergy (RR 0.60; 95% CI, 0.46–0.77; I 2 = 0%) [4]. Evidence was assessed as high certainty by GRADE. Individual studies used different protocols, including different forms of egg, different risk groups (and different definitions of high and low risk) and different timings of introduction in both the intervention and control groups (Appendix S2).
3.2.2.1.1. High and Low Risk Groups
There is evidence from a post hoc subgroup analysis that earlier introduction of egg was associated with a reduced risk of egg allergy in high risk (defined by Scarpone et al. as family or personal history of allergy) infants (n = 5 studies, 1361 participants, RR 0.53, 95% CI 0.37–0.75) [4]. Although the reduction in egg allergy in the standard/low risk group (n = 4 studies, 3450 participants) was not significant (RR 0.73, 95% CI 0.45–1.17), there was no evidence that the effectiveness of this intervention differed between risk groups (p = 0.29). Therefore, ASCIA recommends timely introduction of egg for infants irrespective of their family or personal history of allergy.
3.2.2.1.2. Specific Timing Windows
Of the 9 egg introduction trials, 6 compared introduction of egg before age 6 months with introduction at 6 months or beyond. Specifically, these trials compared introduction at 3 months (n = 1), 3–4 months (n = 2) and 4–6 months (n = 3) with introduction after 6 months.
Translating this into practice is difficult as many of the trials that contributed to this evidence base reporting high participant compliance with ingestion of egg from 4 to 6 months, used pasteurised raw egg powder which has a different texture to cooked egg, thus easier to eat. However, the only trials reporting a significant reduction in egg allergy were the two trials from Japan using heated egg powder [31, 33]. There is a practical infant feeding development issue as most infants cannot manage the texture of well‐cooked egg before 6 months of age. This was highlighted by the very poor compliance with early egg consumption in the EAT Trial [34].
3.2.2.2. Strength of Recommendation
There is high certainty evidence that timely introduction of egg is associated with a decreased risk of egg allergy. The evidence of a benefit is less clear for ‘standard/low risk’ infants compared to ‘high risk’ infants. However, studies use different definitions of ‘high risk’, and differing recommendations based on risk profile may cause confusion for parents, carers and healthcare providers.
Evidence supports introduction of egg around 4–6 months of age, rather than earlier or later. In Australia, most infants start solid foods in the 5th month of age [35]. The recommendation that well cooked egg should be introduced soon after the infant has started solid foods is based on the balance of benefits and harms and supports introduction once the infant is developmentally ready and accepting solid food.
3.2.2.3. Practical Implications
Well cooked egg should be included in the diet, soon after the infant has started solid foods. Egg is a source of protein and dietary iron [36]. Well cooked egg is recommended compared to raw or lightly cooked egg as it is less likely to cause an allergic reaction [37]. Raw egg also carries a risk of food borne infections [38].
When introduced, egg should be offered in a form that is suitable for the infant's oro‐motor skills, such as mashed well cooked egg mixed with mashed vegetables.
Infants with eczema—particularly moderate to severe—within the first months of life are at higher risk of developing an egg allergy [39]. The recommendation to introduce well cooked egg into the diet, once solid foods have been introduced at around 6 months of age, also applies to these infants. Eczema should be well managed.
3.2.3. 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.
3.2.3.1. Reason for Recommendation
The most recent systematic review identified is the 2023 review by Scarpone et al. [4, 16].
A meta‐analysis of 4 trials (3796 participants) showed that earlier introduction of peanut, between 3 and 10 months of age, was associated with a decreased risk of peanut allergy (RR 0.31 95% CI 0.19–0.51, I 2 = 21%). Evidence was assessed as high certainty by GRADE. Details of individual study protocols are provided at the end of this document (Appendix S3).
3.2.3.1.1. High and Low Risk Groups
A post hoc subgroup analysis of these 4 trials showed that this reduced risk of peanut allergy occurred in both high risk and standard/low risk infants [4]. Therefore, ASCIA recommends timely introduction of peanut for infants irrespective of their family or personal history of allergy.
3.2.3.1.2. Specific Timing Windows
Of the 4 trials of early peanut introduction, 3 compared introduction starting before age 6 months with introduction at ≥ 6 months. Specifically, these trials compared introduction at 3 months (n = 1) and 3–4 months (n = 2) with introduction ≥ 6 months.
A post hoc analysis of data from the LEAP [40] and EAT [34] trials modelled the effects of early introduction of peanut at different times. Results suggested that prevention decreased with increasing age at introduction, from 4 to 12 months of age [41]. Based on these results, the authors recommended peanut introduction at 4–6 months of age rather than earlier or later [41].
3.2.3.2. Strength of Recommendation
There is high certainty evidence that timely introduction of peanut is associated with a decreased risk of peanut allergy. There is evidence of a benefit for all infants including those considered to be at high risk of developing peanut allergy.
Evidence supports introduction of peanut around 4 to 6 months of age, rather than earlier or later. In Australia, most infants start solid foods in the 5th month of age [35]. The recommendation that peanut should be introduced soon after the infant has started solid foods is based on the balance of benefits and harms and supports introduction once the infant is developmentally ready and accepting solid food.
3.2.3.3. Practical Implications
Peanut should be included in the diet, soon after the infant has started solid foods in a developmentally appropriate form. Peanut is a plant‐based protein and a source of dietary iron. Peanut should be introduced in a form that is appropriate for the infant's oro‐motor skills such as thinned smooth peanut paste, finely crushed peanut or powdered peanut mixed with food that the infant tolerates.
3.2.4. 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.
3.2.4.1. Reason for Recommendation
There is emerging evidence that introducing other common food allergens in the first year of life promotes tolerance to these foods and prevents the development of food allergy.
Meta‐analysis of 4 trials (3295 participants) showed moderate‐certainty evidence that introduction of multiple food allergens between ages 2 and 12 months (median age 3–4 months) was associated with decreased risk of ‘any food allergy’ from 1 to 3 years of age (RR 0.49, 95% CI 0.33–0.74, I 2 = 49%) [4]. However, there was also moderate‐certainty evidence that this intervention was associated with risk of withdrawal from the trials, possibly due to the inability of infants to eat the texture and quantities of the trial intervention foods especially before 6 months of age (5 trials [4703 participants]; RR 2.29, 95% CI 1.45–3.63, I 2 = 89%) [4].
More specific evidence around optimal timing of introduction of individual common food allergens other than peanut and egg is still limited.
Meta‐analysis of 6 trials (3900 participants) indicated no association between earlier introduction of cow's milk, between the first day of life and age 4 months, and risk of cow's milk allergy (RR 0.84, 95% CI 0.38–1.87, I 2 = 36%) with very low‐certainty evidence. Most information was from studies with high risk of bias [4].
Some trials examined tree nut, wheat, soy, fish and shellfish introduction, usually as part of a multiple food allergen introduction intervention; however, only small numbers of participants developed allergy to these foods. Meta‐analysis of 3 trials for timing of wheat introduction and wheat allergy found no evidence for a difference between groups (3 trials [3169 participants]; RR 0.66 95% CI 0.10–4.47, I 2 = 2%). There was insufficient data to conduct meta‐analysis for tree nut, soy, fish and shellfish allergy outcomes [4].
Sesame was not examined in the review by Scarpone et al. An earlier systematic review published in 2019, which included both observational studies and RCTs, concluded that there was limited evidence for an association between timing of introduction of sesame and sesame allergy [27].
3.2.4.2. Strength of Recommendation
There is convincing evidence that delayed (later than 12 months) introduction of common food allergens does not reduce food allergy risk; however, there is limited evidence as to whether earlier introduction of foods (other than peanut or egg) reduces the risk of food allergy. Based on immunological first principles and evidence from egg and peanut trials, the panel agreed that including other common food allergens in the diet from 4 to 6 months of age had potential benefits that outweighed any risks, but does not recommend a specific timeframe beyond ‘in the first year of life’.
3.2.4.3. Practical Implications
Common food allergens that are regularly included in the usual family diet should also be offered regularly to the infant. Environmental exposure to food allergens in the household without being eaten by the infant may be a risk factor for development of allergy [42, 43].
Once introduced, it is easier to maintain the food allergens in the infant's diet when those foods are regularly eaten by the rest of the family. This promotes consumption of a diverse range of foods and is consistent with NHMRC infant feeding guidelines that recommend that by 1 year of age children should be consuming a modified family diet [6].
3.2.5. Recommendation 6
If there is an allergy to a specific food, other common food allergens should still be introduced into the infant's diet.
3.2.5.1. Reason for Recommendation
If an infant has a food allergy to one food, delaying the introduction of other food allergens may increase the chance of an infant developing allergies to those foods.
3.2.5.2. Strength of Recommendation
Expert consensus.
3.2.6. 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.
3.2.6.1. Reason for Recommendation
Removing a food when it is unlikely that the reaction is allergy based may increase the likelihood of developing an allergy to that food.
3.2.6.2. Practical Implications
To protect the perioral area, barrier cream application prior to eating/feeding can be used to reduce the risk of irritation from direct food contact. This particularly applies for infants and young children with perioral eczema.
3.2.6.3. Strength of Recommendation
Expert consensus.
3.2.7. 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.
3.2.7.1. Reason for Recommendation
Many foods can cause local perioral irritation/redness if they contact the skin. This does not indicate an allergic reaction.
3.2.7.2. Strength of Recommendation
Expert consensus.
3.3. Ongoing Feeding of Common Food Allergens Once Introduced
There is limited evidence about the frequency of food allergen exposure in the diet, including egg and peanut consumption, required to maintain tolerance, so statements related to frequency were developed based on expert consensus.
3.3.1. 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.
3.3.1.1. Reason for Recommendation
Introducing a food allergen and then not offering it regularly may be associated with the development of food allergy, and consuming a range of food allergens at least once per week was considered to be practical for families.
3.3.1.2. Strength of Recommendation
Expert consensus.
3.3.2. 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.
3.3.2.1. Reason for Recommendation
Regular consumption may be important to maintain tolerance and consuming a range of food allergens at least once per week was considered to be practical for families.
3.3.2.2. Strength of Recommendation
Expert consensus.
3.3.3. 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.
3.3.3.1. Reason for Recommendation
Regular consumption may be important to maintain tolerance and consuming a range of food allergens at least once per week was considered to be practical for families.
3.3.3.2. Strength of Recommendation
Expert consensus.
3.4. Breastfeeding and Breastmilk Substitutes
ASCIA guidelines state that standard cow's milk‐based formula can be used if breastfeeding is not possible [3]. Recommendations about breastfeeding and infant formula are provided based on evidence where available and expert consensus where there is a paucity of evidence.
3.4.1. Recommendation 12
It is not necessary to remove common food allergens from the diet of breastfeeding mothers to prevent food allergy.
3.4.1.1. Reason for Recommendation
Removing common food allergens from the breastfeeding mother's diet has not been shown to prevent the development of food allergies in the infant and may compromise the mother's nutrition.
3.4.1.2. Strength of Recommendation
Expert consensus.
3.4.2. Recommendation 13
Hydrolysed (partially and extensively) infant formula is not recommended for the prevention of food allergy.
3.4.2.1. Reason for Recommendation
This recommendation is consistent with statements in previous versions of the ASCIA guidelines, based on a 2016 systematic review that reported no consistent convincing evidence to support partially or extensively hydrolysed formulas for prevention of food allergy [44]. This is consistent with the findings of two more recent systematic reviews [10, 45].
3.4.2.2. Strength of Recommendation
The quality of evidence was assessed as very low by all three systematic reviews.
3.4.2.3. Practical Implications
There is no evidence to support the use of hydrolysed infant formula for food allergy prevention.
3.4.3. Recommendation 14
Soy‐based infant formula is not recommended for the prevention of food allergy.
3.4.3.1. Reason for Recommendation
This recommendation is consistent with statements in previous versions of the ASCIA guidelines, based on a 2006 systematic review that reported no evidence to support soy formula compared to cow's milk‐based formula for the prevention of allergic disease [46]. A more recent systematic review found that soy‐based formulas may have little to no effect on food allergy in early childhood, based on very low certainty evidence [10].
3.4.3.2. Strength of Recommendation
The quality of evidence was assessed as very low by both systematic reviews.
3.4.3.3. Practical Implications
There is no evidence that soy formula reduces the risk of food allergy.
3.4.4. 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.
3.4.4.1. Strength of Recommendation
None of these infant formulas have been studied in the context of allergy prevention.
3.4.5. 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.
3.4.5.1. Reason for Recommendation
A recent systematic review found limited, low certainty evidence (based on a single trial [47]) that avoiding temporary supplementation with cow's milk formula in the first 3 days of life may decrease the risk of cow's milk allergy [10].
3.4.5.2. Strength of Recommendation
Very low.
3.4.5.3. Practical Implications
Avoid transient supplementary feeding with cow's milk‐based formula in the first week of life, unless it is required for a medical reason and given with parental consent.
The 16 recommendations and their certainty of evidence are summarised in Table 1.
TABLE 1.
Summary of recommendations.
| Certainty of evidence | |
|---|---|
| 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 |
| 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% (21/22)—Round 2 |
|
Recommendation 3 Well cooked egg should be included in the infant's diet soon after the infant has started solid foods. |
Moderate |
|
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. |
Moderate |
|
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. |
Very low |
|
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% (22/24) – Round 1 |
|
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% (20/24) – Round 1 |
|
Recommendation 8 Food should not be smeared onto the skin to test if a child 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% (20/24) – Round 1 |
| 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% (22/23) – Round 2 |
|
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% (21/23) – Round 2 |
|
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% (21/23) – Round 2 |
| 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% (20/24) – Round 1 |
|
Recommendation 13 Hydrolysed (partially and extensively) infant formula is not recommended for the prevention of food allergy. |
Very low |
|
Recommendation 14 Soy‐based infant formula is not recommended for the prevention of food allergy. |
Very low |
|
Recommendation 15 Due to a lack of evidence, infant formula based on alternative proteins are not recommended for food allergy prevention. This includes infant formula based on goat milk, sheep milk, rice, oat, pea or coconut protein. |
Very low |
|
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. |
Very low |
4. Implementation
This guideline will be implemented by the NAC (a partnership between ASCIA and A&AA) through the Nip allergies in the Bub program. ‘Nip allergies in the Bub’ is a public health program developed in 2018 with funding from the Australian Government Department of Health and Aged Care [14]. This program includes practical, easy to understand information and resources for parents as well as information and education resources for health professionals.
In addition, ASCIA developed specific resources to support primary healthcare providers.
4.1. Monitoring
Monitoring the uptake of recommendations in the ASCIA guideline, as well as their impact on food allergy prevalence, is important to assess the impact of this prevention guideline.
Changes in infant feeding practices since the 2016 ASCIA guideline was released have been assessed by several Australian studies. The Australian Bureau of Statistics [35] reports on breast feeding initiation and duration, and timing of introduction to solid foods. The EarlyNuts study, a population‐based cross‐sectional study of 12‐month‐old infants in Melbourne Australia, questioned parents about infant feeding and assessed food allergy status at 12 months of age [48, 49]. Parental adherence to the ASCIA guidelines was assessed when the infant was 6, 9 and 12 months of age through a novel national monitoring tool [50]. Timing of introduction to common food allergens was also reported by two other studies [51, 52]. These studies all showed a shift towards earlier introduction of allergenic foods (peanut and egg) in the general population following the introduction of the 2016 ASCIA guidelines. Direct provision of the 2016 ASCIA guidelines to families when their infant was 6 months old was reported to be associated with reduced peanut, egg and cow's milk allergies [53].
It is recommended that ongoing, well‐designed studies be conducted to monitor adherence and impact of this revised guideline.
Author Contributions
S.L.V., M.J.N., J.J.K., C.J.H. and L.S.F. drafted the manuscript. All authors significantly contributed to the review and writing of the manuscript. The authors gratefully acknowledge the contributions of all who attended stakeholder meetings and participated in the Delphi panel which supported the development of this guideline. Stakeholder meeting attendees are listed in Appendix S1. The NACE and CFAR evidence Synthesis Teams acknowledge Dr. Desalegn Shifti's contributions to the evidence summary presented at the in‐person meeting in March 2024.
Funding
This ASCIA guideline has been developed with significant input and support from the NAC, the NACE, CFAR and A&AA. Funding was received from the Australian Government Department of Health, Disability and Ageing. This guideline has not been funded or influenced by commercial organisations. ASCIA does not accept or receive educational grants from specialised infant formula suppliers. These suppliers can be involved as sponsors and exhibitors at ASCIA Annual Conferences, but they do not influence the program content. ASCIA Annual Conference sponsored sessions are held at specified times outside of the main program and clearly titled as sponsored sessions. Unrestricted educational grants from Nutricia and Nestle were received to support implementation of the National Allergy Strategy prior to 2019. The NAC and the NACE are funded by the Australian Government Department of Health, Disability and Ageing and CFAR is a Centre of Research Excellence funded by the NHMRC. KPP is supported by a Melbourne Children's Clinician–Scientist Fellowship and a NHMRC fellowship, GNT2008911. NACE and CFAR are hosted by the Murdoch Children's Research Institute and supported by the Victorian Government's Operational Infrastructure Support Program.
Conflicts of Interest
Dr. Sandra Vale, Dr. Lara Ford, Dr. Catherine Hornung, Dr. Preeti Joshi, A/Prof Jennifer Koplin, Dr. Vicki McWilliam, Dr. Merryn Netting, A/Prof Debbie Palmer, Ingrid Roche, A/Prof Kristina Rueter, Jill Smith, Caroline South and Dr. Angela Young report no competing interests. Prof Dianne Campbell reports personal fees from DBV technologies (part‐time salary) and Westmead Fertility Centre as a member of advisory and governance boards outside the submitted work. Prof Kirsten Perrett has received research grants from Aravax, DBV Technologies, Novartis and Siolta and consultant fees from Aravax, Novartis and RAPT Therapeutics, paid to their institution, outside the submitted work. Jill Smith (ASCIA CEO) reports that ASCIA does not accept or receive educational grants from specialised infant formula suppliers. These suppliers can be involved as sponsors and exhibitors at ASCIA Annual Conferences, but they do not influence the program content. ASCIA Annual Conference sponsored sessions are held at specified times outside of the main program and are clearly titled as sponsored sessions. Unrestricted educational grants from Nutricia and Nestle were received to support implementation of the National Allergy Strategy prior to 2019. Kylie Hollinshead reports that Allergy & Anaphylaxis Australia receives unrestricted educational grants and sponsorship from Nutricia and Nestle. Kirsten Perrett reports that the National Allergy Centre of Excellence receives funding from the Australian Government and has no competing interests. Sandra Vale reports that the National Allergy Council receives funding from the Australian Government and has no competing interests.
Supporting information
Appendix S1: cea70217‐sup‐0001‐AppendixS1.docx.
Appendix S2: cea70217‐sup‐0002‐AppendixS2.docx.
Appendix S3: cea70217‐sup‐0003‐AppendixS3.docx.
Data Availability Statement
The authors have nothing to report.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1: cea70217‐sup‐0001‐AppendixS1.docx.
Appendix S2: cea70217‐sup‐0002‐AppendixS2.docx.
Appendix S3: cea70217‐sup‐0003‐AppendixS3.docx.
Data Availability Statement
The authors have nothing to report.