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A systematic review of infant feeding food allergy prevention guidelines – can we AGREE?

Open AccessPublished:May 29, 2021DOI:https://doi.org/10.1016/j.waojou.2021.100550

      Abstract

      Food allergy is a significant issue worldwide, particularly in Westernised countries. There is no clear explanation why food allergy appears to have increased so rapidly in recent years, particularly in young children, hence ongoing research to identify effective primary prevention strategies. Food allergy prevention guidelines for health professionals have been developed based on existing clinical trial evidence for effective translation and implementation. As these guidelines underpin clinical practice, it is important to ensure robust processes of development. We conducted a systematic review to identify food allergy prevention guidelines for health professional use; to compare the recommendations made by the identified guideline documents; and to assess the quality of the identified guideline documents.
      We searched Medline, EMBASE, CINAHL, Scopus, Global Health and Guidelines International Network for the period 1990 to 13 August 2019, to identify articles referring to English-language food allergy prevention guidelines or the guidelines themselves. A grey literature search of Google Scholar and reference checking was also undertaken. The guidelines were compared for recommendation similarities and differences. An Appraisal Guidelines for Research and Evaluation (AGREE II) appraisal was undertaken to assess guideline quality.
      The electronic database search yielded 1121 publications and reference checking identified an additional 16 publications. After title, abstract and full text screening, data extraction was undertaken on 156 publications and with additional reference checking, 28 food allergy prevention guidelines and advice documents were identified. Comparison of the recommendations within the guidelines and advice documents indicated the greatest variation in recommendations related to exclusive breastfeeding and timing of solid food introduction. Eight of the 10 guidelines and none of the 18 advice documents met the quality threshold set by the reviewers. Overall, documents specifically termed "guidelines" scored better than advice documents when assessed using the AGREE II tool.
      Variation in recommendations may create confusion for health professionals and result in inconsistent advice being provided to parents, and less translation of the evidence into actual food allergy reduction in the population. Appraisal using the AGREE II tool identified that there is considerable room for improvement in the development of guidelines and advice documents for food allergy prevention. The AGREE II appraisal identified common areas of poorer quality development and/or documentation of processes to inform future guideline development. Based on this study, we recommend the use of validated guideline development tools, to direct food allergy prevention guideline review or development. Use of the AGREE II tool, to direct the review and development of guidelines, is very likely to improve guideline quality.

      Keywords

      Introduction

      Food allergy is a significant issue worldwide, particularly in Westernised countries.
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      Several large RCTs have examined the effect of early introduction of egg into the diet compared with delayed introduction and have shown some evidence that, depending on the baseline risk status of the treatment group, prevention of IgE-egg sensitisation or egg allergy may be associated with earlier introduction of egg.
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      Enquiring about Tolerance (EAT) study: feasibility of an early allergenic food introduction regimen.
      and the Prevention of Egg allergy with Tiny amount of InTake (PETIT) study in infants with well controlled eczema (high risk)
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      Two-step egg introduction for prevention of egg allergy in high-riak infants with eczema (PETIT): a radnomized, double-blind, placebo-controlled trial.
      showed the greatest benefits with cooked egg.
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      • Sayre P.H.
      • et al.
      Randomized trial of peanut consumption in infants at risk for peanut allergy.
      This study demonstrated an 86.1% relative reduction in peanut allergy prevalence in the consumption group compared to the control group.
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      • Sayre P.H.
      • et al.
      Randomized trial of peanut consumption in infants at risk for peanut allergy.
      These studies provide a foundation for evidence-based food allergy prevention guidelines and advice documents.
      Clinical practice guidelines are designed for health professionals and are important to ensure the best health outcomes for patients.
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      • Eccles Martin
      • Grimshaw Jeremy
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      ,
      • Consensus report, Institute of Medicine
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      Food allergy prevention guidelines for health professionals should be developed based on existing clinical trial evidence for effective translation and implementation. As guidelines are intended to underpin clinical practice, it is important that high quality evidence is integrated, and the development and reported process is robust.
      The Appraisal Guidelines for Research and Evaluation (AGREE II) tool
      • Brouwers M.C.
      • Kerkvliet K.
      • Spithoff K.
      The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.
      ,
      • Brouwers M.C.
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      • Feder G.
      AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care.
      is a validated instrument used to assess guideline quality.
      The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.
      ,
      AGREE Next Steps Consortium
      The AGREE II Instrument.
      The AGREE II tool assesses guidelines across 6 domains: scope/purpose; stakeholder involvement; rigor of development; presentation; applicability; and editorial independence. Assessing the quality of guidelines (including advice documents) is important to determine (1) if adequate guideline development processes were used; and (2) where the guideline documents differ in quality based on their nominated title (eg, guideline vs. consensus statement) and processes used in development.
      This systematic review aimed to identify food allergy prevention guidelines for health professional use; to compare the recommendations made by the identified guideline documents; and to assess the quality of the identified guideline documents.

      Methodology

      In this review, the word "guideline" is defined as any document termed an evidence-based guideline, expert recommendation, consensus statement, joint statement, position paper, or clinical report/guidance document, in accordance with the World Health Organisation (WHO) definition of “any document that contains recommendation for clinical health practice or public health policy”.
      World Health Organisation
      WHO Handbook for Guideline Development.
      The AGREE II consortium acknowledges that documents specifically titled as "guidelines" generally score higher when appraised using the AGREE II tool than non-official guideline documents. Hence, for this AGREE II assessment, a comparison has been made between documents specifically named "guidelines" by their authors in their title and all other documents which have been grouped together as "advice documents".

      Search strategy

      The literature was systematically searched to identify guidelines and advice documents developed for health professional use for the primary prevention of food allergy. A two-phase search was employed with the initial phase identifying both guideline documents and publications that referred to a guideline document. The second phase involved sourcing all the guideline documents identified in phase 1.
      The following databases were searched for the period 1990 to 13 August 2019: Medline, EMBASE, CINAHL, Scopus, Global Health and Guidelines International Network. A grey literature search of Google Scholar was also undertaken. In addition, a search of the reference lists from publications included in the full-text screen and references from identified guideline documents was undertaken. English language restrictions were applied. Guideline documents and studies reporting guideline documents between January 1990 and the date of the search (13 August 2019) were sought.
      The following search terms were used: (“health professionals” OR “general practitioners” OR “nurses” OR “dietitians” OR “dieticians”) AND (“food allergy” OR “food hypersensitivity” OR “allergy”) AND (“guidelines” OR “guideline” OR “policies” OR “policy” OR “strategy” OR “recommendation” OR “statement” OR “protocol” OR “consensus” OR “clinical practice”) AND (“prevention” OR “primary prevention”).

      Article selection

      Publications identified from the search were exported to Endnote reference management software, version 8 (Clarivate Analytics, Philadelphia, PA), duplicates removed, then uploaded to Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) for screening. Two reviewers independently screened the titles and abstracts of all publications identified in the search. All publications meeting the inclusion criteria were retained. Where the titles and abstracts provided insufficient details, full-text publications were retrieved and screened again by both reviewers against the inclusion criteria. All disagreements were resolved by discussion between the reviewers without the need for moderation.
      Two reviewers independently extracted data of interest using standardised data extraction forms developed for this review. The following information, where available, was extracted for each publication: authors; article title; name of guideline document; year of guideline document; name of organisation; country. Once identified through data extraction, the guideline documents were retrieved.

      Selection criteria

      For phase 1 of the search, the following were included: guideline documents whose stated purpose was the primary prevention of food allergy (including the original guideline document and articles referring to such guideline documents); guideline documents and articles in English; and guideline documents intended specifically for health professional use. Guideline documents for stated purposes other than primary prevention of food allergy were included only if they provided detailed, specific recommendations regarding food allergy prevention within their scope.
      For phase 2 of the search, English language guideline documents whose stated purpose was the primary prevention of food allergy for health professionals were included; and guideline documents for stated purposes other than primary prevention of food allergy were included only if they provided detailed, specific recommendations regarding food allergy prevention within their scope.
      If one professional organisation or government published more than one guideline document, all versions meeting the selection criteria were included in the review.

      Guideline comparison

      The recommendations contained within the guideline documents relating to maternal diet during pregnancy and lactation; breastfeeding substitutes; solid food timing; advice regarding introduction of common food allergens; specific advice regarding egg and peanut introduction; and spacing of introduction of new foods, were retrieved as these are key factors in relation to food allergy prevention. The guidelines were compared for their recommendations relating to these factors. Other interventions such as Vitamin D, omega-3 fatty acid supplementation, and modification of the maternal diet and the infant microbiome, were not included in this review.

      Quality appraisal of guideline documents

      Quality assessment of all identified guideline documents was undertaken independently by 2 reviewers who reviewed and scored each guideline document using the AGREE II tool.
      • Brouwers M.C.
      • Kerkvliet K.
      • Spithoff K.
      The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.
      ,
      • Brouwers M.C.
      • Kho M.E.
      • Browman G.P.
      • Burgers J.S.
      • Cluzeau F.
      • Feder G.
      AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care.
      The AGREE II tool assesses guidelines using the following domains: scope/purpose (objectives, question, population); stakeholder involvement (group membership, target population, target users); rigor of development (search methods, evidence criteria, evidence strengths and limitations, recommendations, benefits and harms considerations, recommendations and evidence link, external review, and updating procedures); presentation clarity (specific, unambiguous recommendations, management options, and identifiable key recommendations); applicability (application facilitators and barriers, implementation of advice/tools, resource implications, and monitor/audit criteria); and editorial independence (funding body, competing interests).
      The reviewers referred to the AGREE II tool with the user's manual
      AGREE Next Steps Consortium
      The AGREE II Instrument.
      when assessing the guideline documents and were masked to scores assigned by the other reviewer. Each domain has a different number of quality assessment questions, each requiring a score between 1 and 7 (7 being the highest score). The quality scores were synthesised and domain scores for each guideline document calculated according to the AGREE II manual protocol.
      AGREE Next Steps Consortium
      The AGREE II Instrument.
      Domain scores are calculated by subtracting the minimum possible score for the domain from the obtained score for the domain; this is then divided by the maximum possible score for the domain minus the minimum possible score for the domain; this score is multiplied by 100 to achieve a percentage.
      AGREE Next Steps Consortium
      The AGREE II Instrument.

      Interpretation of domain scores

      The AGREE II tool does not specify cut-off scores equating to guideline quality.
      AGREE Next Steps Consortium
      The AGREE II Instrument.
      For this review, consistent with other reviews,
      • Zhang Z.
      • Guo J.
      • Su G.
      • Li J.
      • Wu H.
      • Xie X.
      Evaluation of the quality of guidelines for myasthenia gravis with the AGREE II instrument.
      ,
      • Gao Y.
      • Wang J.
      • Luo X.
      • et al.
      Quality appraisal of clinical practice guidelines for diabetes mellitus published in China between 2007 and 2017 using the AGREE II instrument.
      the quality threshold for guideline acceptability was defined as guideline documents achieving at least 50% for Domain 3 (rigor of development) and at least 50% for at least 2 other domains.

      Statistical analysis

      Data were analysed in SPSS 26.0 (SPSS Inc, Chicago, IL). Descriptive statistics for the AGREE II assessment were obtained, and comparison of the means of the guidelines compared to the advice documents was undertaken using an independent t-test.

      Results

      The electronic database search yielded 1121 publications and reference checking identified an additional 18 publications. After removal of duplicates (n = 477); title and abstract screening was undertaken on 660 publications; 239 publications underwent full-text screening. Data extraction was undertaken on 156 publications to identify guideline documents including: the name of the guideline, creator/owner, country, and date. Two additional guideline documents were identified through reference searching. This yielded 28 guideline documents (from 17 organisations) over a period of 21 years (Supplemental Figure 1). The AGREE II appraisal was undertaken on all 28 guideline documents identified.

      Identified guideline documents

      A summary of included guideline documents is provided in Table 1.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      • Fleischer D.M.
      • Sicherer S.
      • Greenhawt M.
      • et al.
      Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      • Fiocchi A.
      • Assa'ad A.
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      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      Of the 28 food allergy prevention guideline documents, 10 were specifically titled as "guidelines",
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      ,
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      ,
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      ,
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      and 18 were titled as consensus statements, position statements, joint statements or recommendations and were grouped together as "advice documents".
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      • Fleischer D.M.
      • Sicherer S.
      • Greenhawt M.
      • et al.
      Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      ,
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      ,
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      ,
      Where an organisation had more than 1 version of their guideline document, all versions were included. A timeline of the 28 food allergy prevention guidelines is provided in Fig. 1.
      Table 1Summary of included guideline documents
      OrganisationName of documentAuthor specified type of documentRegionYear
      American Academy of PaediatricsEffects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolysed formulas
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      Clinical report/GuidanceUnited States2008
      American Academy of PaediatricsConsensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants
      • Fleischer D.M.
      • Sicherer S.
      • Greenhawt M.
      • et al.
      Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants.
      Consensus communicationUnited States2015
      American Academy of PaediatricsThe effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolysed formulas and timing of introduction of allergenic complementary foods
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      Clinical report/GuidanceUnited States2019
      American College of Allergy, Asthma and Immunology (ACAAI)Food allergy and introduction of solid foods to infants: a consensus document
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      Consensus documentUnited States2006
      Asia Pacific Association of Paediatric Allergy, Respirology & Immunology (APAPARI)Early introduction of allergenic foods for the prevention of food allergy from an Asian perspective - An APAPARI consensus statement
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      Consensus statementAsia2017
      Australasian Society of Clinical Immunology and Allergy (ASCIA)Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Position statementAustralia & New Zealand2005
      Australasian Society of Clinical Immunology and Allergy (ASCIA)Infant feeding advice
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      AdviceAustralia & New Zealand2008
      Australasian Society of Clinical Immunology and Allergy (ASCIA)ASCIA Guidelines for infant feeding and allergy prevention
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      GuidelineAustralia & New Zealand2016
      ASCIA Guidelines: Infant feeding and allergy prevention
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      British Society for Allergy & Clinical Immunology (BSACI)Preventing food allergy in higher risk infants: guidance for healthcare professionals
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      GuidanceUnited Kingdom2018
      Implementing primary prevention of food allergy in infants: New BSACI guidance published
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      Canadian Paediatric Society (CPS) and Canadian Society of Allergy and Clinical Immunology (CSACI)Dietary exposures and allergy prevention in high-risk infants
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      Joint statementCanada2013
      Canadian Paediatric Society (CPS) and Canadian Society of Allergy and Clinical Immunology (CSACI)Timing of introduction of allergenic solids for infants at high risk
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      Practice pointCanada2019
      European Academy of Allergy and Clinical Immunology (EAACI)Dietary prevention of allergic diseases in infants and small children
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      RecommendationsEurope2004
      European Academy of Allergy and Clinical Immunology (EAACI)EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      GuidelineEurope2014
      European Society for Paediatric Allergology and Clinical Immunology (ESPACI) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)Dietary products used in infants for treatment and prevention of food allergy
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      Joint statementEurope1999
      European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)Complementary feeding: A commentary by the ESPGHAN Committee on Nutrition
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      Position paperEurope2007
      European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      Position paperEurope2017
      Finnish Allergy ProgrammeAllergy in children: practical recommendations of the Finish Allergy Programme 2008–2018 for prevention, diagnosis and treatment
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      RecommendationsFinland2012
      German Society for Allergology and Clinical Immunology (DGAKI) and the German Society for Paediatric and Adolescent Medicine (DGKJ)Allergy Prevention
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      Clinical practice guidelineGermany2009
      German Society for Allergology and Clinical Immunology (DGAKI) and the German Society for Paediatric and Adolescent Medicine (DGKJ)S3-Guideline on allergy prevention: 2014 update
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      GuidelineGermany2014
      Hong Kong Institute of Allergy (HKIA)Guidelines for allergy prevention in Hong Kong
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      GuidelineHong Kong2015
      Guidelines for Allergy Prevention in Hong Kong
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      Hong Kong Institute of Allergy (HKIA)HKIA position paper on prevention of peanut allergy in high risk infants
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      Position paperHong Kong2016
      Italian Society of Preventative and Social Paediatrics (ISPSP), the Italian Society of Paediatric Allergy and Immunology (ISPAI) and the Italian Society of Pediatrics (ISP)Prevention of food and airway allergy: consensus of the Italian Society of Preventative and Social Paediatrics, the Italian Society of Paediatric Allergy and Immunology, and Italian Society of Pediatrics
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      Consensus statementItaly2016
      Japanese Society of Paediatric Allergy and Clinical Immunology (JSPACI)Japanese guidelines for food allergy 2017
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      GuidelineJapan2017
      National Institute of Allergy and Infectious Diseases (NIAID)Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      GuidelineUnited States2010
      National Institute of Allergy and Infectious Diseases (NIAID)NIAID Addendum guidelines for prevention of peanut allergy in the United States
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      GuidelineUnited States2017
      Philippine Society of Allergy, Asthma and Immunology (PSAAI) and the Philippine Society for Paediatric Gastroenterology, Hepatology and Nutrition (PSPGHN)Dietary prevention of allergic diseases in children: the Philippine guidelines
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      GuidelinePhilippines2017
      Scientific Advisory Committee on Nutrition (SACN) and Committee on Toxicity of Chemicals in food Consumer products and the Environment (COT)Assessing health benefits and risks of the introduction of peanut and hen's egg into the infant diet before six months of age in the UK
      Joint statementUnited Kingdom2018
      Academy of Medicine, Singapore Ministry of Health (AMS-MOH)Management of food allergy
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      Clinical practice guidelineSingapore2010
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.

      Guideline comparison

      The recommendations within the 28 guidelines document in relation to maternal diet, exclusive breastfeeding, breastmilk substitutes, timing of solid food introduction, and any recommendations for specific food introduction are summarised in Table 2.
      Table 2Summary of comparison of recommendations.
      Guideline documentMaternal diet (pregnancy and breastfeeding)BreastfeedingBreastmilk substitutesSolid food timingPeanut and egg
      AAP 2019No restrictions
      • -
        not applicable for 2015 document
      • -
        no change from 2008 document
      Exclusive BF for at least 4 months
      • -
        not applicable for 2015 document
      • -
        no change from 2008 document
      Hydrolysed formula not recommended
      • -
        not applicable for 2015 document
      • -
        2008 document ‘soy formula not recommended’
      4–6 months of age: Do not delay common allergens
      • -
        not applicable for 2015 document
      • -
        no change from 2008 document
      HRI - earliest age of peanut introduction is 4–6 months and consider evaluation of HRI by allergist before peanut introduction; Infants with mild-moderate eczema - earliest age of peanut introduction is around 6 months; Infants with no eczema or any food allergy - earliest age of peanut introduction is age appropriate and based on family meals and culture

      2015 document ‘For HRI - introduce peanut between 4 and 11 months of age; Consider evaluation of HRI by allergist before peanut introduction’
      ACAAI 2006Not applicableExclusive BF for 6 monthsStandard cow's milk formula6 months of age; Delay introduction of common allergens; Cooked, homogenised foods should be preferred over fresh counterparts if reduced allergenicity (e.g. beef and kiwifruit); egg, peanut, tree nuts fish and seafood introduction requires cautionPeanut and egg introduction requires caution
      APAPARI 2017Not applicableContinue BF alongside solid food introduction up to 2 years if possible, according to cultural practiceNot specifiedHRI - recommend allergy testing to egg and peanut; At risk infants - no delay in introduction of allergenic foods; Healthy infants - 6 months of ageAllergy testing for HRI prior to introduction of egg and peanut
      ASCIA 2016No restrictions; Healthy balanced diet; Up to 3 serves oily fish/week during pregnancy
      • -
        2005 and 2008 documents only stipulated ‘no restrictions’
      At least 6 months (where possible) and for as long as mother and infant wish to continue
      • -
        No change from 2008 document
      • -
        2005 document ‘exclusive BF for 4–6 months’
      All infants - standard cow's milk formula
      • -
        2008 document ‘pHF for HRI; soy milk is not recommended’
      • -
        2005 document ‘pHF or eHF for HRI; soy milk is not recommended’
      When infant is ready, around 6 months, not before 4 months; Introduce all common allergens; egg should be cooked; Continue to regularly include in infant diet once introduced
      • -
        2008 document ‘From around 4–6 months; Introduce all common allergens’
      • -
        2005 document ‘From 4 to 6 months; Introduce; peanut, nuts and shellfish for the first 2–4 years of life may be recommended. However, peanut, nut and shellfish avoidance may be recommended’
      Introduce cooked egg and peanut before 12 months of age; Procedure for high risk infants
      • -
        2008 document ‘Do not delay’
      • -
        2005 document ‘Peanut avoidance for first 2–4 years may be recommended’
      BSACI 2018Not applicableExclusive BF for around 6 months; Continue to breastfeed while introducing solids if possibleStandard cow's milk formulaFrom around 6 months, but not before 4 months, when infant is ready; HRI - parents may wish to introduce solids from 4 months, cooked egg then peanut should be given, then other allergenic foods; egg should be cooked; Introduce before 12 months of age; Continue to regularly include in infant diet once introducedHRI - may benefit from introduction of peanut and egg from 4 months alongside other foods
      CPS and CSACI 2019Not applicable
      • -
        2013 document ‘no restrictions’
      Breastfeed for up to 2 years and beyond - 2013 document ‘Exclusive BF for first 6 months’Not applicable
      • -
        2013 document ‘Hydrolysed formula; Soy formula not recommended’
      HRI - around 6 months of age but not before 4 months; All other infants - around 6 months; Introduce all common allergens; Continue to regularly include in infant diet once introduced
      • -
        2013 dcoument ‘From 6 months of age; introduce all common allergens’
      Do not delay
      • -
        No change from 2013 dcoument
      DGAKI and DGKJ 2014Balanced and varied diet; No restrictions; Fish should form part of the maternal diet
      • -
        No change from 2009 document
      Predominantly breastfed up to 4 months of age
      • -
        2009 document ‘Exclusive BF up to 4 months of age’
      Hydrolysed infant formula until 4 months of age; Soy based formula is not recommended for allergy prevention
      • -
        2009 specified pHF or eHF, otherwise no change
      From over the age of 4 months; Common allergens should not be delayed; Fish should be introduced by 12 months of age
      • -
        No change from 2009 document
      Not specified
      • -
        No change from 2009 document
      EAACI 2014No restrictions; No supplements while breastfeeding
      • -
        2004 only stipulated ‘no restrictions’
      Exclusive BF for 4–6 months
      • -
        2004 document ‘Exclusive BF for at least 4 months’
      HRI - hydrolysed formula until 4 months of age then standard cow's milk formula; All other infants - standard cow's milk formula; Soy and hydrolysed formulas not recommended
      • -
        2004 document ‘eHF until 4–6 months; pHF may have an effect; Soy formulas not recommended’
      From 4 to 6 months of age, when infant is ready; Neither withhold nor encourage exposure of common food allergens
      • -
        2004 document ‘Preferably 6 months but at least 4 months of age; No evidence for restrictive diets beyond 6 months for common food allergens’
      Not specified
      • -
        No change from 2004 document
      ESPGHAN 2017Not applicable
      • -
        No change from 1999 to 2017 documents
      Continue BF while introducing solid foods
      • -
        2007 document ‘Exclusive BF for around 6 months
      • -
        1999 document ‘Exclusive BF for 4–6 months’
      Not specified
      • -
        No change from 2007 document
      • -
        1999 document ‘HRI - reduced allergenicity formula; All other infants - standard cow's milk formula’
      Not before 17 weeks; Do not delay common food allergens
      • -
        No change from 2007 document
      • -
        1999 document ‘From 5 months; no information specified regarding common food allergens’
      High risk infants - introduce peanut between 4 and 11 months
      • -
        2007 document ‘Do not delay’
      • -
        Not specified in 1999 document
      Finish Allergy Program 2012No restrictionsExclusive BF for 4–6 monthsStandard cow's milk formulaFrom 4 to 6 months while continuing BF; Introduce wheat and oats by 6 months of ageDo not delay
      HKIA 2016Not applicable
      • -
        2015 document ‘Healthy diet during pregnancy; No restrictions’
      Not applicable
      • -
        2015 document ‘At least 4–6 months’
      Not applicable
      • -
        2015 document ‘HRI - consider hydrolysed formula if exclusive breastfeeding is not possible’
      HRI - SPT before introduction encouraged; Low risk infants - introduce peanut upon introduction of foods; Do not delay common food allergens
      • -
        2015 document ‘From 4 to 6 months of age when developmentally ready; Neither withhold nor encourage exposure to common food allergens’
      HRI - SPT; negative and mild positive SPT - 6g peanut protein/wk 3 times/wk until 5 years of age; Positive SPT - oral peanut challenge, include peanut if negative challenge an avoid peanut if positive challenge
      • -
        Not specified in 2015 document
      ISPSP and ISPAI and ISP 2016Fish oil supplementation not recommendedExclusive BF for at least 4 months (possibly 6 months)Standard cow's milk formulaAfter the 4th month and if possible after the 6th month; Introduce common food allergens in the same way as for children without allergic riskNot specified
      JSPACI 2017No restrictionsInsufficient evidence to indicate superiority of BF in the prevention of allergic diseaseInsufficient evidence to support the use of hydrolysed formulaFrom 5 to 6 months of age when developmentally ready; Do not delay common food allergensIntroduce peanuts sooner rather than later after weaning
      NIAID 2017Not applicable
      • -
        2010 document ‘no restrictions’
      Not applicable
      • -
        2010 document ‘Exclusive BF until 4–6 months of age, unless BF is contraindicated for medical reasons’
      Not applicable
      • -
        2010 document ‘HRI - hydrolysed formulas may be considered; Soy formula not recommended’
      4–6 months of age; Introduce common food allergens from 4 to 6 months of age
      • -
        No change from 2010 document
      HRI - earliest age of peanut introduction is 4–6 months and consider evaluation of HRI by allergist before peanut introduction; Infants with mild-moderate eczema - earliest age of peanut introduction is around 6 months; Infants with no eczema or any food allergy - earliest age of peanut introduction is age appropriate and based on family meals and culture
      • -
        Not specified in 2010 document
      PSAAI and PSPGHN 2017No increased intake of certain foods recommended; No restrictionsExclusive BF for at least 3–6 monthsHRI – pHF or eHF recommended for at least 6 months; Soy milk not recommendedFrom 6 months of age; Cooked egg at 4–6 months; wheat before 6 months; fish at 6–9 months; peanut at 4–11 monthsCooked egg at 4–6 months; peanut at 4–11 months
      SACN and COT 2018Not applicableExclusive BF for around 6 monthsNot specifiedAround 6 months of age; No information regarding common food allergensIntroduce peanut and egg around 6 months of age; If history of eczema or suspected food allergy, medical advice before peanut introduction may be sought; once introduced, peanut and egg should continue to be consumed as part of the usual infant diet
      AMS-MOH 2010No restrictionsExclusive BF for at least 4–6 monthsHRI - hydrolysed formula recommended; Avoid cow's milk formula in the first 5 days of life4–6 months of age for all infants; No information regarding common food allergensNot specified
      Abbreviations: BF = breastfeeding; HRI = High risk infants; SPT = Skin prick test; AAP = American Academy of Pediatrics; ACAAI = American College of Allergy, Asthma and Immunology; APAPARI = Asia Pacific Association of Paediatric Allergy, Respirology & Immunology; ASCIA = Australasian Society of Clinical Immunology and Allergy; BSACI = British Society for Allergy & Clinical Immunology; CPS = Canadian Paediatric Society; CSACI = Canadian Society of Allergy and Clinical Immunology; DGAKI = German Society for Allergology and Clinical Immunology; DGKJ = German Society for Paediatric and Adolescent Medicine; EAACI = European Academy for Allergy and Clinical Immunology; ESPACI = European Society for Paediatric Allergology and Clinical Immunology; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HKIA = Hong Kong Institute of Allergy; ISPSP = Italian Society of Preventative and Social Paediatrics; ISPAI = Italian Society of Paediatric Allergy and Immunology; ISP = Italian Society of Pediatrics; JSPACI = Japanese Society of Paediatric Allergy and Clinical Immunology; NIAID = National Institute of Allergy and Infectious Diseases; PSAAI = Philippine Society of Allergy, Asthma and Immunology; PSPGHN = Philippine Society for Paediatric Gastroenterology, Hepatology and Nutrition; SACN = Scientific Advisory Committee on Nutrition; COT = Committee on Toxicity of Chemicals in food, consumer products and the environment; AMS-MOH = Academy of Medicine, Singapore Ministry of Health

      Maternal diet

      Of the 28 guideline documents, 17
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ,
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      included recommendations regarding maternal diet during pregnancy and lactation. Eleven guideline documents did not include maternal dietary recommendations as they were guidelines specific to infant feeding. Of the 17 with maternal diet recommendations, all stipulated "no dietary restrictions".
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ,
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      In addition to the "no dietary restrictions" recommendation, 4 guideline documents also recommended a healthy balanced maternal diet;
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      ,
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      ,
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      3 guideline documents recommended the inclusion of fish;
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      ,
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      ,
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      ,
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      and 1 document stipulated that fish oil supplements were not recommended.
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.

      Exclusive breastfeeding

      Twenty-five guideline documents made recommendations regarding exclusive breastfeeding.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      The remaining 3 made no exclusive feeding recommendations, as these guideline documents were specifically related to peanut introduction.
      • Fleischer D.M.
      • Sicherer S.
      • Greenhawt M.
      • et al.
      Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants.
      ,
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      ,
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      Of those that did make breastfeeding recommendations, 6 recommended "exclusive/predominantly exclusive breastfeeding for at least 4 months".
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      ,
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      "Exclusive breastfeeding for 4–6 months" was recommended by 7 guideline documents;
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      7 recommended "exclusive breastfeeding for 6 months or around 6 months or at least 6 months".
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      ,
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      ,
      Two guideline documents provided no recommendation regarding exclusive breastfeeding but stipulated that breastfeeding "should continue up to 2 years or longer".
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.

      Breastmilk substitutes

      Twenty of the 28 guideline documents provided recommendations for breastmilk substitutes for primary prevention of allergy;
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ,
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      ,
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      4 of the remaining documents focussed on solid food introduction, and, therefore, were not intended to include breastfeeding information,
      • Fleischer D.M.
      • Sicherer S.
      • Greenhawt M.
      • et al.
      Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants.
      ,
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      ,
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      ,
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      and 4 made no recommendation.
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      ,
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      ,
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      ,
      Of these, soy formula was not recommended by 10 documents.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      ,
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      Specific recommendations for high risk infants were made in 8 documents,
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      with partially hydrolysed formula (pHF) recommended in all 8 documents
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      and extensively hydrolysed formula (eHF) recommended in 7 of the 8 documents.
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      Where documented, the majority of documents that recommended the use of hydrolysed formulas were based on evidence suggesting potential reduction in allergic disease generally;
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      atopic eczema;
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.
      asthma and allergic rhinitis;
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      ,
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      ,
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.
      food intolerance;
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      ,
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      ,
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      or food allergy.
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      ,
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      ,
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      ,
      • Ministry of Health Singapore
      Management of Food Allergy: AMS-MOH Clinical Practice Guidelines 2.
      ,
      • Lee B.W.
      • Aw M.M.
      • Chiang W.C.
      • et al.
      Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy.

      Timing of solid food introduction into the infant diet

      Twenty-seven documents made recommendations regarding the timing of solid food introduction.
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on nutrition; section on allergy and immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      • Fiocchi A.
      • Assa'ad A.
      • Bahna S.
      Adverse reactions to foods committee; American College of allergy, asthma and immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse reactions to foods committee, American College of allergy, asthma and immunology.
      • Tham E.H.
      • Shek L.P.
      • Van Bever H.P.
      • et al.
      Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI). Early introduction of allergenic foods for the prevention of food allergy from an asian perspective-an Asia pacific association of pediatric allergy, Respirology & immunology (APAPARI) consensus statement.
      • Prescott S.L.
      • Tang M.L.K.
      The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children.
      Australasian Society of Clinical Immunology and Allergy
      ASCIA Infant Feeding Advice.
      • Joshi P.A.
      • Smith J.
      • Vale S.
      • Campbell D.E.
      The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines.
      Australasian Society of Clinical Immunology and Allergy (ASCIA)
      ASCIA Guidelines: Infant Feeding and Allergy Prevention.
      • Stiefel G.
      • Anagnostou K.
      • Boyle R.J.
      • et al.
      BSACI guideline for the diagnosis and management of peanut and tree nut allergy.
      • Turner P.J.
      • Feeney M.
      • Meyer R.
      • Perkin M.R.
      • Fox A.T.
      Implementing primary prevention of food allergy in infants: new BSACI guidance published.
      • Chan E.S.
      • Cummings C.
      Canadian paediatric society, community Paediatrics committee and allergy section. Dietary exposures and allergy prevention in high-risk infants: a joint statement with the Canadian society of allergy and clinical immunology.
      • Abrams E.M.
      • Hildebrand K.
      • Blair B.
      • Chan E.S.
      Timing of introduction of allergenic solids for infants at high risk.
      • Muraro A.
      • Dreborg S.
      • Halken S.
      • et al.
      Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.
      • Muraro A.∗
      • Halken S.∗
      • Arshad S.H.
      • et al.
      EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy.
      • Høst A.
      • Koletzko B.
      • Dreborg S.
      • et al.
      Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European society for paediatric Allergology and clinical immunology (ESPACI) committee on hypoallergenic formulas and the European society for paediatric Gastroenterology, Hepatology and nutrition (ESPGHAN) committee on nutrition.
      • Agostoni C.
      • Decsi T.
      • Fewtrell M.
      • et al.
      ESPGHAN Committee on Nutrition
      Complementary feeding: a commentary by the ESPGHAN committee on nutrition.
      • Fewtrell M.
      • Bronsky J.
      • Campoy C.
      • et al.
      Complementary feeding: a position paper by the European society for paediatric Gastroenterology, Hepatology, and nutrition (ESPGHAN) committee on nutrition.
      • Pelkonen A.S.
      • Kuitunen M.
      • Dunder T.
      • et al.
      Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.
      • Muche-Borowski C.
      • Kopp M.
      • Reese I.
      • Sitter H.
      • Werfel T.
      • Schäfer T.
      Allergy prevention.
      • Schäfer T.
      • Bauer C.P.
      • Beyer K.
      • et al.
      S3-Guideline on allergy prevention: 2014 update: guideline of the German society for Allergology and clinical immunology (DGAKI) and the German society for pediatric and adolescent medicine (DGKJ).
      • Chan A.W.M.
      • Chan J.K.C.
      • Lee T.H.
      • Leung T.F.
      • Tam A.Y.C.
      Guidelines for Allergy Prevention in Hong Kong.
      • Chan A.W.M.
      • Chan J.K.C.
      • Tam A.Y.C.
      • Lee T.H.
      Guidelines for allergy prevention in Hong Kong.
      • Chan J.K.C.
      • Chan A.W.M.
      • Ho M.H.K.
      • Lee T.H.
      HKIA Position Paper on Prevention of Peanut Allergy in High Risk Infants.
      • di Mauro G.
      • Bernardini R.
      • Barberi S.
      • et al.
      Prevention of food and airway allergy: consensus of the Italian society of preventive and social Paediatrics, the Italian society of paediatric allergy and immunology, and Italian society of Pediatrics.
      • Ebisawa M.
      • Ito K.
      • Fujisawa T.
      Committee for Japanese pediatric guideline for food allergy, the Japanese society of pediatric allergy and clinical immunology, the Japanese society of Allergology. Japanese guidelines for food allergy 2017.
      • Boyce J.A.
      • Assa’ad A.
      • Burks A.W.
      • et al.
      NIAID-Sponsored Expert Panel
      Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.
      • Togias A.
      • Cooper S.F.
      • Acebal M.L.
      • et al.
      Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel.
      • Recto M.S.T.
      • Genuino M.L.G.
      • Castor M.A.R.
      • et al.
      Dietary primary prevention of allergic diseases in children: the Philippine guidelines.