New Allergy Guidelines for People Over 12 Years Old

If you or your kids suffer from allergies, I'm sure you want to know how to best manage them. In addition to limiting exposure, medications can be a big benefit. 

The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (AAAAI and ACAAI) have published new guidelines in the Annals of Internal Medicine for the initial medical treatment of seasonal allergies in people 12 years and older.

The recommendations essentially state:

• Use steroid nasal sprays first without an oral or nasal antihistamine. Many intranasal steroids are available over the counter without a prescription. A great list is included on the AAAAI website. (Be careful to not to confuse them with the nasal antihistamines, which are in the same chart but identified in the column titled "Class".) 
• In those over 15 years, the nasal steroid is preferred over a leukotriene receptor antagonist (ie Singulair or montelukast). For those with asthma, the leukotriene receptor antagonist might offer an additional benefit for asthma, but it is not the preferred treatment in either allergies or asthma. (I think the age change is simply due to the ages studied but it was not specified.)
• In moderate to severe allergic conditions, a combination of nasal steroid and nasal antihistamine can be considered. 

These recommendations are based on a review of many studies to show what treatments worked and what didn't. They also took into consideration the fact that oral antihistamines can cause sedation and the nasal antihistamines do not. In general the nasal steroids worked better than other treatments. They did note that for people who do not tolerate nasal sprays, alternates would be oral antihistamines or leukotriene receptor agonists.

Itchy, sneezy, puffy - All signs of allergy. What can you do?

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what's out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:

• Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

• Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine. Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age. 

• Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Most insurance companies don't cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 

• Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple weeks, they usually don't need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

• Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

• Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)

• Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

• Wash towels and sheets weekly in hot water.  

• Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 

• Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 

• There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 

• Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  

• Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 

• If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 
• Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don't smoke near them.  

What if all of the above isn't helping?

• Maybe it's really not allergies. 

• Allergies to things other than foods are rare before 2 years of age.

• Viruses can cause very similar symptoms to allergies. 

• Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   

• Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!

• Wrong medicine or wrong dose. 

• Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

• Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 

• Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

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Antibiotic Allergy or Just a Rash?

During the winter months more people get sick, so more people are treated with antibiotics. While antibiotics can help treat bacterial infections, they do carry risks. One of those risks is an allergic reaction. This is one of the reasons pediatricians avoid using antibiotics liberally. Most of the time our bodies can fight off the germs that cause illness and antibiotics don't help treat viruses at all.

When someone is on a medicine and they develop a rash it can sometimes be hard to sort out if symptoms are part of the illness, a non-allergic drug reaction, or an allergic reaction. There are many people who had a rash while taking an antibiotic as a child and were told that they are allergic to that antibiotic, but really aren't. Unfortunately this can lead to more expensive and broader-range antibiotics being used inappropriately and unnecessarily.

About 2% of prescription medications (not just antibiotics) cause a "drug rash". The rash usually begins after being on the medicine for over a week (earlier if there was previous exposure to the medicine), and sometimes even after stopping the medicine. It can look different in different people. Some get pink splotchy areas that whiten (blanch) with touch. Others get target-like spots, called Erythema Multiforme. Often the rash seems to worsen before it improves, whether or not the medicine is stopped. Skin can peel in later stages. It can itch but doesn't have to. Some people have mild fever with these symptoms. In adults this type of rash is often a sign of allergic reaction, but in kids a rash is most often a viral rash - meaning they have a virus that causes a rash but they happen to be on an antibiotic (or other medicine). This is why diagnosing allergy versus drug reaction is tricky. These symptoms can mean allergy to the drug, but (especially in kids) is often just a symptom of a virus (or some bacteria, such as Strep or Mycoplasma).

Up to 10% of children taking a penicillin antibiotic (which includes the commonly used amoxicillin and augmentin) develop a rash starting on day 7 of the treatment. (It can be earlier in people who have had the antibiotic previously.) This rash tends to start on the trunk, looks like pink splotches that can grow and darken before fading. It does not involve difficulty breathing, swelling of the face or airway, or severe itching. Because of this reaction many people live their life thinking they have an allergy to penicillin, even though many of them don't. 

Amoxicillin rash after 17th dose (about the 8th day). Photo source: By Skoch3 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

Same child, 8 hours after the above photo. Photo source: By Skoch3 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

Why does this happen? We don't know for sure. But it can cause a very significant rash, especially with the virus that causes mono.

Up to 80 -90 % of people who have mono develop a rash if they are treated with a penicillin antibiotic (like amoxicillin). This is common since symptoms of Strep throat and mono are very similar, and penicillins are the drug of choice for Strep throat. Some people with mono have a false positive test for Strep throat, meaning they do not have Strep but the test is positive. This is why it is very important for the medical clinician to take a careful history of symptoms and do an exam, even with "classic" Strep symptoms. (If I had a dollar for every parent who says the symptoms are just like all her kids when they get Strep, can't I just call it in...) Always be sure to get a Strep test and full exam to evaluate if it is really Strep or possibly mono. Blood tests for mono can be ordered if clinically indicated. Never treat a sore throat without a full evaluation.

Amoxicillin rash that developed several days after starting amoxicillin with mono. Image from Ónodi-Nagy et al. Allergy, Asthma & Clinical Immunology 2015 11:1   doi:10.1186/1710-1492-11-1

How do we know if it's a real allergy? 

Doctors will take a careful history of all symptoms of the illness, the timing of when the rash developed during the illness and when the medicine was given. If it is a classic viral rash, nothing further needs to be done. If there are symptoms (see below) that help identify a true allergy and make a clear diagnosis, then avoidance of that medication should be done. Be sure all your doctors and pharmacists know of this allergy. If it is not clear then further evaluation can be done. Allergists can do skin testing to see if there is a penicillin allergy, but most antibiotics do not have testing available so an oral challenge (in a controlled setting) is used if there were no clear allergy symptoms with a rash.

Mild to moderate allergic reactions can have the following symptoms:

• Hives (raised, extremely itchy spots that come and go over a period of hours)
• Tissue swelling under the skin, often around the face (also known as angioedema)
• Trouble breathing, coughing, and wheezing

Anaphylaxis is a more serious allergic reaction and can include:

• Difficulty breathing or wheezing
• Swelling of the face, tongue, throat, lips, and airway
• Dizziness
• Loss of consciousness
• Shock
• Death

Final Take Away

As you can see, rashes that develop while on medications can be quite a conundrum. If one develops, be sure to get in touch with your doctor. We usually cannot diagnose rashes over the phone, so an appointment may be necessary.

Thank you to Kressly Pediatrics for posting a comment on Twitter (@KresslyPeds) about drug reactions to give me the idea for this blog!

How can we introduce peanut products to infants without increasing choking risks?

For years I have been recommending peanut products to infants who are low risk for peanut allergy. A recent study has really highlighted the benefit of early introduction of peanut product decreasing peanut allergy risk, so more parents are wanting to know exactly how to give a baby peanut products without increasing the choking risk.

Bamba. Photo source: Wikimedia

The study was done using a product similar to Cheetos, made with peanut butter instead of cheese. Bamba is a snack food sold in Israel. You can get it online, but some of the reviews suggest that it may be a different product.

Since there is nothing similar in the US, how can you safely give peanut to your baby on a routine basis to help prevent peanut allergy once they are cleared by their doctor to start peanut products? (And even when there are products like these, don't limit your baby to pre-packaged foods... they are generally less healthy because of all the added ingredients.) It is important that your baby does not get too much peanut butter or a chunk of nut itself because these are choking risks, so a nice thick slab of peanut butter just won't work.

Some ideas of introducing peanut butter:

• Look for peanut butter that doesn't have added sugar - babies don't need the sugar! 
• Most kids love Cheerios (or other brand oat circle cereal). They do make a peanut butter flavor, made with real peanut butter.
• Add peanut butter powder or peanut butter to oatmeal - check the texture to be sure it isn't too thick for your baby, add water, breast milk, or formula to thin it as needed.
• Peanut butter smoothie (There are many recipes online, but be sure yours doesn't have honey if baby is under 12 months! If the recipe calls for milk, you should use your breast milk or formula. Find one that is made with real foods, such as banana + milk + peanut butter. Babies don't need chocolate or added sugars. If your baby doesn't like it cold, use water instead of ice and don't use frozen fruits.)
• Peanut butter cookies (I like this recipe because it doesn't have added sugar. You can leave out the raisins if your baby would choke on that texture.)
• Peanut butter muffins (Look for one without too much sugar and no honey. I couldn't find one without any added sugar -- if you do, please share below!)
• Thin layer of peanut butter on bread, cracker, or even your finger. You can add a little water to the peanut butter to thin it out if needed.
• Chinese chicken with peanut sauce and other foods made with peanut butter sauces. The whole family can enjoy these meals!
• Share your favorite recipes that can be adapted for babies and toddlers below.

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

If you don't want to miss a post, be sure to sign up for an e-mail subscription on the right!

From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety. 

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths. 

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

• Allergy Tips

• Generic Concerta Not Working Like the Brand Used T...

• Screen Free Week April 29-May 5, 2013

• Help! My child has ___ up his nose!

• Group Teaching With Physicals

• Waiting times...

• Feeding Your Newborn

Allergy Tips

photo source: Shutterstock

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. I registered on (and recommend) Pollen.com for free alerts at the beginning of the season to anticipate the need to treat before symptoms begin. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:

• Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. 

• Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. 

• Nasal spray antihistamines are available over the counter and as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 

• Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

• Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

• Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)

• Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

• Wash towels and sheets weekly in hot water.  

• Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 

• Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 

• There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 

• Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  

• Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 

• If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 

What if all of the above isn't helping?

• Maybe it's really not allergies. 

• Allergies to things other than foods are rare before 2 years of age.

• Viruses can cause very similar symptoms to allergies. 

• Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   

• Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!

• Wrong medicine or wrong dose. 

• Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

• Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 

• Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

Starting Solids-- The Old and the New and the Myths

Many parents are excited yet apprehensive to start foods with their infants.  So many questions, so many fears.  So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current.  Change takes time, so not everyone agrees on the "new" rules.  Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.

photo source: Shutterstock

• don't feed before 6 months is now ok to feed at 4 months if baby's ready

• don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy

• don't start more than one food every 3-5 days is now  introducing multiple foods at one time is ok

• start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider's preferences.  

No wonder there is so much confusion!!!!

New rules are much easier.  I like easier.

• Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
• Don't give honey until 1 year of age.
• Don't give any textures your baby will choke on.

Done.  

That's it.  Nothing fancy.  Any foods in any order.  Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods.  Nothing too salted. Try nutritious foods, not junk.  

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies.  In fact, there is research to support that starting foods earlier might prevent food allergies.  A full 180 degree change!  Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases.  If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food.  Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy.  Not just the allergy aspect, but also choking risks.  ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.   

Any of the more allergy prone foods should first be offered in small amounts at home.  These foods include nuts, egg, and fish.  Do this only if there is no one in your house who is allergic to that food.  Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy.  In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.  Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods.  The more colors on our plates, the healthier the meal probably is!

I thought they couldn't have cow's milk until after a year?

Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year.  Cow's milk may lead to allergies or eczema, including formulas made with cow's milk.  Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk.  Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...

Rice cereal has been the first food for generations, probably because grandma said so.  There has never been any research supporting giving it first.  With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.  

Shouldn't we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby!  Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.  

How do we know what they're allergic to if we start several new things at once?

First, most kids are not allergic.  

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was.  This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.  

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool.  If you think your child is allergic to a food, discuss with your doctor.  Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when they show interest in food by reaching for it they might be ready.  They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.  

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age.  That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive's tale that starting solids will help baby sleep through the night.  Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates.  Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods.  As they eat more food, they will need less breast milk or formula.  In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place.  It does not mean they are any better.  They cost more than home made foods.  I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition).  It really isn't hard.  You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila!  Home made food.  There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home on How to Make Your Own Baby Food from What to Expect. (link updated 9.16.17)

My baby only wants table foods. Is that okay? Don't they need pureed foods first?  He doesn't have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves.  If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to  feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.  

Most babies will be able to eat table foods between 9 and 12 months.  They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food.  They need foods broken into small enough pieces until they can bite off a safe bite themselves.  

Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down.  Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke.  Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!  

How much juice should my baby drink?

In general I think babies don't need juice at all. They can practice drinking from a cup with water.  Juice adds little nutritional value and a lot of sugar.  Eating fruit and drinking water is preferable.  If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink!  No more than 4 ounces/day of fruit juice is recommended. 

What about organic? 

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.   

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health.  Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.  

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.  

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).  

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!