For those of you with hungry infants

What the hell… it’s been a while since I’ve done a purely medical post.

So, several years ago there was an episode of “Six Feet Under” in which Lisa (Lili Taylor) yells at Ruth (Frances Conroy) for feeding her baby peanut butter.  In the midst of her freak-out, she reprimands her mother-in-law for increasing her daughter’s risk of “horrible allergies.”  In a later scene, Ruth is seen musing aloud to the child about how, back when she was raising her own kids, nobody seemed worried about feeding their kids peanut butter.  (It’s all a metaphor, you see, for Ruth’s feelings of alienation and loss as the world changes around her.)

Score one for Ruth Fisher.

[OK, so I said I was going to do a purely medical post, but apparently I can’t stop myself from talking about something else.  Wanna know a show that hasn’t aged well?  “Six Feet Under.”  The first time I watched it, at least the first season or two, I loved it.  Then the Better Half and I got the complete series DVD and watched them all a couple of years ago, and I found it a lot less enjoyable.  The later seasons in particular just get nutty, and characters who were complicated but ultimately sympathetic simply become awful and unwatchable.  The plot spins out in all kinds of rococo twists and turns that collapse under their own weight.  The performances remain top-notch, but the writing falls to pieces.]

Where was I?  Oh, yes.  Peanut butter.

If you have been responsible for the nourishment of small children anytime within the past decade or so, chances are you’ve been told to avoid certain foods.  The reasons you have been told to avoid certain foods were probably several.  Some foods are choking hazards, for example, and should be avoided until children are old enough to chew and swallow them appropriately.  (Among them is the treacherous hot dog, a food so dangerous some of my colleagues have proposed a total redesign.  Because parents are apparently incapable of halving them lengthwise.)  Honey should be avoided until after age 1, to prevent a fleetingly rare form of botulism.  If you’re parenting a small child, you should keep following those particular recommendations.

However, for the better part of the past dozen years or so, it’s been recommended that parents avoid feeding their kids certain highly allergenic foods.  Specifically, the recommendation has been to avoid cow’s milk products until age 1, egg until age 2, and fish, peanuts and tree nuts until age 3.  The thinking was that delaying the age of first exposure would lower the risk of developing allergies to these foods.

The problem with this is that there have never been data to support these recommendations.  And wouldn’t you know, the prevalence of allergies to these foods hasn’t dropped since these recommendations became the standard.  In fact, it’s risen.  A lot.

Take it away, American Academy of Allergy, Asthma and Immunology:

 Previous AAP recommendations published in 2000 advised delayed introduction of the following highly allergenic foods in infants at high risk for allergic disease to prevent the development of future allergy: cow’s milk until age 1 year; egg until age 2 years; and peanuts, tree nuts, and fish until age 3 years.88 However, over the next decade, the incidence and prevalence of food allergy and allergic diseases in general have increased substantially, leading to the re-evaluation of the 2000 recommendations. After careful review of the current literature, the AAP’s Committee on Nutrition and Section on Allergy and Immunology published an updated Clinical Report in January 20081 that determined there was no convincing evidence for delaying the introduction of specific highly allergenic foods…


I first came across the AAAAI’s new feeding guidelines a few months ago thanks to Dr. David Hill’s blog Needles.  (I like reading another blog written by a pediatrician who enjoys awards shows and making fun of pop culture.)  Truth be told, I’ve never been sold on the recommendations to avoid certain foods until the early preschool years and have always found the data lacking.  While it’s always a bit unsettling when a set of guidelines is given a 180-degree flip, at least they’re now flipping in the direction I wanted.  From the new set:

Most pediatric guidelines suggest first introducing single-ingredient foods between 4 and 6 months of age, at a rate not faster than one new food every 3 to 5 days.71
Complementary foods in the United States are typically rice or oat cereal, yellow/orange vegetables (eg, sweet potato, squash, and carrots), fruits (eg, apples, pears, and bananas), green vegetables, and then age-appropriate staged foods with meats.92
•We do not suggest introducing one of the highly allergenic foods as one of the first complementary foods; however, once a few typical complementary foods (see above bullet) are tolerated, highly allergenic foods may be introduced as complementary foods.

What that means in real-world-speak is that once your kids have had a few solid foods introduced sometime between 4 and 6 months of age and have tolerated them well, there’s no reason you can’t give them a small amount of peanut butter or eggs or other previously-verboten foods.  While there is a bit of nuance to the guidelines and a few exceptions, the ban on shellfish and fish and nut butters is essentially lifted.  (Certain exceptions apply, such as if there is a family history of severe food allergies or poorly-controlled, moderate-to-severe eczema.  If you have questions about your own kid, probably best to ask a doctor who actually knows him or her rather than trusting some schmoe on the Internet.)

However, this particular schmoe took the cue from the AAAI and has been gleefully feeding his infant daughter peanut butter for weeks.  Kids can be hard enough to feed as it is.  Removing unnecessary restrictions on the foods they can eat will only make the job easier, and I’m happy to have the new guidelines in hand both as a pediatrician and as a parent.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I fondly recall the first two seasons of 6FU as some of the best TV I’ve ever seen. (What ruined the third season was way too much Lisa and not nearly enough Brenda.) But I’m kind of afraid to rewatch it and find out I was deluded.

    • What I wrote about the characters all turning horrible was a broad criticism, but the one who (in my opinion, at least) went from “interesting and complicated but also sympathetic and enjoyable” to “horrible” most dramatically was Brenda. I loved her at the beginning of the show and found her shrill and wholly unlikable by the end.

  2. We had a tremendously difficult time getting our first child to eat solid foods, difficult in a we-saw-a-specialist sort of way. In those early days of getting the child eating and gaining weight, peanut butter was a god-send. The specialist had no problem with pretty much any foods being fed to her (she also said that our daughter would keep losing weight for a little while longer, but not to stress about it… the relaxed attitude was quite helpful). She actually told us that if on one day the child just wanted to eat licorice, well, then the child was eating licorice that day.

    We have, at times, tried to limit exposure to certain foods, but it’s always been in a we-don’t-don’t-want-to-deal-with-a-new-found-love-of-M&Ms way. Things were easier before our youngest ever tasted chocolate or candies. There is, on occasion, a little bit of toddler-rage when we do not stuff her full of pounds of M&Ms.

    • I found one thing very helpful in this situations: have the child help with the cooking.

      One day, I put out of tray of aromatic stuff; fresh basil leaves, ginger root, dill, celery, strawberries. And we sniffed them. I let the toddler (my eldest) decide which was ‘favorite,’ and then we designed a dinner around that ingredient; 2nd favorite the next night. This led to a deep and abiding love of anything with fresh ginger and fresh basil, both ways to include a wide assortment of other colorful vegetables.

  3. How old is your daughter now? The day Zazzy can feed Mayonnaise peanut butter*, her dream of simply being able to plop the jar in front of the two of them as they eat themselves into a food coma will be realized.

    * I clearly should have given Zazzy a food-based pseudonym… this sentence would have been infinitely better.

    • She just turned eight months old. And per these recommendations, there doesn’t seem any reason to delay exposure to peanut butter (starting with a small amount) (assuming there is not a strong family history of peanut allergy, which sounds like “no” in this case) much after Mayonnaise has eaten a few starter solids.

      • Russ,

        If I may, I assume that both your little ones were formula fed as infants, given that you and the Better Half both presumably lack the requisite equipment to provide otherwise. And through our own parent education tour, I have come to understand that there is pretty sound science on the benefits of breast feeding over formula feeding.

        In talking with our pediatrician, I really appreciated the way the practice articulated their approach: In a nutshell, they believe in the benefits of breast feeding and if asked for a recommendation, that is the one they will offer; but if a family chooses otherwise, they respect the decision and do not pressure them to do otherwise.

        But in working with other professionals (some of whom we were “patients” of and some of whom are friends who work in the industry), I saw a certain militarism among breast feeding advocates. La Leche League (which we did not work with) has been described as akin to the mafia, the lactation specialists at the hospital all but said we were actively harming our baby if we chose to do otherwise, and a friend who does parenting consulting thinks it is wrong if anyone stops breast feeding before the child is 2.

        And, curiously, my experience with and understanding of people with such fervent views on the matter tells me they tend to skew liberal, if not hardcore liberal.

        As a medical professional AND as a parent who is (presumably… please correct me if I’m wrong on this) unable to breast feed his child, how do you feel when this militant wing comes out and demonizes those who take another route?

        If this question is too personal or delves too deeply into the intimate details of your parenting, please feel free to ignore it (or delete it entirely). I just know I found certain aspects of these conversations off putting despite the fact that we planned to and do breast feed. And it made me think about families like yours and how they are made to feel when La Leche comes knocking.

        • I feel like I’ve posted about this topic before, but I have no idea if I really did or (if so) when.

          I have zero patience for the attitude you describe. Zilch. None.

          What do I think is “best”? Breast feeding. What do I think is unconscionable? Bullying women who either cannot do so successfully or choose not to. And yes, I have met women who have tried a million different ways to nurse and simply can’t make it happen, and have had to counsel many who feel like failures that they are not. I have had a few mothers who successfully nursed one child and couldn’t with the next. The anxiety many have felt because they weren’t doing the “right thing” for their babies was wholly unnecessary and predicated on mistaking “best” with “only option for right-thinking people.”

          The lactation bullies drive me bananas. (What benefit supposedly accrues to nursing a 2-year-old is beyond me.) The whole “baby-friendly” hospital movement is, as far as I’m concerned, a lot of sound and fury signifying nothing.

          So, yeah… not a fan.

          • I don’t know if they officially qualified as such, but the hospital Zazzy delivered in was definitely on the “baby-friend” end of the spectrum. Certain parts of it, I appreciated. Others, like when 4 different people had their hands on my wife’s breast because, goddamnit, we were going to get that kid to latch within 24 hours… not so much.

            There is something off about drawing a line slightly south of “best” which reads “everything below is evil”.

            And I apologize if you’ve spoken on this and I missed it. I just struggle with the idea of a family like yours or a woman like Zazzy with a slightly less effective mammary gland being told they’re doing it wrong.

          • I’m not actually sure if I’ve written about it or not.

            Maybe next time I’m in the mood to be flamed by a passel of enraged pro-lactation internet trolls, I’ll post something.

          • We should have some sort of March Madness style internet troll competition.

        • Oh, yes, I still have a post to write on the lactivists.

        • Our experience with La Leche was so negative with our first child that we specifically asked the nurses to keep them away from us when our second was born. The last thing new parents need–especially a new mom dealing with a two-weeks premature underweight boy who won’t latch–is someone pressuring them to get it right or their child will suffer.

  4. a bit of related weirdness: the wife has a very severe walnut allergy (as well as pine nuts and avacados. and garlic!), but is ok with peanuts.

    the wee one has eaten peanuts (due to in laws countermanding pediatric allergist’s suggestions because something something something they’re dumb) and eaten foods cooked in peanut oil with no problems (see note about in laws above)

    peanut butter, however, made him break out into a rash and vomit.

    so now he’s not only one of those kids, but i can never take him to my favorite thai restaurant in queens. which sounds more selfish than i mean. it’s just like, i dunno, a world famous shortshop raising a kid who sucks at baseball.

  5. We just started Lain on solids, belatedly I am afraid. It turns out, she hates avacados, but is okay with oatmeal (especially on her face, her legs, and everywhere else).

    Anyhow, I read a while back that our aversion to give babies certain foods might be directly feeding into the allergies. Like they looked at the settlements in Israel and discovered that they fed their kids peanut butter all the time and none of them had allergies (or maybe it was that they never fed their kids peanut butter and had allergies at very high rates). If I didn’t have a crying baby on my lap, I’d try to find it.

    • If you click through to the AAAI link in the OP, they actually cite the Isreali study. Peanut allergy has a ten-fold lower prevalence in Israeli Jews than among Jews living in the UK, where a similar peanut-avoidance recommendation has prevailed.

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