D2.487 - Avoiding Unnecessary Food Avoidance: Outcomes of Infants with Localised Reactions During Weaning

Mild perioral redness or contact urticaria during early feeding commonly prompts referral for suspected food allergy, despite increasing guidance that such reactions may not represent IgE-mediated disease. Recently published ASCIA infant feeding guidelines recommended reexposure at home in infants with localised symptoms (Recommendation 7). Real-world data to support implementation of this recommendation is limited. The aim of this study was to describe outcomes of infants referred with isolated perioral reactions during feeding prior to publication of the ASCIA guidelines. 

We conducted a retrospective review of infants aged 0–12 months referred to a tertiary paediatric allergy service over six months for suspected food allergy. All infants were assessed in person. Infants presenting with isolated perioral redness or urticaria, without systemic symptoms, were analysed in detail. Data included implicated foods, eczema status, sensitisation (skin prick testing and/or specific IgE), supervised feed outcomes, and tolerance on re-introduction.

Ninety-two infants were referred (median age 7 months); 32 infants (36 episodes) presented with isolated perioral reactions and are described in detail here. Twenty-eight (88%) had eczema. Only 16/36 (44%) episodes were classified as IgE-mediated food allergy, all to common allergens (egg n=10, peanut n=4, cow’s milk n=2). All reactions to fruits, vegetables, spices, and salmon were non-allergic and tolerated on home re-introduction. Infants (n=12) with egg or cow’s milk allergy had mild phenotypes and successfully progressed through structured home ladders without clinically significant reactions. Almost two thirds,  7/11(64%) infants referred with isolated symptoms to peanut were not sensitised and tolerated home re-introduction, with no severe reactions observed. Of the four infants with sensitisation (median SPT 6.5, median spigE 3.98), 2 infants had reproducible mild symptoms on reexposure; 2 infants had SPT≥8mm and were managed with avoidance and early follow up planned. 

In this real-world cohort, isolated perioral reactions during infant feeding were frequently non-allergic and rarely associated with clinically significant reactions. These findings support the new ASCIA guideline recommendation that localised symptoms should not prompt automatic avoidance. Selected infants referred with localised symptoms may be safely managed with supported home re-introduction following careful history-taking, potentially reducing unnecessary clinic visits while preserving safety and promoting early tolerance.