Eczema and starting solids

Eczema and food allergy: the link

Eczema (atopic dermatitis) is very common: up to 1 in 4 children have it, and it usually starts before a baby’s first birthday. In babies it often shows up as dry, red, itchy patches on the cheeks, forehead and scalp.

Eczema and food allergy often go together. US and Canadian allergy experts call eczema the biggest risk factor for a food allergy in babies, and the AAP says up to 40% of children with eczema also develop a food allergy. Babies with severe eczema have the highest chance of peanut allergy.

But the link mostly runs one way. Foods typically don’t cause eczema. Eczema comes from a weak skin barrier, and it runs in families. Food allergy is more likely in babies with eczema, but cutting foods out usually doesn’t help the skin.

Why not to delay allergens

It can feel safer to hold back peanut, egg and other allergens from a baby who already has eczema. The evidence says the opposite.

• Delaying allergens doesn’t prevent allergy, and the NHS notes that delaying peanut and egg beyond 6 to 12 months may make an allergy more likely.
• A large study of babies with severe eczema or egg allergy found that eating peanut early and regularly prevented peanut allergy in many of them, and the protection lasted.
• US guidance says to introduce peanut and egg around 6 months, but not before 4 months, along with the other common allergens.

So for babies with eczema, offering allergens on time matters more, not less. Once a food goes well, keep it in their diet regularly.

Mild eczema or severe eczema?

How you start depends on how severe the eczema is.

Severe eczema means eczema that keeps coming back or never fully clears, and needs prescription creams often, even with regular moisturizing. Your doctor can tell you if this fits your baby.

Mild to moderate eczema is eczema that’s usually controlled with moisturizers and occasional treatment.

When to talk to your doctor first

Talk to your pediatrician or GP before offering peanut if your baby:

• has severe eczema, or eczema that’s hard to control
• has an egg allergy, or has had an allergic reaction to any food

These babies have the highest chance of peanut allergy, and early peanut matters most for them, often from around 4 to 6 months. That’s why it helps to raise it early, before your baby starts solids. Your doctor may suggest an allergy test first, or a first taste in their office. Don’t give the first peanut at home until your doctor has told you how.

Whether to test first is your doctor’s call. The 2017 US peanut guidelines, which the AAP’s starting solids page still follows, suggest testing for these babies. The 2021 US and Canadian allergy consensus says testing first isn’t required, though some families prefer it. Either way, talk to your doctor before the first peanut.

If your baby has mild to moderate eczema and no food allergy, US guidance says you can usually introduce peanut at home around 6 months, after a few other first foods. Check with your doctor if you’re unsure.

How to introduce allergens

• Start solids around 6 months, when your baby shows the signs of readiness. The AAP suggests a few low-allergy foods first, like infant cereal or mashed banana, to show your baby is ready.
• Offer one new allergen at a time, in a small amount, on a day your baby is well, at home, when you can watch them for a couple of hours afterward.
• Use a safe form: smooth peanut butter thinned with water, breast milk or formula, or stirred into a food your baby already eats; well-cooked egg; flaked, well-cooked fish. Never whole or chopped nuts, or spoonfuls of thick nut butter.
• Wait a few days before the next new allergen, so you can tell what caused any reaction.

See how to introduce allergens, and the safe first form for each one on the allergens page.

Is it a reaction or a flare?

Babies with eczema have flares that come and go, so it can be hard to tell what’s going on.

A food allergy reaction usually starts within minutes to 2 hours of eating: hives, a red itchy rash, mild puffiness of the face or around the eyes, or vomiting. Lips, mouth, tongue or throat that suddenly swell, or trouble breathing, are an emergency: see signs of anaphylaxis. Some, like cow’s milk allergy, can take up to 3 days, and a worsening of eczema can be one of the signs. If you see a reaction, stop the food and call your doctor before offering it again.

Signs of anaphylaxis are trouble breathing, wheezing or a cough that won’t stop, swelling of the tongue or throat, lips or mouth that suddenly swell, a hoarse cry, turning pale or floppy, becoming very sleepy or unresponsive, or signs in more than one part of the body at once. If you see any of these and your baby has an epinephrine (adrenaline) auto-injector, use it right away, then call for an ambulance. Call 911.Call 999.Call your local emergency number (such as 112 in Europe or 000 in Australia). If you don’t have an auto-injector, call straight away. Keep your baby lying down, never standing or walking (on their side if they’re vomiting, head and shoulders a little raised if breathing is hard). See signs of anaphylaxis.

An eczema flare is often caused by something else: soap or detergent, heat, dry air, scratchy fabrics, or a skin infection.

If you think a food is making your baby’s eczema worse, keep a simple diary of foods and skin changes and show it to your doctor. Don’t cut foods out on your own. The AAP warns that unnecessary elimination diets can be harmful, and may even lead to a reaction when a food that was eaten safely before is brought back. The NHS also advises not changing your own diet if you’re breastfeeding a baby with eczema, unless a doctor tells you to.

Looking after the skin

Good skin care helps eczema itself. The NHS and AAP suggest:

• a thick, fragrance-free moisturizer at least twice a day, even when the skin looks better
• short, lukewarm baths with a gentle cleanser or emollient instead of soap, then moisturizer
• keeping your baby cool, and their nails short
• prescription creams, such as steroid creams, used as your doctor directs

Get an urgent appointment if the eczema is weeping, crusty, blistered, painful or suddenly much worse, or if your baby has a fever or seems unwell. These can be signs of infection.

Where US and UK advice differs

• Who should check first. US guidance asks families to talk to their doctor first if a baby has severe eczema or an egg allergy. The NHS goes further: talk to your GP or health visitor before introducing allergens if your baby has any eczema, or if there’s a family history of food allergy, eczema, asthma or hay fever.
• Nuts. The NHS says to spread nut butter onto a food such as toast (we suggest spreading it thinly), or to give crushed or ground nuts mixed into food, never nut butter on its own. US guidance often suggests thinning smooth peanut butter or stirring it into a puree.