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

Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment

The Finnish Allergy Programme 2008-2018 is a comprehensive plan intended to reduce the burden of allergies. One basic goal is to increase immunologic tolerance and change attitudes to encourage health instead of medicalizing common and mild allergy symptoms. The main goals can be listed as to: (i) prevent the development of allergic symptoms; (ii) increase tolerance to allergens; (iii) improve diagnostics; (iv) reduce work-related allergies; (v) allocate resources to manage and prevent exacerbations of severe allergies, and (vi) reduce costs caused by allergic diseases. So far, the Allergy Programme has organized 135 educational meetings for healthcare professionals around Finland. These meetings are multidisciplinary meetings gathering together all healthcare professionals working with allergic diseases. Since the start of the program in spring 2008, more than 7000 participants have taken part. Educational material for patient care has been provided on special Web sites/therapeutic portals, which can be accessed by all physicians caring for allergic patients. Local Allergy Working Groups have been created in different parts of Finland. As a part of the Programme, a set of guidelines for child welfare clinics was prepared. Child welfare clinics have a key role in the screening of illnesses and providing advice to families with a symptomatic child. The guidelines aimed to facilitate pattern recognition and clinical decision making for public health nurses and doctors are described in this paper.

Breastfeeding and the use of human milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF "Ten Steps to Successful Breastfeeding." National strategies supported by the US Surgeon General's Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The "Business Case for Breastfeeding" details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice.

ICON: food allergy

Food allergies can result in life-threatening reactions and diminish quality of life. In the last several decades, the prevalence of food allergies has increased in several regions throughout the world. Although more than 170 foods have been identified as being potentially allergenic, a minority of these foods cause the majority of reactions, and common food allergens vary between geographic regions. Treatment of food allergy involves strict avoidance of the trigger food. Medications manage symptoms of disease, but currently, there is no cure for food allergy. In light of the increasing burden of allergic diseases, the American Academy of Allergy, Asthma & Immunology; European Academy of Allergy and Clinical Immunology; World Allergy Organization; and American College of Allergy, Asthma & Immunology have come together to increase the communication of information about allergies and asthma at a global level. Within the framework of this collaboration, termed the International Collaboration in Asthma, Allergy and Immunology, a series of consensus documents called International Consensus ON (ICON) are being developed to serve as an important resource and support physicians in managing different allergic diseases. An author group was formed to describe the natural history, prevalence, diagnosis, and treatment of food allergies in the context of the global community.

Breastfeeding and mucosal and cutaneous colonization by Staphylococcus aureus in atopic children

BACKGROUND

Studies on the effects of breastfeeding on the development of Atopic Dermatitis (AD) have shown controversial results. The importance of this condition deserves further studies; in particular, it remains unclear whether colonization of atopic patients by Staphylococcus aureus (S. aureus) through breastfeeding is relevant to the development of AD.

OBJECTIVE

To examine the potential relation between breastfeeding and colonization by S. aureus in atopic patients.

METHOD

Transversal study of atopic patients, aged from 4 to 24 months, both genders, receiving outpatient care and 72 mothers. Data on infant breastfeeding practices and on clinical-epidemiological profile were registered. Swabs of the infants' nares and skin (cubital fossa) and swabs of the mothers' nares were collected. For univariate analysis, X2 (chi-square) and Fischer Exact's test were used.

RESULTS

Among breastfed children, S. aureus was isolated from 8 (25.8%) infants' nares swabs and from 4 (12.9%) skin swabs. Among not breastfed children, S. aureus was isolated from 10 (20.8%) infants' nares swabs and from 11 (22.9%) skin swabs. Sixteen mothers (22.2%) had S. aureus isolated from their nares swabs. There was no significant association between breastfeeding and S. aureus colonization (child skin and/or nares). However, there was a degree of concordance for S. aureus carriage among mothers and infants. Among 72 pairs, 56 (77.8%) were concordant.

CONCLUSION

Breastfeeding was not associated with S. aureus muco-cutaneous colonization in atopic infants.

Differentiating food allergies from food intolerances

Adverse reactions to foods are extremely common, and generally they are attributed to allergy. However, clinical manifestations of various degrees of severity related to ingestion of foods can arise as a result of a number of disorders, only some of which can be defined as allergic, implying an immune mechanism. Recent epidemiological data in North America showed that the prevalence of food allergy in children has increased. The most common food allergens in the United States include egg, milk, peanut, tree nuts, wheat, crustacean shellfish, and soy. This review examines the various forms of food intolerances (immunoglobulin E [IgE] and non-IgE mediated), including celiac disease and gluten sensitivity. Immune mediated reactions can be either IgE mediated or non-IgE mediated. Among the first group, Immediate GI hypersensitivity and oral allergy syndrome are the best described. Often, but not always, IgE-mediated food allergies are entities such as eosinophilic esophagitis and eosinophilic gastroenteropathy. Non IgE-mediated immune mediated food reactions include celiac disease and gluten sensitivity, two increasingly recognized disorders. Finally, non-immune mediated reactions encompass different categories such as disorders of digestion and absorption, inborn errors of metabolism, as well as pharmacological and toxic reactions.

Food allergy

Food allergy appears to be increasing in prevalence and is estimated to affect >2% and possibly up to 10% of the population. Food allergies are defined by an immune response triggered by food proteins. Emerging data suggest that carbohydrate moieties on food proteins, specifically mammalian meats, may also elicit allergic responses. Food is the most common trigger of anaphylaxis in the community, which can be fatal. The underlying mechanisms of food allergy usually involve food-specific immunoglobulin E antibodies, but cell-mediated disorders account for a variety of chronic or subacute skin and gastrointestinal reactions. Eosinophilic esophagitis is an emerging food-related chronic disorder. The diagnosis of food allergy is complicated by the observation that detection of food-specific immunoglobulin E (sensitization) does not necessarily indicate clinical allergy. Diagnosis requires a careful medical history, laboratory studies, and, in many cases, oral food challenges to confirm a diagnosis. Novel diagnostic methods, many of which rely upon evaluating immune responses to specific food proteins or epitopes, may improve diagnosis and prognosis in the future. Current management relies upon allergen avoidance and preparation to promptly treat severe reactions with epinephrine. Studies suggest that some children with milk or egg allergy might tolerate extensively heated forms, for example milk or egg baked into muffins, without symptoms and possibly with some immunotherapeutic benefits. Novel therapeutic strategies are under study, including oral and sublingual immunotherapy, Chinese herbal medicine, anti-immunoglobulin E antibodies, and modified vaccines.

Different implications of paternal and maternal atopy for perinatal IgE production and asthma development

Asthma is a hereditary disease associated with IgE-mediated reaction. Whether maternal atopy and paternal atopy have different impacts on perinatal IgE production and asthma development remains unclear. This paper reviews and summarizes the effects of maternal and paternal atopy on the developmental aspects of IgE production and asthma. Maternal atopy affects both pre- and postnatal IgE production, whereas paternal atopy mainly affects the latter. Maternally transmitted genes GSTP1 and FceRI-beta are associated with lung function and allergic sensitization, respectively. In IgE production and asthma development, the maternal influence on gene-environment interaction is greater than paternal influence. Maternal, paternal, and/or postnatal environmental modulation of allergic responses have been linked to epigenetic mechanisms, which may be good targets for early prevention of asthma.

Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia

OBJECTIVE

To perform an economic evaluation of a specific brand of partially hydrolyzed infant formula (PHF-W) in the prevention of atopic dermatitis (AD) among Australian infants.

METHODS

A cost-effectiveness analysis was undertaken from the perspectives of the Department of Health and Aging (DHA), of the family of the affected subject and of society as a whole in Australia, based on a decision-analytic model following a hypothetical representative cohort of Australian newborns who are not exclusively breastfed and who have a familial history of allergic disease (i.e., are deemed 'at risk'). Costs, consequences, and incremental cost-effectiveness ratios (ICER) were calculated for PHF-W vs standard cow's milk based infant formula (SF), and, in a secondary analysis, vs extensively hydrolyzed infant formula (EHF-Whey), when the latter was used for the prevention of AD.

RESULTS

From a representative starting cohort of 87,724 'at risk' newborns in Australia in 2009, the expected ICERs for PHF-W vs SF were AU$496 from the perspective of the DHA and savings of AUD1739 and AU$1243 from the family and societal perspectives, respectively. When compared to EHF-Whey, PHF-W was associated with savings for the cohort of AU$5,183,474 and AU$6,736,513 from the DHA and societal perspectives.

LIMITATIONS

The generalizability and transferability of results to other settings, populations, or brands of infant formula should be made with caution. Whenever possible, a conservative approach directing bias against PHF-W rather than its comparators was applied in the base case analysis. Assumptions were verified in one-way and probabilistic sensitivity analyses, which confirmed the robustness of the model.

CONCLUSIONS

PHF-W appears to be cost-effective when compared to SF from the DHA perspective, dominant over SF from the other perspectives, and dominant over EHF-Whey from all perspectives, in the prevention of AD in 'at risk' infants not exclusively breastfed, in Australia.

Breastfeeding and allergy: the evidence

Whether breastfeeding protects against the development of allergic disease has been a frequent subject of study and debate for 75 years. This paper summarizes the published evidence concerning the risks of atopic dermatitis, asthma, allergic rhinitis, positive allergen skin tests, and food allergy associated with infant feeding. The summary is based largely on systematic reviews and meta-analyses carried out by other authors. In addition, I also incorporate the evidence from our long-term follow-up of Belarusian children participating in a cluster-randomized trial of a breastfeeding promotion intervention.

Strategies to prevent or reduce allergic disease

The need for allergy prevention strategies has never been greater. Surging rates of food allergy and eczema are now adding to the already substantial burden of asthma and respiratory allergic diseases. The parallel rise in many other immune diseases suggests that the developing immune system is highly vulnerable to modern environmental changes. These strong environmental pressures may be one reason why simple allergen avoidance strategies have not been successful. Another more recent strategy to curtail the allergy epidemic has been to identify factors associated with modern lifestyle that may be causally linked with allergic disease, in an attempt to restore more favourable conditions for immune tolerance during early development. More hygienic conditions and disruption of microbial exposure have prompted strategies to restore this balance using probiotic and prebiotic supplements. Modern dietary changes linked with allergic diseases have prompted supplementation studies to assess the preventive merits of specific immunomodulatory dietary nutrients such as polyunsaturated fatty acids. Other nutrients such as antioxidants, folate, and vitamin D are also currently under investigation. Modern environmental pollutants have also been associated with adverse effects on immune development and the risk of disease. While many of these avenues have provided some promise, they have not yet translated into specific recommendations. Current evidence-based guidelines for allergy prevention remain limited to avoidance of cigarette smoke, promotion of breastfeeding and the use of hydrolysed formula when breastfeeding is not possible. Allergen avoidance strategies have been largely removed from most guidelines. It is hoped that a number of ongoing studies will help provide clearer recommendations around the use of probiotics, prebiotics, specific dietary nutrients and the role of early introduction of allergenic foods for the promotion of tolerance. Despite the current uncertainties, prevention remains the best long-term strategy to reduce the growing burden of allergic disease.

Can we prevent food allergy by manipulating the timing of food exposure?

Prevention of food allergies by maternal and infant feeding practices serves as a simple, inexpensive approach to address the growing number of subjects with food allergies in comparison with any emerging interventional therapies for existing food allergies, such as oral immunotherapy. This article provides a careful evaluation of the rationale and existing data on the effect of timing of the introduction of food allergens (during pregnancy, lactation, and early childhood) on the development of specific food allergies.

The introduction of solid food and growth in the first 2 y of life in formula-fed children: analysis of data from a European cohort study

BACKGROUND

Early introduction of solid food has been suspected to induce excessive infant energy intake and weight gain.

OBJECTIVE

The objective of this study was to test whether introduction of solid foods influences energy intake or growth.

DESIGN

Healthy, formula-fed infants who were recruited in 5 European countries were eligible for study participation. Anthropometric measurements were taken at recruitment and at 3, 6, 12, and 24 mo. Time of introduction of solid foods and energy intake were determined by questionnaires and 3-d weighed food records at monthly intervals. Age at introduction of solid food was categorized into 4 groups: ≤ 13 wk, 14-17 wk, 18-21 wk, and ≥ 22 wk.

RESULTS

Of 1090 recruited infants, 830 (76%) had data available for age at first introduction of solid food, and 671 (61%) completed the study until 24 mo of age. The median age at introduction of solid food was 19 wk. The time of introduction of solid foods was associated with country, sex, birth weight, parental education and marital status, and maternal smoking. Energy intake was higher in the first 8 mo of life in children with solid-food intake. Solid-food introduction did not predict anthropometric measures at 24 mo. Growth trajectories differed significantly: children with solid-food introduction in the first 12 wk experienced early catch-up growth, whereas those introduced to solid food at >22 wk of age grew more slowly and stayed on lower trajectories.

CONCLUSIONS

Solid foods do not simply replace infant formula but increase energy intake. Time of introduction of solid food has little influence on infant growth. This trial was registered at clinicaltrials.gov as NCT00338689.

Early diet and the risk of allergy: what can we learn from the prospective birth cohort studies GINIplus and LISAplus?

Recently, the American Academy of Pediatrics and the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition published new guidelines on early nutrition and allergy prevention in infants and children. This article reviews epidemiologic evidence from 2 prospective German birth cohort studies, the GINIplus and the LISAplus, regarding maternal diet during pregnancy and feeding patterns in early life and the risk of allergy in light of the new recommendations. The 2 cohorts include a total of 9088 infants who were recruited within different regions of Germany between 1995 and 1999. A subgroup of 2252 infants with a hereditary risk of atopy was enrolled in a double-blind, randomized trial to investigate the effect of feeding regimen in infancy on the development of allergy with the strict recommendation that allergenic solid food be introduced late in the study. The results of the GINIplus and LISAplus studies mainly support the new finding regarding allergy prevention that a delayed introduction of solid foods or the avoidance of highly allergenic foods during the first year does not seem to be beneficial for allergy prevention. A very early introduction of solid foods and a high diversity before week 17 of age may increase the risk of later allergy. We showed that a high intake of margarine, vegetable oils, and some allergenic fruit and vegetables during pregnancy was associated with an increased risk of allergies, especially eczema. Because maternal diet during pregnancy is not reflected in the current recommendations, it should be the focus of future studies.

ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Feeding practices among children attending child welfare clinics in Ragama MOH area: a descriptive cross-sectional study

Background

Feeding during early childhood is important for normal physical and mental growth as well as for health in later life. Currently, Sri Lanka has adopted the WHO recommendation of exclusive breastfeeding for six months, followed by addition of complementary feeds thereafter, with continuation of breastfeeding up to or beyond two years. This study was conducted to evaluate the current feeding practices among Sri Lankan children during early childhood.

Methods

This study was a descriptive cross-sectional study conducted in the Ragama Medical Officer of Health (MOH) area. It was conducted between 10 August 2010 and 30 October 2010. Children between the ages of 24 and 60 months, attending child welfare clinics, were included in the study on consecutive basis. An interviewer-administered questionnaire was used to collect data regarding sociodemographic characteristics and feeding practices.

Results

There were 208 boys and 202 girls in the study population. Of them, 255 (62.2%) were exclusively breastfed up to 6 months. Younger children had a statistically significant, higher rate of exclusive breastfeeding compared to older children. Three hundred and fifty one (85.6%) children had received infant formula, and it was started before the age of 6 months in 61 children, and in 212 before one year. Sugar was added to infant formula in 330 (80.4%) children, and out of them 144 had sugar added within first year of life. Complementary foods were started before 4 months in 29 (7%) children. Of the 410 children, 294 (71.7%) were breastfed beyond 2 years and 41.6% of them were breastfed at regular intervals throughout the day. Three hundred and thirty eight (82.6%) children were receiving overnight feeding of either breast milk or infant formula even after 2 years.

Conclusions

Though a high rate of exclusive breastfeeding was observed in this study population, there are many other issues related to feeding during the early years of life that need immediate intervention. Too early introduction of complementary food, using infant formula without an indication, adding sugar to infant formula, too frequent breastfeeding and overnight feeding of older children are among them.

Food allergy

Food allergy is defined as an adverse immunologic response to a dietary protein. Food-related reactions are associated with a broad array of signs and symptoms that may involve many bodily systems including the skin, gastrointestinal and respiratory tracts, and cardiovascular system. Food allergy is a leading cause of anaphylaxis and, therefore, referral to an allergist for appropriate and timely diagnosis and treatment is imperative. Diagnosis involves a careful history and diagnostic tests, such as skin prick testing, serum-specific immunoglobulin E (IgE) testing and, if indicated, oral food challenges. Once the diagnosis of food allergy is confirmed, strict elimination of the offending food allergen from the diet is generally necessary. For patients with significant systemic symptoms, the treatment of choice is epinephrine administered by intramuscular injection into the lateral thigh. Although most children "outgrow" allergies to milk, egg, soy and wheat, allergies to peanut, tree nuts, fish and shellfish are often lifelong. This article provides an overview of the epidemiology, pathophysiology, diagnosis, management and prognosis of patients with food allergy.

Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two

BACKGROUND

Exclusive breastfeeding for at least 4 months is recommended by many governments and allergy organizations to prevent allergic disease.

OBJECTIVES

To investigate whether exclusive breastfeeding protects against childhood eczema.

METHODS

Study subjects comprised 51,119 randomly selected 8- to 12-year-old schoolchildren in 21 countries. Information on eczema and breastfeeding was gathered by parental questionnaire. Children were also examined for flexural eczema and underwent skin prick testing. Odds ratios (ORs) were calculated for each study centre and then pooled across populations.

RESULTS

There was a small increase in the risk of reported 'eczema ever' in association with 'breastfeeding ever' and breastfeeding < 6 months [pooled adjusted OR 1·11, 95% confidence interval (CI) 1·00-1·22 and OR 1·10, 95% CI 1·02-1·20, respectively]. There was no significant association between reported 'eczema ever' and breastfeeding > 6 months (pooled adjusted OR 1·09, 95% CI 0·94-1·26). Risk estimates were very similar for exclusive breastfeeding < 2 months, 2-4 months and > 4 months and for eczema symptoms in the past 12 months and eczema on skin examination. As for more severe eczema, breastfeeding per se conveyed a risk reduction on sleep disturbed eczema (pooled adjusted OR 0·71, 95% CI 0·53-0·96), but this effect was lost where children had been exclusively breastfed for > 4 months (pooled adjusted OR 1·02, 95% CI 0·67-1·54). Allergic sensitization and a history of maternal allergic disease did not modify any of these findings.

CONCLUSIONS

Although there was a protective effect of ever having been breastfed on more severe disease, we found no evidence that exclusive breastfeeding for 4 months or longer protects against eczema. Our results are consistent with findings from a recent systematic review of prospective studies. The U.K. breastfeeding guidelines with regard to eczema should be reviewed. Intervention studies are now required to explore how and when solids should be introduced alongside breastfeeding to aid protection against eczema and other allergic diseases.

Global analysis of breast feeding and risk of symptoms of asthma, rhinoconjunctivitis and eczema in 6-7 year old children: ISAAC Phase Three

BACKGROUND

In Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC), we investigated the relationship between breast feeding in infancy and symptoms of asthma, rhinoconjunctivitis and eczema in 6-7 year old children.

METHODS

Parents or guardians of 6-7 year old children completed written questionnaires on current symptoms of asthma, rhinoconjunctivitis and eczema, and on a range of possible asthma risk factors including a history of breast feeding ever. Prevalence odds ratios were estimated using logistic regression, adjusted for gender, region of the world, language, per capita gross national income, and other risk factors.

RESULTS

In all 206,453 children from 72 centres in 31 countries participated in the study. Reported breast feeding ever was not associated with current wheeze, with an odds ratio (adjusted for gender, region of the world, language, per capita gross national income, and factors encountered in infancy) of 0.99 (95% CI 0.92-1.05), current rhinoconjunctivitis (OR 1.00, 95% CI 0.93-1.08), current eczema (OR 1.05, 95% CI 0.97-1.12), or symptoms of severe asthma (OR 0.95, 95% CI 0.87-1.05). Breast feeding was however associated with a reduced risk of severe rhinoconjunctivitis (OR 0.74, 95% CI 0.59-0.94) and severe eczema (OR 0.79, 95% CI 0.66-0.95).

CONCLUSIONS

There was no consistent association between breast feeding use in the first year of life and either a history or current symptoms of wheezing, rhinoconjunctivitis or eczema in 6-7 year old children, but possibly an effect on severe symptoms of the latter two conditions.

NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population

Data from many studies have suggested a rise in the prevalence of food allergies during the past 10 to 20 years. Currently, no curative treatments for food allergy exist, and there are no effective means of preventing the disease. Management of food allergy involves strict avoidance of the allergen in the patient's diet and treatment of symptoms as they arise. Because diagnosis and management of the disease can vary between clinical practice settings, the National Institute of Allergy and Infectious Diseases (NIAID) sponsored development of clinical guidelines for the diagnosis and management of food allergy. The guidelines establish consensus and consistency in definitions, diagnostic criteria, and management practices. They also provide concise recommendations on how to diagnose and manage food allergy and treat acute food allergy reactions. The original guidelines encompass practices relevant to patients of all ages, but food allergy presents unique and specific concerns for infants, children, and teenagers. To focus on those concerns, we describe here the guidelines most pertinent to the pediatric population.

Influência regional no consumo precoce de alimentos diferentes do leite materno em menores de seis meses residentes nas capitais brasileiras e Distrito Federal

Objetivou-se avaliar a influência regional no consumo precoce de alimentos diferentes do leite materno em menores de seis meses residentes nas capitais brasileiras. Analisaram-se dados de 18.929 crianças da II Pesquisa de Prevalência de Aleitamento Materno nas Capitais Brasileiras - 2008. As frequências do consumo de chá, sucos, leite artificial e mingau/papa foram calculadas para as capitais das cinco regiões brasileiras. Curvas do consumo foram obtidas pela análise de logitos e estimativas das razões de prevalência (RP) por modelos de Poisson. O consumo de leite artificial foi maior quando comparado aos demais alimentos em todas as capitais. As capitais do Sul apresentaram a maior razão de prevalência para o consumo de chá (RP = 2,37) e as do Nordeste e Sudeste, para o consumo de outros tipos de leite (RP = 1,50 e 1,47) e de suco (RP = 1,57 e 1,55). Nas capitais do Nordeste, o consumo precoce de mingau/papa foi maior (RP = 3,0). A região tem influência no consumo precoce de alimentos, o que deve ser levado em consideração na elaboração de políticas públicas.

The incidence and risk factors of immediate type food allergy during the first year of life in Korean infants: a birth cohort study

OBJECTIVES

We conducted this study to determine the incidence of food allergy (FA) in Korean infants and identify the risk factors of FAs during the first year of life in a birth cohort study.

METHODS

Pregnant women ≥34 weeks of gestation were enrolled in this study. Participants were asked to complete questionnaires describing basic demographic information including family history of allergic diseases. Since birth, all the babies were regularly followed up for FA symptoms through telephone interviews at 4, 8, and 12 months of age. FA was defined as a repetitive convincing history of immediate allergic reactions following the ingestion of offending food.

RESULTS & CONCLUSIONS

A total of 1177 infants and their parents completed this study. The prevalence of FA was 5.3% in infants. The three leading food allergens were hen's eggs (33/62), cow's milk (20/62) and peanut/nuts (8/62). Children with a history of maternal AD showed a significantly higher prevalence of FA (P = 0.012) [aRR = 3.17]. In addition, children who were born during autumn had a higher prevalence than those born during spring (p = 0.005) [aRR = 3.48]. In conclusion, we identified several characteristics that may influence the development of FA in the next generation, including maternal AD and autumn birth.

Dietary immunomodulatory factors in the development of immune tolerance

Emerging evidence suggests that exposures during pregnancy and the early postnatal period can modify gene expression and disease propensity. Diet is a major environmental exposure, and dietary factors, including polyunsaturated fatty acids, probiotics, oligosaccharides, antioxidants, folate, and other vitamins, have effects on immune function. Some also have been implicated in reduced risk of allergy in observational studies. Intervention trials with polyunsaturated fatty acids, probiotics, and oligosaccharides suggest preliminary but as-of-yet-unconfirmed benefits. Food allergen avoidance during pregnancy, lactation, or infancy has provided no consistent evidence in allergy prevention and is no longer recommended. Rather, there is now a focus on food allergens in tolerance induction. Specific nutrients can induce changes in gene expression during early development and have been implicated in potentially heritable "epigenetic" changes in disease predisposition. Collectively, these observations emphasize that early exposures may modify tolerance development and that further research on these exposures should remain a priority.

Partially hydrolyzed cow's milk formula has a therapeutic effect on the infants with mild to moderate atopic dermatitis: a randomized, double-blind study

OBJECTIVE

The allergy-preventing effect of partially hydrolyzed cow's milk formula (phCMF) in infants at high risk of atopic dermatitis (AD) has been demonstrated in many studies. However, the therapeutic potential of phCMF in treating the infants with AD has not been reported. We sought to assess such therapeutic efficacy of phCMF in infants with mild to moderate AD.

METHODS

From 2006 to 2008, 113 infants <6 months of age with AD were randomized to receive either partially hydrolyzed cow's milk formula (phCMF) or conventional cow's milk formula (CMF) in a double-blind clinical trial. Assessments were made at enrollment and at weeks 4, 8, and 12. The severity of AD was assessed using two scoring systems: Standard guideline for management (diagnosis, severity scoring, and therapy) of AD by the Japanese Dermatological Association Scoring System (JDASS) and the SCORing Atopic Dermatitis (SCORAD). Growth status of the infants was evaluated. Allergy profile was assessed by measuring total blood eosinophils (EOS), total/specific IgE, Th1/Th2 cytokine profiles, and the percentage of regulatory T cells.

RESULTS

After follow-up for 12 wk, 27 infants (23.89%) dropped off study. Analysis was performed on 86 infants by the end of 12-wk observation. The AD severity scores were significantly reduced in the phCMF group (n = 56) compared with CMF group (n = 30) after 12 wk (p < 0.05). The severity scores of phCMF group were significantly reduced at weeks 4, 8, and 12 compared to enrollment (p < 0.05). In contrast, no significant improvement was observed for CMF group at any of those time points (p > 0.05). The number of AD flare-ups was significantly decreased in the phCMF group (p = 0.002). Th1/Th2 ratio in phCMF was significantly increased compared with CMF group (p = 0.041). The growth rates did not differ significantly between these feeding groups at any assessed time point (p > 0.05) and were in the normal range.

CONCLUSION

This study suggests a novel therapeutic effect of phCMF in treating infants with mild to moderate AD during the first 6 months of their life without affecting their nutritional status.

Coenzyme A contained in mothers' milk is associated with the potential to induce atopic dermatitis

T(h)2 adjuvant activity can be qualitatively and quantitatively evaluated using a mixed lymphocyte reaction and by changes in the intracellular cyclic adenosine 3',5'-monophosphate concentration, using human dendritic cells in vitro. The current study shows that mothers, whose children (n = 55) developed atopic dermatitis (AD) within 6 months after birth, often demonstrate a higher T(h)2 adjuvant activity in their milk, in comparison to those whose children did not develop such symptoms. Such an activity was recovered in a liquid phase of mothers' milk and was eluted as a single fraction by reversed-phase HPLC. Further analysis of this fraction by mass spectrometry showed that signals originating from a factor with a molecular weight of 767.53 are observed, exclusively in milk with a high T(h)2 adjuvant activity. The mass is exactly that of Coenzyme A (CoA), and indeed, a low concentration of CoA exhibited T(h)2 adjuvant activity both in vitro and in vivo. Moreover, mesenteric lymph node non-T cells obtained from mice that were orally treated with CoA led allogeneic naive CD4(+) T cells to differentiate into T(h)2. Furthermore, the oral administration of CoA induced rough skin, hyperplasia of the epidermis, hypergranulosis in the spinous layer and the thickening of the stratum in mice. These data collectively indicate that some of the patients with AD were exposed to mothers' milk carrying high T(h)2 adjuvant activity right after birth, which may be attributable to presence of CoA contained in the milk.

The allergic march: can we prevent allergies and asthma?

The allergic march is a progression of atopic disease from eczema to asthma, and then to allergic rhinoconjunctivitis. It appears to be caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation. Genetic and environmental factors predispose to developing the allergic march. There are data to support 4 possible interventions to prevent the allergic march from progressing to asthma: (1) supplements of dietary probiotics, (2) exclusive breast feeding during the first few months of life, or, alternatively (3) use of extensively hydrolyzed infant formulas, (4) treatment with inhalant allergen immunotherapy by either subcutaneous or sublingual methods.

Infant nutrition and allergy

Over the past several decades, the incidence of atopic diseases such as asthma, atopic dermatitis and food allergies has increased dramatically. Although atopic diseases have a clear genetic basis, environmental factors, including early infant nutrition, may have an important influence on their development. Therefore, attempts have been made to reduce the risk of the development of allergy using dietary modifications, mainly focused on longer breast-feeding and delayed introduction or elimination of foods identified as potentially most allergenic. Recently, there is also an increasing interest in the active prevention of atopy using specific dietary components. Many studies have shown that breast-feeding may have the protective effect against future atopic dermatitis and early childhood wheezing. Concerning complementary feeding, there is evidence that the introduction of complementary foods before 4 months of age may increase the risk for atopic dermatitis. However, there is no current convincing evidence that delaying introduction of solids after 6 months of age has a significant protective effect on the development of atopic disease regardless of whether infants are fed cow's milk protein formula or human subject's milk, and this includes delaying the introduction of foods that are considered to be highly allergic, such as fish, eggs and foods containing peanut protein. In conclusion, as early nutrition may have profound implications for long-term health and atopy later in life, it presents an opportunity to prevent or delay the onset of atopic diseases.

Nutrient intake variability and number of days needed to assess intake in preschool children

The duration of the period of time during which diet should be recorded for sufficiently accurate results on the usual intake of an individual is an especially challenging issue in prospective studies among children. We set out to describe nutrient intake variability in preschoolers and to determine the number of record days required (D) to estimate intake of energy and thirty-two nutrients. The diet and the use of dietary supplements were assessed with three consecutive daily food records including one weekend day in 1639 children participating in the population-based birth cohort of the Type 1 Diabetes Prediction and Prevention Project (DIPP) in Finland. Variance ratios and D stratified by sex and age groups were calculated for 455 (1-year-old), 471 (3-year-old) and 713 (6-year-old) children (born between 1998 and 2003). Within:between variance ratios and D increase with increasing age, and are slightly higher for girls. Vitamin A, cholesterol, n-3 and n-6 fatty acids, β-carotene and folate intakes require the most replicates. Including supplemental intake has an impact on the variance estimates according to the proportion of supplement users. In the DIPP Nutrition Study with 3 d food records, the correlation coefficients between observed and true intakes of energy and thirty-two nutrients averaged 0·91 in 1-year-old children, 0·79 in 3-year-old children and 0·74 in 6-year-old children. For providing accurate nutrient intake estimates, three replicates of food records are reasonable in 1-year-old children but must be questioned for several nutrients in 3- and 6-year-old children. The accuracy of ranking boys is greater than that for girls.

Food Allergy: State of the Science--Allergy, Asthma and Immunology Committee

In the past several years, food allergies have taken center stage in the media and have become a topic of great concern for our patients and their families. Whether or not this is due to a rise in the prevalence of food allergies or just a heightened awareness, it is our responsibility as clinicians and scientists to critically analyze the current evidence available concerning the epidemiology, manifestations, diagnosis, and management of this disease. In 2010, the National Institute of Allergy and Infectious Diseases (NIAID) published guidelines concerning the diagnosis and management of food allergies. Since 2009, the Allergy, Asthma and Immunology Committee of the American Academy of Otolaryngology-Head and Neck Surgery has sponsored a miniseminar titled, "Food Allergy: State of the Science." This commentary focuses on the highlights from the 2010 meeting and provides some thoughts on what this latest publication means to otolaryngologists.

Maternal peanut consumption provides protection in offspring against peanut sensitization that is further enhanced when co-administered with bacterial mucosal adjuvant

The aims of the present study were to assess whether protection against peanut (PN) sensitization can be conferred by maternal PN consumption alone and if so, whether protection was increased by mucosal adjuvant co-administration. Mice were fed with low dose of either PN or PN with cholera toxin (CT) preconceptionally, and during pregnancy and lactation. Offspring serum PN-specific immunoglobulins and cellular responses by splenocytes and mesenteric lymph node (MLN) cells were determined after an active PN sensitization protocol. Milk was collected from lactating mothers of 11-21-day-old pups for evaluation of PN-specific immunoglobulin levels. We found that offspring of PN fed mothers exhibited lower PN-specific IgE levels and reduced PN-stimulated splenocyte and MLN cells cytokine secretion than offspring of non PN fed mothers. CT co-administration with PN enhanced these responses.. Milk from mothers fed PN and CT, but not PN alone preconceptionally and during pregnancy and lactation contained markedly and significantly increased levels of both peanut-specific IgG2a and IgA. Our study demonstrated that maternal feeding of PN alone had a protective effect against PN sensitization of the progeny, which was enhanced by co-administration of a mucosal adjuvant. Increased levels of PN-specific IgG2a and/or IgA in milk were seen when PN and CT were administered together, suggesting that transmission of maternal immunoglobulins may play a role in the observed protection.

The introduction of allergenic foods and the development of reported wheezing and eczema in childhood: the Generation R study

OBJECTIVE

To examine whether the timing of introduction of the allergenic foods cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten is associated with eczema and wheezing in children 4 years of age or younger.

DESIGN

Population-based prospective cohort study from fetal life until young adulthood.

SETTING

Rotterdam, the Netherlands, from April 2002 through January 2006.

PARTICIPANTS

A total of 6905 preschool children participating in the Generation R study.

MAIN EXPOSURE

Timing of introduction of cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten collected by questionnaires at 6 and 12 months of age.

MAIN OUTCOME MEASURES

Information on the outcomes eczema and wheezing were obtained by questions from the age-adapted version of the "International Study of Asthma and Allergies in Childhood" core questionnaire and questionnaire data on parentally reported physician diagnosis for eczema.

RESULTS

Of 6905 children, wheezing was reported in 31% at age 2 years and in 14% at ages 3 and 4 years. Eczema was reported in 38%, 20%, and 18% of children at the ages of 2, 3, and 4 years, respectively. The introduction of cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten before the age of 6 months was not significantly associated with eczema or wheezing at any age after adjustment for potential confounders (P > .10 for all comparisons). The results did not alter after stratification according to the child's history of cow's milk allergy and parental history of atopy.

CONCLUSION

This study does not support the recommendation for delayed introduction of allergenic foods after age 6 months for the prevention of eczema and wheezing.

The role of microbes in developmental immunologic programming

The role of microorganisms in the gastrointestinal tract has undergone significant modification in the past few decades with new observations from clinical, epidemiologic, and basic science research. We now know that the perception of these gut microbes as pathogens or even as commensals is somewhat outdated. It is becoming increasingly clear that the gut microbiome plays an important role in a host of activities including digestion, protection from potentially pathogenic organisms, and the regulation and development of the host immune system. The complex interactions between microbes and host combined with recent clinical observations and epidemiologic trends may point to the convergence of two well-supported (though imperfect) hypotheses: the "hygiene hypothesis" and the "fetal programming hypothesis." We are beginning to understand that exposure to microbes before conception, during gestation, and in the neonatal period have profound effects on the developing immune system. Recent observations from a variety of fields help support the expansion of the "fetal programming hypothesis" to a host-microbe corollary that microbe-host interactions at critical windows influence the future immune phenotype, the maintenance of immune health, and the development of immune-mediated disease.

An update on immunotherapy for food allergy

PURPOSE OF REVIEW

Recent investigation has resulted in significant advances toward definitive therapeutic options for food allergy. In this review, we will explore novel immunotherapeutic interventions for the active treatment of food allergy.

RECENT FINDINGS

Because the injection route for allergen immunotherapy to foods has been associated with an unacceptable risk of severe anaphylactic reactions, use of mucosally targeted therapeutic strategies is of significant interest for food allergy. Allergen-specific immunotherapeutic approaches such as oral, sublingual, epicutaneous, and peptide immunotherapy have demonstrated efficacy in increasing threshold dose and inducing immunologic changes associated with both desensitization and oral tolerance in animal and human trials. More global immunomodulatory strategies, such as Traditional Chinese Medicine and anti-IgE therapy have been shown to effectively target the allergic response, and clinical trials are ongoing to determine the efficacy and safety in human food allergy.

SUMMARY

The advent of therapies that target the mucosal immune response to promote oral tolerance have shown great promise in the treatment of food hypersensitivity. However, there is still significant risk of adverse reactions associated with these therapeutic strategies and further study is needed to carefully advance these therapeutic modalities toward general clinical implementation.

Maternal diet during lactation and allergic sensitization in the offspring at age of 5

The objective of this study was to examine the effect of maternal dietary intake during lactation on allergic sensitization at the age of 5 in children carrying HLA-DQB1-conferred susceptibility to type 1 diabetes. We analyzed data for 652 consecutively born children with complete information on maternal diet and allergen-specific immunoglobulin E (IgE) measurements who are participating in the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) Nutrition and allergy study. Analysis was performed using logistic regression. In models that included the significant uncorrelated dietary variables, maternal intake of butters and saturated fatty acids was associated with increased risk, while margarine was associated with a decreased risk, of sensitization to wheat allergen in the offspring. Maternal intake of potatoes, milks, and margarine and low-fat spreads were associated with decreased risk of sensitization to birch allergen. On the other hand, intake of potatoes decreased the risk, while vitamin C and eggs increased the risk, of cat allergic sensitization. Maternal intake of butters and saturated fatty acids during lactation may increase the risk, while margarines may decrease the risk, of sensitization to wheat allergen in the offspring. Maternal intake of potatoes, milks, and margarines may decrease the risk of sensitization to birch allergen. On the other hand, intake of potatoes may decrease the risk, while vitamin C and eggs may increase the risk, of cat allergic sensitization. These effects may persist regardless of maternal or parental allergic status.