Breastfeeding and risk of atopic dermatitis up to the age 42 months: a birth cohort study in Japan

Pearls and Pitfalls of Weaning an Infant with Severe Atopic Dermatitis and Sensitization/Allergy to Food

Atopic dermatitis (AD) is a common chronic inflammatory skin disorder in childhood. Skin barrier impairment exposes infants to food allergens, potentially causing sensitization followed by IgE-mediated food allergy. We describe the case of an infant with severe AD in whom several sensitizations to foods are detected, with consequently difficult weaning, and a history of anaphylaxis to cashew nut. Foods for which skin tests were negative were introduced into the infant's diet. Then, when AD control was managed, oral food challenges (OFCs) for foods to which the patient was sensitized, with the exception of cashew nut, were performed. The simultaneous presence of sensitization toward multiple foods made it difficult to introduce them using classic OFC. Therefore, it was decided to perform the low-dose, gradual controlled OFC. This led to an introduction of sensitized foods into the infant's diet, with the exception of cashew nut, avoiding allergic reactions. Absolute recommendations on how, when, and where to perform OFCs with allergenic food to which the child with AD is sensitized are lacking so far. In our opinion, OFCs and the subsequent ntroduction of allergenic foods should be individualized, evaluating some factors such as their social and nutritional importance, the patient's age and clinical phenotype (including the history of anaphylaxis), and the sensitization profile. There is agreement on the fact that the dietary approach in children with moderate-severe AD should no longer include a strict elimination diet. We believe that an early, gradual controlled introduction of all allergenics to identify the amount of food tolerated in the absence of reactions, even if low dose, may improve patients' and families' quality of life. However, even if discussing a vast relevant literature, the limitation of our work is that we describe the management of a single patient. Extensive and high-quality research is needed in this field to improve the available evidence in the area.

Regional Differences in the Prevalence of Atopic Dermatitis among Schoolchildren in Japan and Its Associated Factors from 2006 to 2018

The trends in the prevalence of atopic dermatitis for each prefecture over recent years have not been investigated in Japan, and no studies investigating the factors associated with the prevalence using nationwide data have been conducted. We investigated the trends in the prevalence of atopic dermatitis among schoolchildren for each prefecture in Japan from 2006 to 2018 and identified the factors associated with regional differences in prevalence. The data on the atopic dermatitis prevalence in schoolchildren aged 6–17 years were collected as part of the School Health Statistics Research. The demographic, socioeconomic, medical, and environmental characteristics of the prefectures were examined for possible associations with the prevalence. The age-standardized prevalence rates of atopic dermatitis were calculated separately for boys and girls and by prefecture and year. We examined the associations between the age-standardized prevalence rates and prefectural characteristics using an ecological study. The age-standardized prevalence rates of atopic dermatitis tended to be stable for Japan as a whole, whereas the trend in the age-standardized prevalence rates differed across prefectures. In the regression analysis, the year was negatively associated and the number of medical clinics per 100,000 persons was positively associated with the age-standardized prevalence in girls. The taxable income per capita was positively associated with the age-standardized prevalence both in boys and in girls.

Timing of Cow's Milk or Cow's Milk Formula Introduction to the Infant Diet and Atopic Risk in Children: a Systematic Review and Meta-analysis

Infant feeding is an important early-life exposure that may influence the development of atopic disease. The optimal timing of introduction of food allergens, including cow's milk (CM), is not known. This study aims to systematically review the evidence describing the effects of timing of CM or cow's milk formula (CMF) introduction to the infant diet on the development of atopic diseases during childhood. Pubmed, Embase, CINAHL, Cochrane CENTRAL, and CNKI were searched through May 30, 2019. Study screening and data extraction by two reviewers followed the PRISMA statement. Data were extracted independently in duplicate, and meta-analyses were performed by pooling unadjusted and adjusted odds ratio (OR) separately. Heterogeneity was explored using I² and publication bias by funnel plots and Begg's tests. In total, 45 studies from 20 countries were included. Meta-analyses using adjusted data showed that no associations were observed between early introduction of CM or CMF and the risk of asthma (< 4 vs. ≥ 4 months: OR 1.16, 95% confidence interval (CI) 0.89, 1.51), wheeze (< 6 vs. ≥ 6 months: OR 1.15, 95% CI 0.85, 1.56), and eczema or atopic dermatitis (< 6 vs. ≥ 6 months: OR 0.96, 95% CI 0.65, 1.41). Overall, quite little high-quality evidence was identified to allow for definitive conclusions on the association between early CM or CMF introduction and risk of allergic diseases. Our meta-analysis on this topic highlights the specific gaps in information for public recommendations regarding CM or CMF feeding practice in an early stage of life, particularly before 3 months of age.

Association between breastfeeding and Kawasaki disease: a case-control study

The association between breastfeeding and Kawasaki disease is not fully understood. We performed a case-control study to examine the association between breastfeeding and Kawasaki disease. In this study, 389 children diagnosed with Kawasaki disease and 426 gender- and age-matched controls were identified at Renmin Hospital of Wuhan University between November 2013 and March 2019. Demographic and clinical data were collected from a structured telephone interview and medical record database. Odds ratio and 95% confidence interval for risk of Kawasaki disease were estimated. Children who were breastfed exclusively had a decrease in developing Kawasaki disease (adjusted odds ratios and 95% confidence intervals 0.53 (0.38-0.74). Although the risk reduction was not statistically different, partial breastfeeding also provided a protective effect (adjusted odds ratios and 95% confidence intervals 0.70 (0.48-1.01). In the stratified analysis, we still observed that exclusive breastfeeding was inversely associated with the development of complete Kawasaki disease (adjusted odds ratios and 95% confidence intervals 0.52 (0.31-0.88) and incomplete Kawasaki disease (adjusted odds ratios and 95% confidence intervals 0.54 (0.38-0.77). However, there was no significant association between exclusive breastfeeding and the intravenous immunoglobulin treatment response (adjusted odds ratios and 95% confidence intervals 0.69 (0.27-1.69) and the risk of coronary artery lesions (adjusted odds ratios and 95% confidence intervals 0.79 (0.49-1.31) in Kawasaki disease.Conclusion: Our analysis suggests that exclusive breastfeeding was inversely associated with the development of Kawasaki disease and that breastfeeding might be a potential protective factor against Kawasaki diseaseWhat is known• Previous studies have demonstrated that breastfeeding has been shown to potentially confer protection against several autoimmune disorders of childhood.• The association between breastfeeding and Kawasaki disease is not fully understood.What is newThe first study to evaluate the association between breastfeeding and the development of Kawasaki disease in China with a large sample size.• Exclusive breastfeeding was inversely associated with the development of Kawasaki disease and breastfeeding might be a potential protective factor against Kawasaki disease.

Relationship Between Atopic Dermatitis and Food Allergy

Consistent evidence has been found on the relationship between food allergy (FA) and atopic dermatitis (AD) in some children. Food sensitization can be often found in these patients. Allergy should be confirmed, though, with a food challenge test (FC) before advising a restrictive diet which could be harmful for the patient. Younger children with AD frequently show sensitization to egg, milk or peanut, while older ones and adults are more often sensitized to environmental allergens such as house dust mites, moulds, animal dander or pollens. It is well known that a barrier disturbance plays a main role in the development of sensitization and allergy. Therefore, due to the early appearance of AD, preventive newborn skincare with emollients and early introduction of food appear to be very important to determine food tolerance.

Prenatal and neonatal factors involved in the development of childhood allergic diseases in Guangzhou primary and middle school students

BACKGROUND

Allergic diseases, such as asthma, dermatitis, rhinitis, and eczema, are highly prevalent in Chinese school children. Environmental factors, including air pollution and automobile exhaust, play an important role in the etiology of these diseases. However, prenatal and neonatal factors, such as gender, maternal diseases during pregnancy, and premature birth, may also be associated with allergic disease occurrence. The objective of this study was to explore prenatal and neonatal factors that are involved in the development of allergic diseases among primary and middle school students in Guangzhou, China.

METHODS

A cross-sectional survey was launched by the Health Promotion Centre for Primary and Secondary Schools of the Guangzhou Municipality in October 2017. All primary and middle school students in Guangzhou were notified to participate in the questionnaire online under the direction of their parents. The results of the physical examination were reported by the schools' medical department. The results of the questionnaire were collected and analyzed by the researchers. The prevalence of asthma, allergic rhinitis, allergic dermatitis, and eczema was identified.

RESULTS

Based on reported 183,449 questionnaires and medical records, the data indicate that the sex, birth weight, neonatal feeding type, delivery mode, and students' father smoking status were significantly associated with the prevalence of all four allergic diseases in primary and middle school children. In further stratified analyses of the children with normal birth weight (2500-4000 g) and without any maternal diseases during pregnancy, the factors of male sex, high birth weight, cesarean delivery, and father smoking status all increased the risk of asthma, dermatitis, rhinitis, and eczema. Also, unlike exclusive breastfeeding, breast plus formula feeding increased these risks, but pure formula feeding had the opposite effect.

CONCLUSION

Prenatal and neonatal factors, including male sex, high birth weight, cesarean delivery, only child, and father smoking status are associated with the risks of allergic diseases in school children.

Breastfeeding duration modifies the effect of smoking during pregnancy on eczema from early childhood to adolescence

BACKGROUND

Cigarette smoke contains compounds similar to coal tar, an ancient remedy of eczema. Some studies have reported protective effects of maternal gestational smoking on offspring eczema; however, others have shown no or increased risks. Similarly, studies linking breastfeeding duration and eczema have demonstrated contradictory findings. No study has yet investigated combined effects of these two factors on eczema.

OBJECTIVE

Since tobacco compounds can pass to offspring via breast milk, we investigated their combined effects on eczema development from childhood to adolescence.

METHODS

We obtained information regarding gestational smoking, exclusive breastfeeding duration, and eczema at ages 1-or-2, 4, 10, and 18 years from the Isle of Wight (IOW) birth cohort, UK. Using generalized estimating equations, we assessed the interaction of gestational smoking and residual exclusive breastfeeding duration (Resid-BF-duration, obtained by regressing the latter on maternal smoking) on eczema over time adjusting for confounders. For the three transition periods of 1-or-2 to 4 years, 4-10, and 10-18 years, we estimated risks of persistent, incident, and remitting eczema associated with the interaction using repeated measurements.

RESULTS

If the mother smoked during gestation, longer Resid-BF-duration was associated with a lower risk of eczema, compared to if she did not smoke. The risk ratios (95% CI) if the mother smoked during gestation and exclusively breastfed for at least 3, 9, 15, 21 weeks are 0.7 (0.6, 1.7), 0.6 (0. 4, 0.9), 0.5 (0.3, 0.8), and 0.4 (0.2, 0. 8), respectively. Additionally, in all three transition periods, the risk of persistent eczema was lower with longer Resid-BF-duration if the mother smoked during gestation.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest a protective effect of gestational smoking combined with longer duration of exclusive breastfeeding on early-onset persistent eczema. Future studies should examine underlying biological mechanisms. Prolonged breastfeeding should be encouraged even if the mother smoked during gestation.

Breastfeeding and Atopic Dermatitis Risk: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

OBJECTIVES

The effect of breastfeeding on atopic dermatitis (AD) remains controversial. To determine the association -between breastfeeding and AD, we conducted an updated meta-analysis of prospective cohort studies.

METHODS

A comprehensive search of PubMed, EMBASE, MEDLINE and Cochrane Library was conducted. Studies meeting the predetermined criteria were evaluated by 2 authors independently. The pooled relative risk (RR) adjusted for confounders with its 95% CI was calculated by a random-effects model. Heterogeneity was explored by subgroup analysis and meta-regression.

RESULTS

A total of 27 studies were included for meta-analysis. The pooled estimates for the effect of total and exclusive breastfeeding on AD were 1.01 (95% CI 0.93-1.10) and 0.99 (95% CI 0.88-1.11), respectively. Heterogeneity was substantial across studies (total: p < 0.01 or I2 = 65.2%; exclusive: p < 0.01 or I2 = 72.3%). There was a weak evidence for a protective effect of breastfeeding against AD in cohorts with atopic heredity (total: RR 0.85, 95% CI 0.74-0.98; exclusive: RR 0.83, 95% CI 0.70-0.97). In cohorts without atopic heredity, the effect shifted to the risk side when limited to exclusive breastfeeding (RR 1.19, 95% CI 1.02-1.40) while it dropped towards null when limited to total breastfeeding (RR 1.11, 95% CI 0.94-1.31).

CONCLUSIONS

There is no association between AD and breastfeeding, regardless of total or exclusive breastfeeding patterns. There is some evidence for a protective function of exclusive and total breastfeeding in a cohort with atopic heredity. The effect shifts to the risk side in cohorts without atopic heredity. However, these findings should be interpreted with caution because heterogeneity is evident.

Soluble CD14 in Breast Milk and Its Relation to Atopic Manifestations in Early Infancy

Soluble CD14 (sCD14) is one of the immunomodulatory factors in breast milk (BM). Although it may be involved in the prevention of atopic symptoms and sensitization to both food and inhalant allergens, conflicting evidence exists concerning its protective effects. In this study, we investigated the relationship between sCD14 in colostrum and 1-month BM, and the development of atopic dermatitis (AD) and sensitization to food and aeroallergens at 9 months of age in infants who were exclusively or almost exclusively breastfed up to 4 months of age. BM samples were collected from lactating mothers who participated in a 2 × 2 factorial, randomized, nontreatment controlled trial study set in Tokyo, which looked at the efficacy of emollients and synbiotics in preventing AD and food allergy in children during the first year of life. A total of 258 colostrum samples and 269 1-month BM samples were analyzed. We found that one-month BM sCD14 levels in the AD group were significantly lower than in the non-AD group. Levels of sCD14 in 1-month BM were not related to allergen sensitization in the overall analysis, but egg white sensitization correlated inversely with 1-month BM sCD14 in infants without AD. The results suggest that sCD14 in BM may be involved in atopic manifestations in early infancy.

Early aggressive intervention for infantile atopic dermatitis to prevent development of food allergy: a multicenter, investigator-blinded, randomized, parallel group controlled trial (PACI Study)-protocol for a randomized controlled trial

Background

Atopic dermatitis is the first clinical manifestation of the atopic march, with the highest incidence in the first year of life. Those affected often go on to develop other allergic diseases including food allergy, asthma, and allergic rhinitis. Recent evidence suggests that sensitization to foods may occur through a defective skin barrier which is common in atopic dermatitis in early life. We hypothesize that therapeutic aggressive intervention to treat new onset atopic dermatitis may prevent the development of later allergen sensitization, and associated food allergy, asthma, and allergic rhinitis.

Methods

This study is a multi-center, pragmatic, two-parallel group, assessor-blind, superiority, individually randomized controlled trial. Atopic dermatitis infants (N = 650) 7–13 weeks old who develop an itchy rash within the previous 28 days are randomly assigned to the aggressive treatment or the conventional treatment in a 1:1 ratio. The primary outcome is oral food challenge-proven IgE-mediated hen’s egg allergy at the age of 28 weeks.

Discussion

This is a novel pragmatic RCT study to examine the efficacy of early aggressive treatment for atopic dermatitis to prevent later food allergy. If our hypothesis is correct, we hope that such a strategy might impact on disease prevention in countries where food allergy is common, and that our results might reduce the frequency and associated costs of all food allergies as well as hens egg food allergy. Long-term follow and other similar studies will help to determine whether such a strategy will reduce the burden of other allergic diseases such as asthma and allergic rhinitis.

Trial registration UMIN-CTR: UMIN000028043

Electronic supplementary material

The online version of this article (10.1186/s13601-018-0233-8) contains supplementary material, which is available to authorized users.

Retrospective observational cohort study regarding the effect of breastfeeding on challenge-proven food allergy

BACKGROUND/OBJECTIVES

Human breast milk is generally regarded as the best nutrition for infants in their first months of life. Whether breastfeeding has a protective effect on food allergy is a point of debate and the subject of this study.

SUBJECTS/METHODS

This retrospective study was conducted in 649 children who underwent a double-blind placebo-controlled food challenge (DBPCFC) as part of routine care in a tertiary care clinic. Food allergy was defined as having at least one positive DBPCFC to any food. The association between both "any" breastfeeding (yes/no) and its duration in months with food allergy was studied by logistic regression analysis with correction for confounding variables.

RESULTS

The prevalence of food allergy was 58.9% (n = 382). Of all subjects, 75.8% (n = 492) was breastfed and 24.2% (n = 157) bottle-fed. There was no significant association between food allergy and breastfeeding versus bottle-feeding after correction for the confounding effect of increased breastfeeding by atopic parents and a history of asthma in the child (OR = 1.24, 95% CI = 0.85-1.79, p = 0.27). However, in breastfed children, every additional month of breastfeeding lowered the risk for food allergy by ~4% (OR = 0.96, 95% CI = 0.93-0.99, p = 0.02). No confounders were identified in this association.

CONCLUSION

These results show for the first time that in children investigated for possible food allergy, every additional month of breastfeeding is associated with a lower risk of developing clinical food allergy as diagnosed by DBPCFC. However, overall, there was no association between the prevalence of food allergy and breastfeeding versus bottle-feeding in this tertiary care population.

Does Breast-feeding Relate to Development of Atopic Dermatitis in Young Korean Children?: Based on the Fourth and Fifth Korea National Health and Nutrition Examination Survey 2007-2012

Purpose

There have been conflicting reports concerning the relationship between breast-feeding and the development of atopic dermatitis (AD) in early childhood. The objective of this study was to investigate the associations between breast-feeding and the risk of AD in early childhood in Korea.

Methods

We combined the fourth and fifth Korea National Health and Nutrition Examination Survey data collected from 2007 to 2012 and analyzed 2,015 children at 1 to 3 years old. Regression analysis was used to determine the association of the following variables: AD, feeding types, duration of breast-feeding, and others.

Results

The annual prevalence of exclusive breast-feeding and AD decreased. Parents with allergic diseases preferred breast-feeding and extended duration of feeding compared with those without. In multiple logistic regression analyses, exclusive breast-feeding in feeding type I (P=0.070; adjusted odds ratio [OR]=1.990), exclusive breast-feeding in feeding type II (P=0.095; adjusted OR=1.495) and breast-feeding duration (P=0.430; adjusted OR=1.013) were not significantly related to AD.

Conclusions

Breast-feeding was not found to be associated with an occurrence of AD in young children. Rather, parents with histories of allergic diseases tended to prefer breast-feeding and extend its duration. To clarify the role of breast-feeding in the development of AD, a nation-wide prospective study is needed.

Treatment of allergic children - Where is the progress (for the practicing allergist)?

For any kind of therapeutic intervention in allergic diseases such as environmental control, pharmacological, or immunomodulating treatment including educational programs, children are addressed separately from adults. Health authorities like the Food and Drug Administration in the United States of America or the European Medicine Agency in Europe request a specific 'Pediatric investigational plan' with studies addressing dose-response relationship, safety, and efficacy for infants, children, and adolescents. During the last 2 years, promising advances have been reported for the treatment of a variety of allergic and immunologic disorders. This review summarizes the progress in the treatment of pediatric asthma and allergic diseases, based on publications of approximately the last 2.5 years (end of 2013 until May 2016) in and beyond this journal. Meanwhile, it highlights areas with promising novel therapeutic approaches, which are likely to change treatment for allergic children in the near future.

Early weaning is beneficial to prevent atopic dermatitis occurrence in young children

BACKGROUND

Epidemiological data on infant feeding practices and allergic diseases are controversial. The purpose of this study was to explore the association of early weaning with the occurrence of atopic dermatitis (AD).

METHODS

We conducted a matched case-control study on incident physician-diagnosed AD in early childhood including 451 cases and 451 controls. Data on several factors, including feeding practices, were collected through an interviewer-administered questionnaire. Odds ratios (OR) and the corresponding 95% confidence intervals (CIs) were estimated through logistic regression models, conditioned on study center, age, sex, and period of interview, and adjusted for potential confounders.

RESULTS

Early weaning, defined as the introduction of solid foods at 4 or 5 months of age, was inversely related to the risk of AD, with children weaned at 4 months having lower AD risk (OR = 0.41, 95% CI, 0.20-0.87) compared to those exclusively breastfed. Similar results were observed for weaning started at 5 months of age (OR = 0.39, 95% CI, 0.18-0.83). This association persisted when children with and without family history of allergy were considered separately. Prolonged partial breastfeeding (breastmilk plus milk formulas) was not associated with AD. Consistently, the introduction of a high number of different solid foods reduced the risk of AD (P trend = 0.02 at 4 months of age and P trend = 0.04 at 5 months).

CONCLUSION

Our data provide evidence against the preventing role of prolonged exclusive (but not partial) breastfeeding in AD occurrence and confirm recent results indicating a beneficial role of early weaning in AD.

Does breastfeeding help to reduce the risk of childhood overweight and obesity? A propensity score analysis of data from the KiGGS study

BACKGROUND

Current studies suggest that the beneficial effect of breastfeeding on overweight and obesity may have been largely overestimated. We examined the relationship between >4 months of full breastfeeding and overweight/obesity in children living in Germany.

METHODS

We analyzed retrospectively collected data on breastfeeding from children aged 3-17 years who participated in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS baseline study) between 2003 and 2006 (n = 13163). To minimize confounding, we applied propensity score matching and multivariate logistic regression analyses to estimate the effect of breastfeeding on childhood overweight and obesity.

RESULTS

Adjusted analyses of the matched dataset (n = 8034) indicated that children who were breastfed for >4 months had a significant reduction in the odds of overweight (OR 0.81 [95% CI 0.71–0.92]) and obesity (OR 0.75 [95% CI 0.61–0.92]) compared to children who were not breastfed or who were breastfed for a shorter duration [corrected].Further analyses stratified by age group showed that the association was strongest in children aged 7-10 years (OR 0.67 [95% CI 0.53-0.84] for overweight and OR 0.56 [95% CI 0.39-0.81] for obesity), while no significant effect could be seen in other age groups.

DISCUSSION

Our findings support the hypothesis that breastfeeding does have a beneficial effect on childhood overweight and obesity, although the effect seems to be strongest in children of primary school age.