Evaluation of diet and growth in children with and without atopic eczema: follow-up study from birth to 4 years

Association between dietary antioxidants intake and childhood eczema: results from the NHANES database

BACKGROUND

High dietary intake of antioxidants reduces the risk of allergic sensitization in children. However, there was no sufficient evidence for the effect of dietary antioxidants intake on childhood eczema. Herein, this study aimed to explore the roles of different dietary antioxidants in childhood eczema.

METHODS

Data of 2305 children and adolescents aged < 18 years old were extracted from the National Health and Nutrition Examination Survey database in 2005-2006 in this cross-sectional study. The associations between dietary antioxidants intake and childhood eczema were explored using univariate and multivariate logistic regression analyses, with odds ratios (ORs) and confidence intervals (CIs). Subgroup analyses based on age and gender were also performed.

RESULTS

A total of 268 (11.6%) children had eczema. After adjusting for covariates, we found no significant associations between dietary intake of β-carotene, vitamin C, selenium (Se), and retinol and childhood eczema. However, compared with children and adolescents whose dietary zinc (Zn) intake < 7.47 mg, those who had dietary Zn intake level ≥ 11.83 mg seemed to have lower odds of eczema [OR 0.45, 95% CI 0.28-0.73]. In addition, subgroup analysis showed that especially in children and adolescents aged 1-11 years old, whatever the gender, a higher dietary intake level of Zn may benefit childhood eczema (all P < 0.05).

CONCLUSION

We concluded dietary Zn intake was negatively associated with childhood eczema. Further studies are needed to explore the roles of dietary antioxidants intake in childhood eczema.

Growth, tolerance and safety outcomes with use of an extensively hydrolyzed casein-based formula in infants with cow's milk protein allergy

Objective

To evaluate growth, tolerance and safety outcomes with use of an extensively hydrolyzed casein-based formula (eHCF) in infants with cow's milk protein allergy (CMPA).

Methods

A total of 226 infants (mean ± SD age: 106.5 ± 39.5 days, 52.7% were girls) with CMPA who received eHCF comprising at least half of the daily dietary intake were included. Data on anthropometrics [weight for age (WFA), length for age (LFA) and weight for length (WFL) z-scores] were recorded at baseline (visit 1), while data on infant feeding and stool records, anthropometrics and Infant Feeding and Stool Patterns and Formula Satisfaction Questionnaires were recorded at visit 2 (on Days 15 ± 5) and visit 3 (on Days 30 ± 5).

Results

From baseline to visit 2 and visit 3, WFA z-scores (from -0.60 ± 1.13 to -0.54 ± 1.09 at visit 2, and to -0.44 ± 1.05 at visit 3, p < 0.001) and WFL z-scores (from -0.80 ± 1.30 to -0.71 ± 1.22 at visit 2, and to -0.64 ± 1.13 at visit 3, p = 0.002) were significantly increased. At least half of infants never experienced irritability or feeding refusal (55.7%) and spit-up after feeding (50.2%). The majority of mothers were satisfied with the study formula (93.2%), and wished to continue using it (92.2%).

Conclusions

In conclusion, eHCF was well-accepted and tolerated by an intended use population of infants  ≤ 6 months of age with CMPA and enabled adequate volume consumption and improved growth indices within 30 days of utilization alongside a favorable gastrointestinal tolerance and a high level of parental satisfaction.

Efficacy and safety profile of antioxidants in the treatment of atopic dermatitis: A systematic review and meta-analysis of randomized controlled trials

The use of antioxidants in atopic dermatitis (AD) is controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of antioxidants therapy in AD. Randomised clinical trials were identified from Medline, Embase and Cochrane library. Changes from baseline in severity and itch score were extracted from individual studies and pooled using random-effects. Eighteen trials including 763 AD patients were eligible. Overall, antioxidants were associated with statistically significant reductions in diseases severity (p < 0.0001), but not with itch score (p = 0.59). No serious adverse events were recorded. Subgroup analyses revealed that antioxidants were associated with a significant reduction in severity score regardless of disease severity at baseline and treatment duration (p < 0.05). However, antioxidants had additional benefit only in children (p = 0.02) but not in adults (p = 0.30). Oral supplementation with vitamin D, combined vitamins D and E, combined vitamins A, D and E and topical vitamin B₁₂ was associated with significantly lower severity score (p < 0.05). There was significant heterogeneity between studies (I²  = 50%; p = 0.003). The effect estimates did not change statistically after excluding sources of study heterogeneity. This meta-analysis suggests that antioxidants may be a safe and effective treatment for AD patients, especially when supplemented with oral vitamin D and topical vitamin B₁₂ , as well as in pediatric patients. This article is protected by copyright. All rights reserved.

Investigation of the Efficacy of Lactobacillus rhamnosus GG in Infants With Cow's Milk Protein Allergy: a Randomised Double-Blind Placebo-Controlled Trial

This investigation has been performed to show the efficacy of Lactobacillus rhamnosus GG (LGG) together with milk-free diet in patients with cow's milk protein allergy (CMPA). This multicentre prospective investigation has been performed in 0-12 months of age children diagnosed as CMPA clinically and biochemically. Patients have been randomly divided in to two groups. İnfants in probiotic group were received with cow's milk protein free diet and per oral (p.o.) daily 1X10⁹ CFU LGG and in placebo group with milk-free diet and placebo. Mothers of all breast-fed patients have been put on milk-free diet and all patients fed with formula, offered to extensively hydrolysed formula. Symptoms like diarrhoea, vomiting, mucousy or bloody stool, abdominal pain or distension, constipation, dermatitis and restiveness were recorded at the beginning and weekly during the receiving dietary by the investigator. One-hundred infants diagnosed CMPA were included in this double-blind placebo controlled study. Forty-eight infants placed in probiotic group and 52 in placebo group. After 4 weeks of receiving dietary, infants in probiotic group have showed statistically significant improvement in symptoms of bloody stool, diarrhoea, restiveness and abdominal distension (p ≤ 0.001). Whilst statistically significant improvement was also observed in symptoms of mucousy stool (p = 0.038) and vomiting (p = 0.034), no significant improvement were observed in abdominal pain (p = 0.325), constipation (p = 0.917) and dermatitis (p = 0.071). In this study we observed significant improvement in symptoms of infants diagnosed CMPA receiving dietary LGG with cow's milk-free diet.

Illness perceptions and quality of life in families with child with atopic dermatitis

OBJECTIVE

To assess the Quality of Life (QoL) of children with Atopic Dermatitis (AD) and their families and the impact of the mothers' illness perceptions on the family QoL.

MATERIALS AND METHODS

Seventy-five children with AD (54 infants and 21 children) and their mothers participated in the study. The following questionnaires were administrated: 1. Brief Illness Perception Questionnaire (Brief IPQ); 2. Infant's Dermatitis Quality of Life Index (IDQOL); 3. Children's Dermatology Life Quality Index (CDLQI); 4. Dermatitis Family Impact Questionnaire (DFIQ) and 5. The Severity Scoring of Atopic Dermatitis (SCORAD).

RESULTS

Atopic dermatitis had a moderate impact on the QoL of the infants (6.67±5.30), children (7.86±7.19) and their families (9.42±7.03). The DFIQ was associated with certain dimensions of the Brief IPQ, specifically, with Illness Identity (greater symptom burden) (r=0.615, p=0.000), beliefs about the Consequences of the illness (r=0.542, p=0.000), the Concerns (r=0.421, p=0.000) and the Emotional Representations (r=0.510, p=0.000). Correlation was demonstrated between IDQOL and DFIQ (r=0.662, p=0.000) and between CDLQI and DFIQ (r=0.832, p=0.000), and a weaker correlation between SCORAD and DFIQ (r=0.255, p=0.035). The chronicity of the AD showed negative association with DFIQ (p<0.001).

CONCLUSIONS

The QoL of families with a child with AD is associated with the mother's illness perceptions about AD, the children's QoL and with both the severity and the chronicity of the disease. Therefore, clinicians should pay attention not only to the clinical characteristics of the children, but also to the parents' beliefs and emotions, to improve the family QoL.

The Role of Environmental Exposures in Atopic Dermatitis

PURPOSE OF REVIEW

Although genetic factors clearly play a role in the development of atopic dermatitis (AD), the recent dramatic increase in the prevalence of AD in low- and middle-income countries is not consistent with only a role of genetic factors. These findings strongly suggest that environmental factors may play an important role in the pathogenesis of AD.

RECENT FINDINGS

We reviewed the role of gene-environment studies; in utero exposures including tobacco smoke, alcohol, maternal stress, various digestive supplements, and gestational diabetes; early-life exposures including diet, gut microbiota, antibiotics, and breastfeeding; climate including temperature, ultraviolet radiation exposure, and air pollution; and household products, indoor allergens, water hardness, pH, and skin microbiota and their effects on AD. Environmental factors definitely play a role in the pathogenesis of AD. However, identifying definitive factors continues to be difficult in the setting of conflicting evidence and the complex interactions between genotypes and the environment resulting in a multitude of AD phenotypes. All of the different environmental interactions discussed highlight the importance of intervening on multiple levels in a patient's environment to improve or even prevent AD symptoms. Further, the importance of modifying environmental factors early on in a person's life is demonstrated. When possible, all of these environmental factors should be considered in treating a patient with AD and the appropriate modifications should be made at population and individual levels.

Vitamin A deficiency exacerbates extrinsic atopic dermatitis development by potentiating type 2 helper T cell-type inflammation and mast cell activation

BACKGROUND

Vitamin A deficiency (VAD) has been hypothesized to play a role in the pathophysiology of atopic dermatitis (AD).

OBJECTIVE

We sought to verify whether VAD can exacerbate AD development, and explore the possible pathophysiologic mechanism.

METHODS

We detected serum vitamin A (VA) concentration in different phenotypes of AD infants (intrinsic AD, iAD and extrinsic AD, eAD), and established ovalbumin (OVA) percutaneous sensitized AD model and passive cutaneous anaphylaxis (PCA) model on VAD and vitamin A supplementation (VAS) model in wild-type mice (C57BL/6) and established AD model on both normal VA (VAN) and VAD feeding mast cell deficiency mice (ckit^w-sh/w-sh ).

RESULTS

The average serum VA concentration of eAD was significantly lower than that of iAD, as well as healthy controls. In OVA-induced C57BL/6 mouse AD model, compared with VAN group, VAD mice manifested significantly more mast cells accumulation in the skin lesions, more severe Th2-mediated inflammation, including higher serum IgG1 and IgE levels, more IL-4, IL-13 mRNA expression in OVA-sensitized skin, and lower Th1 immune response, including lower serum IgG2a and IFN-γ mRNA expression in the skin. But there was no significant difference in the expression of IL-17 mRNA between OVA-treated skin of VAN and VAD mice. However, in OVA-induced ckit^w-sh/w-sh mouse AD model, we did not find any significant differences in the above measurements between VAD and VAN group. In PCA model, VAD mice showed remarkable more blue dye leakage than that in VAN mice. Compared with VAD group, the above-mentioned inflammatory measurements in VAS group and VAN group were similar in OVA-induced AD model mice.

CONCLUSIONS AND CLINICAL RELEVANCE

VAD can exacerbate extrinsic AD by augmenting Th2-mediated inflammation and mast cell activation. Therapeutic VAS can rescue VAD-aggravated eAD. It may provide a new strategy for future prevention or treatment of atopic dermatitis.

Fourteen steps to relevance: taking probiotics from the bench to the consumer

Much is made of the need to translate scientific research into improved care of people or other life forms. Grant applications invariably start with the extent of a problem and end by claiming that their work will or could result in making an impact. In truth, very few projects ever lead to translation at the level of the host, nor was that really their intent. For those who are focused on applied science, there are many ways to reach the desired goal, sometimes through serendipity or by logical stepwise progress. The following paper will provide personal insight into the stages, pitfalls, and ultimate assessment of relevance in the context of using probiotic lactobacilli for human health and other applications.

Forty-five-year evolution of probiotic therapy

In the past forty-five years, the field of probiotics has grown from a handful of laboratory studies and clinical ideas into a legitimate research and translational entity conferring multiple benefits to humans around the world. This has been founded upon three principles: (i) the need for alterna-tives to drugs that either have sub-optimal efficacy or severe adverse effects; (ii) a growing interest in natural products and microbes, in particular cata-lyzed by studies showing the extent of microbes within humans and on our planet; and (iii) evidence on the genetics and metabolic properties of probi-otic strains, and clinical studies showing their effectiveness. While some man-ufacturers have sadly taken advantage of the market growth to sell supple-ments and foods they term probiotic, without the necessary human study evidence, there are more and more companies basing their formulations on science. Adherence to the definition of what constitutes a probiotic, conclu-sions based on tested products not generalizations of the whole field, and applications emanating from microbiome research identifying new strains that provide benefits, will make the next forty-five years significantly changed approaches to health management. Exciting applications will emerge for car-diovascular, urogenital, respiratory, brain, digestive and skin health, detoxifi-cation, as well as usage across the world's ecosystems.

Micronutrients in Atopic Dermatitis: A Systematic Review

Objective: The pathophysiology of atopic dermatitis (AD) involves a complex interplay between immune system dysfunction, genetics, and environmental factors. It is well known that nutritional status is essential to a proper functioning immune system, leading to a highly debated question regarding the role of dietary factors in the pathogenesis of AD. Food allergies and elimination diets have been broadly studied in atopy; however, less consideration has been given to how vitamins, minerals, and other micronutrients influence the risk for AD and severity of symptoms. This systematic review discusses evidence on how various micronutrients, including vitamins (C, E, and D) and trace minerals (zinc, selenium, iron, copper, magnesium, and strontium) are associated with AD, and how supplementation influence disease severity. Design: A systematic search was conducted to identify the role that oral micronutrients have on AD. The authors reviewed 49 studies herein. Results: While there are weak associations between vitamins C or E and AD, there is sufficient evidence to suggest that vitamin D supplementation provides benefit in AD patients. Deficiency of selenium and zinc may exacerbate AD. Current reports are not sufficient to confidently discern the role of other vitamins and trace minerals on AD. Conclusions: Though oral micronutrients may play a role in AD, the current literature is limited, and there is a need for more comprehensive randomized controlled trials (RCTs) to truly decipher the role between oral micronutrients and AD.

Probiotics for treating eczema

BACKGROUND

Eczema is a common chronic skin condition. Probiotics have been proposed as an effective treatment for eczema; their use is increasing, as numerous clinical trials are under way. This is an update of a Cochrane Review first published in 2008, which suggested that probiotics may not be an effective treatment for eczema but identified areas in which evidence was lacking.

OBJECTIVES

To assess the effects of probiotics for treating patients of all ages with eczema.

SEARCH METHODS

We updated our searches of the following databases to January 2017: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, the Global Resource of Eczema Trials (GREAT) database, MEDLINE, Embase, PsycINFO, the Allied and Complementary Medicine Database (AMED), and Latin American Caribbean Health Sciences Literature (LILACS). We searched five trials registers and checked the reference lists of included studies and relevant reviews for further references to relevant randomised controlled trials (RCTs). We also handsearched a number of conference proceedings. We updated the searches of the main databases in January 2018 and of trials registries in March 2018, but we have not yet incorporated these results into the review.

SELECTION CRITERIA

Randomised controlled trials of probiotics (live orally ingested micro-organisms) compared with no treatment, placebo, or other active intervention with no probiotics for the treatment of eczema diagnosed by a doctor.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. We recorded adverse events from the included studies and from a separate adverse events search conducted for the first review. We formally assessed reporting bias by preparing funnel plots, and we performed trial sequential analysis for the first primary outcome - eczema symptoms at the end of active treatment.We used GRADE to assess the quality of the evidence for each outcome (in italic font).

MAIN RESULTS

We included 39 randomised controlled trials involving 2599 randomised participants. We included participants of either gender, aged from the first year of life through to 55 years (only six studies assessed adults), who had mild to severe eczema. Trials were undertaken in primary and secondary healthcare settings, mainly in Europe or Asia. Duration of treatment ranged from four weeks to six months, and duration of follow-up after end of treatment ranged from zero to 36 months. We selected no standard dose: researchers used a variety of doses and concentrations of probiotics. The probiotics used were bacteria of the Lactobacillus and Bifidobacteria species, which were taken alone or combined with other probiotics, and were given with or without prebiotics. Comparators were no treatment, placebo, and other treatments with no probiotics.For all results described in this abstract, the comparator was no probiotics. Active treatment ranged from six weeks to three months for all of the following results, apart from the investigator-rated eczema severity outcome, for which the upper limit of active treatment was 16 weeks. With regard to score, the higher the score, the more severe were the symptoms. All key results reported in this abstract were measured at the end of active treatment, except for adverse events, which were measured during the active treatment period.Probiotics probably make little or no difference in participant- or parent-rated symptoms of eczema (13 trials; 754 participants): symptom severity on a scale from 0 to 20 was 0.44 points lower after probiotic treatment (95% confidence interval (CI) -1.22 to 0.33; moderate-quality evidence). Trial sequential analysis shows that target sample sizes of 258 and 456, which are necessary to demonstrate a minimum mean difference of -2 and -1.5, respectively, with 90% power, have been exceeded, suggesting that further trials with similar probiotic strains for this outcome at the end of active treatment may be futile.We found no evidence suggesting that probiotics make a difference in QoL for patients with eczema (six studies; 552 participants; standardised mean difference (SMD) 0.03, 95% CI -0.36 to 0.42; low-quality evidence) when measured by the participant or the parent using validated disease-specific QoL instruments.Probiotics may slightly reduce investigator-rated eczema severity scores (24 trials; 1596 participants). On a scale of 0 to 103 for total Severity Scoring of Atopic Dermatitis (SCORAD), a score combining investigator-rated eczema severity score and participant scoring for eczema symptoms of itch and sleep loss was 3.91 points lower after probiotic treatment than after no probiotic treatment (95% CI -5.86 to -1.96; low-quality evidence). The minimum clinically important difference for SCORAD has been estimated to be 8.7 points.We noted significant to extreme levels of unexplainable heterogeneity between the results of individual studies. We judged most studies to be at unclear risk of bias; six studies had high attrition bias, and nine were at low risk of bias overall.We found no evidence to show that probiotics make a difference in the risk of adverse events during active treatment (risk ratio (RR) 1.54, 95% CI 0.90 to 2.63; seven trials; 402 participants; low-quality evidence). Studies in our review that reported adverse effects described gastrointestinal symptoms.

AUTHORS' CONCLUSIONS

Evidence suggests that, compared with no probiotic, currently available probiotic strains probably make little or no difference in improving patient-rated eczema symptoms. Probiotics may make little or no difference in QoL for people with eczema nor in investigator-rated eczema severity score (combined with participant scoring for eczema symptoms of itch and sleep loss); for the latter, the observed effect was small and of uncertain clinical significance. Therefore, use of probiotics for the treatment of eczema is currently not evidence-based. This update found no evidence of increased adverse effects with probiotic use during studies, but a separate adverse events search from the first review revealed that probiotic treatment carries a small risk of adverse events.Results show significant, unexplainable heterogeneity between individual trial results. Only a small number of studies measured some outcomes.Future studies should better measure QoL scores and adverse events, and should report on new probiotics. Researchers should also consider studying subgroups of patients (e.g. patients with atopy or food allergies, adults) and standardising doses/concentrations of probiotics given.

Pre- and probiotics for allergy prevention: time to revisit recommendations?

Reduced intensity and diversity of microbial exposure is considered a major factor driving abnormal postnatal immune maturation and increasing allergy prevalence, particularly in more affluent regions. Quantitatively, the largest important source of early immune-microbial interaction, the gut microbiota, is of particular interest in this context, with variations in composition and diversity in the first months of life associated with subsequent allergy development. Attempting to restore the health consequences of the 'dysbiotic drift' in modern society, interventions modulating gut microbiota for allergy prevention have been evaluated in several randomized placebo-controlled trials. In this review, we provide an overview of these trials and discuss recommendations from international expert bodies regarding prebiotic, probiotic and synbiotic interventions. Recent guidelines from the World Allergy Organization recommend the use of probiotics for the primary prevention of eczema in pregnant and breastfeeding mothers of infants at high risk for developing allergy and in high-risk infants. It is however stressed that these recommendations are conditional, based on very low-quality evidence and great heterogeneity between studies, which also impedes specific and practical advice to consumers on the most effective regimens. We discuss how the choice of probiotic strains, timing and duration of administration can critically influence the outcome due to different effects on immune modulation and gut microbiota composition. Furthermore, we propose strategies to potentially improve allergy-preventive effects and enable future evidence-based implementation.

Long-term safety assessment in children who received hydrolyzed protein formulas with Lactobacillus rhamnosus GG: a 5-year follow-up

Extensively hydrolyzed (EH) formula with Lactobacillus rhamnosus GG (LGG) was demonstrated to alleviate cow's milk allergy (CMA) symptoms and promote faster acquisition of tolerance to cow's milk protein. We previously demonstrated that partially hydrolyzed (PH) and EH formulas with LGG supported normal growth in healthy-term infants through 120 days of age. The objective of the current study was to evaluate growth, development, and specific adverse events through 5 years of age in participants from that cohort who continued receiving study formula. Infants who completed a double-blind, randomized growth and tolerance study were eligible to continue receiving the assigned study formula through 1 year of age (control: EH casein formula, EHF, or one of two investigational formulas: EH casein formula with LGG (EHF-LGG) or a PH formula with LGG (PHF-LGG)) and participate in follow-up through 5 years of age. Anthropometric measures, behavior development, and specific adverse events were recorded. No significant differences in achieved weight and height or behavioral development outcomes at 3 or 5 years of age were observed among study groups. Few statistically significant differences in the incidence of specific infection-related events through years 3 or 5 were observed among study groups, none of which were considered clinically relevant.

CONCLUSION

Extensively and partially hydrolyzed formulas with LGG were associated with normal growth and development and long-term safety through 5 years of age. What is Known: • Infants with cow's milk allergy often experience allergic manifestations that can lead to poor nutrition status and poor growth. • Providing partially hydrolyzed (PH) and EH formulas with or without LGG in infants can support normal growth in healthy-term infants. What is New: • This study provides long-term safety data for the first 5 years of life on the use of extensively and partially hydrolyzed formulas with LGG when fed through 1 year of age. • Extensively and partially hydrolyzed formulas with LGG are associated with normal growth, development, and long-term safety through 5 years of age.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Position document: IgE-mediated cow's milk allergy

The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy.

The adverse effect profile of oral azathioprine in pediatric atopic dermatitis, and recommendations for monitoring

Background

Azathioprine is efficacious in the treatment of severe childhood atopic dermatitis; however, robust data on adverse effects in this population are lacking.

Objective

We sought to assess adverse effects of azathioprine treatment in a pediatric atopic dermatitis cohort, and make recommendations for monitoring based on these data.

Methods

Blood test results for all 82 children prescribed oral azathioprine for atopic dermatitis in our department between 2010 and 2012 were collated prospectively, and clinical notes were reviewed retrospectively.

Results

Mean age at commencing azathioprine was 8.3 years (SEM 0.4). Mean maximum doses were 2.4 mg/kg (SEM 0.1) and 1.5 mg/kg (SEM 0.1) for normal and reduced serum thiopurine-S-methyltransferase levels, respectively. Adverse effects on blood indices occurred in 34 of 82 patients (41%), with pronounced effects in 18 of 82 (22%) after a median time of 0.4 years. Two patients stopped therapy as a result of abnormal blood indices. Clinical adverse effects occurred in 16 of 82 (20%), two resulting in cessation of therapy. Incidence of adverse effects was unaffected by age, sex, thiopurine-S-methyltransferase level, and drug dose on multivariate regression.

Limitations

Comparison with other studies is limited by varying definitions of adverse effects.

Conclusion

Oral azathioprine was associated with few pronounced adverse effects for the duration of use and dosage in this cohort. Recommendations for monitoring are made.

Harnessing microbiome and probiotic research in sub-Saharan Africa: recommendations from an African workshop

To augment capacity-building for microbiome and probiotic research in Africa, a workshop was held in Nairobi, Kenya, at which researchers discussed human, animal, insect, and agricultural microbiome and probiotics/prebiotics topics. Five recommendations were made to promote future basic and translational research that benefits Africans.

Nutritional management and follow up of infants and children with food allergy: Italian Society of Pediatric Nutrition/Italian Society of Pediatric Allergy and Immunology Task Force Position Statement

Although the guidelines on the diagnosis and treatment of food allergy recognize the role of nutrition, there is few literature on the practical issues concerning the nutritional management of children with food allergies.

This Consensus Position Statement focuses on the nutritional management and follow-up of infants and children with food allergy.

It provides practical advices for the management of children on exclusion diet and it represents an evidence-based consensus on nutritional intervention and follow-up of infants and children with food allergy.

Children with food allergies have poor growth compared to non-affected subjects directly proportional to the quantity of foods excluded and the duration of the diet. Nutritional intervention, if properly planned and properly monitored, has proven to be an effective mean to substantiate a recovery in growth.

Nutritional intervention depends on the subject’s nutritional status at the time of the diagnosis.

The assessment of the nutritional status of children with food allergies should follow a diagnostic pathway that involves a series of successive steps, beginning from the collection of a detailed diet-history.

It is essential that children following an exclusion diet are followed up regularly.

The periodic re-evaluation of the child is needed to assess the nutritional needs, changing with the age, and the compliance to the diet.

The follow- up plan should be established on the basis of the age of the child and following the growth pattern.

Nutritional aspects in diagnosis and management of food hypersensitivity-the dietitians role

Many common foods including cow's milk, hen's egg, soya, peanut, tree nuts, fish, shellfish, and wheat may cause food allergies. The prevalence of these immune-mediated adverse reactions to foods ranges from 0.5% to 9% in different populations. In simple terms, the cornerstone of managing food allergy is to avoid consumption of foods causing symptoms and to replace them with nutritionally equivalent foods. If poorly managed, food allergy impairs quality of life more than necessary, affects normal growth in children, and causes an additional economic burden to society. Delay in diagnosis may be a further incremental factor. Thus, an increased awareness of the appropriate procedures for both diagnosis and management is of importance. This paper sets out to present principles for taking an allergy-focused diet history as part of the diagnostic work-up of food allergy. A short overview of guidelines and principles for dietary management of food allergy is discussed focusing on the nutritional management of food allergies and the particular role of the dietitian in this process.

Maternal probiotic supplementation during pregnancy and breast-feeding reduces the risk of eczema in the infant

BACKGROUND

Probiotics have shown promising potential in reducing the risk of eczema in infants. Optimal probiotic intervention regimen remains to be determined.

OBJECTIVE

We investigated whether maternal probiotic supplementation during pregnancy and breast-feeding reduces the risk of developing eczema in high-risk infants.

METHODS

This was a parallel, double-blind placebo-controlled trial of 241 mother-infant pairs. Mothers with allergic disease and atopic sensitization were randomly assigned to receive (1) Lactobacillus rhamnosus LPR and Bifidobacterium longum BL999 (LPR+BL999), (2) L paracasei ST11 and B longum BL999 (ST11+BL999), or (3) placebo, beginning 2 months before delivery and during the first 2 months of breast-feeding. The infants were followed until the age of 24 months. Skin prick tests were performed at the ages of 6, 12, and 24 months.

RESULTS

Altogether 205 infants completed the follow-up and were included in the analyses. The risk of developing eczema during the first 24 months of life was significantly reduced in infants of mothers receiving LPR+BL999 (odds ratio [OR], 0.17; 95% CI, 0.08-0.35; P < .001) and ST11+BL999 (OR, 0.16; 95% CI, 0.08-0.35; P < .001). The respective ORs for chronically persistent eczema were 0.30 (95% CI, 0.12-0.80; P = .016) and 0.17 (95% CI, 0.05-0.56; P = .003). Probiotics had no effect on the risk of atopic sensitization in the infants. No adverse effects were related to the use of probiotics.

CONCLUSION

Prevention regimen with specific probiotics administered to the pregnant and breast-feeding mother, that is, prenatally and postnatally, is safe and effective in reducing the risk of eczema in infants with allergic mothers positive for skin prick test.

Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines

OBJECTIVES

This guideline provides recommendations for the diagnosis and management of suspected cow's-milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence-based guidelines on CMPA.

DIAGNOSIS

If CMPA is suspected by history and examination, then strict allergen avoidance is initiated. In certain circumstances (eg, a clear history of immediate symptoms, a life-threatening reaction with a positive test for CMP-specific IgE), the diagnosis can be made without a milk challenge. In all other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis of CMPA.

TREATMENT

In breast-fed infants, the mother should start a strict CMP-free diet. Non-breast-fed infants with confirmed CMPA should receive an extensively hydrolyzed protein-based formula with proven efficacy in appropriate clinical trials; amino acids-based formulae are reserved for certain situations. Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth are mandatory in all age groups requiring CMP exclusion. REEVALUATION: Patients should be reevaluated every 6 to 12 months to assess whether they have developed tolerance to CMP. This is achieved in >75% by 3 years of age and >90% by 6 years of age. Inappropriate or overly long dietary eliminations should be avoided. Such restrictions may impair the quality of life of both child and family, induce improper growth, and incur unnecessary health care costs.

How should an incident case of atopic dermatitis be defined? A systematic review of primary prevention studies

BACKGROUND

Eczema prevention is now an active area of dermatologic and allergy research. Defining an incident case is therefore a prerequisite for such a study.

OBJECTIVE

We sought to examine how an incident case of atopic dermatitis was defined in previous atopic dermatitis prevention studies in order to make recommendations on a standard definition of new atopic dermatitis cases for use in future prevention trials.

METHODS

We conducted a systematic review of controlled interventional atopic dermatitis prevention studies by using searches of MEDLINE and Cochrane databases for studies published from 1980 to the end of January 2011. Studies that included atopic dermatitis as a secondary outcome, such as asthma prevention trials, were included.

RESULTS

One hundred two studies were included in the final analysis, of which 27 (26.5%) did not describe any criteria for defining an incident case of atopic dermatitis. Of the remaining 75 studies with reported disease criteria, the Hanifin-Rajka criteria were the most commonly used (28 studies). A disease definition unique to that particular study (21 studies) was the second most commonly used disease definition, although the sources for such novel definitions were not cited.

CONCLUSIONS

The results from this systematic review highlight the need for improved reporting and standardization of the definition used for an incident case in atopic dermatitis prevention studies. Most prevention studies have used disease definitions such as the Hanifin-Rajka criteria that include disease chronicity. While acceptable for cumulative incidence outcomes, inclusion of disease chronicity precludes the precise measurement of disease onset. We propose a definition based on existing scientific studies that could be used in future prospective studies.

Extensively hydrolysed casein formula supplemented with Lactobacillus rhamnosus GG maintains hypoallergenic status: randomised double-blind, placebo-controlled crossover trial

OBJECTIVE

To evaluate the hypoallergenicity of an extensively hydrolysed (EH) casein formula supplemented with Lactobacillus rhamnosus GG (LGG).

DESIGN

A prospective, randomised, double-blind, placebo-controlled crossover trial.

SETTING

Two study sites in Italy and The Netherlands.

STUDY PARTICIPANTS

Children with documented cow's milk allergy were eligible for inclusion in this trial.

INTERVENTIONS

After a 7-day period of strict avoidance of cow's milk protein and other suspected food allergens, participants were tested with an EH casein formula with demonstrated hypoallergenicity (control, EHF) and a formula of the same composition with LGG added at 10(8) colony-forming units per gram powder (EHF-LGG) in randomised order in a double-blind placebo-controlled food challenge (DBPCFC). After absence of adverse reactions in the DBPCFC, an open challenge was performed with EHF-LGG, followed by a 7-day home feeding period with the same formula.

MAIN OUTCOME MEASURE

Clinical assessment of any adverse reactions to ingestion of study formulae during the DBPCFC.

RESULTS

For all participants with confirmed cow's milk allergy (n=31), the DBPCFC and open challenge were classified as negative.

CONCLUSION

The EH casein formula supplemented with LGG is hypoallergenic and can be recommended for infants and children allergic to cow's milk who require an alternative to formulae containing intact cow's milk protein.

TRIAL REGISTRATION NUMBER

http://ClinicalTrials.gov Identifier: NCT01181297.

Early fish introduction is associated with less eczema, but not sensitization, in infants

OBJECTIVE

To investigate if the development of allergic diseases during the child's first 18 months of life is influenced by the time at which different food items were introduced into the child's diet.

METHOD

A birth cohort of 184 children was followed to 18 months of age. Diaries were used to document feeding practices, and parental interviews were performed at 6 and 12 months of age, probing for symptoms suggesting allergic disease, general health-related issues and food introduction regimes. Symptoms promoted prompt clinical examination, and all children were examined clinically, and tested for sensitization to common airborne and food allergens at 18 months of age.

RESULTS

The earlier the fish was introduced into the child's diet the lower was the frequency of eczema. This association remained after control for confounding factors. The timing of fish introduction and asthma development showed a similar pattern, but did not reach statistical significance. Sensitization was not influenced by the timing of fish introduction. Other food items or feeding practices did not seem to influence allergy development.

CONCLUSION

  Early introduction of fish into the child's diet was associated with less eczema development, and a tendency to less asthma. Sensitization was not associated with the timing of fish introduction.

Pediatric Atopic Dermatitis: A Review of the Medical Management

Objective:

To evaluate the available treatment options for pediatric atopic dermatitis,

Data Sources:

A literature review was performed in MEDLINE (1950-February 2010) using the key word atopic dermatitis. The references identified were evaluated in comparative treatment. The references included in this review were limited to studies conducted in children less than 18 years of age and written in the English language.

Study Selection and Data Extraction:

All of the literature retrieved that was published within the last 5 years (2005-2010) was included in this review. Other pertinent articles published prior to 2005 were also included.

Data Synthesis:

Atopic dermatitis is a chronic inflammatory skin disorder that usually begins during infancy. Potential causes include irritants such as soap and detergents, food allergens, contact allergens, and skin infections. Emollients, moisturizing agents that inhibit water loss and provide a protective coating, are recommended in all patients with atopic dermatitis. Additionally, emollients may reduce the need to use topical corticosteroids. Patients receiving desanide 0.05% plus an emollient achieved significant reductions in severity scores compared to those receiving desonide 0.05% as monotherapy (80% vs 70%; p < 0.01). Topical calcineurin inhibitors are not recommended as first-line therapy in pediatric patients with atopic dermatitis; however, their use in children above 2 years of age who fail to respond to topical corticosteroids may be considered.

Conclusions:

Emollients are recommended in pediatric patients with a diagnosis of atopic dermatitis regardless of symptoms. Topical corticosteroids reduce the inflammation and pruritus associated with atopic dermatitis and are available in several formulations and strengths. Calcineurin inhibitors may be an alternative in children older than 2 years of age who do not respond to topical corticosteroids,

Antioxidant nutrient intakes and corresponding biomarkers associated with the risk of atopic dermatitis in young children

BACKGROUND/OBJECTIVES

To investigate the association of antioxidant nutritional status with the risk of atopic dermatitis (AD) in young children in a case-control, population-based study.

SUBJECTS/METHODS

Identified from preschools by using the Korean version of the International Study of Asthma and Allergies in Childhood (ISAAC). Final analysis included 180 AD (mean age 5.3+/-0.9 years) and 242 non-AD (mean age 5.2+/-1.0 years) children. Diet was assessed using a validated semi-quantitative food frequency questionnaire. Fasting blood samples were used for analyses of fat-soluble vitamins (retinol, alpha-tocopherol, and beta-carotene) and vitamin C.

RESULTS

AD was associated negatively with intakes of antioxidant-related nutrients. The adjusted odds ratio (OR) and 95% confidence interval (95% CI) were 0.44 (0.22-0.88) for the highest (vs lowest) quintile of beta-carotene. A similar association was observed for dietary vitamin E (OR=0.33, 95% CI=0.16-0.67), folic acid (OR=0.37, 95% CI=0.18-0.73), and iron (OR=0.39, 95% CI=0.19-0.79). Reduced AD risk was found with 1 s.d. increase of serum alpha-tocopherol [OR=0.64, 95% CI=0.41-0.98) and retinol (OR=0.74, 95% CI=0.58-0.96) concentrations, and marginally with that of serum beta-carotene levels (P=0.0749 for trend). There was no relationship of AD risk with dietary and plasma vitamin C as well as nutrient supplement intake regardless of nutrient type. AD was predicted better by the intake measure than the corresponding blood biomarker regarding vitamin E and beta-carotene.

CONCLUSIONS

These findings suggest that higher antioxidant nutritional status reduces the risk of AD and that such risk-reduction effects depend on nutrient type.

Factors influencing the incidence and prevalence of food allergy

Food allergy is an increasing problem in Europe and elsewhere and severe reactions to food are also becoming more common. As food allergy is usually associated with other forms of allergic sensitisation it is likely that many risk factors are common to all forms of allergy. However the potential severity of the disease and the specific public heath measures required for food allergy make it important to identify the specific risk factors for this condition. Food allergy is unusual in that it often manifests itself very early in life and commonly remits with the development of tolerance. Hypotheses that explain the distribution of food allergy include specific genetic polymorphisms, the nature of the allergens involved and the unique exposure to large quantities of allergen through the gut. Progress has been made in developing more specific and testable hypotheses but the evidence for any of these is still only preliminary. Further collaborative research is required to develop an appropriate public health response to this growing problem.

Growth and tolerance of healthy term infants receiving hydrolyzed infant formulas supplemented with Lactobacillus rhamnosus GG: randomized, double-blind, controlled trial

Healthy, term infants received extensively hydrolyzed casein formula (EHF; control), the same formula supplemented with Lactobacillus rhamnosus GG (EHF-LGG), or partially hydrolyzed whey:casein (60:40) formula supplemented with LGG (PHF-LGG), in this double-blind, randomized, controlled, parallel, prospective study. Anthropometric measures and 24-hour dietary and tolerance recalls were obtained at 30, 60, 90, 120, and 150 days of age. Blood collected in a subset of infants was analyzed for fatty acid profiles in plasma and red blood cells and for markers of allergic sensitization. Adverse events were recorded throughout the study. Growth rates were not statistically different between EHF and PHF-LGG and between EHF and EHF-LGG from day 14 to day 30, 120, or 150. No relevant differences in formula tolerance, adverse events, or allergic and immune markers were demonstrated between groups. The extensively and partially hydrolyzed formulas supplemented with LGG support normal growth in healthy, term infants and are well tolerated and safe.

Probiotics for preventive health

Gut flora and probiotics have potential to affect health and disease far beyond the gut. There is increasing evidence that probiotics have beneficial effects in preventing a wide range of conditions and improving health. Randomized, double-blind studies have provided evidence of the effectiveness of probiotics for preventing various diarrheal illnesses as well as allergic disorders. Evidence for their efficacy for use in the prevention and treatment of bacterial vaginosis and urinary tract infections is also mounting. In addition, probiotics may be useful for preventing respiratory infections, dental caries, necrotizing enterocolitis, and certain aspects of inflammatory bowel disease. Data also suggest that probiotics may promote good health in day care and work settings, and may enhance growth in healthy as well as ill and malnourished children. Results from meta-analyses and systematic reviews that combine results of studies from different types of probiotics to examine the effects in any disease state should be interpreted with caution. Specific strains are effective in specific disease states. No 2 probiotics are exactly alike; we should not expect reproducible results from studies that employ different species or strains, variable formulations, and diverse dosing schedules.

What is "high risk?" a systematic review of atopy risk and implications for primary prevention

Atopic diseases are common and becoming more prevalent. Efforts have focused on primary disease prevention by identifying high-risk children and applying preventative strategies. Our aim was to evaluate methods used to identify high-risk children in atopy prevention studies. A literature search for relevant articles published between 1986 and 2006 was conducted, and all abstracts were reviewed. The search yielded 1,535 publications, 133 were reviewed in detail, and 57 met inclusion criteria. High risk was defined by 30 different methods. First-degree relatives with an atopic disorder were included in all methods, but only three publications used referenced questionnaires to determine this. Less frequently included were cord blood immunoglobulin E measurements and skin prick or radioallergosorbent testing, and 16 methods relied on history alone. Family history was the most common method used to predict high risk of atopic disease in a child, but a minority of studies used a tested questionnaire to determine the presence of atopy in family members. The methods used to identify high-risk children are variable, and the development and widespread use of a validated, practical screening tool is needed.

Positive interactions with the microbiota: probiotics

Rigorous research in the field of probiotics is a fairly new phenomenon although first reports about beneficial effects of specific gut bacteria on human health originated already a century ago. A prerequisite for such a scrutiny has been a definition of criteria for probiotics. Recently, novel molecular technologies have characterized both potential targets of probiotic action, like gut microbiota and established and candidate probiotic strains in more detail. We thus propose here revised criteria for selection ofprobiotics. In addition to several promising clinical studies e.g., in the prevention and treatment of atopic eczema, certain probiotics have been found to maintain intestinal equilibrium by enhancing the gut mucosal barrier via manipulation of expression of several their own and the host's genes. Introduction of genetic engineering has provided advanced tools to amend probiotics' properties in the fight against different inflammatory conditions.

Probiotics for treating eczema

BACKGROUND

Probiotics have been proposed as an effective treatment for eczema, and recently a number of clinical trials have been undertaken.

OBJECTIVES

To assess the effects of probiotics for the treatment of eczema

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (to April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2,2008) MEDLINE (from 2003 to April 2008), EMBASE (from 2005 to April 2008), PsycINFO, AMED and LILACS (from inception to April 2008) and ISI Web of Science (to December 2006) and reference lists of articles. We also searched registries of ongoing clinical trials, conference proceedings and searched for adverse events.

SELECTION CRITERIA

Randomised controlled trials of live orally ingested microorganisms for the treatment of eczema.

DATA COLLECTION AND ANALYSIS

Two authors independently applied eligibility criteria, assessed the quality of trials and extracted data. We contacted study authors for more information where necessary. We recorded adverse events from the included studies, and from the separate adverse events search.

MAIN RESULTS

Twelve randomised controlled trials involving 781 participants met the inclusion criteria. All trial participants were children. There was no significant difference in participant or parent-rated symptom scores in favour of probiotic treatment (5 trials, 313 participants). Symptom severity on a scale from 0 to 20 was 0.90 points lower after probiotic treatment than after placebo (95%CI -1.04, 2.84; p = 0.36).There was also no significant difference in participant or parent-rated overall eczema severity in favour of probiotic treatment (3 trials, 150 participants). There was no significant difference in investigator rated eczema severity between probiotic and placebo treatments (7 trials, 588 participants). On a scale from 0 to 102 investigator rated eczema severity was 2.46 points lower after probiotic treatment than after placebo treatment (95%CI -2.53, 7.45 p = 0.33). Significant heterogeneity was noted between the results of individual studies, which may be explained by the use of different probiotic strains. Subgroup analysis by age of participant, severity of eczema, presence of atopy or presence of food allergy did not identify a population with different treatment outcomes to the population as a whole. The adverse events search identified some case reports of infections and bowel ischaemia caused by probiotics.

AUTHORS' CONCLUSIONS

The evidence suggests that probiotics are not an effective treatment for eczema, and probiotic treatment carries a small risk of adverse events.

Probiotics in preterm infants: a controversial issue

Current research is directed toward innovative dietary compositions that exert specific effects on health promotion and reducing the risk of diseases. For example, the demonstration that the gut microbiota is an important constituent in the intestine's mucosal barrier has led to new therapeutic strategies for infections as well as allergic and inflammatory conditions. Specific probiotic bacteria have been shown to stabilize the gut microbial environment and the intestine's permeability barrier, and to enhance systemic and mucosal IgA responses. These comprise important targets in the preterm infant, who is particularly susceptible to infection and inflammation and in whom the immature enterocyte responds to intraluminal antigens with proinflammatory cytokines. Recent data point to differences in immunomodulatory effects between candidate probiotic bacteria. Each probiotic strain is a unique component itself, and each strain has specific properties that cannot be extrapolated from other, even closely related, strains. Therefore, these properties of probiotic bacteria should be characterized during preclinical and clinical evaluations. Furthermore, because probiotics are a tool with which to modify the gut barrier and microbiota, the strains used must be obtained from acceptable sources with a proven safety record and efficacy to guarantee their future clinical applications. The approach of supplementation with single components, however, overlooks the role of dietary composition, with its range of nutrients and other potentially active components, and also the conceivable combined effects. Consequently, research now focuses both on characterizing specific probiotic strains and on how the food matrix and the dietary content interact with the most efficient probiotic strains.

Growth of infants with IgE-mediated cow's milk allergy fed different formulas in the complementary feeding period

Observational studies have shown that allergic infants, irrespective of the type of diet, show various degrees of growth depression in the first year of life. We investigated whether the type of milk in the complementary feeding period (6-12 months of age) is associated with differences in the increase of standardized growth indices (weight-for-age, WA; length-for-age, LA; and weight-for-length, WL, z-scores) in infants with cow's milk allergy (CMA). Infants with immunoglobulin E-mediated CMA breastfed at least 4 months and progressively weaned in the 5- to 6-month period were randomly assigned to three special formulas, a soy formula (n = 32), a casein hydrolysate (n = 31), and a rice hydrolysate (n = 30). A fourth, non-randomized group was made up by allergic infants still breastfed up to 12 months (n = 32). Groups were compared for WA, LA, and WL z-scores at 6, 9 and 12 months of age. All groups showed low WA and LA z-scores at 6 months of age. Infants fed hydrolyzed products showed a trend toward higher WA z-score increments in the 6- to 12-month period. The use of casein- and rice-based hydrolyzed formulas resulted in higher changes in WA compared with soy formula. Further research should be aimed at optimizing the dietary needs and feeding regimens for infants with CMA.

Dietary counseling and probiotic supplementation during pregnancy modify placental phospholipid fatty acids

It has previously been shown that maternal nutrition affects the fetal environment, with consequences for the infant's health. From early pregnancy onwards participants here received a combination of dietary counseling and probiotics (Lactobacillus GG and Bifidobacterium lactis Bb12; n = 10), dietary counseling with placebo (n = 12), or placebo alone (n = 8). The major differences in placental fatty acids were attributable to a higher concentration of n-3 polyunsaturated fatty acids in both intervention arms than in controls. Further, dietary counseling with probiotics resulted in higher concentrations of linoleic (18:2n-6) and dihomo-gamma-linolenic acids (20:3n-6) compared with dietary counseling with placebo or controls.

A mixture of prebiotic oligosaccharides reduces the incidence of atopic dermatitis during the first six months of age

BACKGROUND

Oligosaccharides may alter postnatal immune development by influencing the constitution of gastrointestinal bacterial flora.

AIMS

To investigate the effect of a prebiotic mixture of galacto- and long chain fructo-oligosaccharides on the incidence of atopic dermatitis (AD) during the first six months of life in formula fed infants at high risk of atopy.

METHODS

Prospective, double-blind, randomised, placebo controlled trial; 259 infants at risk for atopy were enrolled. A total of 102 infants in the prebiotic group and 104 infants in the placebo group completed the study. If bottle feeding was started, the infant was randomly assigned to one of two hydrolysed protein formula groups (0.8 g/100 ml prebiotics or maltodextrine as placebo). All infants were examined for clinical evidence of atopic dermatitis. In a subgroup of 98 infants, faecal flora was analysed.

RESULTS

Ten infants (9.8%; 95 CI 5.4-17.1%) in the intervention group and 24 infants (23.1%; 95 CI 16.0-32.1%) in the control group developed AD. The severity of the dermatitis was not affected by diet. Prebiotic supplements were associated with a significantly higher number of faecal bifidobacteria compared with controls but there was no significant difference in lactobacilli counts.

CONCLUSION

Results show for the first time a beneficial effect of prebiotics on the development of atopic dermatitis in a high risk population of infants. Although the mechanism of this effect requires further investigation, it appears likely that oligosaccharides modulate postnatal immune development by altering bowel flora and have a potential role in primary allergy prevention during infancy.

Impact of national fortification of fluid milks and margarines with vitamin D on dietary intake and serum 25-hydroxyvitamin D concentration in 4-year-old children

OBJECTIVE

To assess the impact of national fortification of fluid milks and margarines with vitamin D on dietary intake and on serum 25-hydroxyvitamin D concentration in Finnish 4-year-old children.

DESIGN, SUBJECTS AND METHODS

Two cohorts of children were studied during wintertime, one before (n=82) in 2001-2002 and the other after (n=36) the initiation of fortification in 2003-2004. Dietary intake was estimated by 4-day food records and serum 25-hydroxyvitamin D concentration was analyzed by radioimmunoassay.

RESULTS

The mean intake of vitamin D was higher the after initiation of fortification (mean (95% confidence interval (CI)); 4.5 (3.8-5.1) microg) than before it (2.1 (95% CI 1.8-2.3) microg; P<0.001), although there were no differences in consumption of the main food sources of vitamin D between the two cohorts. The difference between the cohorts was also evident when the intake of vitamin D was adjusted for energy intake (0.78 (95% CI 0.70-0.90) and 0.37 (95% CI 0.32-0.42) microg/MJ after and before fortification, respectively, P<0.001). After fortification, the mean intake approached that recommended, but was achieved by only 30.6% of the children. Equally, the serum 25-hydroxyvitamin D concentration was higher after fortification (64.9 (95% CI 59.7-70.1) nmol/l) compared to prior it (54.7 (95% CI 51.0-58.4) nmol/l; P=0.002).

CONCLUSIONS

The results indicate that the national fortification of fluid milks and margarines with vitamin D safely improved the vitamin D status of children. This approach, in view of the novel health effects beyond bone metabolism, encourages fortification of new food sources with vitamin D or use of vitamin D supplements particularly during wintertime.

Probiotic intervention in the first months of life: short-term effects on gastrointestinal symptoms and long-term effects on gut microbiota

OBJECTIVES

To determine whether probiotics administered for 6 months postnatally affect gastrointestinal symptoms, crying and the compositional development of the gut microbiota through infancy.

METHODS

The study comprised of 132 newborns whose mothers were randomized to receive placebo or Lactobacillus rhamnosus GG (ATCC 53103) before delivery. The treatments of mothers/infants continued for 6 months postnatally. A specific symptom chart was used to monitor gastrointestinal symptoms and infant's crying during the 7th and the 12th weeks of life. Fluorescent in situ hybridization was used to establish the Bifidobacterium, Lactobacillus/Enterococcus, Bacteroides and Clostridium counts in fecal samples at 6, 12, 18 and 24 months of age.

RESULTS

Numbers of different types of stools, vomits and crying time were comparable between the groups during the 7th and the 12th weeks of life. Dominant microbiota consisted of bifidobacteria throughout the study. At 6 months, there were less clostridia in faeces in the placebo compared with the probiotic group (P = 0.026), whereas after long-term follow-up at 2 years, there were less lactobacilli/enterococci and clostridia in faeces in the probiotic group than in the placebo group (P = 0.011 and P = 0.032, respectively), reflecting the impact of clostridia as a marker of microbiota succession in healthy infants.

CONCLUSIONS

Probiotic administration in the first months of life was well tolerated and did not significantly interfere with long-term composition or quantity of gut microbiota.

Oral tolerance and allergic responses to food proteins

PURPOSE OF REVIEW

The default response to protein antigens in the intestine is the induction of systemic and local hyporesponsiveness, ensuring the prevention of coeliac disease and food allergies. Interest is increasing in the role of dietary manipulation and probiotics in treating allergic and other diseases, but less is known about how these regimens might influence systemic and local immune responses. This paper addresses the mechanisms at the interface of innate and adaptive immunity that determine how the body responds to orally administered proteins and how local bacteria modify these.

RECENT FINDINGS

This paper discusses evidence that dendritic cells in the intestinal mucosa are the critical cells that take up dietary proteins and migrate to the draining mesenteric lymph node, where they induce regulatory CD4 T-cell differentiation. The properties of tolerized T cells are discussed and it is proposed that the gut microenvironment maintains homeostasis by conditioning dendritic cells to remain in a quiescent state. Inhibitory signalling by commensal bacteria possibly contributes to this process.

SUMMARY

A regulatory network controls how dietary antigens are taken up and presented to T lymphocytes by specialized antigen-presenting cells. Elucidating their nature and how they are influenced by external factors such as probiotics may help develop novel therapies for allergy and help understand diseases such as coeliac disease.

Breast milk fatty acids may link innate and adaptive immune regulation: analysis of soluble CD14, prostaglandin E2, and fatty acids

In addition to its role in sensing intraluminal microbial antigens, soluble (s)CD14 may regulate immune responses by its lesser known function as a lipid carrier with possible influences in the production of fatty acid-derived eicosanoids. We investigated the interrelations of fatty acids, prostaglandin E2 (PGE2), and sCD14 and their role in infant atopic eczema during the first year of life. Serum and breast milk samples from mothers and serum samples from their infants were collected at infant's age 3 mo and analyzed for sCD14 and PGE2 concentrations and for fatty acid compositions. The main correlation of sCD14 was with arachidonic acid (20:4n-6) (AA). Dihomo-gamma-linolenic acid (20:3n-6) (DHGLA) and the ratio of n-6 to n-3 fatty acids correlated positively and docosahexaenoic acid (22:6n-3) (DHA) and sum of n-3 fatty acid negatively with PGE2 in mother's serum and linoleic acid (LA) negatively with PGE2 in breast milk. Soluble CD14 tended to be higher and LA, total polyunsaturated fatty acid (PUFA), and sum of n-6 fatty acids were lower in breast milk received by infants with atopic eczema compared with those without. These results suggest that fatty acids contribute to the regulation of innate and adaptive immune responses and link intraluminal exposures, mother's diet, and microbes.

Proceedings of the 4th Georg Rajka International Symposium on Atopic Dermatitis, Arcachon, France, September 15-17, 2005

The 4th Georg Rajka International Symposium on Atopic Dermatitis presented a comprehensive view of our current understanding and management of atopic dermatitis (AD). These proceedings highlight contributions related to the history of AD doctrines; genetic and epigenetic background; epidemiology; maturation of the immune system; infection and innate-adaptive immunity; epidermal inflammation, including neurogenic inflammation and pruritus; animal models; skin barrier; evidence-based therapy and education programs; prognostic and severity markers; and allergy testing. Several studies in animal models and human subjects point to impaired skin barrier function as a primary defect that facilitates the effect of environmental factors and immune dysregulation found in AD. The new frontier in AD therapy should, in the near future, reflect our better understanding of the skin barrier. The influence of environmental factors on the skin and other epithelial barriers in the perinatal period needs to be better understood to implement appropriate prevention programs.

Management of food allergy: vitamins, fatty acids or probiotics?

The dietary approach to allergic disease in infancy is evolving from passive allergen avoidance to active stimulation of the immature immune system, the aim of which is to support the establishment of tolerance. This may include probiotics providing maturational signals for the gut-associated lymphoid tissue and by balancing the generation of pro and anti-inflammatory cytokines in addition to their capacity to reduce the dietary antigen load by degrading and modifying macromolecules. Probiotics have also been shown to reverse the increased intestinal permeability characteristic of children with food allergy and to enhance specific IgA responses frequently defective in children with food allergy. The promotion of gut barrier functions by probiotics also includes the normalization of the gut microecology, alterations in which have been demonstrated in allergic individuals. Dietary lipids, especially long-chain polyunsaturated fatty acids, regulate immune function and may modify the adherence of microbes in the mucosa thereby contributing to host-microbe interactions. The properties of specific dietary compounds in optimal combinations and the joint effects of nutrients can be exploited in the development of specific prophylactic and therapeutic interventions. To meet these targets, rigorous scientific effort is required to elucidate how the food matrix and the dietary content impacts on the complex cascade of interrelated immunological mechanisms in food allergy.