Perspectives on Non-IgE-Mediated Gastrointestinal Food Allergy in Pediatrics: A Review of Current Evidence and Guidelines

Food allergy is an immune-mediated disease that can result in considerable morbidity and even mortality, with a significant negative impact on patients' quality of life. It is characterized by allergic symptoms that can occur shortly after a relevant food allergen ingestion, or can be delayed or chronic, which make it more difficult for diagnosis. The symptoms of this disease can range from mild to severe, and rarely can cause anaphylaxis, a life-threatening allergic reaction. The prevalence of non-immunoglobulin E (IgE)-mediated food allergy is poorly established outside of cow's milk allergy, with an adjusted incidence ranging between 0.13% and 0.72%. Several disorders are classified as non-immunoglobulin E (IgE)-mediated food allergies that predominantly affect the gastrointestinal tract including food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), food protein-induced allergic enteropathy (FPE), and food protein-induced dysmotility disorders (GORD and constipation). Eosinophilic esophagitis (EoE) is listed in this group, even though it considered by some authorities to be mixed reaction with both IgE and cell-mediated immune response to be involved in the reaction. The most common types of non-IgE-mediated food allergy are food protein-induced enterocolitis syndrome (FPIES) and food protein-induced allergic proctocolitis (FPIAP). These disorders typically present in infancy and are often triggered by cow's milk protein. Patients with FPIES present with profuse emesis and dehydration, while FPIAP patients present with hematochezia in otherwise healthy infants. Since there are no specific confirmatory non-invasive diagnostic laboratory tests, the diagnosis is usually made clinically when typical symptoms improve upon the removal of the culprit food. Food reintroduction should be attempted, when possible, with documentation of symptoms of relapse to confirm the diagnosis. The management includes dietary avoidance, supportive treatment in the case of accidental exposure, and nutritional counseling. This review focuses on the clinical manifestations, epidemiology, management, and recent guidelines of the most common non-IgE-mediated food hypersensitivity disorders (FPIES, FPIAP, and FPE).

Evaluation of the Safety of a Plant-Based Infant Formula Containing Almonds and Buckwheat in a Neonatal Piglet Model

A randomized neonatal piglet trial was conducted to evaluate the safety and the effects of a plant-based formula containing almonds and buckwheat as the main ingredients on growth and plasma parameters. From postnatal day (PND) 2 to 21, the piglets were fed a dairy-based milk formula (Similac Advance) or a plant-based formula (Else Nutrition) and all piglets were euthanized at day 21. No diarrhea was observed after PND 8 and all the piglets completed the trial. Body growth, kcal intake, the complete plasma count parameters and hematological parameters were within the reference range in both groups. Organ growth and development was similar between the two groups. Plasma glucose was higher in the dairy-based-fed piglets relative to the plant-based at 2 weeks of age. Liver function biomarkers levels were greater in the plasma of the plant-based compared to the dairy-based fed group. In addition, calcium levels were higher in the plant-based fed piglets at 1 week of age. Thus, the plant-based formula tested in this study was well tolerated by the piglets and supported similar growth compared to dairy-based milk formula. Therefore, the results support the safety of the tested plant-based infant formula during the neonatal period in comparison to the dairy-based formula fed group.

Developmental exposure to phytoestrogens found in soy: New findings and clinical implications

Exposure to naturally derived estrogen receptor activators, such as the phytoestrogen genistein, can occur at physiologically relevant concentrations in the human diet. Soy-based infant formulas are of particular concern because infants consuming these products have serum genistein levels almost 20 times greater than those seen in vegetarian adults. Comparable exposures in animal studies have adverse physiologic effects. The timing of exposure is particularly concerning because infants undergo a steroid hormone-sensitive period termed "minipuberty" during which estrogenic chemical exposure may alter normal reproductive tissue patterning and function. The delay between genistein exposure and reproductive outcomes poses a unique challenge to collecting epidemiological data. In 2010, the U.S. National Toxicology Program monograph on the safety of the use of soy formula stated that the use of soy-based infant formula posed minimal concern and emphasized a lack of data from human subjects. Since then, several new human and animal studies have advanced our epidemiological and mechanistic understanding of the risks and benefits of phytoestrogen exposure. Here we aim to identify clinically relevant findings regarding phytoestrogen exposure and female reproductive outcomes from the past 10 years, with a focus on the phytoestrogen genistein, and explore the implications of these findings for soy infant formula recommendations. Research presented in this review will inform clinical practice and dietary recommendations for infants based on evidence from both clinical epidemiology and basic research advances in endocrinology and developmental biology from mechanistic in vitro and animal studies.

Association between parental self-reported knowledge on soy and phytoestrogen and their children's intake of soy-based infant formulae-a cross-sectional study of Israeli parents

OBJECTIVES

Though natural phytoestrogen (PE) is a major factor in health authorities' considerations regarding soy-based infant formula (SBIF), missing their concentrations may interfere with parents' informed decision.

METHODS

We performed an Internet survey investigating soy-related knowledge of parents. We built multiple logistic regression models adjusted for personal covariates for the association between parental knowledge on PE and children intake of SBIF and checked the effect of having children ≤ 2 years old on this association.

RESULTS

We enrolled 304 parents, 48.3% men, mean age 33.8 (standard deviation, SD 4.9), mostly with higher education. Of them, 76% had children under two years of age. Mean parental knowledge on PE was 9.83 (SD 3.28) from 20 possible points. Parental knowledge on PE reduced children's intake of SBIF (odds ratio, OR = 0.85 [95% confidence interval 0.70; 1.02]). Stronger inverse association was found for parents with children ≤ 2 comparing with those with older children (OR = 0.85 [0.67; 1.09] and OR = 0.68 [0.39; 1.18], respectively), although these differences were not statistically significant.

CONCLUSIONS

Adding PE content to information on SBIF may support informed decision.

Skeletal Effects of Early-Life Exposure to Soy Isoflavones-A Review of Evidence From Rodent Models

Isoflavones are dietary phytoestrogens commonly found in soy-based products. The widespread presence of isoflavones in soy infant formula and breast milk may have long-lasting effects on the development of sex hormone-sensitive organs like the skeleton. Animal early-life programming models are suitable for testing the skeletal effects of pre- and neonatal exposure of soy isoflavones. This review aims to collate the impacts of early-life exposure of soy isoflavones as evidenced in animal models. The isoflavones previously studied include daidzein, genistein, or a combination of both. They were administered to rodent pups during the first few days postnatal, but prolonged exposure had also been studied. The skeletal effects were observed when the animals reached sexual maturity or after castration to induce bone loss. In general, neonatal exposure to soy isoflavones exerted beneficial effects on the skeletal system of female rodents, but the effects on male rodents seem to depend on the time of exposure and require further examinations. It might also protect the animals against bone loss due to ovariectomy at adulthood but not upon orchidectomy. The potential benefits of isoflavones on the skeletal system should be interpreted together with its non-skeletal effects in the assessment of its safety and impacts.

Nutrition of infants and young children (one to three years) and its effect on later health: A systematic review of current recommendations (EarlyNutrition project)

BACKGROUND

EarlyNutrition ( www.project-earlynutrition.eu ) is an international research project investigating the effects of early nutrition on metabolic programming.

OBJECTIVE

To summarize, by performing a systematic review, current standards, recommendations, guidelines, and regulations (hereafter, referred to as documents) on the nutrition of children up to three years of age. Special emphasis was placed on long-term effects of early nutrition, such as the risk of cardiovascular disease, hypertension, overweight, obesity, metabolic syndrome, diabetes, or glucose intolerance.

METHODS

MEDLINE, selected databases, and websites were searched for documents published between 2008 and January 2013.

RESULTS

Forty two documents met the inclusion criteria. The strongest and most consistent evidence for a protective, long-term effect was documented for breastfeeding. Also, limiting the intake of sodium and rapidly absorbed carbohydrates, use of a specific meal pattern, reducing the consumption of saturated fatty acids by replacing them with polyunsaturated fatty acids, and lowering the intake of trans fatty acids, seems beneficial. Many documents did not evaluate long-term outcomes of interest to us, or reported insufficient or imprecise data. Inconsistency in recommendations for some outcomes and research gaps were identified.

CONCLUSIONS

Our findings may serve as a helpful tool in planning further research, preventive actions against important diet-related diseases, and guidelines improvement.

Types of Infant Formulas Consumed in the United States

We examined consumption of different types of infant formula (eg, cow's milk, soy, gentle/lactose-reduced, and specialty) and regular milk among a nationally representative sample of 1864 infants, 0 to 12 months old, from the National Health and Nutrition Examination Survey, 2003-2010. Among the 81% of infants who were fed formula or regular milk, 69% consumed cow's milk formula, 12% consumed soy formula, 5% consumed gentle/ lactose-reduced formulas, 6% consumed specialty formulas, and 13% consumed regular milk products. There were differences by household education and income in the percentage of infants consuming cow's milk formula and regular milk products. The majority of infants in the United States who were fed formula or regular milk consumed cow's milk formula (69%), with lower percentages receiving soy, specialty, gentle/sensitive, or lactose-free/reduced formulas. Contrary to national recommendations, 13% of infants younger than 1 year consumed regular milk, and the percentage varied by household education and income levels.

Comparative study about some physical properties, in vitro digestibility and immunoreactivity of soybean protein isolate for infant formula

The objective of this study was to determine molecular weight subunit distributions of soy protein isolate (SPI) by SDS-PAGE and gel size exclusion chromatography, and further to investigate the differences of thixotropy, viscosity, in vitro digestibility and immunoreactivity of SPI for infant formula produced in Chinese domestic companies and world famous SPI manufacturers such as Dupont and Fuji. The molecular subunit distributions were analyzed by SDS-PAGE and gel size exclusion chromatography, indicating that Solae and Fuji were hydrolyzed by proteolytic enzymes. The thixotropy of Fuji and Solae significantly reduced around by 95 %, compared with those of Mantianxue and Dupont Zhengzhou. The allergen contents of Fuji and Solae strikingly decreased by 60 and 84 % respectively, in contrast to that of Mantianxue. The in vitro protein digestibility of Solae at the end of pepsin and trypsin digestion markedly increased by 11.7 and 11.3 %, respectively, in comparison to those of Mantianxue. Suitable enzymatic hydrolyzed SPIs showed lower thixotropy, viscosity, immunoreactivity and higher in vitro protein digestibility than those from the other SPIs. The lower thixotropy indicates low difficulty or shear stress in swallowing for infants. The lower immunoreactivity will improve the safety of SPI for cow milk allergic babies.