Preventing food allergy in infancy and childhood: Systematic review of randomised controlled trials

Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy

Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.

Association between gut microbiota development and allergy in infants born during pandemic-related social distancing restrictions

BACKGROUND

Several hypotheses link reduced microbial exposure to increased prevalence of allergies. Here we capitalize on the opportunity to study a cohort of infants (CORAL), raised during COVID-19 associated social distancing measures, to identify the environmental exposures and dietary factors that contribute to early life microbiota development and to examine their associations with allergic outcomes.

METHODS

Fecal samples were sequenced from infants at 6 (n = 351) and repeated at 12 (n = 343) months, using 16S sequencing. Published 16S data from pre-pandemic cohorts were included for microbiota comparisons. Online questionnaires collected epidemiological information on home environment, healthcare utilization, infant health, allergic diseases, and diet. Skin prick testing (SPT) was performed at 12 (n = 343) and 24 (n = 320) months of age, accompanied by atopic dermatitis and food allergy assessments.

RESULTS

The relative abundance of bifidobacteria was higher, while environmentally transmitted bacteria such as Clostridia was lower in CORAL infants compared to previous cohorts. The abundance of multiple Clostridia taxa correlated with a microbial exposure index. Plant based foods during weaning positively impacted microbiota development. Bifidobacteria levels at 6 months of age, and relative abundance of butyrate producers at 12 months of age, were negatively associated with AD and SPT positivity. The prevalence of allergen sensitization, food allergy, and AD did not increase over pre-pandemic levels.

CONCLUSIONS

Environmental exposures and dietary components significantly impact microbiota community assembly. Our results also suggest that vertically transmitted bacteria and appropriate dietary supports may be more important than exposure to environmental microbes alone for protection against allergic diseases in infancy.

Maternal and Infant Dietary Patterns Are Not Related to Food Allergy Risk in Singapore Children: GUSTO Cohort Study

BACKGROUND

We previously reported that delayed allergenic food introduction in infancy did not increase food allergy risk until age 4 y within our prospective cohort. However, it remains unclear whether other aspects of maternal or infant diet play roles in the development of childhood food allergy.

OBJECTIVES

We examined the relationship between maternal pregnancy and infant dietary patterns and the development of food allergies until age 8 y.

METHODS

Among 1152 Singapore Growing Up in Singapore Towards healthy Outcomes study mother-infant dyads, the infant's diet was ascertained using food frequency questionnaires at 18 mo. Maternal dietary patterns during pregnancy were derived from 24-h diet recalls. Food allergy was determined through interviewer-administered questionnaires at regular time points from infancy to age 8 y and defined as a positive history of allergic reactions, alongside skin prick tests at 18 mo, 3, 5, and 8 y.

RESULTS

Food allergy prevalence was 2.5% (22/883) at 12 mo and generally decreased over time by 8 y (1.9%; 14/736). Higher maternal dietary quality was associated with increased risk of food allergy (P ≤ 0.016); however, odds ratios were modest. Offspring food allergy risk ≤8 y showed no associations with measures of infant diet including timing of solids/food introduction (adjusted odds ratio [aOR]: 0.90; 95% confidence interval [CI]: 0.42, 1.92), infant's diet quality (aOR: 0.93; 95% CI: 0.88, 0.99) or diet diversity (aOR: 0.84; 95% CI: 0.6, 1.19). Most infants (89%) were first introduced to cow milk protein within the first month of life, while egg and peanut introduction were delayed (58.3% introduced by mean age 8.8 mo and 59.8% by mean age 18.1 mo, respectively).

CONCLUSIONS

Apart from maternal diet quality showing a modest association, infant's allergenic food introduction, diet quality, and dietary diversity were not associated with food allergy development in this Asian pediatric population. Interventional studies are needed to evaluate the efficacy of these approaches to food allergy prevention across different populations.

Regular consumption following early introduction of allergenic foods and aggressive treatment of eczema are necessary for preventing the development of food allergy in children

PURPOSE OF REVIEW

Over the past two decades, food allergy prevention strategies have shifted from 'delayed introduction' to 'no delayed introduction' to 'early introduction' of allergenic foods. This article reviews important research in this field published in the early 2020s to support future strategies for food allergy prevention.

RECENT FINDINGS

Recent randomized controlled trials (RCTs), systematic reviews, meta-analyses, and real-world studies have reported that early allergenic food introduction, especially peanut and egg, are effective for preventing food allergies. However, there are also reports that food-induced anaphylaxis admission rates in infants are increasing.

SUMMARY

Early allergenic food introduction by itself is not sufficient to prevent the development of food allergies. Recent RCTs (SPADE study and COMEET study) have demonstrated that continued regular cow's milk consumption after early introduction is important for preventing the onset of cow's milk allergy. Furthermore, an RCT (PACI study) reported that early and aggressive anti-inflammatory topical therapy for eczema can contribute to the prevention of egg allergy by suppressing percutaneous sensitization. Food allergies may be prevented through a combination of early food introduction, regular consumption, and active eczema treatment. Further research is needed to develop well tolerated, effective, and practical strategies to prevent food allergies.

The role of pediatricians in the diagnosis and management of IgE-mediated food allergy: a review

Importance

Food allergy can often cause a significant burden on patients, families, and healthcare systems. The complexity of food allergy management requires a multidisciplinary approach involving different types of healthcare providers, including allergists, dieticians, psychologists, nurses, family practitioners and, of particular relevance for this article, pediatric primary caretakers. Pediatricians may be the first-line healthcare providers for food allergy: strategies for management and guideline adherence have been highlighted.

Observations

This review article summarizes the up-to-date recommendations on the role of pediatricians in the diagnosis, management, and prevention of IgE-mediated food allergy. Early introduction of allergenic foods like peanut is known to be of importance to reduce the development of peanut allergy in infants, and pediatricians are essential for educating and supporting parents in this decision. In scenarios of limited allergist availability, as is often the case among rural, Medicaid and minority populations, pediatricians can assist in the evaluation and management of food allergy, and provide action plans, education and counselling for patients and families.

Conclusions and relevance

Pediatric primary caretakers play a key role in the diagnosis, management, and prevention of IgE-mediated food allergy. As more diagnostic tools and therapies in food allergy become available, the need for a multidisciplinary team is paramount to optimize patient care.

Characteristics of infant formula consumed in the first months of life and allergy in the EDEN mother-child cohort

The evidence regarding the association between infant formula (IF) composition and the prevention of allergy and respiratory diseases remains sparse and inconclusive. This study aimed to evaluate whether some IF characteristics were associated with the risk of allergy or respiratory diseases in childhood. Among 1243 formula-fed children from the EDEN mother-child cohort, IF characteristics concerning long-chain polyunsaturated fatty acids (LCPUFAs) enrichment, prebiotic/probiotic enrichment, and hydrolysis of proteins were identified from the ingredients list. Eczema, wheezing, food allergy, asthma, and allergic rhinitis up to age 8 years were prospectively collected and summarized into four allergic and respiratory multimorbidity clusters. Associations between 4-month IF characteristics and risk of allergy or respiratory diseases were tested using logistic regressions adjusted on main confounders. The consumption of LCPUFA-enriched formula was not linked to allergic and respiratory multimorbidity clusters, but to a lower risk of any allergy, eczema, and wheezing. Probiotic-enriched formula consumption was associated with a lower risk of belonging to the 'Allergy without asthma' cluster (odds ratio [OR] [95% confidence interval, CI] = 0.63 [0.40-0.99]), and consumption of a formula enriched in Bifidobacterium lactis was associated with a lower risk of any allergy (OR [95% CI] = 0.59 [0.41-0.85]). Partially hydrolysed formula (pHF) consumption was associated with a higher risk of belonging to the 'Allergy without asthma' cluster (OR [95% CI] = 2.73 [1.65-4.51]). This study confirms the positive association between pHF consumption and the risk of allergy found in previous observational studies and suggests that consumption of LCPUFA-enriched or probiotic-enriched formula was associated with a lower risk of allergy.

Differences in the Course, Diagnosis, and Treatment of Food Allergies Depending on Age-Comparison of Children and Adults

Food allergy (FA) has become a common global public health issue, with a growing prevalence in the modern world and a significant impact on the lives of patients, their families, and caregivers. It affects every area of life and is associated with elevated costs. Food allergy is an adverse immune reaction that occurs in response to a given food. The symptoms vary from mild to severe and can lead to anaphylaxis. This is why it is important to focus on the factors influencing the occurrence of food allergies, specific diagnostic methods, effective therapies, and especially prevention. Recently, many guidelines have emphasized the impact of introducing specific foods into a child's diet at an early age in order to prevent food allergies. Childhood allergies vary with age. In infants, the most common allergy is to cow's milk. Later in life, peanut allergy is more frequently diagnosed. Numerous common childhood allergies can be outgrown by adulthood. Adults can also develop new IgE-mediated FA. The gold standard for diagnosis is the oral provocation test. Skin prick tests, specific IgE measurements, and component-resolved diagnostic techniques are helpful in the diagnosis. Multiple different approaches are being tried as possible treatments, such as immunotherapy or monoclonal antibodies. This article focuses on the prevention and quality of life of allergic patients. This article aims to systematize the latest knowledge and highlight the differences between food allergies in pediatric and adult populations.

Clinical characteristics, laboratory findings, and tolerance acquisition in infants with cow's milk protein allergy in a private center in Lima, Peru for the period 2021-2022

BACKGROUND

Cow's milk protein allergy (CMPA) remains relatively understudied in Latin America.

METHODS

In this observational study, we enrolled 64 patients with a median age of 3 months, of whom 60% were male. Patients included had a history of IgE-mediated reactions with IgE sensitization or non-IgE-mediated reactions or symptoms following exposure to cow's milk. They underwent skin prick test, ImmunoCAP, fecal calprotectin (FC), and fecal eosinophil-derived neurotoxin (EDN), in addition to double-blinded placebo-controlled oral food challenges (DBPCFC), with clinical evolution and tolerance acquisition observed over 1 year.

RESULTS

Malnutrition was present in 78.1% of patients, and 87.5% had a family history of atopy, with 51.6% receiving exclusive breastfeeding. Gastrointestinal manifestations were prevalent in 90.6% of patients, followed by dermatological manifestations (10.9%), with only 2 experiencing anaphylaxis. IgE-mediated CMPA was observed in only six patients. In those with non-IgE-mediated CMPA, FC had a median of 284 mg/dL (IQR: 138.5-415.5), while EDN had a median of 508.5 mg/dL (IQR: 160.25-868). One year after diagnosis, median FC significantly decreased (p < 0.0001), and malnutrition prevalence reduced to 17.1%. Moreover, 81% of patients acquired tolerance following DBPCFC, with 52% utilizing nutritional replacement formulas at diagnosis. Notably, 94% of those extensively hydrolyzed casein-based formulas achieved tolerance (p = 0.08).

CONCLUSION

Our findings provide a foundational framework for future investigations into CMPA diagnosis, tolerance acquisition, and the utilization of hypoallergenic formulas tailored to the unique characteristics of our region.

Introduction of allergenic food to infants and allergic and autoimmune conditions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the effects of early introduction to allergenic foods compared with late introduction and its impact on food allergy, food sensitisation and autoimmune disease risk.

DESIGN AND SETTING

The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Four electronic databases (MEDLINE, CENTRAL, EMBASE and CINAHL) were searched from inception till 24 October 2022 using keywords and MeSH without limitations on publication's language or date. A forward and backwards citation analysis was also conducted. Risk of bias was assessed by three authors independently, in pairs using the Cochrane Risk of Bias Tool 2. Findings were narratively and quantitatively synthesised. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

PARTICIPANTS

Randomised controlled trials (RCTs) on allergenic food introduction prior to 12 months of age that evaluated its effect on the development of allergic and autoimmune conditions.

INTERVENTION

Early introduction to allergenic foods to infants diet.

MAIN OUTCOME MEASURES

(1) Food allergy and sensitisation with main measures including oral food challenge, specific-IgE, skin prick testing, physician assessment and parental reporting. (2) Allergic and autoimmune conditions such as asthma and eczema.

RESULTS

Of the 9060 identified records, we included 12 RCTs. We found high to moderate certainty evidence suggested that early introduction of allergen-containing foods reduces the risk of multiple food allergies (4 RCTs, 3854 participants, RR 0.49, 95% CI 0.33 to 0.74), egg (8 RCTs, 5193 participants, RR 0.58, 95% CI 0.44 to 0.78), peanut (3 RCTs, 4183 participants, RR 0.31, 95% CI 0.17 to 0.54) and atopic dermatitis or eczema (4 RCTs, 3579 participants, RR 0.88, 95% CI 0.78 to 1.00). Effects on other food allergies including milk, wheat, fish; autoimmune conditions, and food sensitisation are very uncertain and informed by low and very-low certainty evidence. No important subgroup differences were observed related to baseline risk of allergy and age at introduction. Sensitivity analyses limited to low risk of bias RCTs showed similar results.

CONCLUSIONS

This systematic review and meta-analysis shows that early introduction of allergen-containing food from 4 to 12 months of age, was associated with lower risk of multiple food allergy and eczema. Further research on other allergenic foods, and their long-term impact on food allergy and autoimmune risk is essential for enhancing our understanding on development of these conditions and guiding future clinical recommendations.

PROSPERO REGISTRATION NUMBER

CRD42022375679.

Infant feeding-a scoping review for Nordic Nutrition Recommendations 2023

The 2012 edition of the Nordic Nutrition Recommendations (NNR) included recommendations on breastfeeding, based on the most recent guidelines and recommendations from major national food and health authorities and organizations, systematic reviews, and some original research. For NNR 2023, the scope has been expanded and also includes formula feeding and the introduction of solid food. The main focus in this scoping review is on infants aged 0-12 months but also considers parts both before and beyond the first year, as the concept of 'the first 1000 days' emphasizes the importance of factors during pregnancy and the first 2 years of life for immediate and later health: physical as well as emotional and mental health. Breastmilk is the natural and sustainable way to feed an infant during the first months of life. Numerous studies have indicated immediate as well as long-term beneficial effects of breastfeeding on health for both the infant and the breastfeeding mother, and from a public health perspective, it is therefore important to protect, support, and promote breastfeeding. For full-term, normal weight infants, breastmilk is sufficient as the only form of nutrition for the first 6 months, except for vitamin D that needs to be given as supplement. The World Health Organization (WHO) and several other authoritative bodies therefore recommend exclusive breastfeeding during the first 6 months. Starting solids at about 6 months is necessary for both nutritional and developmental reasons. According to the European Food Safety Authority (EFSA) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), solid foods are safe to give from 4 months although exclusive breastfeeding until 6 months is the desirable goal. Breastfeeding can continue together with complementary foods as long as it is mutually desired by the mother and child. If breastfeeding is not enough or for some reason discontinued before the infant is 4 months of age, the infant should be fed infant formula, and, when possible, breastfeeding should be continued alongside the formula feeding. If the infant is 4 months or older, starting with solids together with continued breastfeeding and/or formula feeding is an option. Infant formulas have been developed for infants who are not breastfed or do not get enough breastmilk. Home-made formula should not be given.

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.

Nuts, vegetables, fruits, and protein dietary pattern during pregnancy is inversely associated with risk of childhood allergies: a case-control study

Allergic diseases are prevalent chronic conditions among children and can lead to significant health and economic issues. It is hypothesized that healthy and high quality diet during pregnancy can prevent the onset of allergic diseases in offspring. This study aimed to investigate the potential relationship between major dietary patterns during pregnancy and allergies in children under one year of age. This case-control study was conducted involving 244 participants (122 mothers of allergic children and 122 healthy controls) who visited pediatricians and allergy outpatient clinics in Khuzestan Province, Iran, between June 2022 and March 2023. Demographic information was recorded using a socio-demographic questionnaire. A food frequency questionnaire was used to identify the foods consumed during pregnancy. Major dietary patterns were extracted using principal component analysis, and the potential relationship between these patterns and childhood allergies was investigated using multivariable logistic regression models. The crude odds ratio (OR) analysis showed that the fourth quartile of "Nut, vegetables, fruits, and protein" dietary pattern was associated with lower occurrence of childhood allergies (OR: 0.214, 95% CI = 0.068-0.679; P trend = 0.211). After adjusting for cofactors in Model 3, this association was still observed in the fourth quartile (OR = 0.108, 95% CI = 0.019-0.613; P trend, 0.001). However, no significant association was observed between "Carbohydrate and cereals" and "Salty" dietary patterns and childhood allergies. The study findings suggest that a maternal dietary pattern rich in nuts, vegetables, and fruits during pregnancy may reduce the risk of allergic diseases in offspring.

[Risk factors for food allergy]

Allergy is the result of genetic and environmental interactions, including time, route, and dose of food exposure in susceptible patients. Risk factors can be: 1) genetic and 2) environmental, and these, in turn, are divided into prenatal, perinatal and postnatal. Food allergy appears frequently and depends on multiple risk factors (genetic and environmental), which in turn are divided into: prenatal, natal and postnatal factors; They participate in the expression of the disease and clinical intervention is not possible in all cases.

[Food anaphylaxis]

Anaphylaxis, a potentially life-threatening reaction, is characterized by acute symptoms affecting various systems and requires immediate medical intervention. While the overall mortality rate is low, anaphylaxis induced by foods and drugs has seen an increase. Common triggers include foods, drugs, and Hymenoptera venom. Epidemiology varies by region and age, with a global incidence of 50-112 episodes per 100,000 people annually. Implicated foods vary by age and region, with peanuts and nuts being common triggers. Two mechanisms of anaphylaxis are recognized: IgE-mediated and non-IgE-mediated. Diagnosis is based on clinical criteria and serum tryptase levels. Treatment includes epinephrine, oxygen, and intravenous fluids. Exercise-induced food-dependent anaphylaxis is addressed, where exercise, combined with certain foods, triggers anaphylactic reactions. Proper understanding and management are crucial to mitigate risks.

[Introduction to food allergy]

Food allergy is a common chronic disorder that affects infants, children, adolescents, and adults. The prevalence of food allergy has increased in recent decades throughout the world, not limited to Western countries. Since there is no treatment, this focuses on avoiding allergens, in addition to educating patients and caregivers in the emergency treatment of acute reactions, for example: application of epinephrine. Studies suggest that accidental reactions occur in about 45% of children with food allergies each year, although most reactions are mild or moderate in severity. Hospital admissions for food anaphylaxis vary from 4 to 20 per 100,000 inhabitants; Deaths are rare, with an estimated incidence of 0.03 to 0.3 per million people with food allergy. Death from food anaphylaxis is rare and appears to have remained stable, possibly due to increases in food allergen labeling, diagnostic services, rates of intramuscular epinephrine prescription, and awareness of food allergies. Omalizumab is a drug approved for several disorders (chronic hives or difficult asthma) and may help reduce symptoms associated with food allergy. The relative importance of alternative technologies, management strategies and policies for food allergy varies from one region to another, due to differences in the epidemiology, education, socioeconomic well-being, and cultural preferences of the population.

[Prevention in food allergies]

Preventing food allergies is key to reducing the incidence of the disease. Exclusive breastfeeding is recommended during the first months of life, in addition to supplementation with vitamin D and, due to the importance of the microbiota, addition of probiotics, prebiotics and symbiotic. Currently, late exposure to foods is controversial, and it is suggested to introduce allergenic foods early, trying not to expose the cutaneous route. The application of biologics in food allergy is an evolving area of research and treatment. Biologics are indicated in diseases evaluated in various studies, such as atopic dermatitis, and are approved by the FDA for prescription; However, its potential administration in the treatment of severe allergic reactions caused by food is still debated. These therapies may change the way food allergy is addressed in the future, but they are still in experimental stages and not widely available. Food anaphylaxis is a life-threatening allergic reaction that requires quick action. Prevention involves avoiding the triggering food, awareness of symptoms, and availability of epinephrine for immediate administration in case of a reaction.

Timing of complementary feeding for early childhood allergy prevention: An overview of systematic reviews

OBJECTIVE

To summarise and critically appraise systematic review (SR) evidence on the effects of timing of complementary feeding (CF) on the occurrence of allergic sensitisation and disease.

DESIGN

Overview of SRs. AMSTAR-2 and ROBIS were used to assess methodological quality and risk of bias (RoB) of SRs. RoB 2 Tool was used to assess RoB of primary randomised controlled trials (RCTs) (or extracted). The certainty of evidence (CoE) was assessed using GRADE. Findings were synthesised narratively.

DATA SOURCES

MEDLINE (via PubMed and Ovid), the Cochrane Library and Web of Science Core Collection (2010 to 27 February 2023).

ELIGIBILITY CRITERIA

SRs investigating the effects of timing of CF in infants or young children (0-3 years) on risk of developing food allergy (FA), allergic sensitisation, asthma, allergic rhinitis, atopic eczema and adverse events based on RCT evidence.

RESULTS

Eleven SRs were included. Only two SRs had low RoB; common issues were failure to report on funding of primary studies and failure to provide a list of excluded trials. Common limitations of included trials were lack of blinding of outcome assessment or detailed trial preregistration, and inadequate handling of high loss to follow up. Primary study overlap was very high for specific FA and slight to moderate for FA in general and other primary outcomes. Introducing specific foods (peanut, cooked egg) early probably reduces the risk of specific FA. Evidence for other allergic outcomes was mostly very uncertain and based on few primary studies. Trials varied regarding timing of CF, nature of complementary foods and population risk, which limited comparability between SRs.

CONCLUSIONS

For developing guidelines to support decision-making on the timing of CF as a preventive strategy, early introduction of specific foods (i.e. egg and peanut) seems promising and safe, whereas more extensive research is required regarding other allergic outcomes and potential adverse events.

Cow's milk-based infant formula supplements in breastfed infants and primary prevention of cow's milk allergy: A commentary of the Committee on Nutrition of the French Society of Pediatrics

The role of nutritional interventions for the primary prevention of cow's milk allergy (CMA) remains debated as well as the role of early introduction of allergenic foods, which is largely encouraged from the beginning of complementary feeding. Considering the introduction of cow's milk protein (CMP), current recommendations suggest avoidance of any cow's milk formula (CMF) supplements in breastfed infants in the maternity ward. By contrast, based on poor evidence, some authors support systematic supplements of CMP in breastfed children at risk of allergy from the first week of life. The Committee on Nutrition of the French Society of Pediatrics considers that such a proposal requires more clinical studies and mainly randomized and placebo-controlled clinical trials before becoming a recommendation.

Tackling food allergens-The role of food processing on proteins' allergenicity

This chapter examines how innovative and emerging food processing technologies, such as those that use heat, electricity, electromagnetic waves, and pressure, can modify protein denaturation, aggregation, and intermolecular interactions pathways, which can result in varying immunoreactive responses. It emphasizes the need to understand how these processing methods affect the protein epitopes recognized by antibodies and their respective priming pathways, especially during the sensitization stage that precedes an allergic response. Although traditional processing methods have been investigated, the impact of novel technologies on food protein allergenicity remains largely unknown. The chapter specifically focuses on milk proteins, which have clinical significance and are associated with cow's milk allergy, one of the most common food allergies in young children. Additionally, it examines potential scientific advancements that novel processing methods may bring to this field.

The Effect of Food Allergen Exclusion on the Growth of Saudi Children

With a variety of symptoms that can impede children's development, food allergies are an important public health concern. With the help of information from the King Fahad Medical City Hospital in Riyadh, we looked at how restricting certain foods affected the growth of Saudi children who had food allergies. An anonymous self-administered questionnaire asking about the individuals' demographics and their restricted eating habits was completed by 72 children (48 boys and 24 girls) between the ages of 2 and 14. The sensitivity of six allergens (hen eggs, cow milk, fish, wheat, peanuts, and soybeans), anthropometric indices, specific Immunoglobulin E (IgE) levels, and sensitivity were examined. The Statistical Package for Social Science (SPSS), version 26, was used to analyze the data. Chi-square and t-tests were used to examine the relationships between various category variables. According to the findings, most of the mothers of the children were between the ages of 30 and 40 (80.6%), had a college degree (72.3%), were unemployed (59.7%), and had a monthly family income between 5000 and 15,000 SAR (69.4%). Both sexes had specific IgE antibodies for allergens in classes 2 and 3, with boys having noticeably (p ≤ 0.05) higher quantities than girls. While females were more sensitive to fish and peanuts, boys were more likely than girls to show specific IgE sensitivity to egg white, cow milk, wheat, and soybeans. Both sexes' allergy levels were considerably (p ≤ 0.01) higher in children aged 5.01 to 10 than in other age groups. In terms of classifications of thinness, overweightness, and obesity, boys were slenderer than girls, and a greater percentage of boys than girls were overweight or obese. The exclusion of hen eggs, cow milk, wheat, and peanuts from the diet had a significant and detrimental effect on body mass index (BMI) and height-for-age ratio among children with impaired growth, in contrast to the demographic factors, which had a significant and favorable effect on the growth of other children. In conclusion, restrictions on food allergens impairs growth in Saudi children, particularly boys' growth.

A review of current evidence on food allergies during pregnancy

Food allergy is the reaction of the immune system of the body that occurs after consuming specific foods. During specific physiological ages of pregnancy, women are more prone to different allergic reactions and mostly these reactions may prolong and have long-term effects. The hypersensitivity of different types of allergens is mainly linked with the adversity of reactions. The chances of suffering food allergies in women are greater than in men; women are usually more prone to get allergic to some foods during their specific physiological age of pregnancy. Food allergies are more common in pregnant women as every fifth pregnant woman is affected by some kind of allergy. The specific reasons and evidence of the causes of these food allergies during pregnancies have yet to be explored. A pregnant woman should take a balanced diet and avoid consuming known allergic foods to minimize the risk and complications. This review aimed to broaden the knowledge on food allergies during pregnancies, their onset in the babies, and to make it easy for pregnant women to cope with the complications caused by these food allergies. It also aimed to figure out the certain food that might be responsible for the onset of allergies in women during pregnancy and the effect of these allergies on their babies.

Biomarkers associated with persistence and severity of IgE-mediated food allergies: a systematic review

OBJECTIVE

The prevalence of food allergies (FA) has increased worldwide over the last few decades. Milk, eggs, and peanuts are among the most common allergens and can cause anaphylaxis. Therefore, we aimed to identify biomarkers that could predict the persistence and/or severity of IgE-mediated allergies to milk, eggs, and peanuts via a systematic review.

METHODS

This systematic review proceeded according to a protocol registered in the International Prospective Register of Systematic Reviews. Two independent authors extracted studies of interest from PubMed, SciELO, EMBASE, Scopus, and Ebsco databases and assessed their quality using the Newcastle-Ottawa Scale.

RESULTS

We selected 14 articles describing 1,398 patients. Among eight identified biomarkers, total IgE, specific IgE (sIgE), and IgG4 were the most often cited biomarkers of persistent allergies to milk, eggs, and peanuts. Skin prick tests, endpoint tests, and sIgE cutoff levels may predict positive responses to challenges with these foods. The basophil activation test is a biomarker for the severity and/or threshold of allergic reactions to milk and peanuts.

CONCLUSION

Only a few publications identified possible prognostic indicators of the persistence or severity of FA and outcomes of oral food challenges, indicating that more accessible biomarkers are needed to determine the likelihood of having a severe food allergic reaction.

Introduction of Complementary Foods and the Risk of Sensitization and Allergy in Children up to Three Years of Age

BACKGROUND

Allergy is known to be influenced by both diet and the immune system. In addition, the time of first exposure to food allergens and their type appear to play a particularly important role in the development of allergies.

AIM

To determine the influence of the time of exposure, and the type, degree of processing, and frequency of supply of complementary foods and the development of sensitization and allergies in children up to three years of age. Materials and metods: The study was conducted prospectively in two stages. The first stage included 106 children aged 6-18 months, while the second stage included 86 children selected from the first stage, after a further 12 months. A questionnaire based on validated FFQ sheets was created for the purpose of the study. The following were assessed: nutrition in the first year of life (time, type, degree of processing), frequency of supply of complementary foods and allergic symptoms, sIgE concentration against 10 foods and 10 inhalant allergens. Four groups of patients were formed. This paper presents the results of the second stage of the study.

RESULTS

For all participants, allergenic products, viz. hen's egg, milk, peanuts, wheat, soybean, fish, tree nuts and shellfish were typically introduced at an age of 7 to 12 months. During this period, egg white was introduced in 47 (85.5%) children with allergy (p = 0.894), in 29 (82.9%) with allergy and sensitization (p = 1.00), and in 38 (82.6%) children with sensitization alone (p = 0.533). Milk was introduced at 7 to 12 months in 35 (64.8%) children with allergy (p = 0.64), 22 (64.7%) with both allergy and sensitization (p = 0.815), and 26 (57.8%) children with sensitization alone (p = 0.627). For other foods, the time of introduction appeared not to significantly influence the presence of allergies or sensitization. Heat-treated peanuts were introduced significantly more often to children without allergies and without sensitization (n = 9; 56.2%) than those without allergies but with sensitization (n = 6; 54.5%) (p = 0.028). Fish was consumed significantly more often by children with allergies, i.e., 1-3x/week (n = 43; 79.6%) than children without allergies, i.e., 1-3x/month (n = 9; 30%) (p = 0.009).

CONCLUSIONS

No relationship was observed between the introduction time of complementary foods, including allergenic ones, or their type, and the development of allergies and sensitization in children up to three years of age. The degree of processing and the frequency of supply of products may affect the development of allergies and sensitization.

Quality of systematic reviews on timing of complementary feeding for early childhood allergy prevention

BACKGROUND

Only rigorously prepared analyses can provide the highest level of evidence to inform decision-making. Several recent systematic reviews (SRs) examined the hypothesis that the early introduction of specific allergenic complementary foods (CFs) to infants may lead to a lower incidence of one or more allergic outcomes. However, the methodological rigour and quality of reporting of SRs in this area has not yet been systematically evaluated.

METHODS

We comprehensively searched PubMed, Medline (Ovid), and Web of Science Core Collection on 13th January 2022, using a pre-specified and tested search syntax for SRs with RCT evidence on the early introduction of allergenic CFs as a means for allergy prevention in infants and children. We examined the quality and risk of bias (RoB) using AMSTAR-2 and ROBIS tools, examined adherence to the Preferred Reporting Items for SRs and Meta-Analyses (PRISMA), and checked whether certainty of the evidence was assessed.

RESULTS

Twelve SRs were included. Application of both tools resulted in similar overall judgements in terms of direction and extent for nine of the 12 SRs. Nine SRs were found to be of critically low to low quality according to AMSTAR-2 and to be at high RoB according to ROBIS. One SR received a moderate quality rating (AMSTAR-2) and high RoB rating (ROBIS). However, for two SRs, judgements between AMSTAR-2 and ROBIS were at stark variance. Only two SRs fully adhered to the PRISMA checklist. Six SRs evaluated the certainty of the body of RCT evidence. Several SRs failed to consider unpublished studies either by an explicit a priori exclusion or by inadequate search strategies.

CONCLUSIONS

Well-conducted SRs are important for decision-making and informing guideline development, the quality of their methodology should therefore be considered. The methodological rigour and the reporting quality of SRs on the timing of CF for allergy prevention must be improved.

REGISTRATION

https://osf.io/7cs4b .

Prevention of food allergy in infancy: the role of maternal interventions and exposures during pregnancy and lactation

There is increased focus on the role of maternal interventions in the prevention of food allergy in infancy. There is no role for maternal dietary modifications during pregnancy or lactation, such as allergen avoidance, as a means of infant allergy prevention. Although exclusive breastfeeding is the recommended infant nutrition source globally, the effect of breastfeeding on infant allergy prevention remains unclear. There is emerging evidence that irregular cow's milk exposure (ie, infrequent formula supplementation) might increase the risk of cow's milk allergy. Although further studies are required, there is also emerging evidence that maternal peanut ingestion during breastfeeding along with early peanut introduction in infancy might have a preventive role. The effect of maternal dietary supplementation with vitamin D, omega-3, and prebiotics or probiotics remains unclear.

A clinical focus on oral tolerance in the development, prevention, and management of food allergy

Food allergy impacts up to 10 % of the population and can result in life-threatening anaphylactic reactions. The pathogenesis of food allergy is not entirely understood but the disruption in naturally occurring oral tolerance is presumed to be involved. Research has been directed not only toward prevention of food allergy but on the restoration of oral tolerance by various means including immunotherapy (oral, sublingual, and epicutaneous), as well as adjunctive therapies including biologicals and probiotics. This review paper briefly discusses the involvement of oral tolerance in the pathogenesis of food allergy and how food allergy might be prevented; however, the main focus is on the potential for restoration of oral tolerance with various treatment modalities (oral immunotherapy with and without adjunctive therapies).

Epicutaneous Sensitization and Food Allergy: Preventive Strategies Targeting Skin Barrier Repair-Facts and Challenges

Food allergy represents a growing public health and socio-economic problem with an increasing prevalence over the last two decades. Despite its substantial impact on the quality of life, current treatment options for food allergy are limited to strict allergen avoidance and emergency management, creating an urgent need for effective preventive strategies. Advances in the understanding of the food allergy pathogenesis allow to develop more precise approaches targeting specific pathophysiological pathways. Recently, the skin has become an important target for food allergy prevention strategies, as it has been hypothesized that allergen exposure through the impaired skin barrier might induce an immune response resulting in subsequent development of food allergy. This review aims to discuss current evidence supporting this complex interplay between the skin barrier dysfunction and food allergy by highlighting the crucial role of epicutaneous sensitization in the causality pathway leading to food allergen sensitization and progression to clinical food allergy. We also summarize recently studied prophylactic and therapeutic interventions targeting the skin barrier repair as an emerging food allergy prevention strategy and discuss current evidence controversies and future challenges. Further studies are needed before these promising strategies can be routinely implemented as prevention advice for the general population.

Food Allergy in Preschoolers: Parents' Perception and Self-Reported Prevalence

BACKGROUND

Food allergy is a potentially fatal condition (in the case of anaphylaxis, for example) and is characterized by an increasing prevalence. The main purpose of this study is to identify preschool children with parent-reported food allergies and characterize this population and type of allergy.

METHODS

This is a cross-sectional study, based on questionnaires to parents/legal guardians. All children who attend daycare or preschool in an area of the city of Porto, Portugal, were included.

RESULTS

A total of 740 questionnaires were distributed to nine schools, and responses were obtained from 363 (49.1%). Self-reported food reaction and/or allergy was related in 11.2% of children. The median age of the first reaction was 12 months and the most registered foods were milk, dry seed, and peanut. Cutaneous (48.7%) and gastrointestinal (35.9%) symptoms were the main manifestations. History of parents' and siblings' food allergies had statistically significant associations with food reactions and/or allergies of the child, with OR 3.05 (p=0.04, 95% CI 1.01-8.81) and OR 8.69 (p<0.01, 95% CI 2.11-35.79), respectively. Besides that, children's atopic dermatitis also had a statistically significant association with self-reported food reactions and/or allergies, with OR 2.30 (p<0.05, 95% CI 1.01-5.21).

CONCLUSION

Food reactions and/or allergies were reported in 11.2% of children. The history of parents' and siblings' food allergies and children's atopic dermatitis had statistically significant associations with food reactions and/or allergies, which shows that it may be an important factor to consider.

Complementary and Allergenic Food Introduction in Infants: An Umbrella Review

BACKGROUND

Multiple systematic reviews examine the introduction of foods in relation to individual health outcomes, but the balance of harms and benefits has not been overviewed systematically.

OBJECTIVES

We aimed to perform an overview of systematic reviews on age of introduction of complementary and allergenic foods to the infant diet and long and short-term health outcomes.

DATA SOURCES

We searched Medline, Embase, Cochrane, and PubMed (July 25, 2022).

STUDY SELECTION

Included systematic reviews examining the introduction of complementary or allergenic foods before age 1. Outcomes included allergic, autoimmune, and inflammatory diseases, neurodevelopment, nutrition, and weight.

DATA EXTRACTION

Extraction and quality assessment were performed in duplicate (A Measurement Tool to Assess Systematic Reviews) and strength of evidence was assessed.

RESULTS

We screened 4015 articles and included 32 systematic reviews. There was moderate evidence that peanut and egg should be introduced from 4 to 11 months to prevent food allergy (6 of 10 reviews). Complementary food introduction was not associated with food allergy. Moderate certainty evidence suggested age of complementary food introduction was not associated with eczema. Age at introduction of gluten was not associated with celiac disease (high certainty evidence; 3 of 4 reviews). Low certainty evidence indicated that introducing solids before 4 months may increase the risk of childhood obesity, but not growth. There was insufficient evidence regarding an association between any food introduction and bone health, gastrointestinal diseases, autoimmune disorders, asthma, or allergic rhinitis.

LIMITATIONS

Gray literature was not included.

CONCLUSIONS

Current evidence supports introducing complementary foods around 6 months and allergenic foods before 11 months.

Consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition: COCO 2023

Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

Synbiotics in the Management of Pediatric Gastrointestinal Disorders: Position Paper of the ESPGHAN Special Interest Group on Gut Microbiota and Modifications

BACKGROUND

Synbiotics are a mixture comprising of live microorganisms and substrate(s) selectively utilized by host microorganisms that confers a health benefit on the host. There is an increasing number of studies investigating their role in different diseases and disorders.

AIM

The purpose of this article is to provide recommendations for the use of synbiotics in the management of pediatric gastrointestinal disorders. The recommendations are developed by the ESPGHAN Special Interest Group on Gut Microbiota and Modifications.

METHODS

From existing literature databases, we searched and appraised all systematic reviews and/or meta-analyses, and subsequently published randomized controlled trials (RCTs) that compared the use of synbiotics, in all delivery vehicles and formulations, at any dose, compared to no synbiotics. Synbiotics which are part of infant formula were not assessed. The recommendations were formulated only if at least 2 RCTs that used a well-defined synbiotic were available.

RESULTS

Based on the currently available evidence, no recommendation can be formulated in favor or against the use of evaluated synbiotic combination in the treatment of acute gastroenteritis, prevention of necrotizing enterocolitis, Helicobacter pylori infection, inflammatory bowel disease, functional gastrointestinal disorders, and allergy in infants and children.

CONCLUSIONS

There is a need for more, well-designed RCTs on the role of synbiotics in gastrointestinal disorders with the same outcome measures to enable the inter-studies comparisons.

Camel Milk Cannot Prevent the Development of Cow's Milk Allergy-A Study in Brown Norway Rats

SCOPE

Currently there are no specific recommendations for the use of any particular infant formula in the prevention of cow's milk allergy (CMA). Recently, there has been an increasing interest in alternative infant formulas based on milk proteins from other sources than the cow, including milk from other mammalians such as goat, sheep, donkey, horse, and camel. Whereas these have been studied for their usability in CMA management, there are no studies of their CMA preventive capacity. Thus, the aim of this study is to evaluate whether camel milk can prevent CMA and vice versa.

METHODS AND RESULTS

The capacity of camel milk in preventing CMA and vice versa is evaluated in a well-established prophylactic Brown Norway rat model. IgG1, IgE, and IgA responses, allergy elicitation, intestinal and mLN gene expression, and protein uptake are analyzed. The study demonstrates that camel and cow's milk in general has an insignificant cross-preventive capacity. Yet, whereas cow's milk is shown to have a low transient capacity to prevent sensitization and clinically active camel milk allergy, camel milk does not show this effect for CMA.

CONCLUSIONS

This study suggests that due to lack of cross-tolerance camel milk cannot be used for CMA prevention.

Food Allergy and Eosinophilic Gastrointestinal Diseases-The Next 10 Years

The first report of food allergy desensitization was in 1908, at least a few years before the first published description of a diagnostic test for food allergy. It has taken almost 100 years for food allergy to move from passive management of avoidance to a more proactive approach including prevention and treatment. In parallel, this has been matched by recognition of eosinophil gastrointestinal diseases, which were first described in the 1980s (although eosinophilic esophagitis was itself described in 1978). As we celebrate 10 years of The Journal of Allergy and Clinical Immunology: In Practice, we take the opportunity to look into the future and speculate how our practice may develop over the next decade.

Microbiome Therapeutics for Food Allergy

The prevalence of food allergies continues to rise, and with limited existing therapeutic options there is a growing need for new and innovative treatments. Food allergies are, in a large part, related to environmental influences on immune tolerance in early life, and represent a significant therapeutic challenge. An expanding body of evidence on molecular mechanisms in murine models and microbiome associations in humans have highlighted the critical role of gut dysbiosis in the pathogenesis of food allergies. As such, the gut microbiome is a rational target for novel strategies aimed at preventing and treating food allergies, and new methods of modifying the gastrointestinal microbiome to combat immune dysregulation represent promising avenues for translation to future clinical practice. In this review, we discuss the intersection between the gut microbiome and the development of food allergies, with particular focus on microbiome therapeutic strategies. These emerging microbiome approaches to food allergies are subject to continued investigation and include dietary interventions, pre- and probiotics, microbiota metabolism-based interventions, and targeted live biotherapeutics. This exciting frontier may reveal disease-modifying food allergy treatments, and deserves careful study through ongoing clinical trials.

Effects of regular soy formula intake between 1 and 2 months of age on food sensitization in infancy

BACKGROUND

The effects of regular soy formula (SF) intake on the development of food sensitization in infancy remain unclear. This study aimed to assess the effects of regular SF intake between 1 and 2 months of age on food sensitization development by 6 months of age.

METHODS

Using data from a randomized controlled trial of a birth cohort from four Japanese hospitals that assessed cow's milk allergy development, we performed a retrospective cohort study of 235 infants who avoided cow's milk formula and supplemented breastfeeding with SF as required between 1 and 2 months of age. Regular SF intake was defined as SF consumption of ≥14 days per month and ≥1350 ml per month. Food sensitization was defined as positive skin prick test reactions to hen's egg, cow's milk, wheat, and/or soy. Using multivariable logistic regression models that adjusted for parental, perinatal, and environmental factors, we calculated the adjusted odds ratios of regular SF intake for food, hen's egg, and cow's milk sensitization by 6 months of age.

RESULTS

From the 235 participants, 114 (48.5%) had regular SF intake. The adjusted odds ratios of regular SF intake for food, hen's egg, and cow's milk sensitization were 0.32 (95% confidence interval: 0.16-0.62, p = .0007), 0.42 (0.20-0.88, p = .02), and 0.33 (0.14-0.81, p = .02), respectively.

CONCLUSION

Regular SF intake between 1 and 2 months of age in infants avoiding cow's milk formula was significantly associated with a reduced risk of food sensitization in infancy.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective for preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess the effects of skin care interventions such as emollients for primary prevention of eczema and food allergy in infants. Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We performed an updated search of the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase in September 2021. We searched two trials registers in July 2021. We checked the reference lists of included studies and relevant systematic reviews, and scanned conference proceedings to identify further references to relevant randomised controlled trials (RCTs).  SELECTION CRITERIA: We included RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (≤ 12 months) without pre-existing eczema, food allergy, or other skin condition. Eligible comparisons were standard care in the locality or no treatment. Types of skin care interventions could include moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured at the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

We identified 33 RCTs comprising 25,827 participants. Of these, 17 studies randomising 5823 participants reported information on one or more outcomes specified in this review.  We included 11 studies, randomising 5217 participants, in one or more meta-analyses (range 2 to 9 studies per individual meta-analysis), with 10 of these studies providing IPD; the remaining 6 studies were included in the narrative results only.   Most studies were conducted at children's hospitals. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although the definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to three years. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported information on our prespecified outcomes, 13 assessed emollients. We assessed most of the evidence in the review as low certainty and had some concerns about risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. We assessed the evidence for the primary food allergy outcome as high risk of bias due to the inclusion of only one trial, where findings varied based on different assumptions about missing data. Skin care interventions during infancy probably do not change the risk of eczema by one to three years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; risk difference 5 more cases per 1000 infants, 95% CI 28 less to 47 more; moderate-certainty evidence; 3075 participants, 7 trials) or time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). Skin care interventions during infancy may increase the risk of IgE-mediated food allergy by one to three years of age (RR 2.53, 95% CI 0.99 to 6.49; low-certainty evidence; 976 participants, 1 trial) but may not change risk of allergic sensitisation to a food allergen by age one to three years (RR 1.05, 95% CI 0.64 to 1.71; low-certainty evidence; 1794 participants, 3 trials). Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial); however, this was only seen for cow's milk, and may be unreliable due to over-reporting of milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.33, 95% CI 1.01 to 1.75; risk difference 17 more cases per 1000 infants, 95% CI one more to 38 more; moderate-certainty evidence; 2728 participants, 6 trials) and may increase the risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) and stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although CIs for slippages and stinging/allergic reactions were wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses showed that the effects of interventions were not influenced by age, duration of intervention, hereditary risk, filaggrin (FLG) mutation, chromosome 11 intergenic variant rs2212434, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and eczema or food allergy development.

AUTHORS' CONCLUSIONS

Based on low- to moderate-certainty evidence, skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema; may increase risk of food allergy; and probably increase risk of skin infection. Further study is needed to understand whether different approaches to infant skin care might prevent eczema or food allergy.

Sialic acid and food allergies: The link between nutrition and immunology

Food allergies (FA), a major public health problem recognized by the World Health Organization, affect an estimated 3%-10% of adults and 8% of children worldwide. However, effective treatments for FA are still lacking. Recent advances in glycoimmunology have demonstrated the great potential of sialic acids (SAs) in the treatment of FA. SAs are a group of nine-carbon α-ketoacids usually linked to glycoproteins and glycolipids as terminal glycans. They play an essential role in modulating immune responses and may be an effective target for FA intervention. As exogenous food components, sialylated polysaccharides have anti-FA effects. In contrast, as endogenous components, SAs on immunoglobulin E and immune cell surfaces contribute to the pathogenesis of FA. Given the lack of comprehensive information on the effects of SAs on FA, we reviewed the roles of endogenous and exogenous SAs in the pathogenesis and treatment of FA. In addition, we considered the structure-function relationship of SAs to provide a theoretical basis for the development of SA-based FA treatments.

Role of dietary fiber in promoting immune health-An EAACI position paper

Microbial metabolism of specific dietary components, such as fiber, contributes to the sophisticated inter-kingdom dialogue in the gut that maintains a stable environment with important beneficial physiological, metabolic, and immunological effects on the host. Historical changes in fiber intake may be contributing to the increase of allergic and hypersensitivity disorders as fiber-derived metabolites are evolutionarily hardwired into the molecular circuitry governing immune cell decision-making processes. In this review, we highlight the importance of fiber as a dietary ingredient, its effects on the microbiome, its effects on immune regulation, the importance of appropriate timing of intervention to target any potential window of opportunity, and potential mechanisms for dietary fibers in the prevention and management of allergic diseases. In addition, we review the human studies examining fiber or prebiotic interventions on asthma and respiratory outcomes, allergic rhinitis, atopic dermatitis, and overall risk of atopic disorders. While exposures, interventions, and outcomes were too heterogeneous for meta-analysis, there is significant potential for using fiber in targeted manipulations of the gut microbiome and its metabolic functions in promoting immune health.

Effectiveness of educational interventions for quality of life of parents and children with food allergy: A systematic review

BACKGROUND

Educational intervention along with medical treatment is important to improve the quality of life of children with food allergies and their parents. This systematic review was designed to investigate the effects of education programs for parents and children with food allergies to provide a direction for developing an intervention program to improve their quality of life.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies published between January 2010 and August 2021 were identified through a systematic search of 5 databases (PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trial, and Psycho Info).

RESULTS

A total of 2351 articles were identified. Of these, 9 met the inclusion criteria after duplicates were removed. Among these, only 2 studies, using the support and handbook provided, showed significant results on quality of life.

DISCUSSION

There is a lack of educational interventions for children with food allergies and their parents. Educational intervention, an essential intervention, can maximize medical treatment and improve overall quality of life. Hence, these interventions should be actively developed and applied in the future.

Predictors and biomarkers of food allergy and sensitization in early childhood

OBJECTIVE

To review existing literature on the early risk factors for and biomarkers of food allergy (FA) and food sensitization (FS) and highlight opportunities for future research that will further the understanding of FA pathogenesis in infancy and toddlerhood.

DATA SOURCES

PubMed search of English-language articles related to FA and atopic disease.

STUDY SELECTIONS

Human studies with outcomes related to FA, FS, and other atopic disease in childhood were selected and reviewed. Studies published after 2015 were prioritized.

RESULTS

The prevalence of FA has greatly increased in recent decades and is now a global public health concern. A complex network of early life risk factors has been associated with development of FA and FS in childhood. Food allergy has a genetic component, but recent evidence suggests that interactions between risk alleles and other environmental exposures are important for disease pathogenesis, potentially through epigenetic mechanisms. Lifestyle factors, such as delivery mode, antibiotic use, and pet exposure also influence FA risk, which may be through their effect on the early life gut microbiome. How these early life risk factors, along with route and timing of antigen exposure, collectively target the developing immune system remains an ongoing and important area of study.

CONCLUSION

The current body of evidence emphasizes the first 1000 days of life as a critical period for FA development. More observational studies and adequately powered clinical trials spanning early pregnancy through childhood are needed to identify novel biomarkers and risk factors that can predict susceptibility toward or protection against FA.

Consensus document on the primary prevention of cow's milk protein allergy in infants aged less than 7 days

INTRODUCTION

Cow's milk protein allergy (CMPA) is the most frequent food allergy in the first year of life. There is no clear consensus regarding its prevention. A recommendation to avoid CMP in the first week of life as a preventive measure in all infants, regardless of their atopic risk, has recently been published. The purpose of this document is to issue a recommendation on the use of extensively hydrolyzed CMP formulas in the first week of life for the primary prevention of CMPA.

METHODS

A group of experts was formed with members proposed by the Spanish Association of Pediatrics (AEP), the Spanish Society of Clinical Immunology and Allergology and Pediatric Asthma (SEICAAP), the Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition (SEGHNP) and the Spanish Society of Neonatology (SENEO). The group conducted a critical review of the evidence on the subject published in the last 10 years.

RESULTS

The search yielded 72 studies, of which 66 were rejected for not meeting the inclusion criteria. The final review included 6 documents: 3 clinical trials and 3 systematic reviews, 2 of them with meta-analysis. There was no evidence of a statistically significant reduction in the incidence of CMPA in the infants who received hypoallergenic formulae or exclusive breastfeeding.

CONCLUSION

Based on the current evidence, it is not possible to draw clear conclusions about the effect of avoiding CMP in the first week of life for prevention of CMPA. Although there are data that suggest a certain beneficial effect of avoiding CMPA in atopic risk infants, these results are not conclusive enough to extend the recommendation to the general population.

Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial

BACKGROUND

Primary prevention of food allergy by early introduction of allergenic foods seems promising. We aimed to determine whether early food introduction or the application of regular skin emollients in infants from a general population reduced the risk of food allergy.

METHODS

This 2 × 2 factorial, cluster-randomised trial was done at Oslo University Hospital and Østfold Hospital Trust, Oslo, Norway, and Karolinska University Hospital, Stockholm, Sweden. Infants of women recruited antenatally at the routine 18-week ultrasound examination were cluster-randomised at birth to the following groups: (1) no intervention group; (2) the skin intervention group (skin emollients; bath additives and facial cream; from age 2 weeks to <9 months, both at least four times per week); (3) the food intervention group (early complementary feeding of peanut, cow's milk, wheat, and egg from age 3 months); or (4) combined intervention group (skin and food interventions). Participants were randomly assigned (1:1:1:1) using computer-generated randomisation based on clusters of 92 geographical areas and eight 3-month time blocks. Study personnel performing clinical assessments were masked to group allocation. The primary outcome was allergy to any interventional food at 36 months of age. The primary efficacy analysis was done by intention-to-treat analysis, which included all participants who were randomly assigned, apart from three individuals who withdrew their consent. This was a study performed within ORAACLE (the Oslo Research Group of Asthma and Allergy in Childhood; the Lung and Environment). This study is registered as ClinicalTrials.gov, NCT02449850.

FINDINGS

We recruited 2697 women with 2701 pregnancies, from whom 2397 newborn infants were enrolled between April 14, 2015, and April 11, 2017. Of these infants, 597 were randomly assigned to the no intervention group, 575 to the skin intervention group, 642 to the food intervention group, and 583 to the combined intervention group. One participant in each of the no intervention, food intervention, and skin intervention groups withdrew consent and were therefore not included in any analyses. Food allergy was diagnosed in 44 children; 14 (2·3%) of 596 infants in the non-intervention group, 17 (3·0%) of 574 infants in the skin intervention group, six (0·9%) of 641 infants in the food intervention group, and seven (1·2%) of 583 infants in the combined intervention group. Peanut allergy was diagnosed in 32 children, egg allergy in 12 children, and milk allergy in four children. None had allergy to wheat. Prevalence of food allergy was reduced in the food intervention group compared with the no food intervention group (risk difference -1·6% [95% CI -2·7 to -0·5]; odds ratio [OR] 0·4 [95% CI 0·2 to 0·8]), but not compared with the skin intervention group (0·4% [95% CI -0·6 to 1· 5%]; OR 1·3 [0·7 to 2·3]), with no significant interaction effect (p=1·0). Preventing food allergy in one child required early exposure to allergenic foods in 63 children. No serious adverse events were observed.

INTERPRETATION

Exposure to allergenic foods from 3 months of age reduced food allergy at 36 months in a general population. Our results support that early introduction of common allergenic foods is a safe and effective strategy to prevent food allergy.

FUNDING

Full funding sources listed at end of paper (see Acknowledgments).

Early Introduction of Allergenic Foods and the Prevention of Food Allergy

The increasing prevalence of food allergies is a growing public health problem. For children considered high risk of developing food allergy (particularly due to the presence of other food allergies or severe eczema), the evidence for the early introduction of allergenic foods, and in particular peanut and egg, is robust. In such cases, the consensus is clear that not only should such foods not be delayed, but that they should be introduced at approximately 4 to 6 months of age in order to minimize the risk of food allergy development. The early introduction of allergenic foods appears to be an effective strategy for minimizing the public health burden of food allergy, though further studies on the generalizability of this approach in low-risk populations is needed.

Environmental determinants of human milk composition in relation to health outcomes

Humans are exposed to environmental factors at every stage of life including infancy. The aim of this mini-review was to present a narrative of environmental factors influencing human milk composition. Current literature shows lactation is a dynamic process and is responsive to multiple environmental challenges including geographical location, lifestyle, persistent pollutants and maternal factors (ethnicity, diet, stress, allergy and adiposity) that may influence human milk composition in a synergistic manner and should be considered in order to improve infant and maternal outcomes on a populations scale. Further interventional studies on larger international cohorts are needed to elucidate these complex relationships. Lactating women should aim for a healthy lifestyle and maintain a healthy body composition prior to and throughout the reproductive period, including during lactation.

The Risk Reduction Effect of a Nutritional Intervention With a Partially Hydrolyzed Whey-Based Formula on Cow's Milk Protein Allergy and Atopic Dermatitis in High-Risk Infants Within the First 6 Months of Life: The Allergy Reduction Trial (A.R.T.), a Multicenter Double-Blinded Randomized Controlled Study

Background

The role of partially hydrolyzed formulas (pHF) as part of nutritional interventions to prevent the development of allergic manifestations (AM) is questioned, and efficacy of each specific pHF should be substantiated.

Objective

To investigate the risk-reduction effect of a whey-based pHF on the development of cow's milk protein allergy (CMPA) and atopic dermatitis (AD) in infants at high-risk for allergy within the first 6 months of life.

Materials and Methods

In a multicenter double-blinded randomized controlled setting, healthy non-exclusively breastfed full-term infants, received either a specific whey-based pHF or a standard cow's milk-based formula (SF) and were clinically assessed for AM at 2, 4, and 6 months of age, supported by the objective scoring tools SCORAD and CoMiSS. CMPA was confirmed by open food challenge. Intention-to-Treat (ITT) and Per-Protocol (PP) analyses were performed.

Results

Of 331 randomized subjects (ITT analysis set), 160 received the pHF and 171 the SF. Six (3.8%) infants in the pHF and 12 (7%) in the SF group developed CMPA (p = 0.186). AD incidence was significantly lower in those receiving pHF as compared to SF (10.6% vs. 18.7%, p = 0.024) with a relative risk (RR, 95% CI) of 0.54 (0.32, 0.92), in particular when adjusting for family history of AD [6.5% vs. 27.3%, RR 0.24 (0.07, 0.78), p = 0.018] representing a risk reduction of 76%. The PP analysis showed similar results.

Conclusion

This specific whey-based pHF reduced the risk of AD development, particularly in those with a family history of AD, and tended to reduce the development of CMPA in non-exclusively breastfed infants at high-risk for allergy. The A.R.T. study suggests that this particular pHF may contribute to measures aimed at prevention of allergic manifestations. However, further studies are needed to confirm this risk-reduction effect.