Post on 24-Mar-2020
La importancia de la prevención de alergia a los alimentos
Ricardo Sorensen, MDChairman,
Department of PediatricsLSUHSC
Department of Pediatrics
LSUHSC
AllergyAllergy
IgE Mediated
Non-Atopic Atopic
Food allergyAllergic rhinitisAllergic asthma
Single food allergyVenom reactionDrug reaction
Celiac diseaseNARESIgG – mediated
alveolitis
Non-IgE Mediated
EosinophilicgastroenteropathiesAtopic dermatitis
Food hypersensitivity
Non-allergic (non-immune)food hypersensitivity
Food allergy
IgE-mediated food allergy
Non-IgE-mediated food allergy
CLASSIFICATION OF CLINICAL MANIFESTATIONS
CLASSIFICATION OF CLINICAL MANIFESTATIONS
A. Clinical course1. Occasional ingestion ---
Acute manifestations2. Frequent ingestion ---
Chronic symptomsB. Location of symptoms
1. Gastrointestinal2. Gastrointestinal and distal3. Distal manifestations only
A. Clinical course1. Occasional ingestion ---
Acute manifestations2. Frequent ingestion ---
Chronic symptomsB. Location of symptoms
1. Gastrointestinal2. Gastrointestinal and distal3. Distal manifestations only
•Gastrointestinal Manifestations of Food Allergy•Gastrointestinal Manifestations of Food Allergy
IgE Non-IgE Acute Chronicmediated mediated
Perioral + +
Vomit + + + +
Diarrhea + + + +
Abdominal Pain + + + +
•Systemic Manifestations of Food Allergy•Systemic Manifestations of Food Allergy
IgE Non-IgE Acute Chronicmediated mediated
Anaphylaxis + +
Respiratory Manifestations of Food AllergyRespiratory Manifestations of Food Allergy
IgE Non-IgE Acute Chronicmediated mediated
Throat tightness + +
Rhinitis + + +
Asthma + + +
Skin Manifestations of Food AllergySkin Manifestations of Food Allergy
IgE Non-IgE Acute Chronicmediated mediated
Urticaria + + + + +Angioedema + ++ +Atopic dermatitis + + + + + +
IgE Non-IgE Acute Chronicmediated mediated
Urticaria + + + + +Angioedema + ++ +Atopic dermatitis + + + + + +
Atopic Dermatitis: SignificanceAtopic Dermatitis: Significance
The most common chronic skin disease in children.Atopic dermatitis in the U.S.• Prevalence 10-20% overall†
• Affects 15 million Americans‡
• 17% prevalence by 6 months of age*• 7 million visits per year ‡
Up to 60% of children with severe atopic dermatitis have food hypersensitivity**
The most common chronic skin disease in children.Atopic dermatitis in the U.S.• Prevalence 10-20% overall†
• Affects 15 million Americans‡
• 17% prevalence by 6 months of age*• 7 million visits per year ‡
Up to 60% of children with severe atopic dermatitis have food hypersensitivity**† NIH- HHS Publication No. 03-4272, Rev April 2003‡ CDC Nat Ctr for Health Statistics Vital and Health Statistics Series, 1996, 13:134* Moore MM - Pediatrics - 01-MAR-2004; 113(3 Pt 1): 468-74
** Burkes et al. J Pediatr 1998, 132(1):132-610
† NIH- HHS Publication No. 03-4272, Rev April 2003‡ CDC Nat Ctr for Health Statistics Vital and Health Statistics Series, 1996, 13:134* Moore MM - Pediatrics - 01-MAR-2004; 113(3 Pt 1): 468-74
** Burkes et al. J Pediatr 1998, 132(1):132-610
Trends in Prevalence of Atopic DermatitisTrends in Prevalence of Atopic Dermatitis
0
5
10
15
20
25
1946 1958 1970 1996
% P
reva
lenc
e
0
5
10
15
20
25
1946 1958 1970 1996
% P
reva
lenc
e
*Secular trends in the UKEichenfield et al , 2003 Pediatrics 111: 608-16*Secular trends in the UKEichenfield et al , 2003 Pediatrics 111: 608-16
Atopic Dermatitis and Quality of LifeAtopic Dermatitis and Quality of Life
In infants• Itchiness & Irritability & Altered Sleep• Pain / Colic when associated to GI allergy• Stress associated to treatment• Disruption of family- child interactions
In children• Stress related to treatments• Disruption of daily routine• Sleep deprivation, nighttime scratching during all stages of sleep• Affects school, social interactions, personal relationships, and self-
consciousness
In infants• Itchiness & Irritability & Altered Sleep• Pain / Colic when associated to GI allergy• Stress associated to treatment• Disruption of family- child interactions
In children• Stress related to treatments• Disruption of daily routine• Sleep deprivation, nighttime scratching during all stages of sleep• Affects school, social interactions, personal relationships, and self-
consciousness
Howlett et al. Br J Dermatol 1999;140:381-4. Reuveni et al. Arch Pediatr Adoles Med 1999;153:249-53 Chamlin et al. Pediatrics 2004; 114(3); 607-11
Howlett et al. Br J Dermatol 1999;140:381-4. Reuveni et al. Arch Pediatr Adoles Med 1999;153:249-53 Chamlin et al. Pediatrics 2004; 114(3); 607-11
Increasing Prevalence of Asthma & Atopy
Increasing Prevalence of Asthma & Atopy
0
5
10
15
Eczema Hayfever Asthma
% P
reva
lenc
e (C
hild
ren
8-13
yrs
.)
1964 1989
0
5
10
15
Eczema Hayfever Asthma
% P
reva
lenc
e (C
hild
ren
8-13
yrs
.)
1964 1989
Ninan et al., 1992; BMJ 304: 873-75Ninan et al., 1992; BMJ 304: 873-75
Atopic Dermatitis: SignificanceAtopic Dermatitis: Significance
May be the first step in the Allergy March:the relationship between allergic manifestations throughout life
• Approximately 75- 80% of atopic dermatitis patients develop allergic rhinitis
• More than 50% of atopic dermatitis patients develop asthma
May be the first step in the Allergy March:the relationship between allergic manifestations throughout life
• Approximately 75- 80% of atopic dermatitis patients develop allergic rhinitis
• More than 50% of atopic dermatitis patients develop asthma
Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27
Prevalence of Allergic Manifestations by AgePrevalence of Allergic Manifestations by Age
Adapted from Saarinen, 1995; Lancet. 346: 1065-69
0
10
20
30
40
1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Years
0
10
20
30
40
1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Years
SkinSkin
RespiratoryRespiratory
GIGI
Pathogenesis of Childhood AsthmaPathogenesis of Childhood AsthmaPathogenesis of Childhood Asthma
Genetics
Environ-ment
Age + Allergens
Tolerance
SensitizationFood allergyEczema
AllergicRhinitis
AsthmaRecurrentWheezing
Immunologic SensitizationImmunologic Sensitization
Immunologic sensitizationImmunologic sensitization
Re-exposure to sensitizing proteinRe-exposure to sensitizing protein
Manifestations of allergySigns and symptoms in target organs
Skin, GI, Lungs
Manifestations of allergySigns and symptoms in target organs
Skin, GI, Lungs
Food Allergies: 90% accounted for by 5 foodsFood Allergies: 90% accounted for by 5 foods
5 most common allergens in infants
Other
• Cow Milk• Soy• Wheat• Peanuts/Tree nuts• Egg
Cow milk protein: • the most common food antigen in infants• the most common protein used in infant formulas
Food Allergy — TreatmentFood Allergy — Treatment
Avoidance• Meticulous attention to labels• Education on sources of “hidden foods”
Extensive hydrolysate (hypoallergenic) formulasAmino acid formulas
Avoidance• Meticulous attention to labels• Education on sources of “hidden foods”
Extensive hydrolysate (hypoallergenic) formulasAmino acid formulas
Preventing Pediatric AllergyPreventing Pediatric Allergy
Allergy, particularly atopic dermatitis, is a significant health issue • High incidence in developed countries• Increasing incidence and prevalence• High costs of treatment• Impact on quality of life• Allergy March may greatly magnify the problem
Allergy, particularly atopic dermatitis, is a significant health issue • High incidence in developed countries• Increasing incidence and prevalence• High costs of treatment• Impact on quality of life• Allergy March may greatly magnify the problem
Primary Prevention is a PriorityPrimary Prevention is a Priority
Pathogenesis of Childhood AsthmaPathogenesis of Childhood AsthmaPathogenesis of Childhood Asthma
Genetics
Environ-ment
Age + Allergens
Tolerance
SensitizationFood allergyEczema
AllergicRhinitis
AsthmaRecurrentWheezing
EarlyIntervention
Pathogenesis of Childhood AsthmaPathogenesis of Childhood AsthmaPathogenesis of Childhood Asthma
Genetics
Environ-ment
Age + Allergens
Tolerance
SensitizationFood allergyEczema
AllergicRhinitis
AsthmaRecurrentWheezing
SecondaryPrevention
Pathogenesis of Childhood AsthmaPathogenesis of Childhood AsthmaPathogenesis of Childhood Asthma
Genetics
Environ-ment
Age + Allergens
Tolerance
SensitizationFood allergyEczema
AllergicRhinitis
AsthmaRecurrentWheezing
PrimaryPrevention
The StandardThe Standard
Nutritionally
Immunologically
Nutritionally
Immunologically
Historically, formulas have evolved to make cow’s milk nutritionally and functionally closer to human milk
Processed Whole
Cows Milk
Raw Cow Milk
“Formula”with Evaporated
Cow Milk
“Casein Predominant”
Formula
“WheyPredominant”
Formula
Protein size and AllergenicityProtein size and Allergenicity
High Molecular WeightHigh Molecular Weight Low Molecular WeightLow Molecular Weight
Potential for Hypersensitivity (Allergic Reaction)Potential for Hypersensitivity (Allergic Reaction)
Immune SystemImmune System
Hydrolysis Can Reduce Allergenicityof Cow Milk Proteins
Hydrolysis Can Reduce Allergenicityof Cow Milk Proteins
Median Molecular Weight of Infant FormulasMedian Molecular Weight of Infant Formulas
450 1,100
10,000
0
2,000
4,000
6,000
8,000
10,000
12,000
ExtensivelyHydrolyzed Casein
PartiallyHydrolyzed Whey
Whole ProteinCasein/Whey
Dalto
ns
Cumulative Incidence of Atopic Manifestations
Extensively Hydrolyzed Casein Formula vs Cow Milk Formula in Prevention Studies
Cumulative Incidence of Atopic Manifestations
Extensively Hydrolyzed Casein Formula vs Cow Milk Formula in Prevention Studies
p=0.025p=0.025
p<0.02p<0.02
p=0.032p=0.032p=NSp=NS
0
20
40
60
80
Von Berg 2003 Oldaeus 1997 Zeiger 1995 Mallet 1992
Cum
ulat
ive In
ciden
ce o
f AM
(%)
Extensively Hydrolyzed CaseinIntact Cow Milk
* Graph depicts only published, peer-reviewed, prospective trials. Studies up to 12 mo of Age ** For all extensively hydrolyzed casein formula studies, AM includes AD as one of the allergic outcomes assessed.*** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992
Cumulative Incidence of Atopic Dermatitis
Extensively Hydrolyzed Casein Formula vs Cow Milk Formula in Prevention Studies
Cumulative Incidence of Atopic Dermatitis
Extensively Hydrolyzed Casein Formula vs Cow Milk Formula in Prevention Studies
p=0.006p=0.006
p=0.007p=0.007p=NSp=NS
p=0.059p=0.059
p<0.005p<0.005
0
20
40
60
80
Von Berg2003
Oldaeus 1997 Zeiger 1995 Mallet 1992 Chandra1989
Cum
ulat
ive In
ciden
ce o
f AD
(%)
Extensively Hydrolyzed CaseinIntact Cow Milk
* Graph depicts only published, peer-reviewed, prospective trials. ** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992; 18 months: Chandra 1989* Graph depicts only published, peer-reviewed, prospective trials.
** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992; 18 months: Chandra 1989
Cumulative Incidence of Atopic Manifestations
Partially Hydrolyzed Whey Formula vs Cow Milk Formula in Prevention Studies
Cumulative Incidence of Atopic Manifestations
Partially Hydrolyzed Whey Formula vs Cow Milk Formula in Prevention Studies
p=0.109p=0.109
p<0.05p<0.05
p<0.05p<0.05
p<0.05p<0.05
p=0.021p=0.021
p=NSp=NS p<0.001p<0.001
p=0.063p=0.063
p<0.05p<0.05
0
20
40
60
80
Becker 2004 Von Berg2003
Exl 2000 Chandra1997
Marini 1996 Vandenplas1995
de Seta 1994 Willems1993
Vandenplas1988
Cum
ulat
ive In
ciden
ce o
f AM
(%)
Partially Hydrolyzed WheyIntact Cow Milk
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. ** For all studies except Becker 2004, AM includes AD as one of the allergic outcomes assessed; for Becker 2004, AM refers to asthma alone.
*** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Becker 2004, Von Berg 2003, Chandra 1997, Marini 1996, Vandenplas 1995, Willems 1993
**** p-values in italics indicate that no p-value is reported in publication; p-value is based on calculated OR and CI
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. ** For all studies except Becker 2004, AM includes AD as one of the allergic outcomes assessed; for Becker 2004, AM refers to asthma alone.
*** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Becker 2004, Von Berg 2003, Chandra 1997, Marini 1996, Vandenplas 1995, Willems 1993
**** p-values in italics indicate that no p-value is reported in publication; p-value is based on calculated OR and CI
Cumulative Incidence of Atopic Dermatitis
Partially Hydrolyzed Whey Formula vs Cow Milk Formula in Prevention Studies
Cumulative Incidence of Atopic Dermatitis
Partially Hydrolyzed Whey Formula vs Cow Milk Formula in Prevention Studies
p=0.048p=0.048
p=0.004p=0.004
p<0.05p<0.05
p<0.02p<0.02p=NSp=NS p<0.05p<0.05
p>0.05p>0.05
p>0.05p>0.05
0.0
20.0
40.0
60.0
Von Berg2003
Chan 2002 Exl 2000 Chandra 1997 Marini 1996 Vandenplas1995
Tsai 1991 Vandenplas1988
Cum
ulat
ive In
ciden
ce o
f AD
(%)
Partially Hydrolyzed WheyIntact Cow Milk
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. ** 4 months: Vandenplas 1988; 6 months: Exl 2000; 12 months: Von Berg 2003, Chandra 1997, Marini 1996, Vandenplas 1995, Tsai 1991
**** p-values in italics indicate that no p-value is reported in publication; p-value is based on calculated OR and CI****
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. ** 4 months: Vandenplas 1988; 6 months: Exl 2000; 12 months: Von Berg 2003, Chandra 1997, Marini 1996, Vandenplas 1995, Tsai 1991
p-values in italics indicate that no p-value is reported in publication; p-value is based on calculated OR and CI
Effect of Hydrolyzed Cow Milk Formulafor Allergy Prevention the First Year of Life
The German Infant Nutritional Intervention (GINI) Study
Effect of Hydrolyzed Cow Milk Formulafor Allergy Prevention the First Year of Life
The German Infant Nutritional Intervention (GINI) Study
Independent, government-sponsored study2,252 high-risk infants randomized at birth to: • Intact cow milk formula• Partially hydrolyzed whey formula• Extensively hydrolyzed casein formula• Extensively hydrolyzed whey formula
As needed, randomized formula was given to 6 months of age (no other foods besides breast milk)Allergic manifestations assessed at 1, 4, 8,12 mo• Atopic dermatitis• Allergic urticaria• Food allergy with manifestation in the GI tract
Independent, government-sponsored study2,252 high-risk infants randomized at birth to: • Intact cow milk formula• Partially hydrolyzed whey formula• Extensively hydrolyzed casein formula• Extensively hydrolyzed whey formula
As needed, randomized formula was given to 6 months of age (no other foods besides breast milk)Allergic manifestations assessed at 1, 4, 8,12 mo• Atopic dermatitis• Allergic urticaria• Food allergy with manifestation in the GI tract
Von Berg et al., 2003 J Allergy Clin Immunol 111(3): 533-40Von Berg et al., 2003 J Allergy Clin Immunol 111(3): 533-40
Effect of Hydrolyzed Cow Milk Formulafor Allergy Prevention the First Year of Life
The German Infant Nutritional Intervention (GINI) Study
Effect of Hydrolyzed Cow Milk Formulafor Allergy Prevention the First Year of Life
The German Infant Nutritional Intervention (GINI) Study
2,252 infants enrolled in the study:• 889 exclusively breastfed to 4 mo• 945 infants included in per protocol • 418 infants either non-compliant or drop-outs
• Extensively hydrolyzed casein had significantly higher number of non-compliant subjects than other formula groups (p=0.02)
Incidence of allergic manifestation at 12 months was 13%• 89% of all allergic manifestation was atopic dermatitis
12 month results published, 3-year publication pending, 6-year follow-up planned
2,252 infants enrolled in the study:• 889 exclusively breastfed to 4 mo• 945 infants included in per protocol • 418 infants either non-compliant or drop-outs
• Extensively hydrolyzed casein had significantly higher number of non-compliant subjects than other formula groups (p=0.02)
Incidence of allergic manifestation at 12 months was 13%• 89% of all allergic manifestation was atopic dermatitis
12 month results published, 3-year publication pending, 6-year follow-up planned
Von Berg et al., 2003 J Allergy Clin Immunol 111(3): 533-40Von Berg et al., 2003 J Allergy Clin Immunol 111(3): 533-40
Cumulative Incidence of Atopic Dermatitis
Cumulative Incidence of Atopic Dermatitis
3 Yr. GINI study : Findings not published. Results presented at ESPACI Meeting, 2003
0
5
10
15
20
25
Birth 12mo 24mo 36mo
Intact Cow MilkPartially Hydrolyzed WheyExtensively Hydrolyzed WheyExtensively Hydrolyzed Casein
Odds Ratio — Allergic ManifestationsExtensively Hydrolyzed Casein vs. Intact Cow Milk
Odds Ratio — Allergic ManifestationsExtensively Hydrolyzed Casein vs. Intact Cow Milk
Mallet 1992Mallet 1992
Von Berg 2003Von Berg 2003
Zeiger 1995Zeiger 1995
Oldaeus 1997Oldaeus 1997
0 0.5 1 1.5 2
* Published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992
* Published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992
Odds Ratio — Atopic Dermatitis Extensively Hydrolyzed Casein vs. Intact Cow MilkOdds Ratio — Atopic Dermatitis
Extensively Hydrolyzed Casein vs. Intact Cow Milk
0 0.5 1 1.5 2
Mallet 1992Mallet 1992
Von Berg 2003Von Berg 2003
Zeiger 1995Zeiger 1995
Oldaeus 1997Oldaeus 1997
Chandra 1989 ‡Chandra 1989 ‡
Osborn meta-analysis2003
Osborn meta-analysis2003
* Published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in black are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992
‡ Included in Osborn 2003
* Published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in black are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 9 months: Oldaeus 1997; 12 months: Von Berg 2003, Zeiger 1995, Mallet 1992
‡ Included in Osborn 2003
Odds Ratio — Allergic ManifestationsPartially Hydrolyzed Whey vs. Intact Cow Milk
Odds Ratio — Allergic ManifestationsPartially Hydrolyzed Whey vs. Intact Cow Milk
0 0.5 1 1.5 2
Chandra 1997 ‡Chandra 1997 ‡Exl 2000Exl 2000Von Berg 2003Von Berg 2003
Willems 1993 ‡Willems 1993 ‡
Vandenplas 1988 Vandenplas 1988
Vandenplas 1995 ‡Vandenplas 1995 ‡
Osborn meta-analysis 2003Osborn meta-analysis 2003
Marini 1996 Marini 1996
De Seta 1994 ‡De Seta 1994 ‡
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Von Berg 2003, Chandra 1997, Marini 1996,Vandenplas 1995, Willems 1993
‡ Included in Osborn 2003
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Von Berg 2003, Chandra 1997, Marini 1996,Vandenplas 1995, Willems 1993
‡ Included in Osborn 2003
Odds Ratio — Atopic DermatitisPartially Hydrolyzed Whey vs. Intact Cow Milk
Odds Ratio — Atopic DermatitisPartially Hydrolyzed Whey vs. Intact Cow Milk
0 0.5 1 1.5 2
Chandra 1997 ‡Chandra 1997 ‡Exl 2000Exl 2000
Von Berg 2003Von Berg 2003
Tsai 1991‡Tsai 1991‡
Vandenplas 1988 Vandenplas 1988
Vandenplas 1995Vandenplas 1995
Osborn meta-analysis 2003Osborn meta-analysis 2003
Marini 1996 Marini 1996
De Seta 1994 ‡De Seta 1994 ‡
Chan 2002Chan 2002
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Von Berg 2003, Chandra 1997, Marini 1996,Vandenplas 1995, Willems 1993
‡ Included in Osborn 2003
* Graph depicts only published, peer-reviewed, prospective trials with data collection at timepoints ≤12 months. OR and CI shown in yellow are published values; OR in white and CI in yellow, dashed lines are calculated values.
** 4 months: Vandenplas 1988; 6 months: Exl 2000, De Seta 1994; 12 months: Von Berg 2003, Chandra 1997, Marini 1996,Vandenplas 1995, Willems 1993
‡ Included in Osborn 2003
Meta-Analysis: Formulas containingHydrolysed Protein for Prevention of Allergy
Osborn & Sinn, 2003 - The Cochrane Library
Meta-Analysis: Formulas containingHydrolysed Protein for Prevention of Allergy
Osborn & Sinn, 2003 - The Cochrane Library
Inclusion criteria• Randomized trials comparing use of hydrolyzed infant formula to
human milk or intact cow milk formula• ≥ 80% follow-up of subjects• 18 / 72 studies were eligible for inclusion
Main results• Prolonged feeding of hydrolyzed formula (PHF and EHF combined)
significantly reduced:• Allergy, eczema, cow’s milk allergy incidence in infancy• Asthma, food allergy prevalence in childhood
• No significant difference between PHF and EHF
Inclusion criteria• Randomized trials comparing use of hydrolyzed infant formula to
human milk or intact cow milk formula• ≥ 80% follow-up of subjects• 18 / 72 studies were eligible for inclusion
Main results• Prolonged feeding of hydrolyzed formula (PHF and EHF combined)
significantly reduced:• Allergy, eczema, cow’s milk allergy incidence in infancy• Asthma, food allergy prevalence in childhood
• No significant difference between PHF and EHF
Preventing Pediatric AllergyPreventing Pediatric Allergy
Most studies done in high risk infants• No adequate standard public health mechanism to identify
infants at risk by family history• More than half of infants who develop allergies can not be
identified by family historyAcceptable cost effective strategies are needed for the general population
Most studies done in high risk infants• No adequate standard public health mechanism to identify
infants at risk by family history• More than half of infants who develop allergies can not be
identified by family historyAcceptable cost effective strategies are needed for the general population
Prevalence of atopic disease based on parental history
Prevalence of Parental Atopic History: 64% No Parental Hx 31% Uniparental 5% Biparental
Prevalence of Atopic Disease Total: 17.6% 9.6% 6.4% 1.6%
(10-15%) (20-30%) (30-40%)
Other refs: Halken S et al. Allergy 2000;55: 793-802Bousquet J. et al. J Allergy Clin Immunol 1986;78: 1019-1022;
Kjellman N. et al. Acta Paediatr Scan 1977;66: 565-71Exl BM, Nutr Res 2001;21: 355-79
Bergman, et al. Clinical and Experimental Allergy 1998; 28:905-907
Prevalence of Parental Atopic History: 64% 31% 5%
Prevalence of Atopic Disease in German Infants (total 17.6%):9.6% 6.4% 1.6%
For those who have a family history, there is no mandatory, standardized nor validated mechanism or tool to
elicit parental history
> 50% of children who develop allergy do not have a family history
Most Infants at risk for atopy go unidentified
Preventing Pediatric AllergyPreventing Pediatric Allergy
Needed Strategy
Primary prevention measures applicable for the general population
Needed Strategy
Primary prevention measures applicable for the general population
RECOMMENDATIONS TO DECREASE THE ALLERGIC MARCH APPLICABLE TO ALL CHILDREN
RECOMMENDATIONS TO DECREASE THE ALLERGIC MARCH APPLICABLE TO ALL CHILDREN
• Breastfeeding, 4-12 months If supplements are needed: hydrolysate with proven efficacy No solids before 4 months of age No contact with tobacco smoke
Adapted from Yvan Vandenplas/ 4/03
• Breastfeeding, 4-12 months If supplements are needed: hydrolysate with proven efficacy No solids before 4 months of age No contact with tobacco smoke
Adapted from Yvan Vandenplas/ 4/03
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