Alexandra Papadopoulou - University of Cape Town ALLERGY.pdf · Alexandra Papadopoulou Division of...

Alexandra Papadopoulou

Division of Gastroenterology & Nutrition

First Department of Pediatrics

University of Athens

Athens Interconnected Children’s

Hospitals

“AGIA SOFIA” and «P& A KYRIAKOY»

Educational objectives

• 1. Introduction

• 2. Classification

• 3. Manifestations

• 4. Diagnostic approach

• 5. Treatment

• 6. Prevention

• 7. Summary

Prevance of food allergy

Food allergy: 8% (Sicherer and Sampson 2013); 4-6% (Ostblom et al 2008)

Cow’s milk allergy:

- 2-3% (Sicherer 2011; Rona et al, 2007)

- <1% in children > 6 years (Host et al, 2002)

Egg allergy: 1-2% (Eggesbo et al 2001)

Cow’s milk allergy

No atopic parents 5%

One atopic parent 20-40%

Two atopic parents 40-60%

Two atopic parents with identical type of allergy 80%

Kjellman Acta Paediatr 1976

Food allergies are immunologically mediated adverse

reactions to foods

Main food allergens

Cow’s milk

Egg

Soy

Peanuts

Nuts

Shellfish

Wheat

Fish

Classification of

food allergy

IgE non-IgE

Classification of food allergy by Mechanism

Kokkonen et al, Scand J Gastroenterol 2000

IgE non-IgE

Gastrointestinal immediate reaction

Oral allergy syndrome

Allergic eosinophil esophagitis

Allergic eosinophil gastritis

Allergic eosinophil gastroenterocolitis

Food protein induced enterocolitis

Food protein induced proctocolitis

Food protein induced enteropathy

Sampson and Anderson JPGN 2000

Classification of food allergy presenting with GI

symptoms by Mechanism

IgE non-IgE

Classification of food allergy presenting with

cutaneus symptoms by Mechanism

•Angiooedema

•Urticaria

•Flushing

•Atopic dermatitis

•Contact dermatitis

•Dermatitis herpetiformis

IgE non-IgE

•Acute rhinoconjunctivitis

•Acute bronchospasm

•Asthma

•Food induced haemosiderosis

(Heiner)

Classification of food allergy presenting with

respiratory symptoms by Mechanism

Gastrointestinal


Food protein induced

enteropathy/ enterocolitis /

proctocolitis

Eosinophilic esophagitis /

gastroenteritis

Respiratory

Allergic rhinoconjunctivitis

Wheezing bronchitis

Allergic asthma

Skin

Atopic dermatitis or eczema

Urticaria (hives)

Classification by anatomy

Infants & toddler Older children Immediate reaction

Digestive

(59%)

Dysphagia

Frequent regurgitation

Colic, abdominal pain

Vomiting

Anorexia, refusal to feed

Diarrhea +/- intestinal protein or blood

loss

Constipation +/- perianal rash

Failure to thrive

Occult blood loss

Iron deficiency anemia

Dysphagia

Food impaction

Regurgitation

Dyspepsia, abdominal pain

Nausea, vomiting

Anorexia, early satiety

Diarrhea +/- intestinal protein or

blood loss

Constipation?

Occult blood loss

Iron deficiency anemia

Vomiting

Respiratory

(33%)

Runny nose

Wheezing

Chronic coughing

(all unrelated to infections)

Runny nose

Wheezing

Chronic coughing

(all unrelated to infections)

Wheezing or stridor

Breathing difficulties

Skin

(63%)

Urticaria (unrelated to infections, drug

intake or other causes)

Atopic eczema

Angioedema (swelling of lips or eye lids)

Urticaria (unrelated to infections,

drug intake or other causes)

Atopic eczema

Angioedema (swelling of lips or

eye lids

• Urticaria

Angioedema

General Anaphylaxis

Shock like symptoms with severe

metatobolic acidosis, vomiting & diarrhea

(FPIES) Wheezing

Anaphylaxis

Anaphylaxis

FPIES

Symptoms, which may appear in patients with CMPA in relation to age and time after

ingesting the allergen (Koletzko et al JPGN 2012)

Gastrointestinal manifestations of food allergy in infants and children


Food protein induced enterocolitis

(FPIES)



Eosinophilic Esophagitis /

gastroenteritis

• Symptoms: burning, itching sensation

with erythema and oedema in the mouth

• Presentation: typically <5 years

• Food and aero allergens: fruits,

vegetables, pollen cross reactivity

• Mechanism: IgE mediated (type I allergy)

Food-protein induced enterocolitis (FPIES)

Allergens: cow milk, soy, rice

Presentation: first 3 months of life; acute onset

Clinical symptoms: vomiting, diarroea, hypothermia,

elevated white cell count, thrombocytosis,

hypoalbuminemia, acidosis, failure to thrive

Resolution: until 3 years of age

Nowak-Wegrzyn A, Muraro A. Curr. Op. Allergy Clin. Immun. 2009


Food allergens: 60% breastfed, cow’s milk, egg, rye

Presentation: first 6 months of age, most often during

the first 6-8 weeks

Clinical picture: Bloody stools, no failure to thrive

Lake, 2000; Sampson & Anderson, 2000


Allergens: cow milk, soy, wheat

Presentation: first 2 years of life

Clinical symptoms: vomiting, diarrhoea,

abdominal distention, failure to thrive, mild

hypoalbuminemia, negative anti-tTG, anti-

DGP, EMA ab

Histology of duodenal biopsy

Eosinophilic gastroenteritis

Caldwell et al. 1979

Food allergens: cow’s milk, egg, cod, soy etc Pathology: eosinophilic infiltration of mucosa, submucosa, serosa Symptoms according to the clinical type:

Mucosal

diarrhoea, failure to thrive

Transmural

diarrhoea, obstruction, perforation

Serosal

oedema, ascites, failure to thrive

Grey zone

Is this allergy?

Salvatore S, Vandenplas Y. Pediatrics 2002;110:972-84

DYSPHAGIA

HAEMATEMESIS

MELENA

RUMINATION

NAUSEA/BELCHING

ARCHING

BRADYCARDIA

HICCUPS

SANDIFER’S SYNDROME

ASPIRATION

LARINGITIS/STRIDOR

RESPIRATORY

INFECTIONS

HOARSENESS

VOMITING/REGURGITATION

IRRITABILITY/COLIC

SLEEP DISTURBANCES

FEEDING REFUSAL

FAILURE TO THRIVE

IRON DEFICIENCY ANAEMIA

WHEEZING/APNEA/ALTE

DIARRHEA

BLOODY STOOLS

RHINITIS

NASAL CONGESTION

ANAPHYLAXIS

CONSTIPATION

ECZEMA/DERMATITIS

ANGIOEDEMA

LIP SWELLING

URTICARIA/ITCHING

GERD CMPA

Gastroesophageal reflux disease

and Cow’s milk allergy

• Extensively hydrolysed formulas for 2 weeks in selected cases

• Investigation only if no other cause found

NASPGHAN/ESPGHAN Pediatric GER clinical practice guidelines

J Pediatr Gastroenterol Nutr 2009

GERD or CMPA or other?

Infant irritability

Iacono et al J Pediatr 1995;126:34-39

Open-label study

Cow’s milk protein free diet

21/27 children responded to diet

Constipation may be related to allergy

Constipation

due to CMA

Constipation

unrelated to CMA p value

Intraepithelial

eosinophils

(per 100 deep-

crypt cells)

3,0 ± 1,8 0,8 ± 0,3 p = 0.001

Eosinophils in the

lamina propria

(% of total cells)

7,15 ± 4,31 4,21 ± 2,31 p = 0.009

Iacono G. et al. N Engl J Med 1998

Double-blind crossover study comparing soy milk and cow’s milk

65 patients (age range 11 – 72 month) with lack of response to standard therapy

Borrelli O et al Am J Gastroenterol 2009

33 children (median age: 4,7 years; range: 0,5-11 years) with functional constipation

18 responsive to elimination diet 15 Non-responsive to diet

Schäppi et al - JPGN 2008

• Higher number of Mast Cells and Eosinophils

• Mast cells are associated with nerve fibres

• Mast cells degranulation

• mediators associated with nerves

Constipation and food allergy

a study in unselected population (5113 children aged from

birth to 12 years; 91 with constipation ) evaluated the

association of CMPA with chronic constipation

The study demonstrated a very low prevalence (0.2%) of

refractory chronic constipation which was unrelated to CMPA

Chronic constipation does not seem to be related to CMPA

Simeone et al. Arch Dis Child 2008;93:1044-1047

Constipation is not related to allergy

The opposite view ....

The most common chronic skin disease in children

In 80% to 90% of the cases, onset of the disease occurs before 5 to 7

years of age

Up to 60% of children with severe atopic dermatitis have food

hypersensitivity Burkes et al. J Pediatr 1998, 132(1):132-610

Signs and symptoms

Rash: Erythematous patches with papules

on the face, neck and extensor surfaces

Pruritis

Skin dryness, excoriations, erosions

Distress, irritability

Atopic dermatitis

May be the first step in the Allergy March:

Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117

Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27

•~75- 80% of atopic

dermatitis patients develop

allergic rhinitis

•>50% of atopic dermatitis

patients develop asthma

Thank you for attention!

SCORing Atopic Dermatitis SCORAD

European Task Force on Atopic Dermatitis. Severity scoring of

atopic dermatitis.

Dermatology 1993;186:23–31.

SCORing Atopic Dermatitis SCORAD

European Task Force on Atopic Dermatitis. Severity scoring of atopic dermatitis.

Dermatology 1993;186:23–31.

Intensity

A representative area of eczema is selected. In this area, the intensity of each of the following

signs is assessed as none (0), mild (1), moderate (2) or severe (3).

•Redness

•Swelling

•Oozing / crusting

•Scratch marks

•Skin thickening (lichenification)

•Dryness (this is assessed in an area where there is no inflammation)

Redness: 1; Swelling: 0; Oozing: 0;

Scratching: 0; Lichenification: 1

Redness: 2; Swelling: 1; Oozing: 1;

Scratching: 1; Lichenification: 1. Redness: 1; Swelling: 1; Oozing: 1;

Scratching: 3; Lichenification: 3.

The intensity scores are added together to give 'B' (maximum 18)

May lead to mental health problems at age 10

Schmitt et al. J Allergy Clin Immunol 2010; 125:404-10

P < .001

P = .03

P < .001

Diagnosis of

food allergy

Diagnostic approach and management of cow’s milk protein allergy in infants and children: A practical

guideline of the GI-committee of ESPGHAN

Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schäppi MG, Vandenplas Y

J Pediatr Gastroenterol Nutr. 2012 Aug;55(2):221-9

http://www.jacionline.org/article/S0091-6749(09)01632-7/fulltext#bib21


History Food / Quantity / Timing / Reproducibility

Skin tests: PRICK/APT for common foods

Cow’s milk, egg, cod, peanut, wheat, rye

- False positive results are common

- More useful as a negative predictor

Blood: s-IgE antibodies Cow’s milk, egg, cod, peanut, wheat, rye

Consider for children with cutaneous involvement

DIAGNOSIS OF FOOD ALLERGY

• RAST can exclude an IgE-mediated reaction to a

particular food

• High Negative Predictive Value

• Low Positive Predictive Value

(in general, less sensitive than skin tests)

Sicherer SH. Am Fam Physician 1999;59:415-24

s-IgE antibodies

Laboratory tests for the diagnosis of food allergy

• Children with gastrointestinal manifestations of CMPA are more

likely to have negative specific IgE test results compared with

patients with skin manifestations, but a negative test result does not

exclude CMPA

• A positive test for specific IgE at the time of diagnosis predicts a

longer period of intolerance as compared with those children who

have negative tests

Koletzko et al JPGN 2012

Skin tests: Prick tests

It is considered positive when:

• wheal of ≥ 3mm with flare or

• wheal > 3 mm above wheal of negative control and

50 % wheal of the positive control

• wheal ≥ 8 mm : 100 % specific for CMPA

Karila C. Arch Pediatr 2002;9(Suppl 3):338 – 343

Sporik R. Clin Exp Allergy 2000;30:1540-6.

Sicherer SH. Am Fam Physician 1999;59:415-24

•NPV of skin prick test > 95%

• PPV ~ 50%


Mehl A. J Allergy Clin Immunol. 2006;118:923-9

• Not available everywhere

• Not well validated in children

• The predictive capacity of the APT is improved

when combined with sIgE measurement or the SPT

Skin tests: APT

However, oral food challenges become superfluous in only 0.5% -14%


Endoscopy and biopsies

Allergy diagnosis: challenge is the gold standard!

Double-blind, placebo-

controlled dietary

challenge (DBPCFC)

Children < 3 years Children > 3 years

Elimination diet for 2-4

weeks

Open challenge with

increasing doses

- Medical surveillance

Challenge tests can be performed in inpatient or outpatient settings.

This allows documentation of any signs and symptoms and the milk

volume that provokes symptoms, and allows symptomatic treatment as

needed Koletzko et al JPGN 2012

Allergy diagnosis: challenge is the gold standard!

Challenges should be preferably carried out in a hospital setting

under the following circumstances:

1. A history of immediate allergic reactions

2. Unpredictable reaction (eg, infants with positive specific IgE

who have never been exposed to cow’s milk or have not been

given cow’s milk for a long time)

3. Severe atopic eczema (due to the difficulty in accurately

assessing a reaction)


Oral Food Challenge Procedure With CMP

•The starting dose during an oral milk challenge should be lower

than a dose that can induce a reaction and then be increased

stepwise to 100mL eg, in children with a delayed reaction, stepwise

doses of 1, 3.0, 10.0, 30.0, and 100mL may be given at 30-minute

intervals, as follows:

•If severe reactions are expected, then the challenge should begin

with minimal volumes eg, stepwise dosing of 0.1, 0.3, 1.0, 3.0, 10.0,

30.0, and 100mL given at 30-minute intervals.

•If no reaction occurs, then the milk should be continued at home

every day with at least 200 mL/day for at least 2 weeks. The parents

should be contacted by telephone to document any late reactions.

30 60 90 120 150 180

1ml -3ml -10ml -30ml -50ml -100ml

Oral Food Challenge Procedure With CMP

•In the first year of life, a challenge test is performed

with an infant formula based on cow’s milk

•After the first year of life, fresh pasteurized cow’s milk

can be used

•To rule out a false positive challenge due to primary

lactose intolerance, in children older than about 3

years the challenge procedure may be performed with

lactose-free CMP-containing milk


Clinical suspicion

Elimination diet 2-4 weeks

Challenge: open or blind

Confirm or exclude food allergy

Diagnostic strategy in food allergy

OPEN vs DOUBLE BLIND, PLACEBO CONTROLLED FOOD

CHALLENGES

•If symptoms occur after an open challenge test, DBPCFC is

recommended in cases of uncertain or questionable symptoms, and in

cases of moderate to severe eczema

•The DBPCFC can be omitted if the open challenge elicits objective

symptoms (eg, recurrent vomiting, bronchial obstruction, urticaria) and

those symptoms correlate with the medical history and are supported by

a positive specific IgE test


Infant with diarrhea ….

If CMPA manifests clinically with diarrhea, the

stool frequency and consistency should be

documented (eg, in infants with a stool form

scale)

If significant diarrhea recurs during the challenge

(open and/or DBPC), then the diagnosis of CMPA

is confirmed and a therapeutic formula can be

recommended.

If there are no recurrent symptoms, then the child

should continue to receive its previous formula


Management

Treatment of breast fed infants with CMPA

Mother should avoid the consumtion of cow’s milk

and cow’s milk products and should receive

calcium supplements

If the symptoms persist - elimination of other

possible food allergens from the mother’s diet

Nutritional counseling is required to prevent

nutritional compromise

Attention! •Meticulous attention to labels is needed

• Education on sources of “hidden foods”

Treatment of breast fed infants with severe symptoms due to CMPA

•In breast-fed infants with severe symptoms (eg, severe atopic

eczema or allergic (entero) colitis complicated by growth

faltering and/or hypoproteinemia and/or severe anemia), the

infant may be fed with a therapeutic formula for a period of

from several days to a maximum of 2 weeks

•Aminoacid based formula is used for diagnostic elimination in

these extremely sick exclusively breast-fed infants to stabilize

the child’s condition while the mother expresses breast milk in

transition to her CMP-free diet

•In cases in which symptoms recur on breast milk despite a

strict CMP-free diet in the mother, further elimination of other

highly allergenic foods from the mother’s diet or weaning from

breast milk to a therapeutic formula is recommended


… an infant milk formula is considered hypoallergenic if

it is capable to reverse symptoms in 90% of infants with

cow’s milk allergy

American Academy of Pediatrics 1990

Infant formulas: which is appropriate?

Most

allergenic

Least

allergenic

Tolerance

Intact

protein Extensive

hydrolysate (molecular weight of <3000 Da)

Aminoacids

Extensive hydrolysates were expected to be tolerated by at least 90% of

children with proven CMPA

Partial hydrolysates are

not hypoallergenic and

should not be given to

infants with CMPA

.. Extensively hydrolysed infant formulas are recommended for use to treat CMPA

in bottle fed infants


• Formulae containing free amino acids are recommended in infants

reacting to extensively hydrolyzed infant formulas.

• This risk is estimated to be <10% of all infants with CMPA, but it

may be higher in the presence of severe enteropathy or with

multiple food allergies

de Boissieu et al J Pediatr 2002;141:271–3 ; de Boissieu et al J Pediatr

1997;131:744–7

• Aminoacid formula may be considered a first-line treatment in

infants with severe anaphylactic reactions and infants with severe

enteropathy indicated by hypoproteinemia and faltering growth Isolauri et al, J Pediatr 1995;127:550–7

Aminoacid based formula

Soya protein-based formula


• Between 10% and 14% of affected infants react to soy protein, mainly,

infants younger than 6 months Klemola et al, J Pediatr 2002;140:219–24; Zeiger et al J Pediatr 1999; 134:614–2214,66.

•Soy formulae nutritional disadvantages:

- absorption of minerals and trace elements may be lower because of

their phytate content,

- they contain appreciable amounts of isoflavones with a weak

estrogenic action that can lead to high serum concentrations in

infants.

• ESPGHAN and AAP consider eHF based on CMP or AAF if eHF is not

tolerated preferable over soy protein–based formulae for the dietary treatment

of infants with CMPA Agostoni et al, J Pediatr Gastroenterol Nutr 2006;42:352–61; Bhatia et al Pediatrics 2008;121:1062–8

Soya protein-based formula


Cow’s-milk–based formulae should be preferred over soy formula in healthy

infants, and soy protein–based formulae should not usually be used

during the first 6 months of life.

However, a soy formula may be considered in an infant with CMPA older

than 6 months if eHF is not accepted or tolerated by the child, if these

formulae are too expensive for the parents, or if there are strong parental

preferences (eg, vegan diet)



Rice protein hydrolysates

Partially or extensively hydrolyzed formulae based on rice protein

are also an option provided that they have been proven safe and

efficient in infants with CMPA Reche et al, Pediatr Allergy Immunol 2007;18:599–606.

Because of the limited short- and long-term data on allergic reactions

(not sensitization) to rice-based formulae, we recommend that a

hydrolyzed rice formula may be considered in selected infants, which

are either refusing or not tolerating an eHF based on CMP, or in

vegan families Fiocchi et al, A. Pediatr Allergy Immunol 2010;21(suppl 21): 1–125


• Adverse reactions to lactose in CMPA are not supported in the

literature, and complete avoidance of lactose in CMPA is no longer

warranted

eHFs containing purified lactose are now available and have been

found safe and effective in the treatment of CMPA (Niggemann et al,

Pediatr Allergy Immunol 2008;19:348–54)

•These formulae may also be more palatable for infants older than 6

months

• It is, however, possible for secondary lactose intolerance to coexist in

infants who have enteropathy with diarrhea, and therefore a lactose-free

eHF will be required initially in these cases



Is avoidance of lactose necessary?

Therapeutic diet: for how long?

•Convention is that a challenge with cow’s milk may be performed

after maintaining a therapeutic diet for at least 3 months (eg, specific

IgE negative, mild symptoms) up to 12 months (eg, high-positive IgE

test or severe reaction) to avoid continuing a restrictive diet for an

unnecessarily long time

• If a challenge is positive, then the elimination diet is usually

continued for between 6 and 12 months.

•If the challenge is negative, then cow’s milk is fully reintroduced into

the child’s diet.


CMPA: prognosis

The prognosis for CMPA in infancy and young

childhood is good:

~ 50% of affected children develop tolerance by the

age of 1 year

>75%by the age of 3 years, and

>90% are tolerant at 6 years of age

Host et al 2002;13(suppl 15):23–8

Diagnostic approach and management of cow’s milk protein allergy in infants and children: A practical

guideline of the GI-committee of ESPGHAN

Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schäppi MG, Vandenplas Y

J Pediatr Gastroenterol Nutr. 2012 Aug;55(2):221-9



Algorithm for infants and children with symptoms suggestive of CMPA Koletzko et al JPGN 2012

Prevention of

food allergy

*Approximate numbers in developed countries. Adapted from

1. Bousquet J. et al. J Allergy Clin Immunol 1986;78: 1019-1022

2. Halken S et al. Allergy 2000;55: 793-802

3. Kjellman N. et al. Acta Paediatr Scan 1977;66: 565-71

4. Exl BM, Nutr Res 2001;21: 355-79

% of

newborns

who are

expected

to develop

allergy

later in life

Risk for developing allergy

by parental history of atopy

% of

parents

with history

of atopy

Bager et al, Clinical and Experimental Allergy, 2008; 38: 634–642

Μetaanalyses evaluating the impact of caesarean section

on the risk of atopy

Outcome

• Food allergy/atopy

• Respiratory atopy

• Εkzema/atopic dermititis

• Αllergic rhinitis

• Αsthma

• Hospitalization due to asthma

Οdd’s Ratio

95% CI

1.32 (1.12–1.55)

1.06 (0.87–1.28)

1.03 (0.98–1.09)

1.23 (1.12–1.35)

1.18 (1.11–1.23)

1.23 (1.18–1.27)

No of studies

6

4

8

7

13

7

Hygiene Hypothesis

Improved hygienic conditions

Less microbial exposure during early childhood priming Th1 cells

Slower post-natal maturation of the immune system

Delayed development of the optimal balance between Th-1 and Th-2-like immune response

Stachan, BMJ 1989

… η ζωή κοντά σε στάβλους προστατεύει από την αλλεργία

Exposure to environmental microorganisms and childhood asthma.

Ege MJ. N Engl J Med 2011;364:701-9

Diet of pregnant and lactating woman

and childhood allergy prevention

Cochrane Database Syst Rev. 2006

Jul 19;3:CD000133

• Ηypoallergenic diet during

pregnancy does not decrease the

risk of allergy and may have an

impact on the nutritional status of the

mother and the fetus

• Hypoallergenic diet during breast

feeding may decrease the risk of

developing ekzema, however until

further studies are available, it is not

recommended

Does breast feeding help in preventing

allergic manifestations?

Kull et al, J Allergy Clin Immunol 2005;116:657-61

Swedish birth cohort of 4089 infants followed for 2 years

Breast feeding and allergy prevention

German Infant Nutritional

Intervention study (In high risk infants)

Hydrolyzed infant formulas had a preventive effect persisting

until age 6 years: long-term results from the GINI study

All hydrolysates (extensively hydrolyzed casein

and whey and partial hydrolyzed whey infant

formula) reduce significantly atopic dermatitis in

the overall cohort of formula exposed infants until

the age of 6 years

von Berg A. J Allergy Clin Immunol 2008;121:1442-7

0.82

0.80

18% risk reduction vs CMF


Von Berg et al., J Allergy Clin Immunol. 2008 Jun;121(6):1442-7.

0.90 10% risk reduction vs CMF

Risk of AM at 6 years: Adjusted Odds Ratio



Von Berg et al., J Allergy Clin Immunol. 2008 Jun;121(6):1442-7


Risk of AD at 6 years: Adjusted Odds Ratio

The introduction of 4 solids before 17 weeks

postterm was associated with a higher risk for

eczema in infants with and without a family history

of allergy

Morgan et al, Arch Dis Child.2004; 89 (4):309 –314

2558 infants in the Netherlands

• More delay in introduction of cow milk products was

associated with a higher risk for eczema

• A delayed introduction of other food products was associated with an increased risk for atopy development at the age of 2 years

• Exclusion of infants with early symptoms of eczema and recurrent wheeze (to avoid reverse causation) did not essentially change our results

Age at First Introduction of Cow Milk Products and Other Food Products in

Relation to Infant Atopic Manifestations in the First 2 Years of Life: The

KOALA Birth Cohort Study

Bianca et al. PEDIATRICS Vol. 122 No. 1 July 2008, pp. e115-e122

Delaying the introduction of cow milk or other food products may not be favorable in preventing the development of atopy

Complementary feeding: a

commentary by the ESPGHAN

Committee on Nutrition

Agostoni C. ESPGHAN Committee on Nutrition.

J Pediatr Gastroenterol Nutr. 2008;46:99-110

There is no convincing scientific evidence that

avoidance or delayed introduction of potentially

allergenic foods, such as fish and eggs, reduces

allergies, either in infants considered at increased risk

for the development of allergy or in those not

considered to be at increased risk.

Recommendations for decreasing the risk of allergy in high risk children

During

pregnancy

Not recommended

During lactation Not recommended

Infant feeding • Breast feeding for at least 4-6 months

• If not available – use of hypoallergenic

infant formulas

• Introduction of solids after 4 and before 6

months of age

Exposure to environmental tobacco smoke

and sensitisation in children

Lannerö et al, Thorax 2008; 63:172-176

Smoking by parents during the first 2

months of life increased the risk of

sensitisation to inhalant and/or food

allergens (OR adj 1.28 (95% CI 1.01 to 1.62)

The risk was elevated for

• indoor inhalant allergens, such as cat

(ORadj 1.96 (95% CI 1.28 to 2.99) and

• food allergens (ORadj 1.46 (95% CI

1.11 to 1.93)

4089 infants born in Stockholm during 1994–1996

http://images.google.gr/imgres?imgurl=http://www.everymantri.com/.a/6a00d83451b18a69e2010536b6cf67970c-320wi&imgrefurl=http://www.wellsphere.com/triathlon-article/third-hand-smoke-potentially-just-as-dangerous/546841&usg=__Yr9Tr2Ug36RxUYMe9TQh0OpYeIM=&h=256&w=320&sz=14&hl=el&start=34&tbnid=lqvgH2OuxADQGM:&tbnh=94&tbnw=118&prev=/images%3Fq%3Dcigarette%2Bsmoke%2Bpregant%2Bwoman%26gbv%3D2%26ndsp%3D20%26hl%3Del%26sa%3DN%26start%3D20

Summary (1)

• Food allergy in infants and children is common

• Early diagnosis prevents impairment of growth

• History and careful clinical assessment are important

• Diagnostic testing (RAST, skin prick and/or APT tests ) may be helpful

• Elimination diet is associated with symptom resolution within days to

few weeks depending on the type of food allergy

• Confirmation of diagnosis in most cases requires supervised challenge

• The optimal duration of elimination diet depends on the clinical

scenario

•There is no evidence to support that feeding with a hydrolysed

formula reduces the risk of food allergy compared to exclusive

breast feeding

• In high risk infants who are unable to be breast fed, there is

evidence that feeding with a hydrolysed formula reduces the risk of

infant and child allergy, compared to cow's milk formula

• Further research is required to better understand the mechanism

of tolerance induction

Summary (2)

Thank you for attention!

Alexandra Papadopoulou - University of Cape Town ALLERGY.pdf · Alexandra Papadopoulou Division of...

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