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Jill Mallory, MD, IBCLC

Wildwood Family Clinic

Madison, WI

Define a food allergy and a food intolerance.

List 2 risk factors for the development of food allergies in children?

Describe the prognosis of food allergies in children.

What is the role of lactation in the prevention of food allergies?

What is the role of alteration in maternal diet in the allergic child?

Is weaning ever advisable in the setting of food allergies or intolerances?

List 3 reasons why a nursing baby who has food allergies should continue to nurse.

20 yo living w/ her mom

First baby

10 lbs at birth!

Vaginal delivery

41 weeks gestation

No complications

Took right to the breast

2 weeks old

Well above birth weight

Exclusively breastfed

Very colicky baby

Seems to be in pain all

the time

“About the only time he

isn’t crying is when he’s

asleep or nursing”

Very runny, mucous

stools

“What’s wrong with my

milk?”

Her sister only breastfed

her daughter for 4 mo

because she was so

colicky. When she

switched to soy formula,

it was like magic, and

the baby was happy.

Afraid of months of colic

Grandmother can’t take

the crying and rec

formula

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Definition: an adverse health effect arising

from a specific immune response that occurs

reproducibly on exposure to a specific food.

Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food

allergy: applications in the pediatric population. Pediatrics. 2011

Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10.

Gupta RS, et al. Childhood food allergies: current diagnosis, treatment,

and management strategies. Mayo Clin Proc. 2013 May;88(5):512-26

Food allergies result in IgE-mediated immediate reactions (e.g., anaphylaxis)

and several chronic diseases (e.g., enterocolitis syndromes, eosinophilic

esophagitis, etc),

in which IgE may not play an important role.

Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10.

Gupta RS, et al. Childhood food allergies: current diagnosis, treatment, and management strategies. Mayo Clin Proc. 2013 May;88(5):512-26

In the nursling:

GE reflux

Bloody stools

Eczema

Colic

In older children or adults:

Itching in the mouth or swelling

Vomiting, diarrhea, or abdominal cramps

Hives or eczema

Tightening of the throat and wheezing

Drop in blood pressure

Milk

Egg

Wheat

Soy

Peanut – affects 1-2% of children!

Treenut

Fish

Shellfish

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http://www.ifr.ac.uk/protall/infosheet.htm

IgE presence + symptoms = IgE mediated

allergy

Allergens are usually proteins

Less well-defined

NOT IgE mediated

Symptoms occur after eating a certain food

Headaches

Muscle and joint aches and pains

Tiredness

Abdominal pain and diarrhea

Examples

Celiac disease

Lactose intolerance

In the United States, affects an estimated

12% of children and 13% of adults (self-

reported)

In double-blind food challenges, incidence

looks more like 3% for adults and children

Rise in prevalence in the past 20 years

No effective treatment exists

Management = avoidance

Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications

in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:

10.1542/peds.2011-0539. Epub 2011 Oct 10.

Incidence is poorly defined

0.5-1% of EBF infant will develop allergy to

cow’s milk proteins excreted into mother’s

milk

50-65% of allergic colitis in EBF infants is due

to cow’s milk protein

19% to egg, 6% to corn, and 3% to soy

EBF infants have significantly lower rates of

cow’s milk allergy than those exposed to

formula ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant.

Breastfeed Med. 2011 Dec;6(6):435-40. doi: 10.1089/bfm.2011.9977. Epub 2011 Nov 3.

Eczema and GI sxs most common

Most common GI sx is bloody stools

Generally “well-appearing”

Sxs can be present at birth

Typically develop at 2-6 weeks of age

ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant.

Breastfeed Med. 2011 Dec;6(6):435-40. doi: 10.1089/bfm.2011.9977. Epub 2011 Nov 3.

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2-4 x more likely to have asthma, eczema,

respiratory problems

May co-exist with eosinophilic esophagitis

Food exposure may cause severe asthma

attacks or anaphylaxis

Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications

in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:

10.1542/peds.2011-0539. Epub 2011 Oct 10.

Biologic parents or siblings with a hx of

allergic rhinitis, asthma, atopic dermatitis

(eczema), or food allergy.

Child themselves have other preexisting

allergic disease

37% of children with eczema have IgE-

mediated food allergy

Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications

in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:

10.1542/peds.2011-0539. Epub 2011 Oct 10.

Difficult to predict by

Severity of past reactions

Food specific IgE levels

Wheal size in skin-prick testing

Co-existence of asthma =

marker for severity of

food allergy

AAP Recommends

At risk = at least 1 first degree relative, parent or

sibling with food allergy

All children at risk of should be exclusively

breastfed

If exclusive breastfeeding is not possible

hydrolyzed infant formulas should be used

Complementary food should not be restricted at

6 mo

Intact proteins from the mother’s diet can cross the gut barrier and enter the breastmilk

These proteins can trigger an allergic response and symptoms in some infants.

Vadas P, et al. Detection of peanut allergens in breast milk of lactating women. JAMA 2001;285:1746-1748.

Sorva R, et al. Beta-lactoglobulin secretion in human milk varies widely after cow’s milk ingestion in mothers of infants with cow’s milk allergy. J Allergy Clin Immunol.1994;93:787-792.

Casas R, et al. Detection of IgA antibodies to cat, beta-lactoglobulin, and ovalbumin allergens in human milk. J Allergy Clin Immunol. 2000;105:1236-1240.

Pittschieler K. Cow’s milk protein-induced colitis in the breastfed infant. J Pediatr Gastroenterol Nutr. 1990;10:548-549.

Maternal gut

Infant gut

The crux of it all!

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A healthy gut

Allows nutrients to pass from food into the

bloodstream

Prevents the entrance of pathogenic bacteria and

toxins from the environment into the blood

Physical barriers – tight junctions

Our bacteria friends

Oligosaccharides

Breakdown of these

barriers occur

Large food particles pass

into the blood stream

and interact with the

immune system

This leads to the

development of food

allergies

C. Perrier et al. Gut permeability and food

allergies. Clinical & Experimental Allergy.

Volume 41, Issue 1, pages 20–28, January 2011

Your body houses 10 x more bacterial cells

than human cells

May start prenatally?

Modulated by mode of birth

Further modulated by feeding method

Thum C et al. Can nutritional modulation of maternal intestinal microbiota influence the

development of the infant gastrointestinal tract? J Nutr. 2012 Nov;142(11):1921-8.

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Maternal gut bacteria are

thought to contribute

towards the microbial,

metabolic, and

immunological

programming of the

child.

• Lindsay K et al. Probiotics in pregnancy and maternal

outcomes; a systematic review. J Matern Fetal

Neonatal Med. 2013 Jan 11. [Epub ahead of print]

• Cilieborg MS et al. Bacterial colonization and gut

development in preterm neonates. Early Hum Dev.

2012 Mar;88 Suppl 1:S41-9.

Our gut bacterial population = a hidden organ

Breaks down our food Biotransformation of bile acids

Degradation of oxalate

Breakdown of plant polysaccharides

Production of short chain

fatty acids

Synthesis of biotin, folate,

and vitamin K

O'Hara AM, Shanahan F. The gut flora as a forgotten organ. EMBO Rep. 2006 Jul;7(7):688-93.

Affects: Mucosal immunity

Intestinal disorder

Development of allergies Energy homeostasis

Inflammation

Glucose metabolism

• Guarner F, et al. Gut flora in health and disease. Lancet 2003; 361:512-9.

• Guarner F. Inulin and oligofructose:impact on intestinal diseases and disorders, Br J Nutr 2005;93:S61-5.

• Hatakka K et al. Probiotics in intestinal and non-intestinal infectious disease – clinical evidence. Curr Pharm Des 2008;14:1351-67.

• Cani PD et al. Interplay between obesity and associated metabolic disorders: new insights into the gut microbiota. Curr Opin Pharmacol 2009;9:737-43.

• Greiner T et al. Effects of the gut microbiota on obesity and glucose homeostasis. Trends Endocrinol Metab 2011;22:117-23.

A systematic review

7 studies: 6 RCT’s and 1 prospective cohort 33,399 women in the prospective cohort

Altered Breast milk composition

Infant gut bacterial population

Reduced: Infant allergic disease

Lindsay, K et al. Probiotics in Pregnancy and Maternal Outcomes. The Journal of Maternal-Fetal & Neonatal Medicine 2013 May;26(8):772-8.

Infants born by c-section have different gut bacteria than children born vaginally

Infants born by c-section have a higher incidence of food allergy and other atopic disease

Koplin J, Allen K, Gurrin L, Osborne N, Tang ML, Dharmage S. Is caesarean delivery associated with sensitization to food allergens and IgE-mediated food allergy: a systematic review.

Infants who are exclusively breastfed develop a specific flora by 1 week after birth that reaches dominance by 1 month. (Langhendries JP, et al.1995)

Prebiotic factors in breast milk → a flora predominant in lactobacilli and bifidobacteria (Balmer SE, et al.1989)

Several factors in breastfed infants contribute to an intestine that favors proliferation of these healthy bacteria (Bernt KM, et al.1999)

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The good microorganisms in breastmilk also

produce antibiotic molecules that directly

prevent the growth of harmful organisms.

Dai D, Walker WA. Protective nutrients and bacterial colonization in the immature

human gut. Adv Pediatr 1999; 46:353-82.

This mixture of bacteria and prebiotics

alters the strength and permeability of

the barrier between the intestinal lumen

and the circulating blood

In contrast, in newborns who receive formula at birth an intestinal flora develops that is high in enterobacteria and gram-negative organisms.

Tight junctions do not develop properly in these babies.

Majamas H, Isolauri E. Probiotics: A novel approach in the management of food allergy. J Allergy Clin Immunol 1997; 99:178-85.

Isolauri E, Majamas H, Hrvola T, et al. Lactobacillus casei strain reverses increased intestinal permeability induced by cow's milk in suckling rats. Gastroenterology 1993; 105:1643-50

When damage to the gut barrier occurs from

one exposure to formula, it takes a full

month of exclusive breastfeeding to heal it.

The intestinal permeability increases with

exposure to formula in a dose-related

manner

Taylor SN, et al. Intestinal permeability in preterm infants by feeding type: mother's

milk versus formula. Breastfeed Med. 2009 Mar;4(1):11-5.

C-section + formula exposure

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Poor maternal gut health in pregnancy

Allows larger food particles to cross the placenta

and get into fetal circulation

Affects what bacteria are passed to baby

prenatally, at birth, postpartum

Affects what bacteria are present in the

breastmilk

A mechanism for inheritance of allergic

disease?

Hypothesis: decline in gut health

Both infant and maternal

Rise in c-sections

Decrease in exclusive breastfeeding

Antibiotic and pharmaceutical exposure

Processed foods

Poor diets

Chemical exposure

Environment

Stress

Historically MDs recommended stopping

breastfeeding in:

Severely allergic infants

Blood in the stool

Started on hydrolyzed or elemental formulas

This resolved symptoms BUT . . .

Deprived the mother and infant of the

benefits of breastfeeding AND . . .

Will make the leaky gut issue worse

Specialized formulas are very expensive!

Generally a benign and self-limiting disorder Not an automatic dx of cow’s milk protein

allergy

Arvola T, Ruuska T, Keränen J, Hyöty H, Salminen S, Isolauri E. Rectal bleeding in infancy: clinical, allergological, and microbiological examination. Pediatrics. 2006 Apr;117(4):e760-8.

Most common cause: breastmilk oversupply

Anal tear (fissure) from baby straining with the passage of the stool

Mom has a cracked nipple or other bleeding, then baby may ingest some blood from mom

Mucous and/or blood in the stool after starting vitamin/fluoride drops

Infectious: C. Difficile, campylobacter???

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Incidence is 0.5-1% in breastfed infants

2-3 % in infants overall in the first year of life

Most develop sxs before 1 mo of age Often within 1 week of exposure to formula

50-60% GI sxs

50% rash

20-30% wheezing

Høst A. Frequency of cow's milk allergy in childhood. Ann Allergy Asthma Immunol.

2002 Dec;89(6 Suppl 1):33-7.

Prognosis

Remission rate of 45-50% by 1 year of age

60-75% by 2 years of age

85-90% by 3 years of age

50% will develop allergies to other foods as well

50-80% will develop environmental allergic reactions such as asthma and rhinoconjunctivitis

If GI sxs are the only sxs, remission rates are high

Høst A. Frequency of cow's milk allergy in childhood. Ann Allergy Asthma Immunol.

2002 Dec;89(6 Suppl 1):33-7.

Proteins are made of chains of amino acids

Some other mammalian milks are similar to breastmilk

Some research suggests that exposure to proteins of other mammals may trigger an actual human milk protein allergy

Sx: poor weight gain, GI sxs, not resolving with hypoallergenic diet

This may be one food allergy situation where weaning is advisable

Restani P, et al. Evaluation of the presence of bovine proteins in human milk as a possible cause of allergic symptoms in breast-fed children. Ann Allergy Asthma Immunol.1999;84:353-360.

Bernard H, et al. Molecular basis of IgE cross-reactivity between human beta-casein and bovine beta-casein, a major allergen of milk. Mol Immunol 2000;37:161-167.

Hemoglobin or albumin levels dropping

Use of hypoallergenic formula may be

advisable while awaiting pediatric GI

evaluation

Put mom on hypoallergenic diet (rice, lamb,

pears, squash) for 2 weeks

If baby still symptomatic, may need to wean

ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant.

Breastfeed Med. 2011 Dec;6(6):435-40. doi: 10.1089/bfm.2011.9977. Epub 2011 Nov 3.

Rule of 3’s:

3 weeks of age

More than 3 hours of crying

3 days a week or more

Lasts for more than 3 weeks

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Behavioral theory

Crying results from a disequilibrium in the

maternal/infant interaction/bond

Immunologic model

Possible allergens in breastmilk or infant formula

as a causative agent

Other things to consider

Oversupply, undersupply

Other medical conditions

Infant should be assessed by a medical

professional for:

GERD

Malrotation of the intestine

Intussuscetion

Malabsorption syndromes

Blood in stools

The family should also be assessed

Diet

Food allergies in mom or other family

Asthma

Eczema

Environmental allergies

Atopic disease

Other common foods that can cause colic

symptoms in nurslings:

Peanuts

Eggs

Soy

Wheat

Tree nuts

Corn

Strawberries

Elimination of cow’s milk protein (CMP) from

the maternal diet has led to a decrease in

colicky symptoms in a large number of

infants

A positive challenge test is considered

diagnostic

For some infants, multiple foods may be the

culprit

Iacovou, Marina et al. Dietary Management of Infantile Colic: A Systematic Review

Matern Child Health J (2012) 16:1319–1331

One high quality RCT (n = 90) reported a

reduction >37% (95% CI 15–56%) of colic

symptoms when mothers changed from a

standard diet to a hypoallergenic diet

Elimination of dairy, eggs, peanuts, tree nuts,

wheat, soy, and fish

For seven days

Other studies have had mixed results

Iacovou, Marina et al. Dietary Management of Infantile Colic: A Systematic Review

Matern Child Health J (2012) 16:1319–1331

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Mom and baby to be evaluated by MD

Consider allergy testing - controversial

Mom and baby to start probiotic and eat

plenty of prebiotics

Burdock, raw chicory root, raw jerusalem

artichoke , raw dandelion greens, garlic, leek,

onion, wheat bran, banana

OK to go ahead and advise mom to start an

elimination diet while awaiting MD

evaluation

RAST testing – no longer recommended

IgE testing

False negatives

False positives

Food challenge

Skin testing

IgG testing - not recommended

Applied kinesiology – not recommended

Overused

Varying degrees of success

Symptoms may resolve within 48-72 hours, but may take up to 2 weeks

There may be a big decrease in symptoms without 100% resolution

Burdensome on mothers

emotionally

Nutritional risks

Financial risks

Lots of education needed

Start with dairy

elimination: two weeks,

followed by re-introduction

Consider soy, corn, egg

Lastly: citrus, nuts, wheat,

strawberries, chocolate

Once problem foods are

identified, they should be

eliminated for at least 6

mo

Avoid until 9-12 mo of age

Mother takes 2 tablets of pancrease MT4-

strength tablets with each meal or snack

Pancrease is a digestive enzyme that further

breaks down fats, proteins, and carbohydrates

before they enter the mother’s bloodstream.

First phase of elimination:

Dairy, soy, nuts, strawberries, chocolate

Second phase of elimination:

Wheat, eggs, corn

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Decreased symptoms of colic

Decreased blood in infant’s stool

13/16 were able to continue lactation

without use of specialized formulas

Repucci A. Resolution of stool blood in breast-fed infants with maternal ingestion of

pancreatic enzymes. J Pediatr Gastroenterol Nutr. 1999;29:500A.

What might be causing Leo’s

colic

Should she wean?

Why not?

What should she try instead?

Does it play a role in some of our “low milk

supply” cases?

Case study

Baby #4, exclusively BF

Mom had no hx low supply

Failure to thrive at 6mo

“Whimpy nurser”

Happy baby

Eczema

Food allergy testing: dairy

Maternal elimination -> growth

No benefit to limiting exposure

to non-food allergens (e.g.,

dust mites or pollen)

Insufficient evidence to

recommend allergy testing in

at-risk children without

symptoms, prior to food

introduction

Varied maternal diet may be

helpful

No benefit to

delaying allergenic

foods

That’s right!

Start eggs, dairy,

fish, nut butters,

soy, strawberries,

citrus, wheat all

right at 6 mo when

other foods are

introduced

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Studies on allergic food elimination in pregnant women are conflicting

Restriction of maternal diet during pregnancy or lactation is not recommended

AAP recommends all children with risk factors for food allergy be exclusively breastfed for 4-6 months

Greer FR et al. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008 Jan;121(1):183-91.

The role of breastfeeding in prevention is

debated, mainly due to problems with the

quality of studies

Why?

Many don’t look at exclusivity and think in

terms of breastmilk exposure as a magic

bullet

They really should be thinking from the

perspective of formula exposure as a gut

barrier disruptor

12 criteria for a valid study

Non-reliance on late maternal recall of

breastfeeding

Sufficient duration of exclusive breastfeeding

Strict diagnostic criteria for allergy

Assessment of effects of children at high risk of

allergies

Adequate statistical power

Unfortunately, no studies to date have

completely fulfilled these criteria. Kramer MS. Does breast feeding help protect against atopic disease? Biology,

methodology, and golden jubilee of controversy. J Pediatr. 1988;112:181–190

In order to decrease the risk: Avoid both early (<4 months) and late (≥7 months)

introduction of gluten

Introduce gluten while the infant is still being breastfed

Szajewska H et al. Systematic review: early infant feeding and the prevention of coeliac disease. Aliment Pharmacol Ther. 2012 Oct;36(7):607-18. doi: 10.1111/apt.12023. Epub 2012 Aug 21.

Probiotics

Present in breastmilk

Review of 10 studies

Given to pregnant and postpartum women or newborns

reduces incidence of allergies

Given to children with eczema, reduced the severity

Did not specify feeding type

Foolad N, et al. Effect of nutrient supplementation on atopic dermatitis in children: a

systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol.

2013 Mar;149(3):350-5. Review.

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Prebiotics – oligosaccharides (OS) Present in breastmilk Formula fed kids who

were supplemented with OS had a decreased risk of developing eczema (50% reduction)

Foolad N, et al. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013 Mar;149(3):350-5. Review.

Formula exposure

At least 25% of BF infants are exposed to formula

by day #2 of life in the US

By 3 mo of age, that is up to 80% in some studies

Type of Formula

Mixed results on the benefits of amino acid or

hydrolyzed formulas over standard cow’s milk

formulas

There may be a benefit in prevention of dairy

allergy

Formula exposure

Use of soy formula is not beneficial in prevention

of dairy allergy

There is no evidence that suggests use of

hydrolyzed formulas offer any preventative

benefit over breastmilk

Fatty acids

US pregnant and lactating women have the

lowest DHA levels in the developed world

Gamma-linolenic acid (GLA) and omega-3’s both

components of breastmilk

If a mother has allergic disease, GLA

supplementation in pregnancy may reduce

severity of allergic disease in infants

Foolad N, et al. JAMA Dermatol. 2013 Mar;149(3):350-5. Effect of nutrient

supplementation on atopic dermatitis in children: a systematic review of

probiotics, prebiotics, formula, and fatty acids.

Fatty acids

GLA also appears to reduce severity when given

to infants

Infants and mother’s supplemented with omega-

3’s had lower incidence of allergic disease

Black currant seed oil = GLA + omega 3’s,

beneficial in incidence reduction

Again, does not specify feeding method

Foolad N, et al. JAMA Dermatol. 2013 Mar;149(3):350-5. Effect of nutrient

supplementation on atopic dermatitis in children: a systematic review of probiotics,

prebiotics, formula, and fatty acids.

Hibbeln, Joseph. NIH

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Likely to occur over time with dairy, soy, egg

and wheat

Kids with peanut, tree nut, fish and shellfish

allergies are less likely to outgrow them

Younger children may be re-tested annually

Sublingual Immunotherapy (SLIT)

Liquid or tabs placed under the tongue

More research needed

Oral Immunotherapy (OIT)

May lessen the severity of reactions

More research needed

1. Keet CA, Frischmeyer-Guerrerio PA, Thyagarajan A, et al. The

safety and efficacy of sublingual and oral immunotherapy for milk

allergy. J Allergy Clin Immunol 2012;129(2)448-‐55,455.e1‐5.

2. Burks AW, Jones SM, Wood RA, et al. Oral Immunotherapy for

treatment of egg allergy in children. N Engl J Med

2012;367(3):233‐43

Food Allergy and Anaphylaxis Network

www.foodallergy.org

Consortium of Food Allergy Research’s

online educational program

https://web.emmes.com/study/cofar/

EducationProgram.htm

The Whole Life Nutrition Cookbook

https://wholelifenutrition.net/store/

books/whole-life-nutrition-cookbook

AAP Section on Allergy and Immunology

www.aap.org/sections/allergy

American Academy of Allergy, Asthma & Immunology

(AAAAI) www.aaaai.org/

American College of Allergy, Asthma and Immunology

(ACAAI) www.acaai.org/

Asthma and Allergy Foundation of America (AAFA)

www.aafa.org/

Food Allergy Initiative (FAI)

www.faiusa.org/

Kids With Food Allergies (KFA)

www.kidswithfoodallergies.org/

National Institute of Allergy and Infectious

Diseases (NIAID)

www.niaid.nih.gov/

Infant Proctocolitis – printable handouts!

http://infantproctocolitis.org/