Prevention of allergic diseases

PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC DISEASEDISEASEDISEASEDISEASEDISEASEDISEASEDISEASEDISEASE

CHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD

Outline Outline

�� Food allergen avoidanceFood allergen avoidance

�� HDM avoidanceHDM avoidance�� HDM avoidanceHDM avoidance

�� Multiple interventionMultiple intervention

Food allergen avoidanceFood allergen avoidance

High risk High risk

Definitions/Definitions/interventionsinterventions

AAP 2008 AAP 2008 Clinical Clinical ReportReport

AAP 2000AAP 2000recommendrecommendationsations

‘‘High risk’’‘‘High risk’’ Parent or Parent or BiparentalBiparental or or

Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20082008;;122122::2929--3333..

‘‘High risk’’‘‘High risk’’ Parent or Parent or sibling withsibling withdocumented documented allergicallergicdiseasedisease

BiparentalBiparental or or parent plusparent plussibling history sibling history of allergyof allergy

Atopic risk scoreAtopic risk score

Type and degree of allergy symptomsType and degree of allergy symptomsFamilyFamily Major*Major* Minor**Minor** TotalTotal

OvertOvert ProbableProbable AbsentAbsent OvertOvert ProbableProbable AbsentAbsent

FatherFather 22 11 00 11 0.50.5 00 4.54.5MotherMother 33 22 00 11 0.50.5 00 6.56.5

J. J. NgamphaiboonNgamphaiboon et al Asian Biomedicine 2009; 3:121et al Asian Biomedicine 2009; 3:121--126.126.

MotherMother 33 22 00 11 0.50.5 00 6.56.5SiblingSibling 22 11 00 11 0.50.5 00 4.54.5

*asthma, atopic dermatitis, allergic rhinitis, *asthma, atopic dermatitis, allergic rhinitis, CMA.CMA.****urticariaurticaria, drug allergy, other food allergies , drug allergy, other food allergies except CMA, allergic conjunctivitis.except CMA, allergic conjunctivitis.

P. P. BagerBager et al Clinical and Experimental Allergy 2008;38:634et al Clinical and Experimental Allergy 2008;38:634––642.642.

LiemLiem et al J Allergy et al J Allergy ClinClin ImmunolImmunol 2007;119:12032007;119:1203--9.9.

R. E. Bergmann R. E. Bergmann et al Clinical and Experimental Allergy et al Clinical and Experimental Allergy 19971997;;2727: : 752752--760760..

Allergic marchAllergic march

www.theallergymarch.comwww.theallergymarch.com

Maternal avoidance diet during Maternal avoidance diet during pregnancypregnancy

�� Maternal avoidance cow’s milk and egg Maternal avoidance cow’s milk and egg during pregnancy not affect incidence of during pregnancy not affect incidence of allergic diseaseallergic diseaseallergic diseaseallergic disease

�� No association between maternal peanutNo association between maternal peanut

avoidance during pregnancy and incidenceavoidance during pregnancy and incidence

of peanut allergy in their childrenof peanut allergy in their children

David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.




Pregnancy Pregnancy avoidanceavoidance

Lack of Lack of evidenceevidence

Possibly Possibly peanutpeanut

Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol 2008;122:29J Allergy Clin Immunol 2008;122:29--33.33.

Kramer MS et al Cochrane Database of Systematic Reviews Kramer MS et al Cochrane Database of Systematic Reviews 20062006..

�� No significant benefit to childrenNo significant benefit to children

Maternal avoidance diet during Maternal avoidance diet during lactationlactation

David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..




Maternal Maternal lactationlactationavoidance of avoidance of

Some Some evidence for evidence for reducedreduced

Peanuts, tree Peanuts, tree nuts andnuts and‘‘consider’’ ‘‘consider’’


avoidance of avoidance of allergensallergens

reducedreducedatopic atopic dermatitisdermatitis

‘‘consider’’ ‘‘consider’’ egg, milk, egg, milk, fish,fish,and ‘‘perhaps and ‘‘perhaps other foods’’other foods’’

Kramer MS et al Cochrane Database of Systematic Reviews Kramer MS et al Cochrane Database of Systematic Reviews 20062006..

�� Exclusive breastExclusive breast--feeding for feeding for 3 3 months months

reduce incidence of atopic dermatitis in reduce incidence of atopic dermatitis in

Effect of breastEffect of breast--feeding on feeding on atopic dermatitisatopic dermatitis

reduce incidence of atopic dermatitis in reduce incidence of atopic dermatitis in

childrenchildren


Effect of breastEffect of breast--feeding on feeding on asthmaasthma

�� Exclusive breastExclusive breast--feeding for 3feeding for 3--4 months 4 months

reduces number of early, upper respiratory reduces number of early, upper respiratory


reduces number of early, upper respiratory reduces number of early, upper respiratory

infectioninfection--associated wheezingassociated wheezing

episodes before age of 4 yearsepisodes before age of 4 years

�� HighHigh--risk infants exclusive breastrisk infants exclusive breast--feeding feeding

at least at least 4 4 months lowered risk of cow’s months lowered risk of cow’s

Effect of breastEffect of breast--feeding on feeding on food allergyfood allergy

at least at least 4 4 months lowered risk of cow’s months lowered risk of cow’s

milk allergy (but not food allergy inmilk allergy (but not food allergy in

general)general)


�� Not clearNot clear

Effect of breastEffect of breast--feeding on feeding on allergic rhinitisallergic rhinitis


�� Cow’s milk formulas & partial whey Cow’s milk formulas & partial whey

hydrolysatehydrolysate formulasformulas

Infant formula for primary prevention Infant formula for primary prevention of allergic disease of allergic disease 11

pHFspHFs preventive effect on atopic disease preventive effect on atopic disease

and cow’s milk protein allergyand cow’s milk protein allergy


�� pHFspHFs & extensive casein or extensive & extensive casein or extensive

whey whey hydrolysatehydrolysate formulas (formulas (ehFehF))

Infant formula for primary prevention Infant formula for primary prevention of allergic disease 2of allergic disease 2

No significant difference between No significant difference between pHFpHF and and

eHFeHF in development of infant allergic in development of infant allergic

diseasesdiseases


�� Soy formula & amino acid based Soy formula & amino acid based

formulasformulas

Infant formula for primary prevention Infant formula for primary prevention of allergic disease 3of allergic disease 3

-- Advantage of soy formula not show Advantage of soy formula not show

-- Amino Amino acidebasedacidebased formulas lacking formulas lacking

studiesstudies





Prevention formulasPrevention formulas Compared with Compared with wholewholecow’s milk protein,cow’s milk protein,evidence for certainevidence for certain

‘‘Hypoallergenic ‘‘Hypoallergenic formula’’formula’’(extensive (extensive hydrolysatehydrolysate,,

Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20082008;;122122::2929--3333..

evidence for certainevidence for certainextensive extensive hydrolysateshydrolysates,,partial partial hydrolysateshydrolysates, but, butnot soynot soy

hydrolysatehydrolysate,,possibly partialpossibly partialhydrolysatehydrolysate); not ); not soysoy

I I BrockowBrockow et al et al J Investig Allergol Clin Immunol J Investig Allergol Clin Immunol 20092009;;1919: : 180180--187187..

Introduction of complementary foods Introduction of complementary foods 11

�� Expert panel from European Academy of Expert panel from European Academy of

AllergologyAllergology and Clinical Immunology and Clinical Immunology


recommends introduction of recommends introduction of

complementary foods between complementary foods between 4 4 and and 6 6

months of agemonths of age

Introduction of complementary foods 2Introduction of complementary foods 2

�� Feeding solids before Feeding solids before 4 4 months of age months of age

higher incidence of atopic dermatitishigher incidence of atopic dermatitis


�� No current evidence suggests that delay of No current evidence suggests that delay of

introduction of solid foods beyond introduction of solid foods beyond 4 4 to to 6 6

months of age prevent allergic diseasemonths of age prevent allergic disease




Types of Types of ‘‘solids’’ and‘‘solids’’ andcomplementarycomplementary

Evidence to Evidence to wait 4 (to 6)wait 4 (to 6)mo; lack of mo; lack of

Solids held to Solids held to 6 mo6 moDairy Dairy


complementarycomplementary

foodsfoodsmo; lack of mo; lack of convincingconvincingevidence for evidence for avoidingavoidingspecific specific allergenic allergenic foodsfoods

Dairy Dairy products, age products, age 1 y1 yEgg, age 2 yEgg, age 2 yPeanuts, Peanuts, nuts, fish, nuts, fish, age 3 yage 3 y

HDM avoidanceHDM avoidance

Study on Prevention of Allergy inStudy on Prevention of Allergy inChildren in Europe (SPACE)Children in Europe (SPACE)

NumberNumber Intervention Intervention

started atstarted atInterventionIntervention Main Main

outcomeoutcome

Reduction Reduction inin

Newborn Newborn 696696

BirthBirth Mattress Mattress cover cover

Allergic Allergic sensitizationsensitization

11y allergic y allergic sensitizationsensitization

SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..

696696 cover cover and and general general adviceadvice

sensitizationsensitization sensitizationsensitization

22y no y no effecteffect

Toddler Toddler 636636

22--4 4 yy 11y allergic y allergic sensitizationsensitization

School School children children 242242

55--7 7 yy

Manchester Asthma and Allergy Manchester Asthma and Allergy StudyStudy



outcomeoutcome


620620 PrenatalPrenatal Extensive Extensive --Allergic Allergic HDM HDM

SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.

620620 PrenatalPrenatal Extensive Extensive HDM HDM avoidanceavoidance--covercover--HEPA filterHEPA filter--hardwood hardwood flooringflooring--use of use of AcarosanAcarosan

--Allergic Allergic sensitizationsensitization

--WheezeWheeze--Airway Airway resistanceresistance

HDM HDM allergen allergen levelslevels11Y: only Y: only severe severe wheezewheeze

Prevention and Incidence of Prevention and Incidence of Asthma and Mite Allergy (PIAMA)Asthma and Mite Allergy (PIAMA)


started atstarted atInterventionIntervention MainMain

outcomeoutcome


810810 PrenatalPrenatal Mattress Mattress --Total Total HDM HDM


810810 PrenatalPrenatal Mattress Mattress covers covers and and general general adviceadvice

--Total Total IgEIgE--Specific Specific IgEIgE--Cough, Cough, wheezewheeze--Atopic Atopic dermatitisdermatitis

HDM HDM allergenallergenlevelslevels22y: y: nocturnal nocturnal coughcough

Multiple interventionMultiple intervention

Isle of Wight prevention studyIsle of Wight prevention study



outcomeoutcome


120120 BirthBirth Food and Food and HDM HDM avoidanceavoidance

-- Allergic Allergic sensitizationsensitization-- AsthmaAsthma-- Allergic Allergic rhinitisrhinitis-- Atopic Atopic

HDM HDM allergen allergen levellevel1 1 y:y:Asthma,ADAsthma,ADallergic allergic


-- Atopic Atopic dermatitisdermatitis-- Food Food allergyallergy

allergic allergic sensitizationsensitization22Y:AD Y:AD allergic allergic sensitizationsensitization44Y:AD Y:AD allergic allergic sensitizationsensitization88Y:asthma, Y:asthma, allergic allergic sensitizationsensitization

Prevention of atopic allergyPrevention of atopic allergy



outcomeoutcome


531531 BirthBirth Diet Diet exclusive exclusive BF or BF or

-- Asthma Asthma -- ADAD-- RhinitisRhinitis

44y :any y :any allergyallergy


BF or BF or soya soya formula formula and and environmental environmental

HDM and HDM and ETS ETS avoidanceavoidance

-- RhinitisRhinitis--UrticariaUrticaria

Canadian Asthma Primary Canadian Asthma Primary Prevention StudyPrevention Study



outcomeoutcome


545545 PrenatalPrenatal Diet : breast Diet : breast feeding, feeding, delayed delayed

-- Allergic Allergic sensitizationsensitization-- AsthmaAsthma

HDM HDM allergen allergen levelslevels


delayed delayed introduction introduction of solids and of solids and environment environment reductionreductionHDM and HDM and pet pet exposure exposure and ETS and ETS

-- AsthmaAsthma-- Allergic Allergic rhinitisrhinitis

levelslevels1 Y: asthma 1 Y: asthma and allergic and allergic rhinitisrhinitis2Y :asthma2Y :asthma

Childhood Asthma Prevention Childhood Asthma Prevention StudyStudy



outcomeoutcome


616616 PrenatalPrenatal -- HDM HDM avoidanceavoidance-- Diet : Diet :

-- CoughCough-- AAsthma sthma --AAllergic llergic

11..5 5 y :diet y :diet group; group; wheeze wheeze


-- Diet : Diet : omega omega 3 3 PUFAPUFA-- CombinedCombined

--AAllergic llergic sensitizationsensitization--Total Total IgEIgE at at age age 18 18 monthsmonths

wheeze wheeze HDM groupHDM groupno effectno effect3 3 y diet y diet group;coughgroup;coughHDM group HDM group sensitization sensitization to HDMto HDM

OmegaOmega--3 PUFAs3 PUFAs

�� Dietary modifications of supplementation Dietary modifications of supplementation

with fish oil with fish oil ((rich inomegarich inomega--3 3 PUFAsPUFAs)) might might


be some benefitbe some benefit

�� ProspectiveProspective observational study indicate observational study indicate

introduction of fish into infant’s diet reduces introduction of fish into infant’s diet reduces

occurrence of rhinitis but notoccurrence of rhinitis but not asthmaasthma

ProbioticsProbiotics

�� LactobaccilusLactobaccilus GG given during pregnancy GG given during pregnancy

to mothers with a family history of to mothers with a family history of atopyatopy

for 6 months resulted in significant for 6 months resulted in significant


for 6 months resulted in significant for 6 months resulted in significant

reduction in atopic dermatitis up to thereduction in atopic dermatitis up to the

age of 2 yearsage of 2 years

VaccinationVaccination

�� No clinical trials to assess No clinical trials to assess

immunomodulatoryimmunomodulatory effect ofeffect of


immunomodulatoryimmunomodulatory effect ofeffect of

vaccination in primary prevention of allergyvaccination in primary prevention of allergy

Take Home Message 1Take Home Message 1

�� Maternal avoidance diets during Maternal avoidance diets during

pregnancy and lactation not pregnancy and lactation not

recommended at this timerecommended at this timerecommended at this timerecommended at this time

�� Exclusive breastExclusive breast--feeding recommended feeding recommended

for at least 4 months and up to 6 for at least 4 months and up to 6

months of agemonths of age


�� BreastBreast--feeding reduce incidence of feeding reduce incidence of

atopic dermatitis, reduce early onset atopic dermatitis, reduce early onset

wheezing before age wheezing before age 4 4 years and years and wheezing before age wheezing before age 4 4 years and years and

reduce incidence of cow’s milk allergy reduce incidence of cow’s milk allergy

in the first in the first 2 2 years of lifeyears of life

Take Home Message Take Home Message 33

�� No conclusive evidence supports No conclusive evidence supports

formula over breastformula over breast--feeding to prevent feeding to prevent

atopic diseaseatopic diseaseatopic diseaseatopic disease

�� Complementary foods can be Complementary foods can be

introduced between 4introduced between 4––6 months of age6 months of age


�� Preventive effect of HDM avoidance for Preventive effect of HDM avoidance for

sensitization or respiratory allergy not sensitization or respiratory allergy not

compelling compelling compelling compelling

�� Combining food and aeroallergen Combining food and aeroallergen

avoidance reducing early childhoodavoidance reducing early childhood

wheeze and atopic dermatitis laterwheeze and atopic dermatitis later

asthmaasthma

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Prevention of allergic diseases

Health & Medicine

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