Rickets: Etiology, pathogenesis, clinical features, diagnostics, treatment and prevention
World Allergy Forum Food Allergy: Pathogenesis and Prevention slides.pdf · World Allergy Forum...
Transcript of World Allergy Forum Food Allergy: Pathogenesis and Prevention slides.pdf · World Allergy Forum...
World Allergy ForumFood Allergy: Pathogenesis
and Prevention
Early Dietary Exposures and Feeding Practices
Scott H. Sicherer, MDClinical Professor of Pediatrics
Jaffe Food Allergy InstituteMount Sinai School of Medicine
New York
AAAAI Orlando 2012: Session 3307
Disclosures
• NIH-NIAID Funding for studies• Food Allergy Initiative Consultant
and funding for studies• Food Allergy & Anaphylaxis Network
Medical Advisor
Learning Objectives
• Understand the current data on atopy prevention through infant diet
• Advise families on dietary approaches with regard to food allergy prevention
Suggested References : 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. Greer F, Sicherer S, Burks AW. Pediatrics. 2008;121(1):183-91 and Guidelines for the Diagnosis and Management of Food Allergy in the US Boyce et al. J Allergy Clin Immunol 2010; 126(6 Suppl):S1-58.
Prevention Through Diet• Prevention of… • Through “ingestion”…
Sensitization
Choice of breast milk substitution
Breast feeding-with Maternal diet alteration
Pregnancy
Breast feeding
Disease
Complementary foodsWhen/what
Inflammation
What are “normal” feeding practices?
• Breast feed• Weaning• Solids that are easily managed by an infant• Progression as teeth erupt
Breast Feeding (focus on eczema) • 18 prospective studies ( Gdalevich JAAD 2001; 45:520-
7)– Atopic (OR 0.58; 95% CI, 0.41-0.92)– Non-atopic (OR 0.84; 95% CI, 0.59-1.19)
•Recent studies suggest genetic differences affect risk(Hong et al JACI 2011;128:374-81)
• 21 studies ( Yang YW BJD 2009;161:373-383)• Overall : OR 0.89 (95% CI 0.76-1.04)• vs. formula OR 0.7 (95% CI 0.50-0.99)
•(but p=NS removing Chandra)
• ISAAC Study (Flohr C BJD 2011;165:1280-9)• 51,119 children. No evidence of overall protection.
Recent studies trend to
less protection
Meta-Analysis: Maternal Diet Restriction While Breast Feeding• Insufficient evidence that maternal
allergen avoidance prevents atopic disease
• Possible exception for atopic dermatitis • 2 studies
• 2010 Food Allergy Guidelines: Not recommended to reduce FA
Kramer Kakuma Cochrane database 2006
The German Infant Nutritional Intervention Study
• “At risk” for atopy (one 1 st degree)• Randomized to study formula (within context of
instruction to breast-feed)
– Cow’s milk formula (CMF)– Extensively hydrolyzed casein (eHF-C)– Extensively hydrolyzed whey (eHF-W)– Partially hydrolyzed whey (pHF-W)
Von Berg A JACI 2003; 111:533
0
2
4
6
8
10
12
14
16
%
AtopicDerm
FoodAllergy
Any Atopy
CMFeHF-CeHF-WpHF-W
** *Von Berg JACI 2007Von Berg JACI 2008
• Lesson #1: Cannot assume a formula’s effect (e.g., eHF-W)
• Lesson #2: Impact on subtypes of risk*
The German Infant Nutritional Intervention Study
0
0.2
0.4
0.6
0.8
1
1.2
Odds Ratio
No AD in FH AD in FH
CMFeHF-CeHF-WpHF-W
*Trends
Randomized Trial of 3 Formulas if Weaning
• 620 infants positive family history atopy• Cow’s milk vs. soy vs partially hydrolyzed
whey at weaning• Followed age 2 years (93%) and age 7
(80%)• 50% exposed ~5 months, ~75% 1 year• No differences in AD, food skin tests,
asthma, rhinitis Lowe et al JACI 2011;128:360-5
Prevention Formulas• Soy not recommended for “prevention”
(AAP, NIAID)• “Hydrolyzed infant formulas”
recommended over whole cow’s milk protein for “at risk” (NIAID Guideline) and some evidence for reduced atopic dermatitis (slight advantage of extensive casein hydrolysate versus partial whey hydrolysate weighed by cost (AAP)
Dietary Prevention Program, US
• Randomized, prospective, 288 subjects, one parent with atopy and sensitization
• Program:– Pregnancy, 3 rd trimester-no milk, egg, peanut,
reduced soy/wheat– Lactation, avoid same, supplement casein
hydrolysate– Solids at 6 mo, 12 mo-CM, wheat, soy, 24 mo-
egg, 36 mo-peanut, fish
• Followed to age 7 years
Zeiger JACI 1989;Zeiger PAI 1992;Zeiger JACI 1995
Dietary Prevention Program, USPeriod Prevalence of Disorders
Zeiger JACI 1989;Zeiger PAI 1992;Zeiger JACI 1995
0
5
10
15
20
25
30
35
%
Age 1 Age 2 Age 4 Age 7
Asthma
0
5
10
15
20
25
30
35
%
Age 1 Age 2 Age 4 Age 7
Atopic dermatitis
0
5
10
15
20
25
30
35
%
Age 1 Age 2 Age 4 Age 7
Food Allergy
ProphylaxisNo diet
*
*
“Prevention”
• Breast feed 1 year• If supplement, “hypoallergenic
formula”• Solids delay to age 6 mo • Should eliminate Peanut, Tree nuts,
and consider eliminate egg, milk, fish “others” while nursing
• No Cow’s milk to 12 mo• No Egg to age 2 yr• No Peanut, Tree Nuts, fish to 3 yr• Pregnancy: consider peanut
exclusion
AAP Committee on Nutrition, 2000
Suggestions aimed at “high risk”
Solid Foods*
Rat
e of
Ecz
ema
0
5
10
15
20
25
30
35
No Solids 1-2 Solids 3-4 Solids 5+ Solids
Fergusson et al Clin Allergy 1981
Atopic Dermatitis OR (95% CI)
Veg (>4 mo)
Egg (>8 mo)
Zutavern et al ADC 20040.1 0.2 0.5 1 2 4
05
10152025303540
AD (%)
Age 1 Age 5
3 months6 months
Age of Solid food Introduction
Kajosaari & SaarinenActa Ped Scand 1983
Solid Food Post 2000
• Germany (Filipiak J Pediatr 2007;151:352)
– 4753 infants (birth cohort): Among “at risk” atopy if waited on giving egg (RR 1.8, 95% CI: 1.2-2.6)
• Belgium (Sariachvili PAI 2010;21:74)
– Case Control: Solids before 4 months, less eczema (OR 0.49; 95% CI 0.3-0.7)
• Finland (Nwaru Pediatrics 2010;125:50)
– Cohort 994: Later introduction of solid foods associated with higher food sensitization
• Netherlands (Tromp Arch Pediatr Adolesc Med 2011;165:933)
– Cohort 6905: No relationship of eczema/wheeze to receiving milk, egg, soy, nut, wheat prior to age 6 months
Complementary feeding and food sensitization: Detroit
• Enrolled 1258 women, 44.9% parental atopy
• Dietary inclusion of complementary foods at < 4 months versus food sensitization at age 2-3 years
• 74.2% with data for this analysisFamily Atopy
IgE > 0.7 kUA/L E/M, >0.35 peanut
Adjusted odds ratio
P-value
Yes Egg/milk 0.5 (0.3-0.9) 0.023
Yes Peanut 0.2 (0.1-0.7) 0.007
No Egg/milk 1.0 (0.6-2.0) 0.894
No Peanut 1.3 (0.6-2.7) 0.544
Joseph et al JACI 2011;127:1203-10
Egg Introduction and Egg AllergyEgg Introduction and Egg Allergy
Koplin et al JACI 2010
RR (95% CI)
0 0.1 0.5 1 2 5 10
4-6 mo
7-9 mo
>12 mo
10-12 mo
“HealthNuts” study, 2589 infants population-based, cross-sectional study
� Effects seen in high-risk and low-risk infants with cooked egg introduction� Adjusted for confounding factors� Confirmed egg allergy
Cereal Grain Introduction and Wheat Cereal Grain Introduction and Wheat
AllergyAllergy
OR (95% CI)
0 0.1 0.5 1 2 5 10
0-6 mo
≥7 mo
“Daisy” study (US), 1612 infants, birth cohort obser vational study
Poole et al Pediatrics 2006
� Parent reported wheat allergy in 1%, 4 with positive wheat-IgE � Adjusted for parental allergic diseases and any food allergy < 6mo of age� Designed to investigate natural hx of diabetes and celiac disease in a HLA-
predisposed population
Cow’s Milk Introduction and Milk Allergy
Katz et al JACI 2010
Prospective feeding study of 13019 infants in Israel, telephone interview, encourage to breast feed
� Low prevalence of IgE-mediate allergy 0.5%, which confirmed milk allergy� Regards parental atopy as a potential confounding factor� Nursery milk exposures not considered
Introduction of milk/milk products and atopy outcomes
• KOALA Birth cohort (n=2558, Netherlands)• Followed to age 2: Delayed milk/milk
products associated with eczema; delayed “other foods” with atopy, prolonged BFing-protective.
AdjustedOdds RatioEczema
Age at introduction of milk protein (mo)
Snijders et al Pediatrics 2008;122:e115-22
Government and Pediatric Society Response To Peanut
Allergy “Epidemic”• Avoid peanut during
pregnancy, lactation and wait to age 3 years to feed it
• American Academy of Pediatrics 2000
• Committee on Toxicology (UK) 1999
Ingestion is bad…Uh oh…?
Maybe if you don’t eat it, you touch it, have accidental periodic ingestions that are all sensitizing?
Sicherer et al JACI 2003, 2010 Grundy et al JACI 2002; Du Toit JACI 2008;Fox JACI 2009
Before Advice to avoid
After Advice to avoid
Percentpeanut allergy in children
Source: Sicherer SH and Sampson HA. “Peanut allergy : Emerging concepts and approaches for an apparent epidemic.” J Allergy Clin Immunol 120(3): 491-503.
Peanut
Allergy
Genetic predispositionto peanut allergy
Geneticpredisposition Atopic
Dermatitis
Dietary &Environmental
Exposures
Use ofAntacids
Ingestion of cross-reactiveproteins (soy)
Topicalexposure
Pollenproteins
Manner of processing
Frequencyof ingestion
Timing
Dose
Maternal ingestionduring pregnancy
Maternal ingestionduring breast feeding
What are “normal” feeding practices?
• Breast feed• Weaning• Solids that are easily managed by an infant• Progression as teeth erupt
Weaning Foods
• Thailand-coconut, chilis, tamarind, lemon grass
• Africa-meats• China-rice, fish, vegetables, meat• India-wheat, rice, milk, egg, fish,
legumes• Japan-rice, soy, fish
Source: Wikipedia
What are “normal” feeding practices?
• Breast feed• Weaning• Solids that are easily managed by an infant via pre -mastication• Progression as teeth erupt
Hafeez, S. et al. Arch Pediatr Adolesc Med 2011;165 :92-93.
Characteristics Mothers Completing the Questionnaire Asking Whether They Have Ever Given Pre-masticated Food to Their
Children• Anonymous
survey• 90, HIV
infected mothers
• Brooklyn, NY• Overall, 18%
pre-masticated
N=90 Yes, Premasticates
Born US 18%
Born Carribean or Central America
13%
Born Africa 29%
Hispanic 7%
African American 38%
African 29%
Mother Pre-masticated 42%
Mother did not Pre-masticate 12%
ENDS: MEANS• Prevention of… • Through ingestion…
Breast feeding-with Maternal diet alteration
Pregnancy
Breast feeding
Choice of breast milk substitution
Complementary foodsWhen/what
Sensitization
Disease
Inflammation
ENDS: MEANS• Prevention of… • Through ingestion…
Breast feeding-with Maternal diet alteration
Pregnancy
Breast feeding
Choice of breast milk substitution
Complementary foodsWhen/what
No obviousEffect (?)
Good foreveryone,exclusive to4-6 mo No, but for
high risk maybe (AD)
Certain Hydrolyzedformulas, notsoy, not cow’smilk
Nothingspecial(exceptions?)
Thank You!