The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance

Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants

BACKGROUND

Allergies and food reactions are common and may be associated with foods including adapted cow's milk formula. Formulas containing hydrolysed proteins have been used to treat infants with allergy or food intolerance. However, it is unclear whether hydrolysed formula can be advocated for prevention of allergy and food intolerance in infants without evidence of allergy or food intolerance.

OBJECTIVES

To determine the effect of feeding hydrolysed formulas on allergy and food intolerance in infants and children compared to adapted cow's milk or human breast milk. If hydrolysed formulas are effective, to determine what type of hydrolysed formula is most effective including extensively and partially hydrolysed formulas. To determine which infants benefit, including infants at low or high risk of allergy and infants receiving early, short term or prolonged formula feeding.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. The review was updated with searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2006), MEDLINE (1966-March 2006), EMBASE (1980-March 2006) and CINAHL (1982-March 2006) and previous reviews including cross references.

SELECTION CRITERIA

Randomised and quasi-randomised trials that compare the use of a hydrolysed infant formula to human milk or cow's milk formula. Trials with >80% follow up of participants were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Eligibility of studies for inclusion, methodological quality and data extraction were assessed independently by each review author. Primary outcomes included clinical allergy, specific allergies and food intolerance. Meta-analysis was conducted using a fixed effects model.

MAIN RESULTS

Two trials compared early, short term hydrolysed formula to human milk feeding. No significant difference in infant allergy or childhood cow's milk allergy (CMA) were reported. No eligible trial compared prolonged hydrolysed formula to human milk feeding. Two trials compared early, short term hydrolysed formula to cow's milk formula feeding. No significant benefits were reported. One large quasi-random study reported a reduction in infant CMA of borderline significance in low risk infants (RR 0.62, 95% CI 0.38, 1.00). Ten eligible studies compared prolonged feeding with hydrolysed formula versus cow's milk formula in high risk infants. Meta-analysis found a significant reduction in infant allergy (seven studies, 2514 infants; typical RR 0.79, 95% CI 0.66, 0.94), but not in the incidence of childhood allergy (two studies, 950 infants; typical RR 0.85, 95% CI 0.69, 1.05). There was no significant difference in infant eczema (eight studies, 2558 infants, typical RR 0.84, 95% CI 0.68, 1.04), childhood eczema incidence (two studies, 950 infants, typical RR 0.83, 95% CI 0.63, 1.10), childhood eczema prevalence (one study, 872 infants; RR 0.66, 95% CI 0.43, 1.02), or infant or childhood asthma, rhinitis and food allergy. One study reported a significant reduction in infants with CMA with confirmed atopy (RR 0.36, 95% CI 0.15, 0.89). Subgroup analysis of trials blinded to formula found no significant difference in infant allergy (four studies, 2156 infants; typical RR 0.87, 95% CI 0.69, 1.08) or childhood allergy incidence (one study, 872 infants; RR 0.91, 95% CI 0.73, 1.14). No eligible trial examined the effect of prolonged hydrolysed formula feeding on allergy beyond early childhood. There is evidence that preterm or low birthweight infants fed a hydrolysed preterm formula have significantly reduced weight gain, but not in other growth parameters (head circumference or length). Studies in term infants report no adverse effects on growth. Subgroup analysis of trials of partially hydrolysed versus cow's milk formula found a significant reduction in infant allergy (six studies, 1391 infants; typical RR 0.79, 95% CI 0.65, 0.97) but not childhood allergy, or infant or childhood asthma, eczema or rhinitis. Methodological concerns were the same as for the overall analysis. Analysis of trials of extensively hydrolysed formula versus cow's milk formula found no significant differences in allergy or food intolerance. Infants fed extensively hydrolysed formula compared with partially hydrolysed formula had a significant reduction in food allergy (two studies, 341 infants; typical RR 0.43, 95% CI 0.19, 0.99), but there was no significant difference in all allergy or any other specific allergy incidence. Comparing extensively hydrolysed casein containing formula with cow's milk formula, one study (431 infants) reported a significant reduction in childhood allergy incidence (RR 0.72, 95% CI 0.53, 0.97). Meta-analysis found a significant reduction in infant eczema (three studies, 1237 infants; typical RR 0.71, 95% CI 0.51, 0.97). One study reported a significant reduction in childhood eczema incidence (RR 0.66, 95% CI 0.44, 0.98) and prevalence (RR 0.50, 95% CI 0.27, 0.92).

AUTHORS' CONCLUSIONS

There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant CMA. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.

Patterns of care and referral in children with atopic dermatitis and concern for food allergy

Although many providers believe that up to 30% of atopic dermatitis (AD) is food induced, food challenge studies show that food-induced eczematous reactions are rare. When food allergy is suggested to cause AD, it often leads to allergy testing with a high false-positivity rate, in turn further focusing parents on food allergy. Study subjects were children less than 11 years old with AD and food allergy suspicion. Prior diagnoses, provider, and testing patterns were assessed by questionnaire given to the parents. Thirty-eight patients with AD were enrolled. Most subject's parents suspected food allergy induced AD. Initial skin diagnoses were made by pediatricians (79%) and family practitioners (18%) as eczema. Allergy was suggested by providers as cause for AD in 63% of the present study's patients. Seventy-nine percent had allergy testing. Greater than 90% of parents claimed their children had food allergy and food-induced AD. Sixty-six percent had positive food allergy tests and 37% had definite history of immediate IgE reactions to food. The majority of this population had allergy suggested as causative for eczema by their primary care provider and were subsequently evaluated by allergist and allergy testing. Consensus about the role of food allergy between the different providers of AD in children would result in more effective, efficient, and less costly health care.

Food allergies: prevalence, molecular characterization, and treatment/prevention strategies

A significant proportion of the population is either affected by or concerned about food allergy. Our knowledge about food allergens and how they stimulate the immune system has increased dramatically over the past decade. However, reasons for the increased prevalence of food allergy are not clear. The diagnosis of food allergy requires that the patient and caregivers examine all foods for the presence of potential allergens in order to prevent inadvertent ingestion and further reactions. Fortunately, many children develop tolerance to allergenic foods after a period of dietary elimination. Various immunotherapy approaches are under investigation to alleviate or prevent food-induced reactions in those who have persistent food allergies.

Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology

OBJECTIVE

To make recommendations based on a critical review of the evidence for the timing of the introduction of solid foods and its possible role in the development of food allergy.

DATA SOURCES

MEDLINE searches using the following search algorithm: [weaning AND infant AND allergy]/[food allergy AND sensitization]/[dietary prevention AND food allergy OR allergens]/[Jan 1980-Feb 2006].

STUDY SELECTION

Using the authors' clinical experience and research expertise, 52 studies were retrieved that satisfied the following conditions: English language, journal impact factor above 1 or scientific society, expert, or institutional publication, and appraisable using the World Health Organization categories of evidence.

RESULTS

Available information suggests that early introduction can increase the risk of food allergy, that avoidance of solids can prevent the development of specific food allergies, that some foods are more allergenic than others, and that some food allergies are more persistent than others.

CONCLUSIONS

Pediatricians and allergists should cautiously individualize the introduction of solids into the infants' diet. With assessed risk of allergy, the optimal age for the introduction of selected supplemental foods should be 6 months, dairy products 12 months, hen's egg 24 months, and peanut, tree nuts, fish, and seafood at least 36 months. For all infants, complementary feeding can be introduced from the sixth month, and egg, peanut, tree nuts, fish, and seafood introduction require caution. Foods should be introduced one at a time in small amounts. Mixed foods containing various food allergens should not be given unless tolerance to every ingredient has been assessed.

Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child

BACKGROUND

Some breastfed infants with atopic eczema benefit from elimination of cow milk, egg, or other antigens from their mother's diet. Maternal dietary antigens are also known to cross the placenta.

OBJECTIVES

To assess the effects of prescribing an antigen avoidance diet during pregnancy or lactation, or both, on maternal and infant nutrition and on the prevention or treatment of atopic disease in the child.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2006) and contacted researchers in the field.

SELECTION CRITERIA

All randomized or quasi-randomized comparisons of maternal dietary antigen avoidance prescribed to pregnant or lactating women. We excluded trials of multimodal interventions that included manipulation of the infant's diet other than breast milk or of nondietary aspects of the infant's environment.

DATA COLLECTION AND ANALYSIS

We extracted data from published reports, supplemented by additional information received from the trialists we contacted.

MAIN RESULTS

The evidence from four trials, involving 334 participants, does not suggest a protective effect of maternal dietary antigen avoidance during pregnancy on the incidence of atopic eczema during the first 18 months of life. Data on allergic rhinitis or conjunctivitis, or both, and urticaria are limited to a single trial each and are insufficient to draw meaningful inferences. Longer-term atopic outcomes have not been reported. The restricted diet during pregnancy was associated with a slightly but statistically significantly lower mean gestational weight gain, a nonsignificantly higher risk of preterm birth, and a nonsignificant reduction in mean birthweight.The evidence from one trial, involving 26 participants, did not observe a significant protective effect of maternal antigen avoidance during lactation on the incidence of atopic eczema during the first 18 months.One crossover trial involving 17 lactating mothers of infants with established atopic eczema found that maternal dietary antigen avoidance was associated with a nonsignificant reduction in eczema severity.

AUTHORS' CONCLUSIONS

Prescription of an antigen avoidance diet to a high-risk woman during pregnancy is unlikely to reduce substantially her child's risk of atopic diseases, and such a diet may adversely affect maternal or fetal nutrition, or both. Prescription of an antigen avoidance diet to a high-risk woman during lactation may reduce her child's risk of developing atopic eczema, but better trials are needed. Dietary antigen avoidance by lactating mothers of infants with atopic eczema may reduce the severity of the eczema, but larger trials are needed.

Timing of initial exposure to cereal grains and the risk of wheat allergy

OBJECTIVE

Early exposure to solid foods in infancy has been associated with the development of allergy. The aim of this study was to examine the association between cereal-grain exposures (wheat, barley, rye, oats) in the infant diet and development of wheat allergy.

METHODS

A total of 1612 children were enrolled at birth and followed to the mean age of 4.7 years. Questionnaire data and dietary exposures were obtained at 3, 6, 9, 15, and 24 months and annually thereafter. The main outcome measure was parent report of wheat allergy. Children with celiac disease autoimmunity detected by tissue transglutaminase autoantibodies were excluded. Wheat-specific immunoglobulin E levels on children reported to have wheat allergy were obtained.

RESULTS

Sixteen children (1%) reported wheat allergy. Children who were first exposed to cereals after 6 months of age had an increased risk of wheat allergy compared with children first exposed to cereals before 6 months of age (after controlling for confounders including a family history of allergic disorders and history of food allergy before 6 months of age). All 4 children with detectable wheat-specific immunoglobulin E were first exposed to cereal grains after 6 months. A first-degree relative with asthma, eczema, or hives was also independently associated with an increased risk of wheat-allergy development.

CONCLUSIONS

Delaying initial exposure to cereal grains until after 6 months may increase the risk of developing wheat allergy. These results do not support delaying introduction of cereal grains for the protection of food allergy.

Effectiveness of education for control of house dust mites and cockroaches in Seoul, Korea

We evaluated the efficacy of health education in reducing indoor arthropod allergens in Seoul. The mite control measures comprised the use of mite-proof mattress and pillow coverings, regular washing of potentially infested materials, maintenance of a low humidity, removal of carpets, and frequent vacuum cleaning. Cockroach control measures included trapping, application of insecticides, and protecting food. Of 201 homes enrolled in October 1999, 63 volunteers were included in a 2-year follow-up survey between April 2000 and January 2002. Before intervention, the density of mites/g of dust varied greatly; 27.1/g in childrenos bedding, 20/g in adult bedding, 7.2/g on the floors of childrenos bedrooms, 6.8/g in sofas, 5.9/g on the floors of adultos bedrooms, 3.9/g on living room floors, 3.7/g in carpets, and 1.9 mites/g on kitchen floors. The predominant mite species and house percentages infested were; Dermatophagoides farinae 93%, D. pteronyssinus 9%, and Tyrophagus putrescentiae 8%. Comparing 1999 and 2001 infestations, before and after 25 mo of education, mite abundance was reduced by 98%, from 23.7 to 0.57 mites/g of dust. In 1999, cockroaches were detected in 62% homes: 36% Blattella germanica and 35% Periplaneta spp., including 9% double infestations of B. germanica and P. americana. Following intervention, cockroach infestation rates decreased to 22% of houses in 2000 and 23% in 2001. We conclude that continuous and repetitive health education resulted in the effective control of domestic arthropods.

Atopic dermatitis prevention

A shift in focus from disease therapy toward disease prevention is occurring in many medical specialties, including dermatology. There are no generally accepted strategies for the prevention of atopic dermatitis. Most research has focused on allergen avoidance and has not produced consistently effective interventions. Immune cell modulation and skin barrier protection are examples of new approaches that hold promise for preventing, or modifying the course of, this common disease.

Environmental and dietary risk factors for infantile atopic eczema among a Slovak birth cohort

Infantile atopic eczema (AE) is a risk marker for future asthma. This study assesses the contribution of modifiable exposures to infantile AE. If modifiable exposures contribute substantially to infantile AE, its prevention might be a sensible approach to asthma prevention. Pregnant women (n = 1978) were systematically recruited from maternity hospitals of the Slovak Republic; their birthed cohort of 1990 children were prospectively followed for 1 yr. Children's exposures to selected environmental and dietary factors were assessed via maternal questionnaires administered at delivery and 1 yr of age. A child was considered to have AE, based on physical examination (SCORAD index >2) or mother's report of a previous physician diagnosis. Multivariate logistic regression was used to calculate adjusted odds ratios and percent total regression scores (TRS) for each variable. At 1 yr of age 1326 (67%) of the children remained in the cohort and 207 (15.6%) developed AE. Various modifiable environmental and dietary exposures increased the likelihood of AE (ownership of cats; consumption of infant formula, eggs, and fish) while others decreased the likelihood of AE (ownership of livestock; exclusive breast feeding for > or =4 months). Overall, modifiable exposures contributed less to the TRS than did non-modifiable exposures (38% vs. 62%, respectively). The modifiable exposure category that contributed most to the TRS was infant feeding practices (27.5% TRS). Modifiable exposures -- especially those related to infant feeding practices -- significantly contribute to infantile AE, although modifiable factors contribute less overall than do non-modifiable exposures.

Timing of solid food introduction in relation to atopic dermatitis and atopic sensitization: results from a prospective birth cohort study

OBJECTIVE

Prophylactic feeding guidelines recommend a delayed introduction of solid foods for the prevention of atopic diseases. Scientific evidence for this is scarce. This study investigates whether a delayed introduction of solids (past 4 months or 6 months) is protective against the development of atopic dermatitis (AD) and atopic sensitization when considering reverse causality.

METHODS

Data from 2612 infants in an ongoing birth cohort study were analyzed at 2 years of age. Information on diet and on symptoms and diagnoses of AD was collected semiannually, and information on specific immunoglobulin E levels was collected at 2 years of age.

RESULTS

Solid food introduction past the first 4 months of life decreased the odds of symptomatic AD but not for doctor-diagnosed AD, combined doctor-diagnosed and symptomatic AD, or atopic sensitization. Postponing the introduction beyond the sixth month of life was not protective in relation to either definition of AD or atopic sensitization. There was also no evidence for a protective effect of a delayed introduction of solids on AD and atopic sensitization in children of atopic parents. There was clear evidence for reverse causality between early skin or allergic symptoms and the introduction of solids.

CONCLUSIONS

This study does not find evidence supporting a delayed introduction of solids beyond the sixth month of life for the prevention of AD and atopic sensitization. We cannot rule out that delaying the introduction of solids for the first 4 months of life might offer some protection. Measures to avoid reverse causality have to be considered in the conduction, analysis, and interpretation of cohort studies on the topic.

Intervention during pregnancy and allergic disease in the offspring

The etiology of allergy is multifactorial, with many variables contributing to the final expression of atopic disease. Three breeding grounds are needed to develop allergic disease: the appropriate genetic background, contact with the allergen(s) and environmental factors. Timing and dosing of allergen(s) are of major importance. Contact with (dietary) allergens and various agents such as tobacco smoke and infections occur not only during post-natal life, but also perinatally and even pre-natally. A critical review of published evidence regarding the impact of maternal exposure to antigens during pregnancy on later development of allergy in the offspring can only conclude that more research is urgently needed. Contact with multiple dietary allergens should be in general of benefit to the fetus to develop tolerance. Current knowledge suggests that pregnant women should have a normal diversified diet, avoiding toxic agents such as tobacco and alcohol. The role of maternal intake of poly-unsaturated fatty acids on the development of atopy in the infants needs to be further evaluated. If parental history would be insufficient to determine the fetal risk, preventive measurements would be advisable for all fetuses.

Total serum IgE levels in a large cohort of patients with severe or difficult-to-treat asthma

BACKGROUND

Limited data are available on levels of IgE in large cohorts of patients with severe or difficult-to-treat asthma.

OBJECTIVE

To examine IgE levels and disease in patients from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study.

METHODS

From January 2001 to October 2001, 4,923 patients were screened for inclusion in the study. Of these, 4,756 patients 6 years or older with severe or difficult-to-treat asthma were enrolled and completed a baseline study visit. Total serum IgE levels were measured at the baseline visit and are summarized by geometric means.

RESULTS

The mean total IgE level of the population is 106.6 IU/mL (95% confidence interval, 101.5-112.0 IU/mL). Children (6-12 years old) and adolescents (13-17 years old) have higher mean IgE levels than adults (> or =18 years old) (P < .001). Males have a higher mean IgE level than females (P < .001). IgE levels are higher among nonwhite patients than white patients (P < .001). Current smokers have higher IgE levels than past smokers or never smokers (P < .001). Among children, patients with severe asthma have a higher mean IgE level (280.2 IU/mL) than patients with moderate (145.8 IU/mL) or mild (137.8 IU/mL) asthma (P < .001). Among adults, patients with childhood-onset asthma have higher IgE levels (124.3 IU/mL [n = 1,348]) than patients with adult-onset asthma (65.7 IU/mL [n = 1,956]) (P < .001).

CONCLUSION

In patients with severe or difficult-to-treat asthma from the TENOR study, higher total IgE levels were observed in males, children, smokers, nonwhite racial/ethnic groups, and adults with childhood-onset disease. In addition, IgE levels are associated with asthma severity among younger patients.

Primary prevention of allergy and asthma is possible

Allergic diseases, such as asthma, are the result of complex gene-environment interactions. The focus for prevention of allergic disease has been on environmental control. Environmental exposures begin during the intrauterine period, during which a T-helper-2 immune phenotype is promoted. Food allergy frequently occurs during the first year of life, and avoidance of exposure must begin in early pregnancy and must be complete to be effective. Partial avoidance strategies have not been successful. Current data do not allow us to specifically recommend breastfeeding for the prevention of allergy and allergic diseases, but for other important reasons, breastfeeding (particularly exclusive breastfeeding) should be encouraged for at least the first 4 mo of life. Sensitization to allergens is one of the strongest determinants for subsequent development of asthma. There is a strong relationship between exposure to house dust mites, allergen sensitization, and asthma. However, exposure to pets and animals in a farming environment early in life may actually be protective for the development of allergy and asthma. Specific recommendations relating to these exposures requires additional research, but genetics clearly plays an important role in that process. To date, only a multifaceted intervention program has been successful as a primary prevention strategy for the development of asthma in young children. The specific components of the multifaceted intervention and the duration of protection have not yet been defined. It is increasingly clear that gene-directed environmental manipulation undertaken in a multifaceted manner during a "window of opportunity" is critical in the primary prevention of allergy and allergic diseases like asthma.

Allergic rhinoconjunctivitis: epidemiology

Allergic rhinoconjunctivitis has been studied much less frequently than asthma using epidemiologic approaches. Population-based studies are difficult to conduct because of misclassification arising from the reliance on self-reported questionnaires that use terms such as allergic rhinitis or hay fever to establish the diagnosis. In addition, many epidemiologic studies focus on diagnostic skin testing or allergen-specific IgE antibodies (RASTs) as an objective outcome to assess for hay fever. These techniques are helpful but not perfect measures for predicting hay fever outcomes in epidemiologic studies. It is generally accepted, however, that allergic rhinoconjunctivitis is one of the most common of chronic diseases and is the most common atopic disorder. This article reviews the definition of allergic rhinoconjunctivitis, the epidemiology of this disorder from infancy into adulthood, and environmental risk factors for development of sensitization to certain allergens.

The atopic march: the pattern of allergic disease development in childhood

The sequential development of allergic disease manifestations during early childhood is often referred to as the atopic march. Various epidemiologic and birth-cohort studies have begun to elucidate the evolution of allergic disease manifestations and to identify populations at risk for disease. These studies, along with intervention studies, emphasize the effects of environmental factors and genetic predisposition on the atopic march. This article discusses the populations at risk for the development of atopic conditions and the interventions that have been explored in attempts to modify the progression of allergic disease.

Differences in race, ethnicity, and socioeconomic status in schoolchildren dispensed injectable epinephrine in 3 Massachusetts school districts

BACKGROUND

Published surveys depicting the increase in the incidence of food allergy, especially peanut or tree nut allergy, in children have not reported any differences in race, ethnicity, or socioeconomic status.

OBJECTIVE

To analyze the demographics of schoolchildren with diverse racial, ethnic, and socioeconomic characteristics dispensed injectable epinephrine.

METHODS

School nurses in 44 schools enrolling 21,875 students recorded the characteristics of students dispensed injectable epinephrine in the 2003-2004 school year. Surveyed school districts included 2 affluent suburban districts enrolling 5,855 students (> 92% white) and 1 urban district enrolling 16,020 students (60% nonwhite).

RESULTS

A total of 181 students in all 3 districts were dispensed injectable epinephrine; 118 of these children had peanut or tree nut allergy. Males were more likely to be dispensed injectable epinephrine than females (odds ratio [OR], 1.44; P < .02). Whites were more likely to have been dispensed injectable epinephrine than nonwhites (OR, 4.76; P < .001). Whites were nearly 5 times more likely to be dispensed injectable epinephrine for peanut or tree nut allergy than nonwhites (OR, 4.5; P < .001). Most students (75%) dispensed injectable epinephrine for peanut or tree nut allergy were enrolled in prekindergarten through grade 5 (P < .001). Whites were more likely than nonwhites to be dispensed injectable epinephrine for stinging insect allergy (OR, 8.7; P < .001).

CONCLUSIONS

This study found significant racial, ethnic, and socioeconomic differences in the prevalence of childhood allergic disorders, especially peanut or tree nut allergy, requiring prescribed injectable epinephrine in a school setting. Additional studies are needed to determine whether minority children are being underdiagnosed or undertreated for allergic disorders requiring injectable epinephrine or whether they truly have a lower incidence of such allergic disorders.

The Australasian Society of Clinical Immunology and Allergy position statement: Summary of allergy prevention in children

A family history of allergy and asthma identifies children at high risk of allergic disease. Dietary restrictions in pregnancy are not recommended. Avoiding inhalant allergens during pregnancy has not been shown to reduce allergic disease, and is not recommended. Breastfeeding should be recommended because of other beneficial effects, but if breast feeding is not possible, a hydrolysed formula is recommended (rather than conventional cow's milk formulas) in high-risk infants only. Maternal dietary restrictions during breastfeeding are not recommended. Soy formulas and other formulas (eg, goat's milk) are not recommended for reducing food allergy risk. Complementary foods (including normal cow's milk formulas) should be delayed until a child is aged at least 4-6 months, but a preventive effect from this measure has only been demonstrated in high-risk infants. There is no evidence that an elimination diet after age 4-6 months has a protective effect, although this needs additional investigation. Further research is needed to determine the relationship between house dust mite exposure at an early age and the development of sensitisation and disease; no recommendation can yet be made about avoidance measures for preventing allergic disease. No recommendations can be made about exposure to pets in early life and the development of allergic disease. If a family already has pets it is not necessary to remove them, unless the child develops evidence of pet allergy (as assessed by an allergy specialist). Women should be advised not to smoke while pregnant, and parents should be advised not to smoke. No recommendations can be made on the use of probiotic supplements (or other microbial agents) for preventing allergic disease at this time. Immunotherapy may be considered as a treatment option for children with allergic rhinitis, and may prevent the subsequent development of asthma.

Ontogeny of the Allergic Inflammatory Response

The ability to produce allergic responses begins early in fetal life along with the development of other elements of the immune system. Among the most interesting questions related to the development of allergic disease are whether the fetus in utero commonly is exposed to sufficient allergen to induce IgE production and how much the mother's immune responses affect the developing fetal immune system. After birth, it seems that many factors, including the frequency and severity of infections and the timing and intensity of allergen and animal exposures, continue to influence immune development.

The Wheezing Illnesses Study Leidsche Rijn (WHISTLER): rationale and design

The Wheezing Illnesses Study Leidsche Rijn (WHISTLER) was initiated in December 2001 as a single-centre prospective birth cohort study and will include a population-based sample of at least 2000 healthy newborns. The aims of WHISTLER are to investigate determinants for wheezing illnesses (including neonatal lung function, viral infections, asthma-susceptibility genes and endotoxin exposure) and to derive a comprehensive risk score, that is appropriate for use in primary health care and allows for efficient planning of early preventive strategies. Baseline examination includes a questionnaire evaluating known risk factors for wheezing illnesses; anthropometric measurements; measurements of infant and parental lung function; and sampling of infant and parental DNA. Participants will be followed for respiratory events using data from a daily respiratory symptom questionnaire; visits to the general practitioner (primary health care visits, drugs prescriptions and hospital referral); viral sampling during wheezing episodes; and house dust sampling. Based on actual neonatal care practice and embedded in a larger epidemiological study, the Utrecht Health Project, WHISTLER will provide an unique framework to address issues in childhood respiratory disease that are currently insufficiently understood. In particular, WHISTLER will provide a well-balanced view on the prognostic power of neonatal lung function and genetic and environmental factors (including viral infections and endotoxin exposure) to predict wheezing illnesses from birth to young adulthood and beyond. In the scope of prevention, WHISTLER is expected to support the design of solid based prevention measures to reduce respiratory morbidity, mortality and associated costs, and to improve quality of life.

Atopic characteristics of children with recurrent wheezing at high risk for the development of childhood asthma

BACKGROUND

Few studies have characterized the atopic profile of toddler-aged children with recurrent wheezing at high risk of the development of persistent asthma. Objective We sought to determine the atopic profile of toddler-aged children with frequent wheeze at high risk for the development of persistent asthma who either had a parental history of asthma, a personal history of atopic dermatitis, or both.

METHODS

Participants enrolled in the Prevention of Early Asthma in Kids study (n = 285) on the basis of a modified Asthma Predictive Index were characterized on the basis of allergy and asthma questionnaire responses and allergy skin puncture test results.

RESULTS

The majority of the children (60.7%, n = 148) were sensitized to either food or aeroallergens. Male children were significantly more likely to be sensitized to aeroallergens ( P = .03) and to have a blood eosinophil level of 4% or greater ( P = .03) and a total serum IgE level of greater than 100 IU/mL ( P = .0004). Additionally, eosinophilia and total serum IgE level had the strongest correlation with aeroallergen sensitization.

CONCLUSION

The high prevalence of aeroallergen sensitization in this high-risk cohort suggests that aeroallergens might have an important role in the early development of asthma. As such, the Prevention of Early Asthma in Kids cohort appears to be an appropriate cohort in which to test whether early intervention with an inhaled corticosteroid can significantly attenuate, or perhaps even prevent, the allergic march from the initial stages of allergic sensitization to the subsequent development of asthma in toddlers with episodic wheezing.

A review of the effects of breastfeeding on respiratory infections, atopy, and childhood asthma

The etiology of childhood asthma is not fully understood. Early exposure to certain respiratory infections may be protective for atopy and/or asthma whereas some infections have been suggested to exert the opposite effects. Wheezing lower respiratory illness (LRI) in the first year of life and atopy are independently associated with increased risk for current asthma in childhood and their effects are mediated via different causal pathways. These risk factors are multiplicative when they operate concommitantly within individual children. Exclusive breastfeeding protects against asthma via effects on both these pathways, as well as through other as yet undefined mechanisms. Furthermore, exclusive breastfeeding may protect against asthma and may reduce the incidence of lower respiratory illness, especially respiratory syncytial virus (RSV). We have previously demonstrated a protective effect of exclusive breastfeeding on asthmatic traits in children. The aim of this review was to clarify this protective association from intermediate associations with respiratory infections, atopy, or through other facets of breastfeeding. The bioactivity of breast milk and subsequent pathways that may act upon the development of asthma in children are explored.

Vitamin C in breast milk may reduce the risk of atopy in the infant

OBJECTIVE

To assess the effects of maternal dietary and supplement intake of vitamins C and E on breast milk antioxidant composition (vitamin C, alpha-tocopherol and beta-carotene) and their protective potential against the development of atopy in the infant.

DESIGN, SUBJECTS AND METHODS

Mothers with atopic disease were recruited at the end of gestation and maternal sensitization was assessed by skin-prick testing. The 4-day food records of the mothers and breast milk samples were collected at the infants' age of 1 month. Infants' atopy was defined by the presence of atopic dermatitis during the first year of life and a positive skin-prick test reaction at 12 months of age (n=34).

RESULTS

Maternal intake of vitamin C in diet but not as supplement was shown to determine the concentration of vitamin C in breast milk. A higher concentration of vitamin C in breast milk was associated with a reduced risk of atopy in the infant (OR=0.30; 95% CI 0.09-0.94; P=0.038), whereas alpha-tocopherol had no consistent relationship with atopy. The group at risk of suboptimal vitamin C supply from breast milk was identified as infants whose mothers suffer from food hypersensitivity.

CONCLUSION

A maternal diet rich in natural sources of vitamin C during breastfeeding could reduce the risk of atopy in high-risk infants.

Hypoallergenic formulas--when, to whom and how long: after more than 15 years we know the right indication!

Hypoallergenic formulas are processed by enzymatic hydrolysis of different protein sources such as bovine casein/whey and soy followed by further processing such as heat treatment and/or ultrafiltration, or they are based on amino acid mixtures. The products have been classified according to the degree of protein hydrolysis as 'extensively' or 'partially' hydrolysed protein products. Product properties may be characterized by biochemical techniques, and reduction of allergenicity may be assessed in vitro with various immunological methods, and in vivo with skin prick tests, patch tests and challenge tests. In vitro tests do not predict the allergenic effects in humans, and at present there is no evidence of a specific threshold of immunogenic protein. Only pure amino acid mixtures are considered to be nonallergenic. Other 'hypoallergenic' products contain residual allergenicity. At present, the potential of a product for treatment and prevention of food allergy can only be determined by clinical trials using scientifically appropriate standards. It has been recommended that dietary products for treatment of cow's milk protein allergy in infants should be tolerated by at least 90% (with 95% confidence) of infants with documented cow's milk protein allergy. Some extensively hydrolysed products and amino-acid-based products have met these criteria. Formulas intended for prevention should have a very low, if any, allergenic activity until otherwise proven. So far there are no firm criteria available for the design of hypoallergenic foods for prevention. Newborns included in prevention studies should be from high-risk families; they should be randomized at birth and fed the formula when supplements are needed for at least the first 4-6 months of life. Follow-up should be at least 18 months, and children should be investigated when symptoms appear. Validated clinical criteria, including controlled food challenges, should be used for diagnosis. Infants fed formulas that claim to prevent or delay allergy should have a statistically significant lower prevalence of allergy when compared with infants fed a standard cow's milk formula. Feeding high-risk infants a documented hypoallergenic formula combined with avoidance of solid foods during the first 4-6 months reduces the cumulative incidence of cow's milk protein allergy and atopic dermatitis as compared with a standard cow's-milk-based formula. Partially hydrolysed formulas may have an effect, though it seems to be less than that of extensively hydrolysed formulas at present. Thus, if exclusive breast-feeding for 4-6 months is not possible in high-risk infants, a documented hypoallergenic formula and avoidance of solid foods are recommended for the first 4 months of life.

Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations

The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light on this issue, a group of experts of the Section of Pediatrics EAACI reviewed critically the existing literature on the subject. An analysis of published peer-reviewed observational and interventional studies was performed following the statements of evidence as defined by WHO. The results of the analysis indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is unequivocally effective in the prevention of allergic diseases in high-risk children. In these patients breastfeeding combined with avoidance of solid food and cow's milk for at least 4-6 months is the most effective preventive regimen. In the absence of breast milk, formulas with documented reduced allergenicity for at least 4-6 months should be used.

How atopic is atopic dermatitis?

BACKGROUND

The extent to which the phenotype of atopic dermatitis (AD) is truly atopic has been the subject of much debate.

OBJECTIVE

We sought to systematically evaluate the evidence for the value of measurement of IgE antibodies in diagnosing AD and whether knowledge of IgE sensitization increases clinical diagnostic and predictive ability.

METHODS

We searched Medline from its inception until September 2003. Only studies that measured atopy as either skin prick test positivity or IgE-antibody sensitization to environmental allergens were included within a descriptive analysis. Because the small number of studies of adequate quality did not allow a formal meta-analysis, we assigned strength of evidence according to predefined quality criteria and ranked studies accordingly.

RESULTS

Inclusion of atopy as part of the diagnostic criteria for AD did not enhance the criteria's sensitivity and specificity in relation to the clinical phenotype of AD. The strength of association between atopy and AD varied significantly between hospital studies (47% to 75%; n=14 studies) and was stronger in hospital than in community populations (7.4% to 78%; n=13 studies). Whereas study quality did not have an effect on atopy prevalence in hospital populations, low atopy prevalences in community surveys were seen in less rigidly conducted studies. AD severity was positively associated with the number of positive skin prick test responses or IgE-antibody levels in 7 of 8 studies that measured both. Only one study suggested that IgE-specific sensitization to hen's egg is associated with subsequent development of AD, and 2 studies found that allergen-specific IgE sensitization in patients with AD is a prognostic marker for allergic airway disease in later life. Atopy-associated AD might also have a worse long-term prognosis than AD that is not associated with atopy.

CONCLUSION

Although atopy is clearly associated with AD, the role of IgE sensitization in AD needs further study. Current evidence suggests that up to two thirds of persons with AD are not atopic, which implies that continued use of the term atopic dermatitis is problematic. Longitudinal studies are needed to compare the treatment response and prognosis of IgE-associated and non-IgE-associated AD.

The Prevention of Early Asthma in Kids study: design, rationale and methods for the Childhood Asthma Research and Education network

Pediatric asthma remains an important public health concern as its prevalence and cost to the health care system is rising. In order to promote innovative research in asthma therapies, the National Heart, Lung and Blood Institute created the Childhood Asthma Research and Education Network in 1999. As its first study, the steering committee of the Childhood Asthma Research and Education Network designed a randomized clinical trial to determine if persistent asthma could be prevented in children at a high risk to develop the disease. This communication presents the design of its first clinical trial, the Prevention of Asthma in Kids (PEAK) trial and the organization of the Childhood Asthma Research and Education Network that developed and implemented this trial. Studies of the natural history of asthma have shown that, in persistent asthma, the initial asthma-like symptoms and loss of lung function occur predominately during the first years of life. Therefore, in the Prevention of Asthma in Kids study, children 2 and 3 years old with a positive asthma predictive index were randomized to twice daily treatment with fluticasone 88 microg or placebo via metered-dose inhaler and Aerochamber for 2 years. The double blind treatment period was followed by a 1-year observational period. Lung function was measured by spirometry and oscillometry technique at 4-month intervals throughout the study. Bronchodilator reversibility and exhaled nitric oxide (ENO) studies were performed at the end of the treatment and observation periods. The primary outcome measure was the number of asthma-free days. Other secondary outcomes included number of exacerbations, use of asthma medications and lung function. These measures were chosen to reflect the progression of the disease from intermittent wheezing to persistent asthma and measurement of the extent of airflow limitation and airway reactivity.

Allergy to banana in a 5-month-old infant

Food proteins can sensitize the infants via different sources. A 5-month-old boy suffered three episodes of generalized urticaria 20 min after the ingestion of a fruit purée containing apple, banana and orange. Skin testing showed positive results to banana and chestnut. Other tests were negative. The value of specific immunoglobulin E (Pharmacia CAP-FEIA, Uppsala, Sweden) to banana was 58 KU/l, to orange was 9.7 KU/l, to chestnut was 5.6 KU/l and to latex was 1.6 KU/l. Orange, apple and latex products were well tolerated. He never had eaten chestnut. The parents rejected a banana challenge test. The route of sensitization in our case might be via placenta, breast-milk, and inadvertent oral intake of food or even via inhalation. An early frequent exposure to banana allergens was considered a possibility factor for the development of banana sensitization. We found that the banana consumption during pregnancy and lactation by the mother of our patient was greater than usual. It is not frequent to find so high levels of sensitization to any fruit in first year of life. In our case, latex, chestnut and orange sensitizations did not seem to be clinically relevant. However, latex and foods known to cross-react with banana antigens should be given to banana-sensitive individuals with great caution.

[Atopic dermatitis. Allergological characteristics and association with respiratory disease]

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that frequently precedes the development of asthma or other respiratory allergies. The aim of this study was to review allergen sensitization, type of feeding in infancy, and development of asthma or rhinitis in a group of patients with AD.

METHODOLOGY

One hundred children with AD were selected. All patients underwent skin prick and patch tests to foodstuffs and inhalant allergens, total and specific IgE determination, and oral challenge tests.

RESULTS

The study included 57 boys and 43 girls. The mean age at consultation was 3.77 +/- 2.81 years and mean age at onset of of AD was 1.09 +/- 1.69 years. Twenty-eight percent of the children were exclusively sensitized to food allergens, 20% to inhalant allergens and 22% to both food and inhalant allergens. Mean serum IgE levels were higher in children sensitized to Dermatophagoides pteronyssinus (DPT) (346.86 +/- 430.43 U/ml) than in non-sensitized children (78.24 +/- 132.93 U/m) (p < 0.001). Total IgE levels were also higher in patients with respiratory symptoms (283.77 +/- 336.53 U/ml) than in children without respiratory disease (124.62 +/- 285.21 U/ml) (p = 0.021). Thirty-five percent of the children developed some kind of respiratory allergic disease (asthma and/or rhinitis) in a mean interval of 2.55 years after the onset of dermatitis. Of the children sensitized to inhalant allergens (DPT), 55.26 % developed respiratory symptoms compared with 22.58 % of the non-sensitized children (p < 0.001). The odds ratio of developing respiratory allergy if the patient showed sensitization to DPT was 4.235 (95 % CI 1.768-0.147, p = 0.002).

CONCLUSIONS

Children with AD that develops in the first year of life, associated with high IgE levels and early sensitization, independently of the kind of feeding, develop respiratory allergic disease more frequently than children without these factors.

The effects of exclusion of dietary egg and milk in the management of asthmatic children: a pilot study

Current understanding of the use of exclusion diets in the management of asthma in children is limited and controversial. The aim of this study was to examine the effects of excluding eggs and milk on the occurrence of symptoms in children with asthma and involved 22 children aged between three and 14 years clinically diagnosed as having mild to moderate disease. The investigation was single blind and prospective, and parents were given the option of volunteering to join the 'experiment' group, avoiding eggs, milk and their products for eight weeks, or the 'control' group, who consumed their customary food. Thirteen children were recruited to the experimental group and nine to the control group. A trained paediatrician at the beginning and end of the study period assessed the children. A seven-day assessment of food intake was made before, during and immediately after the period of dietary intervention in both groups. A blood sample was taken from each child for determination of food specific antibodies and in those children who could do so, the peak expiratory flow rate (PEFR) was measured. Based on the recommended nutrient intake (RNI), the mean percentage energy intake of the children in the experimental group was significantly lower (p < 0.05) in the experimental group. After the eight-week study period and compared with baseline values, the mean serum anti-ovalbumin IgG and anti-beta lactoglobulin IgG concentrations were statistically significantly reduced (p < 0.05) for both in the experimental group. In contrast, the values for anti-ovalbumin IgG in the control group were significantly increased and those for anti-beta lactoglobulin IgG were practically unchanged. The total IgE values were unchanged in both groups. Over the study period, the PEFR in those children in the experimental group able to perform the test was significantly increased, but no such change was noted in the children in the control group who could do the test. These results suggest that even over the short time period of eight weeks, an egg- and milk-free diet can reduce atopic symptoms and improve lung function in asthmatic children.

Preventing food allergy

In this review, we examine the critical periods of immune development and how these might be modified to prevent food allergy. The relevant dietary intervention studies, roles of microorganisms and their products, and other strategies are critically analyzed. Additionally, we highlight the potential importance of different routes of allergic sensitization and the role of oral tolerance induction in the pathogenesis and prevention of food allergy.

The introduction of solids in relation to asthma and eczema

BACKGROUND

Despite scarce scientific evidence, current feeding guidelines recommend delayed introduction of solids for the prevention of asthma and allergy.

AIMS

To explore whether late introduction of solids is protective against the development of asthma, eczema, and atopy.

METHODS

A total of 642 children were recruited before birth and followed to the age of 5(1/2) years. Main outcome measures were: doctor's diagnosis of eczema ever, atopy according to skin prick test results against inhalant allergens, preschool wheezing, transient wheezing, all defined at age 5-5(1/2) years. Introduction of solids as main exposure measure was assessed retrospectively at age 1 year.

RESULTS

There was no evidence for a protective effect of late introduction of solids for the development of preschool wheezing, transient wheezing, atopy, or eczema. On the contrary, there was a statistically significant increased risk of eczema in relation to late introduction of egg (aOR 1.6, 95% CI 1.1 to 2.4) and milk (aOR 1.7, 95% CI 1.1 to 2.5). Late introduction of egg was furthermore associated with a non-significant increased risk of preschool wheezing (aOR 1.5, 95% CI 0.92 to 2.4). There was no statistical evidence of feeding practices playing a different role in the development of asthma and eczema after stratification for parental asthma and atopy status.

CONCLUSIONS

Results do not support the recommendations given by present feeding guidelines stating that a delayed introduction of solids is protective against the development of asthma and allergy.

Eczema and early solid feeding in preterm infants

AIMS

To establish whether development of eczema is influenced by feeding practices in preterm infants, while taking account of confounding factors.

METHODS

Data were assembled from 257 infants born prematurely and studied to 12 months post-term. Logistic regression analysis was performed to establish the association between feeding practices and eczema, allowing for potential confounding factors including the infants' gender, parental atopic status, social background, and parental smoking habits.

RESULTS

For the development of eczema (with or without other symptoms) by 12 months post-term, the introduction of four or more solid foods by or before 17 weeks post-term was a significant risk (odds ratio 3.49). Male infants were at significantly higher risk (odds ratio 1.84). In addition, having non-atopic parents who introduced solid foods before 10 weeks post-term or having at least one atopic parent represented a significant risk scenario (odds ratio 2.94).

CONCLUSIONS

Early introduction of a diverse range of solid foods may predispose the preterm infant to eczema development by 12 months post-term. Furthermore, non-atopic parents who practice early as opposed to late introduction of solid foods may be exposing preterm infants to a greater risk of eczema by 12 months post-term.

N-3 polyunsaturated fatty acids and allergic disease

PURPOSE OF REVIEW

With escalating rates of allergic disease, it is vital to explore novel causal pathways. This review examines the evidence for a potential role of changing dietary intake of omega-3 polyunsaturated fatty acids in the development, treatment and prevention of allergic diseases.

RECENT FINDINGS

Although it is difficult to determine the contribution of altered (decreased) dietary intake of omega-3 polyunsaturated fatty acids to the recent rise in the incidence of allergic disease, there is growing evidence that these nutrients have antiinflammatory properties and may modulate immune responses. These fatty acids have few side effects, and may be of some benefit in established allergic diseases (such as asthma and atopic dermatitis), although these effects are not strong. Because of this limited efficacy in established disease, the focus has shifted to the potential benefits of these immune modulators in earlier life for disease prevention. Two recent preliminary reports in infants suggest that dietary omega-3 polyunsaturated fatty acid supplements in pregnancy or in the early postnatal period could have immunomodulatory properties and associated clinical effects, although more studies are now needed. Novel synthetic polyunsaturated fatty acids with more potent and selective antiinflammatory effects may also provide safe therapeutic and preventive strategies in the future.

SUMMARY

Dietary factors are important but still under-explored candidates in the search for environmental strategies to reduce the enormous impact of allergic diseases in modernized societies. There is an ongoing need for further research into the role of omega-3 polyunsaturated fatty acids in allergic disease, particularly in early life before atopy is established.

Addressing the prevalence of respiratory allergy in the home environment

Respiratory allergy prevalence has always depended both on genetic predisposition and specific environmental allergenic stimulation that leads to sensitization and eventual symptomatic disease. Changes brought about by modern technology that have afforded a higher quality of life have also accidentally increased the levels of many respirable and ingestible allergens in the environment. In many cases these higher levels of exposure have exceeded individual thresholds, resulting in the phenotypic expression of allergy in many individuals who were previously asymptomatic even though they were genotypically predisposed to developing allergies. Prevalence can be decreased only if susceptible populations are identified as early as possible through careful family history taking and appropriate testing for sensitivity and if exposure to selected allergens is controlled.

Can we prevent allergy?

Allergic conditions continue to increase steeply. The last two decades have seen many prevention trials, studying the effect of dietary and environmental interventions. These trials have yielded invaluable information about the atopic march and also highlighted the need for a clear and commonly used nomenclature as well as a need for better outcome measures. This review discusses primary and secondary prevention studies and their results.

Does environment mediate earlier onset of the persistent childhood asthma phenotype?

OBJECTIVE

We investigated the role of environmental and hereditary factors in determining whether persistent childhood wheezing phenotypes had an early or late onset.

METHODS

In a whole population birth cohort (n = 1456), children were seen at birth and at 1, 2, 4, and 10 years. At each visit, information was collected prospectively regarding wheeze prevalence and used to classify subjects into wheezing phenotypes. Information on genetic and environmental risk factors in early life was also obtained prospectively, and skin-prick testing to common allergens was performed at 4 years.

RESULTS

Early-onset persistent wheezers (n = 125) had wheeze onset in the first 4 years, still present at age 10, whereas late-onset persistent wheezers (n = 81) had wheeze onset after age 4 years that was still present at 10 years. Multivariate logistic regression analysis identified independent significance only for inherited factors (parental asthma, family history of rhinitis, eczema at 4 years, and atopic status at 4 years) in the development of late-onset persistent wheeze. However, low social class at birth, recurrent chest infections at 2 years, and parental smoking at 2 years plus inherited factors (eczema at 2 years; food allergy at 4 years; maternal asthma, sibling asthma, maternal urticaria, and atopic status at 4 years) demonstrated independent significance for early-onset persistent wheeze.

CONCLUSION

Inheritance seems to be of prime significance in the cause of persistent childhood wheeze. Environmental exposure in early life may combine with this tendency to produce an early onset of persistent wheeze. Absence of these environmental factors might delay but not prevent the onset of wheeze in children with atopic heredity.

Prenatal prediction of infant atopy by maternal but not paternal total IgE levels

BACKGROUND

The atopic history of parents has long been used to predict infant atopy. However, bias from questionnaires of allergic history are also frequently suspected, because a large number of vasomotor rhinitis, intrinsic asthma, and seborrheic dermatitis cases are probably misinterpreted to be atopic diseases.

OBJECTIVE

We attempted to identify a risk factor other than parental atopic history to predict elevated infant IgE levels and infant atopy.

METHODS

A total of 655 core families were prenatally recruited, and finally 545 families completed the study for the prospective analysis of infant atopy at 6 months of age. Atopic history and blood samples of parents were collected in the third trimester during pregnancy. Cord blood (CB) was collected immediately after birth. Infant blood samples and history of infant eczema were collected in the 6-month physical checkup clinic. Blood total IgE and specific IgE levels were determined by use of the Pharmacia CAP system.

RESULTS

In univariate analysis, maternal, but not paternal, atopic history correlated with elevated CB IgE levels and the occurrence of infant eczema. Elevated maternal, but not paternal, total IgE levels (>150 KU/L) significantly correlated with increases of CB IgE levels (median, 0.54 vs 0.17 KU/L, P <.001), infant IgE levels (log-transformed mean values, 1.32 +/- 0.51 vs 1.13 +/- 0.51 KU/L, P <.001), and infant eczema (P =.008). Multivariate logistical regression analysis, however, showed that only maternal total IgE levels correlated with CB and infant IgE levels and the development of infant eczema.

CONCLUSIONS

The maternal, but not paternal, total IgE level correlates with elevated infant IgE levels and infant atopy. This provides a high specificity (83%) and a sensitivity of 34% for prediction of infant atopy. This suggests that maternal factors, placental factors, or both have an impact on perinatal allergic sensitization.