Infant feeding and allergy prevention: a review of current knowledge and recommendations. A EuroPrevall state of the art paper

Consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition: COCO 2023

Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

Different Patterns of Foods Triggering FPIES in Germany

BACKGROUND

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food allergy mainly affecting infants and young children. Allergic FPIES reactions differ from IgE-mediated food allergies, for example, regarding elicitors and clinical course.

OBJECTIVE

The aim of our study was to describe causative agents and development of tolerance in German children with FPIES.

METHODS

We conducted a retrospective survey on children with FPIES from 14 centers in Germany assessing a 6-year period.

RESULTS

We analyzed 142 patients with 190 FPIES reactions, 130 of which met acute FPIES criteria and 60 were defined as chronic FPIES. The most frequent eliciting food for acute FPIES was cow's milk, followed by fish, vegetables (eg, potato, pumpkin), meats (eg, beef), and grains. A total of 119 children reacted to 1 food only, 16 children to 2 or 3 foods, and 7 children to ≥4 foods. In chronic FPIES, all but 4 exclusively breastfed infants reacted to cow's milk feeding. IgE sensitization to the triggering food was found in 21 of 152 (14%) cases. Two children developed additional IgE-mediated symptoms upon a food challenge. Time to proof of tolerance was shortest in cow's milk-induced FPIES, and it was shorter in chronic than in acute FPIES.

CONCLUSION

In our national survey, we identified triggers for acute FPIES that partially differ from those reported internationally. Mainly foods introduced early in infant nutrition triggered acute reactions. Time to proven tolerance was shown to be contingent on FPIES symptomatology and on the triggering food. These data should be considered regarding nutritional advice for infants with FPIES.

Pediatric Obesity-Related Asthma: The Role of Nutrition and Nutrients in Prevention and Treatment

Childhood obesity rates have dramatically risen in numerous countries worldwide. Obesity is likely a factor in increased asthma risk, which is already one of the most widespread chronic respiratory pathologies. The pathogenic mechanism of asthma risk has still not yet been fully elucidated. Moreover, the role of obesity-related inflammation and pulmonary overreaction to environmental triggers, which ultimately result in asthma-like symptoms, and the importance of dietary characteristics is well recognized. Diet is an important adjustable element in the asthma development. Food-specific composition of the diet, in particular fat, sugar, and low-quality nutrients, is likely to promote the chronic inflammatory state seen in asthmatic patients with obesity. An unbalanced diet or supplementation as a way to control asthma more efficiently has been described. A personalized dietary intervention may improve respiratory symptoms and signs and therapeutic response. In this narrative review, we presented and discussed more recent literature on asthma associated with obesity among children, focusing on the risk of asthma among children with obesity, asthma as a result of obesity focusing on the role of adipose tissue as a mediator of systemic and local airway inflammation implicated in asthma regulation, and the impact of nutrition and nutrients in the development and treatment of asthma. Appropriate early nutritional intervention could possibly be critical in preventing and managing asthma associated with obesity among children.

A systematic review of infant feeding food allergy prevention guidelines - can we AGREE?

Food allergy is a significant issue worldwide, particularly in Westernised countries. There is no clear explanation why food allergy appears to have increased so rapidly in recent years, particularly in young children, hence ongoing research to identify effective primary prevention strategies. Food allergy prevention guidelines for health professionals have been developed based on existing clinical trial evidence for effective translation and implementation. As these guidelines underpin clinical practice, it is important to ensure robust processes of development. We conducted a systematic review to identify food allergy prevention guidelines for health professional use; to compare the recommendations made by the identified guideline documents; and to assess the quality of the identified guideline documents. We searched Medline, EMBASE, CINAHL, Scopus, Global Health and Guidelines International Network for the period 1990 to 13 August 2019, to identify articles referring to English-language food allergy prevention guidelines or the guidelines themselves. A grey literature search of Google Scholar and reference checking was also undertaken. The guidelines were compared for recommendation similarities and differences. An Appraisal Guidelines for Research and Evaluation (AGREE II) appraisal was undertaken to assess guideline quality. The electronic database search yielded 1121 publications and reference checking identified an additional 16 publications. After title, abstract and full text screening, data extraction was undertaken on 156 publications and with additional reference checking, 28 food allergy prevention guidelines and advice documents were identified. Comparison of the recommendations within the guidelines and advice documents indicated the greatest variation in recommendations related to exclusive breastfeeding and timing of solid food introduction. Eight of the 10 guidelines and none of the 18 advice documents met the quality threshold set by the reviewers. Overall, documents specifically termed "guidelines" scored better than advice documents when assessed using the AGREE II tool. Variation in recommendations may create confusion for health professionals and result in inconsistent advice being provided to parents, and less translation of the evidence into actual food allergy reduction in the population. Appraisal using the AGREE II tool identified that there is considerable room for improvement in the development of guidelines and advice documents for food allergy prevention. The AGREE II appraisal identified common areas of poorer quality development and/or documentation of processes to inform future guideline development. Based on this study, we recommend the use of validated guideline development tools, to direct food allergy prevention guideline review or development. Use of the AGREE II tool, to direct the review and development of guidelines, is very likely to improve guideline quality.

Food allergy-From food avoidance to active treatment

The prevalence of food allergy (FA) has increased too rapidly, possibly due to environmental factors. The guidelines recommend strict allergen avoidance, but FA is still the main cause of anaphylaxis in all age groups. Immunotherapy is the only treatment able to change the course of allergic disease, and oral immunotherapy (OIT) is the more effective route in FA. However, it carries the risk of adverse reactions, including anaphylaxis. To improve OIT safety, adjuvant therapy with the immunoglobulin E (IgE) monoclonal antibody omalizumab has been extensively used. Results suggest particular benefit in patients with high risk of fatal anaphylaxis. An alternative approach is to use omalizumab instead of OIT to prevent severe allergic reactions upon accidental exposure. This paper reviews current evidence regarding IgE-mediated FA, focusing on natural tolerance and food sensitization acquisition, and on avoidance measures and their limitations.

Advice about infant feeding for allergy prevention: A confusing picture for Australian consumers?

AIM

Early feeding plays an important role in programming the immune system, particularly the risk of food allergy. There are many infant feeding guides published for consumers available in Australia, with most based on the National Health and Medical Research Council (NHMRC) 2012 Infant Feeding Guidelines for Health Workers and the Australasian Society of Clinical Immunology and Allergy (ASCIA) Infant Feeding Advice for allergy prevention. We sought to compare allergy-specific content of infant feeding educational material written for parents with these two documents.

METHODS

Australian websites of children's hospitals, early child health organisations and consumer groups providing information about diet during pregnancy, breastfeeding and early infancy were compared with NHMRC and ASCIA guidelines.

RESULTS

Twenty-five sets of infant feeding information were identified. Food allergy was discussed in 18 resources. Recommended length of exclusive breastfeeding and timing of commencing solid foods was consistently around 6 months, with some variation in wording. Advice regarding to include and not delay introduction of common allergens into babies' diets was generally consistent with NHMRC and ASCIA recommendations, however the audit identified some resources that still recommended delayed introduction of common allergens.

CONCLUSION

As consumers have access to a plethora of health information it is imperative that information about infant feeding from health-care authorities is simple, evidence-based and consistent to avoid confusion. Use of consensus wording related to infant feeding guidelines to prevent allergies will provide clear messages related to the timing of introduction to solid foods and inclusion of allergens in the early diet.

An Australian Consensus on Infant Feeding Guidelines to Prevent Food Allergy: Outcomes From the Australian Infant Feeding Summit

BACKGROUND

Infant feeding in the first postnatal year of life has an important role in an infant's risk of developing food allergy. Consumer infant feeding advice is diverse and lacks consistency.

AIM

The Australian Infant Feeding Summit was held with the aim of achieving national consensus on the wording of guidelines for infant feeding and allergy prevention.

METHODS

Two meetings were hosted by the Centre for Food and Allergy Research, the Australasian Society of Clinical Immunology and Allergy, and the Australian National Allergy Strategy. The first meeting of 30 allergy researchers, clinicians, and consumers assessed the evidence. The second consensus meeting involved 46 expert stakeholders including state and federal health care agencies, consumers, and experts in allergy, infant feeding, and population health.

RESULTS

Partner stakeholders agreed on consensus wording for infant feeding advice: CONCLUSIONS: Consensus was achieved in a context in which there is a high prevalence of food allergy. Guidelines for other countries are being updated. Provision of consistent wording related to infant feeding to reduce food allergy risk will ensure clear consumer advice.

Changes to infant feeding guidelines: Relevance to dermatologists

The newly revised Australian Infant Feeding Guidelines recommends that all infants, including those at high risk of allergy, be introduced foods traditionally considered allergenic (such as peanut butter, dairy, wheat and egg) within the first year of life. High-risk infants are those with early onset eczema (<3-months old) or with moderate to severe eczema not responding to treatment (<6-months old). Eczema can also represent a symptom of allergy presentation and the recommended introduction of some foods in this group may lead to allergic reactions at home. Although there have been no reported deaths from gradual food introduction to infants at home and cohort studies have only reported mild to moderate reactions, there is anecdotal evidence that more severe reactions can occur rarely. Allergic reactions, even if they are not life-threatening, can be a terrifying experience for parents. Dermatologists play an important role when dealing with high-risk infants in promoting the message of early allergenic food introduction yet also instigating appropriate allergy testing when necessary. This short review aims to provide an update to Australasian dermatologists on the newly revised Australian Infant Feeding Guidelines and provide a food allergy screening pathway for high-risk infants prior to commencement of allergenic foods.

Modifying the infant's diet to prevent food allergy

Recommendations and guidelines on the prevention of food allergy have changed in recent decades. The aim of this review of the current evidence and ongoing studies is to provide a comprehensive and up to date picture of prevention of food allergy for healthcare professionals. The review was undertaken as part of the European Union funded Integrated Approaches to Food Allergy and Allergen Management (iFAAM) study. This is a wide ranging project bringing together expertise across the breadth of food allergy research. Specifically, the review discusses dietary manipulation in food allergy prevention, and covers the possible preventive strategies of allergen avoidance, early allergen introduction, general nutrition and supplements, as well as other strategies, such as prebiotics and probiotics. The review concludes that despite agreement that allergen avoidance strategies should not be undertaken for allergy prevention, there is currently no consensus regarding what actions should be recommended beyond exclusive breastfeeding for the first 4-6 months of life. Recent and upcoming trial results, which are detailed in this review, should help inform the debate and add clarity to the topic.

Consumption of milk and dairy products: Facts and figures

OBJECTIVES

Consumption of milk has been declining sharply in recent decades, particularly in developed countries. One of the reasons for this decline is the diagnosis or perception of lactose intolerance. The aim of this study was to investigate average consumption of milk and dairy products in the Campania region of Italy, one of the main producers of dairy products in the country.

METHODS

Individuals aged 18 to 75 y and living in Campania were invited to answer an online questionnaire regarding their average consumption of milk and dairy products. The questionnaire was posted on the public access hospital site, as well as on several Facebook pages of friends and hospital personnel.

RESULTS

The study found that 22.2% (260 of 1173) of responders from Campania do not drink milk, and 18.1% (213 of 1173) drink lactose-free milk, mainly because of gastrointestinal symptoms. The vast majority of the sample population chose to avoid consuming milk without undergoing the breath test for lactose intolerance or consulting a doctor. Women and underweight people drink more lactose-free milk than milk containing lactose. The population sample does not avoid dairy products; rather, they seem to be consumed quite frequently.

CONCLUSION

The data support the need for mandatory implementation of a nutritional campaign to increase understanding regarding, for example, unnecessary avoidance of milk and excessive consumption of cheese.

Formula and breast feeding in infant food allergy: A population-based study

AIM

To determine whether infant-feeding practices, including duration of exclusive breastfeeding and use of partially hydrolysed formula, modify the risk of developing infant food allergy.

METHODS

In an observational population-based study, 1 year olds were recruited from community immunisation clinics in Melbourne, Australia. Parent-reported data on infant-feeding practices and potential confounders were collected prior to infant skin prick testing for four food allergens. Sensitised infants attended hospital-based oral food challenges to establish food allergy status. Multiple logistic regression was used to investigate associations between breastfeeding and formula-feeding and infant food allergy adjusting for possible confounding variables.

RESULTS

A total of 5276 (74% response) infants participated. Of the 4537 for whom food allergy status was determined, 515 (11.3%) were food allergic (challenge-proven in the context of skin prick testing positive (≥2 mm)). After adjusting for confounding variables, there was no association between duration of exclusive breastfeeding and food allergy. Use of partially hydrolysed formula did not reduce the risk of food allergy compared with cow's milk formula in the general population (adjusted odds ratios 1.03 (confidence interval 0.67-1.50)).

CONCLUSION

Duration of exclusive breastfeeding and use of partially hydrolysed formula were not associated with food allergy at 1 year of age in this large population-based study. These findings have implications for population-based infant-feeding guidelines and do not support the use of partially hydrolysed formula for food allergy prevention.

Incidence and natural history of hen's egg allergy in the first 2 years of life-the EuroPrevall birth cohort study

BACKGROUND

Parents and health staff perceive hen's egg allergy (HEA) as a common food allergy in early childhood, but the true incidence is unclear because population-based studies with gold-standard diagnostic criteria are lacking.

OBJECTIVE

To establish the incidence and course of challenge-confirmed HEA in children, from birth until the age of 24 months, in different European regions.

METHODS

In the EuroPrevall birth cohort study, children with a suspected HEA and their age-matched controls were evaluated in 9 countries, using a standardized protocol including measurement of HE-specific immunoglobulin E-antibodies in serum, skin prick tests, and double-blind, placebo-controlled food challenges (DBPCFC).

RESULTS

Across Europe, 12 049 newborns were enrolled, and 9336 (77.5%) were followed up to 2 years of age. In 298 children, HEA was suspected and DBPCFC was offered. HEA by age two was confirmed in 86 of 172 challenged children (mean raw incidence 0.84%, 95% confidence interval (95% CI) 0.67-1.03). Adjusted mean incidence of HEA was 1.23% (95% CI 0.98-1.51) considering possible cases among eligible children who were not challenged. Centre-specific incidence ranged from United Kingdom (2.18%, 95% CI 1.27-3.47) to Greece (0.07%). Half of the HE-allergic children became tolerant to HE within 1 year after the initial diagnosis.

CONCLUSIONS

The largest multinational European birth cohort study on food allergy with gold-standard diagnostic methods showed that the mean adjusted incidence of HEA was considerably lower than previously documented, although differences in incidence rates among countries were noted. Half of the children with documented HEA gained tolerance within 1 year postdiagnosis.

Home environment, lifestyles behaviors, and rhinitis in childhood

The prevalence of children allergic rhinitis has been increasing in China and associated factors still are not clear. In the present paper, we selected 13,335 parent-reported questionnaires of 4-6 years-old children, in a cross-sectional study from April 2011 to April 2012 in Shanghai city, and investigated associations of various factors with parent-reported allergic rhinitis (doctor-diagnosed) and rhinitis symptoms in childhood. After adjusted by age, sex, family history of atopy, and respondent of questionnaire, we find that no siblings, mother in older age during pregnancy, shorter breastfeeding, using antibiotics in the first year, and home dampness-related exposures, had significant associations with increased prevalence of the studied diseases. Location, type, building area, decoration materials and construction period of the residence, also had significant associations with these diseases. Current parental smoking and pet-keeping had no significant associations with the studied diseases. Incense-burning and using mosquito coils had significant associations with reduced risk of allergic rhinitis and with increased risk of rhinitis symptoms. Using air cleaner and cleaning the residence in high frequency had associations with increased risk, but eating fast food and ice cream often had associations with the reduced risk, of the studied diseases. Families with children being diagnosed allergic rhinitis likely change their lifestyle behaviors. In conclusion, childhood rhinitis could be influenced by heredity and many "environmental exposures". Avoidance behaviors and reverse causation in parental smoking, pet-keeping, and dietary habits for childhood rhinitis should be carefully considered.

[The introduction of gluten into the infant diet. Expert group recommendations]

At present there is a degree of uncertainty regarding when, how and in what form gluten should be introduced into the infant diet. For years the recommendations of the ESPGHAN Committee on Nutrition have prevailed, which include avoiding early introduction, before 4 months, and late, after 7 months, and gradually introducing gluten into the diet while the infant is being breastfed, with the aim of reducing the risk of celiac disease, diabetes and gluten allergy. However, 2 independent studies published in The New England Journal of Medicine in October 2014 reached the conclusion that the age of introduction of gluten does not modify the risk of developing celiac disease, and that breastfeeding at any age does not confer protection against celiac disease development. On the other hand, according to available scientific evidence, the introduction of foods other than breast milk or formula into the infants diet is generally recommended around 6 months of age, since the introduction before 4 months could be associated with an increased risk of food allergy and autoimmune diseases, and delaying it beyond 7 months would not have a protective effect. In this context, a group of experts has considered it appropriate to produce a consensus document based on the current scientific evidence and present general recommendations for daily clinical practice on the introduction of gluten into the diet.

Nutritional management of food protein-induced enterocolitis syndrome

PURPOSE OF REVIEW

To summarize the latest information on the nutritional management of food protein-induced enterocolitis syndrome (FPIES), focusing on the foods implicated and how to avoid these whilst maintaining a nutritionally sound diet.

RECENT FINDINGS

A number of foods are implicated in FPIES such as milk, soy and grains, particularly rice. The number of foods implicated in FPIES per individual differs, but the majority of reported cases have two or fewer food triggers involved.

SUMMARY

FPIES is a complex presentation of non-IgE-mediated food allergy. Dietary management is complicated as both common food allergens as well as atypical food allergens can trigger FPIES. Sound nutritional advice is required to ensure appropriate food avoidance, adequate consumption of other foods and sufficient nutritional intake to maintain and ensure growth and development.

Nutrition in early life and the risk of asthma and allergic disease

The prevalence of reported cases of asthma and allergic disease has seen a marked increase throughout the world since the 1960s, particularly in more developed, westernised countries. A key focus of research in this area has been the possible adverse effects of foetal and infant exposure to food allergens. There is some evidence that foetal and infant exposure to a range of allergens via the mother and her breast milk is important in the development of normal immune tolerance. Current advice is that pregnant and breastfeeding women do not need to avoid potential food allergens unless they are allergic themselves, or are advised to modify their diet by a health professional. Delaying the introduction of common food allergies beyond 6 months is unlikely to reduce the likelihood of food allergy and allergic disease. The findings of current ongoing trials investigating the potential benefits of early introduction on allergenic foods into the diet of children-as well as the comprehensive review of complementary and young-child feeding advice currently being conducted by the Scientific Advisory Committee on Nutrition-will help inform guidance in this area.

Optimal timing for solids introduction - why are the guidelines always changing?

There have been dramatic changes in timing of first exposure to solid foods for children over the last 40 years, ranging from exposure prior to 4 months of age for most infants in the 1960s, to guidelines recommending delaying solids until after 6 months of age introduced in the 1990s. Infant diet, specifically age of weaning and age at introduction of allergenic foods, has long been thought to play a role food allergy. However, controversy surrounding the relationship between timing of introduction of foods and development of food allergy has lead to a plethora of inconsistent infant feeding guidelines both between and within countries. The aims of this article were to discuss the history of changing guidelines for optimal timing of introduction of solids in general and allergenic solids in particular and the evidence (or lack thereof) underpinning recommendations at each of these time-points. We present the current clinical equipoise with regards to recently revised guidelines published almost simultaneously in the UK, US and Australia and argue that guideline modification about timing of introduction (both for high risk infants but also for the general population) will require careful review of emerging literature to provide a true evidence base to inform public health practice such as infant feeding guidelines.

Factors associated with the timing of introduction of complementary feeding: the Generation R Study

BACKGROUND/OBJECTIVES

Many parents do not follow recommendations for the timing of introduction of complementary feeding. The aim of this study was to identify determinants associated with the timing of introduction of complementary feeding in a multiethnic birth cohort.

SUBJECTS/METHODS

Subjects were 3561 mothers and infants participating in a prospective cohort study. The timing of introduction of complementary feeding and maternal and infant characteristics were obtained by parent-derived questionnaires. Regression analyses were performed to identify determinants for the timing of introduction of complementary feeding (<3, 3-6 and ≥ 6 months).

RESULTS

In total, 62% of infants were introduced to complementary feeding before the age of 6 months. Determinants for very early (<3 months) introduction were being a single parent and infant day care attendance. Determinants for early (3-6 months) introduction were young maternal age, multiple parities, no infant family history of asthma, atopy and no infant history of allergy to cow's milk. Determinants for both very early and early introduction were low educational level and not fully breastfeeding for 4 months. Maternal educational level was only significantly associated with the timing of introduction in mothers of Western origin.

CONCLUSIONS

This study confirmed determinants for the timing of introduction of complementary feeding that have been identified by previous studies, which may be appropriate targets for education and guidance. Moreover, mothers whose infants attend day care and have a family history of asthma, atopy or allergy to cow's milk may need guidance to follow infant feeding recommendations.

Understanding the evidence for and against the role of breastfeeding in allergy prevention

The relationship between breastfeeding and allergic disease risk has been controversial. This article reviews the current evidence for the role of breastfeeding in the prevention of allergic disease. We found considerable methodological limitations inherent in most studies evaluating the effect of breastfeeding in allergic disease. Nevertheless, since randomized control trials in breast feeding research would be considered unethical, the evidence remains limited to poorer quality observational studies where participation and recall bias can severely affect the objectivity of the data collected. Furthermore, reporting of type of breastfeeding (exclusive, full or partial) may be biased by a participant's inherent belief system of what they think they should be doing. Current evidence is inconclusive regarding the effect of breastfeeding on the development of eczema, with the most recent systemic review reporting no protective effect. There is insufficient data regarding the effects of breastfeeding on objective measures of food allergy at any age. Studies show a paradoxical effect of breastfeeding on the prevention of asthma, with an apparent protective effect against early wheezing illness in the first years of life yet an increased risk of asthma in later life; however, these findings must be interpreted with caution. Existing studies fail to adequately adjust for confounders, including the critical issues of protection against early life respiratory illnesses and reverse causation. Therefore, it is possible that the effect of breastfeeding on early wheezing illness reflects protection against respiratory infection, the predominant trigger of wheezing in early childhood, rather than a true reduction in risk of asthma. In summary, future research that takes into account the potential contribution of confounding factors and effect modifiers is needed to clarify the role of breastfeeding in development of allergic disease and to inform current clinical guidelines on the prevention of allergic disease.

How feasible is Baby-led Weaning as an approach to infant feeding? A review of the evidence

Baby-Led Weaning (BLW) is an alternative method for introducing complementary foods to infants in which the infant feeds themselves hand-held foods instead of being spoon-fed by an adult. The BLW infant also shares family food and mealtimes and is offered milk (ideally breast milk) on demand until they self-wean. Anecdotal evidence suggests that many parents are choosing this method instead of conventional spoon-feeding of purées. Observational studies suggest that BLW may encourage improved eating patterns and lead to a healthier body weight, although it is not yet clear whether these associations are causal. This review evaluates the literature with respect to the prerequisites for BLW, which we have defined as beginning complementary foods at six months (for safety reasons), and exclusive breastfeeding to six months (to align with WHO infant feeding guidelines); the gross and oral motor skills required for successful and safe self-feeding of whole foods from six months; and the practicalities of family meals and continued breastfeeding on demand. Baby-Led Weaning will not suit all infants and families, but it is probably achievable for most. However, ultimately, the feasibility of BLW as an approach to infant feeding can only be determined in a randomized controlled trial. Given the popularity of BLW amongst parents, such a study is urgently needed.

Infant nutrition and later health: a review of current evidence

There is a growing recognition of the need for a lifecourse approach to understanding the aetiology of adult disease, and there is now significant evidence that links patterns of infant feeding to differences in health outcomes, both in the short and longer term. Breastfeeding is associated with lower rates of infection in infancy; in high-income populations, it is associated with reductions in blood pressure and total blood cholesterol, and lower risks of obesity and diabetes in adult life. Breastfeeding rates are suboptimal in many countries, and strategies to promote breastfeeding could therefore confer important benefits for health at a population level. However, there are particular challenges in defining nutritional exposures in infancy, including marked social gradients in initiation and duration of breastfeeding. In recent studies of low and middle-income populations of children and young adults, where the influences on infant feeding practice differ, beneficial effects of breastfeeding on blood pressure, BMI and risk of diabetes have not been confirmed, and further information is needed. Little is currently known about the long-term consequences of differences in the timing and nature of the weaning diet. Future progress will depend on new studies that provide detailed prospective data on duration and exclusivity of breastfeeding together with appropriate characterisation of the weaning diet.

Practical dietary management of protein energy malnutrition in young children with cow's milk protein allergy

Cow's milk protein allergy (CMPA) affects between 1.9 and 4.9% of infants and young children. This food allergy requires the complete elimination of cow's milk and its derivatives, impacting on nutritional status. The risk of having protein energy malnutrition (PEM) in children with CMPA has been well documented. In 2007, the World Health Organisation published guidelines on the dietary management of PEM, which has impacted on the recommendations and composition on specialist feeds for many chronic diseases, but not on CMPA. The main change in management of the child with PEM is the protein energy ratio and energy requirements. The ideal protein energy ratio lies between 8.9 and 11.5%, which would ensure a deposition of about 70% lean and 30% fat mass. In addition, for optimal catch-up growth between 5 and 10 g/kg/day, energy requirements should be between 105 and 126 kcal/kg/day. Although most current hypoallergenic formulas fall well within the recommendation for protein, there is a problem in achieving energy requirements. As a result, modular additions are often made, disturbing the protein energy ratio or feeds are concentrated, which impacts on osmolality. We therefore aimed to review current guidelines on PEM and how these can be applied in the management of the malnourished child with CMPA.

Breastfeeding, asthma, and allergy: a tale of two cities

BACKGROUND

The effect of breastfeeding duration on subsequent asthma and allergy remains the subject of much controversy.

OBJECTIVE

To investigate whether differences in study design or disease-related exposure modification were the cause of the differences in study findings.

METHOD

The data from two cohorts, the Childhood Asthma Prevention Study (CAPS) from Australia and the Barn Allergi Miljo Stockholm cohort from Sweden, which had reported different findings on the association between breastfeeding and asthma, were combined. For this analysis, the definitions for breastfeeding, asthma, and allergy were harmonized. Subjects were included if they had at least one parent with wheeze or asthma and had a gestational age of more than 36 wks (combined n = 882). The risk of disease-related exposure modification was assessed using survival analysis.

RESULTS

Breastfeeding reduced the risk of asthma at 4/5 and 8 yrs of age in children with a family history of asthma. The effect was stronger in the Swedish cohort. Breastfeeding had no effect on the prevalence of sensitization to inhaled allergens in this cohort with a family history of asthma but was a risk factor for sensitization to cow's milk, peanuts, and eggs in the CAPS cohort at 4/5 yrs and in the combined cohort at 8 yrs. There was no evidence to support the existence of disease-related exposure modification in either cohort.

CONCLUSION

These findings point to the importance of harmonization of features of study design, including subject selection criteria and variable definitions, in resolving epidemiological controversies such as those surrounding the impact of breastfeeding on asthma and allergic sensitization.

Early oral ovalbumin exposure during maternal milk feeding prevents spontaneous allergic sensitization in allergy-prone rat pups

There are conflicting data to support the practice of delaying the introduction of allergenic foods into the infant diet to prevent allergy development. This study investigated immune response development after early oral egg antigen (Ovalbumin; OVA) exposure in a rat pup model. Brown Norway (BN) rat pups were randomly allocated into groups: dam reared (DR), DR pups challenged daily (days 4–13) with oral OVA (DR + OVAc), DR pups challenged intermittently (on day 4, 10, 12, and 13) with oral OVA (DR + OVAi), formula-fed pups (FF), and FF pups challenged daily with oral OVA (FF + OVA). Immune parameters assessed included OVA-specific serum IgE, IgG1, and IgA. Ileal and splenic messenger ribonucleic acid (mRNA) expression of transforming growth factor-beta (TGF-β1), mothers against decapentaplegic (Smad) 2/4/7, and forkhead box P3 (Foxp3) were determined. Ileum was stained for TGF-β1 and Smad4. Results. Feeding OVA daily to DR pups maintained systemic and local gut antibody and immunoregulatory marker mRNA responses. Systemic TGF-β1 was lower in DR + OVAi pups compared to DR and DR + OVAc pups. Feeding OVA to FF pups resulted in significantly greater OVA-specific IgE and IgG1, and lower IgA and TGF-β1 and Smad expression compared to DR pups. Conclusions. Early daily OVA exposure in the presence of maternal milk maintains immune markers associated with a regulated immune response, preventing early allergic sensitization.

Infant nutrition and allergy

Over the past several decades, the incidence of atopic diseases such as asthma, atopic dermatitis and food allergies has increased dramatically. Although atopic diseases have a clear genetic basis, environmental factors, including early infant nutrition, may have an important influence on their development. Therefore, attempts have been made to reduce the risk of the development of allergy using dietary modifications, mainly focused on longer breast-feeding and delayed introduction or elimination of foods identified as potentially most allergenic. Recently, there is also an increasing interest in the active prevention of atopy using specific dietary components. Many studies have shown that breast-feeding may have the protective effect against future atopic dermatitis and early childhood wheezing. Concerning complementary feeding, there is evidence that the introduction of complementary foods before 4 months of age may increase the risk for atopic dermatitis. However, there is no current convincing evidence that delaying introduction of solids after 6 months of age has a significant protective effect on the development of atopic disease regardless of whether infants are fed cow's milk protein formula or human subject's milk, and this includes delaying the introduction of foods that are considered to be highly allergic, such as fish, eggs and foods containing peanut protein. In conclusion, as early nutrition may have profound implications for long-term health and atopy later in life, it presents an opportunity to prevent or delay the onset of atopic diseases.