Food Allergy: Pathogenesis and Prevention Early Dietary Exposures - - PowerPoint PPT Presentation
World Allergy Forum Food Allergy: Pathogenesis and Prevention Early Dietary Exposures and Feeding Practices Scott H. Sicherer, MD Clinical Professor of Pediatrics Jaffe Food Allergy Institute Mount Sinai School of Medicine New York AAAAI
Scott H. Sicherer, MD Clinical Professor of Pediatrics Jaffe Food Allergy Institute Mount Sinai School of Medicine New York
AAAAI Orlando 2012: Session 3307
Suggested References : Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Greer F, Sicherer S, Burks AW. Pediatrics. 2008;121(1):183-91 and Guidelines for the Diagnosis and Management of Food Allergy in the US Boyce et al. J Allergy Clin Immunol 2010; 126(6 Suppl):S1-58.
Sensitization Choice of breast milk substitution Breast feeding-with Maternal diet alteration Pregnancy Breast feeding Disease Complementary foods When/what Inflammation
7) – Atopic (OR 0.58; 95% CI, 0.41-0.92) – Non-atopic (OR 0.84; 95% CI, 0.59-1.19)
(Hong et al JACI 2011;128:374-81)
Recent studies trend to less protection
Kramer Kakuma Cochrane database 2006
instruction to breast-feed)
– Cow’s milk formula (CMF) – Extensively hydrolyzed casein (eHF-C) – Extensively hydrolyzed whey (eHF-W) – Partially hydrolyzed whey (pHF-W)
Von Berg A JACI 2003; 111:533
2 4 6 8 10 12 14 16 % Atopic Derm Food Allergy Any Atopy CMF eHF-C eHF-W pHF-W
* * *
Von Berg JACI 2007 Von Berg JACI 2008
0.2 0.4 0.6 0.8 1 1.2 Odds Ratio No AD in FH AD in FH CMF eHF-C eHF-W pHF-W
*Trends
Lowe et al JACI 2011;128:360-5
– Pregnancy, 3rd trimester-no milk, egg, peanut, reduced soy/wheat – Lactation, avoid same, supplement casein hydrolysate – Solids at 6 mo, 12 mo-CM, wheat, soy, 24 mo- egg, 36 mo-peanut, fish
Zeiger JACI 1989;Zeiger PAI 1992;Zeiger JACI 1995
Zeiger JACI 1989;Zeiger PAI 1992;Zeiger JACI 1995
5 10 15 20 25 30 35 % Age 1 Age 2 Age 4 Age 7
Asthma
5 10 15 20 25 30 35 % Age 1 Age 2 Age 4 Age 7
Atopic dermatitis 5 10 15 20 25 30 35 % Age 1 Age 2 Age 4 Age 7 Food Allergy Prophylaxis No diet
* *
formula”
and consider eliminate egg, milk, fish “others” while nursing
exclusion
AAP Committee on Nutrition, 2000
Suggestions aimed at “high risk”
*
Rate of Eczema
5 10 15 20 25 30 35
No Solids 1-2 Solids 3-4 Solids 5+ Solids
Fergusson et al Clin Allergy 1981
Atopic Dermatitis OR (95% CI)
Veg (>4 mo) Egg (>8 mo)
Zutavern et al ADC 2004 0.1 0.2 0.5 1 2 4
5 10 15 20 25 30 35 40 AD (%) Age 1 Age 5 3 months 6 months
Age of Solid food Introduction
Kajosaari & Saarinen Acta Ped Scand 1983
– 4753 infants (birth cohort): Among “at risk” atopy if waited on giving egg (RR 1.8, 95% CI: 1.2-2.6)
– Case Control: Solids before 4 months, less eczema (OR 0.49; 95% CI 0.3-0.7)
– Cohort 994: Later introduction of solid foods associated with higher food sensitization
– Cohort 6905: No relationship of eczema/wheeze to receiving milk, egg, soy, nut, wheat prior to age 6 months
Family Atopy IgE > 0.7 kUA/L E/M, >0.35 peanut Adjusted
P-value Yes Egg/milk 0.5 (0.3-0.9) 0.023 Yes Peanut 0.2 (0.1-0.7) 0.007 No Egg/milk 1.0 (0.6-2.0) 0.894 No Peanut 1.3 (0.6-2.7) 0.544
Joseph et al JACI 2011;127: 1203-10
Koplin et al JACI 2010 RR (95% CI) 0 0.1 0.5 1 2 5 10 4-6 mo 7-9 mo >12 mo 10-12 mo “HealthNuts” study, 2589 infants population-based, cross-sectional study Effects seen in high-risk and low-risk infants with cooked egg introduction Adjusted for confounding factors Confirmed egg allergy
OR (95% CI) 0 0.1 0.5 1 2 5 10 0-6 mo ≥7 mo “Daisy” study (US), 1612 infants, birth cohort observational study Poole et al Pediatrics 2006 Parent reported wheat allergy in 1%, 4 with positive wheat-IgE Adjusted for parental allergic diseases and any food allergy < 6mo of age Designed to investigate natural hx of diabetes and celiac disease in a HLA- predisposed population
Katz et al JACI 2010
Prospective feeding study of 13019 infants in Israel, telephone interview, encourage to breast feed Low prevalence of IgE-mediate allergy 0.5%, which confirmed milk allergy Regards parental atopy as a potential confounding factor Nursery milk exposures not considered
Adjusted Odds Ratio Eczema Age at introduction of milk protein (mo)
Snijders et al Pediatrics 2008;122:e115-22
Maybe if you don’t eat it, you touch it, have accidental periodic ingestions that are all sensitizing?
Sicherer et al JACI 2003, 2010 Grundy et al JACI 2002; Du Toit JACI 2008;Fox JACI 2009
Before Advice to avoid After Advice to avoid Percent peanut allergy in children
Source: Sicherer SH and Sampson HA. “Peanut allergy: Emerging concepts and approaches for an apparent epidemic.” J Allergy Clin Immunol 120(3): 491-503.
Peanut Allergy
Genetic predisposition to peanut allergy Genetic predisposition
Atopic Dermatitis
Dietary & Environmental Exposures
Use of Antacids Ingestion of cross-reactive proteins (soy) Topical exposure Pollen proteins Manner of processing Frequency
Timing Dose
Maternal ingestion during pregnancy Maternal ingestion during breast feeding
Source: Wikipedia
Hafeez, S. et al. Arch Pediatr Adolesc Med 2011;165:92-93.
N=90 Yes, Premasticates Born US 18% Born Carribean or Central America 13% Born Africa 29% Hispanic 7% African American 38% African 29% Mother Pre-masticated 42% Mother did not Pre-masticate 12%
Breast feeding-with Maternal diet alteration Pregnancy Breast feeding Choice of breast milk substitution Complementary foods When/what Sensitization Disease Inflammation
Breast feeding-with Maternal diet alteration Pregnancy Breast feeding Choice of breast milk substitution Complementary foods When/what No obvious Effect (?) Good for everyone, exclusive to 4-6 mo No, but for high risk maybe (AD) Certain Hydrolyzed formulas, not soy, not cow’s milk Nothing special (exceptions?)