Infant Food AllergiesWhere Are We Now?Janice Joneja Ph.D., RD2Food Allergy in the Past 7 Years Nearly 4% of North Americans have food allergies, many more than recorded in the past Incidence of food allergy much higher in Incidence of food allergy much higher in children (8%) than adults (8%) than adults (4 years of age 18 children with confirmed CMA 4 years of age underwent SOTIunderwent SOTI Starting dose 0.05 ml cows milkStarting dose 0.05 ml cows milk Increased to 1 ml on first dayIncreased to 1 ml on first day Increasing dosage weekly up to a daily dose of 200-Increasing dosage weekly up to a daily dose of 200-250 ml250 ml Results: 16/18 tolerated 200-250 ml milkResults: 16/18 tolerated 200-250 ml milk Length of process median 14 weeks (range 11-17 Length of process median 14 weeks (range 11-17 weeks)weeks) Tolerance has been maintained for 1 yearTolerance has been maintained for 1 year_Zapatero et al 20084142Oral Tolerance Induction to Milk, Egg, and Peanut 36% of children with IgE-mediated allergy to 36% of children with IgE-mediated allergy to cows cows milkmilk and and hens egghens egg developed permanent tolerance of developed permanent tolerance of the foods after a median 21 months specific oral the foods after a median 21 months specific oral tolerance induction (SOTI)tolerance induction (SOTI)1 1 4 peanut-allergic children underwent SOTI:4 peanut-allergic children underwent SOTI: Daily doses of Daily doses of peanut flourpeanut flour starting at 5 mg peanut protein starting at 5 mg peanut protein 2-weekly dosage increase up to 800 mg protein2-weekly dosage increase up to 800 mg protein All subjects tolerated at least 10 whole peanuts (2.38 g All subjects tolerated at least 10 whole peanuts (2.38 g protein) on post-intervention challengeprotein) on post-intervention challenge2 2_1Staden et al 2007_2 2Clark et al 20094243Progression of Peanut Allergy Peanut allergy, like many early food allergies, can be Peanut allergy, like many early food allergies, can be outgrownoutgrown In 2001 pediatric allergists in the U.S. reported that In 2001 pediatric allergists in the U.S. reported that about 21.5 per cent of children will eventually about 21.5 per cent of children will eventually outgrow their peanut allergyoutgrow their peanut allergy1 1 Those with a mild peanut allergy, as determined by Those with a mild peanut allergy, as determined by the level of peanut-specific IgE in their blood, have a the level of peanut-specific IgE in their blood, have a 50% chance of outgrowing the allergy50% chance of outgrowing the allergy2 2 Only about 9% of patients are reported to outgrow Only about 9% of patients are reported to outgrow their allergy to tree nutstheir allergy to tree nuts3 3_1Skolnick et al 20012Fleischer et al 20033Fleischer et al 20054344Maintaining Tolerance of Peanut When there is no longer any evidence of symptoms developing after a child has consumed peanuts, it is preferable for that child to eat peanuts regularly, rather than avoid them, in order to maintain tolerance to the peanut Children who outgrow peanut allergy are at risk for recurrence, but the risk has been shown to be significantly higher for those who continue to avoid peanuts after resolution of their symptoms _Fleischer et al 20044445Probiotics and Allergy Prevention Probiotics and prebiotics may change the colonic Probiotics and prebiotics may change the colonic microflora of the neonatemicroflora of the neonate Theory: Theory: Change from Th2 to Th1 response in the neonatal period is Change from Th2 to Th1 response in the neonatal period is required to reduce potential for allergyrequired to reduce potential for allergy This change is mediated by contact with micro-organismsThis change is mediated by contact with micro-organisms Non-allergic children have a predominance of lactobacilli Non-allergic children have a predominance of lactobacilli and bifidobacteriaand bifidobacteria Atopic children tend to have more clostridia and lower Atopic children tend to have more clostridia and lower levels of bifidobacterialevels of bifidobacteria Probiotics could be used to change the “atopic” to a more Probiotics could be used to change the “atopic” to a more “non-atopic flora”“non-atopic flora”_Ozdemir 201046Studies on Probiotics in Allergy Prevention Some studies indicate a positive outcome in reducing the incidence of allergy: Lactobacillus F19 in cereals fed to infants from 4 Lactobacillus F19 in cereals fed to infants from 4 to 13 months of age reduced the incidence of to 13 months of age reduced the incidence of eczemaeczema1 1 Other studies showed no effect: Bifidobacterium + Lactobacillus rhamnosus daily Bifidobacterium + Lactobacillus rhamnosus daily for the first 6 months in at risk infants had no for the first 6 months in at risk infants had no effect compared to placeboeffect compared to placebo2 2_1 West et al 2009_2 Soh et al 200947Current Status of Probiotics in Allergy Prevention Beneficial effects of probiotic therapy depends on:Beneficial effects of probiotic therapy depends on: Type of bacteria selectedType of bacteria selected Dosage of the bacteria delivered to the digestive tractDosage of the bacteria delivered to the digestive tract Method of delivery of the bacteria to the GI tract (in Method of delivery of the bacteria to the GI tract (in formulae; in cereals)formulae; in cereals) Age of the individualAge of the individual Length of duration of deliveryLength of duration of delivery Conclusion at the current state of research:Conclusion at the current state of research: Probiotics cannot be recommended generally for primary Probiotics cannot be recommended generally for primary prevention of atopic diseaseprevention of atopic disease_Ozdemir 2010a48Take Home Message Allergy prevention emphasizes inducing tolerance rather than avoiding sensitization Beginning of tolerance to foods may occur in utero or during breast-feeding Restriction of maternal diet to avoid highly allergenic foods during pregnancy or lactation is contraindicated Unless either mother or baby is allergic to them49Take Home Message Management of established food allergy includes: Accurate identification of the allergenic food(s) Careful avoidance of the food allergens especially if there is any risk of anaphylaxis Avoidance of unnecessary food restrictions50Take Home Message Provision of complete balanced nutrition by substituting foods of equal nutritional value Monitoring the childs response at intervals to determine when the food allergy has been outgrown Maintenance of tolerance by feeding tolerated foods regularly51Invitation to Further Informationwww.allergynutrition.comJoneja, J.M.Vickerstaff Joneja, J.M.Vickerstaff Dealing with Food Allergies in Babies Dealing with Food Allergies in Babies and Childrenand Children Bull Publishing Company, Boulder, Colorado. Bull Publishing Company, Boulder, Colorado. October 2007October 2007