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Treatment and prevention of food allergies in breastfed infants: practice and evidence.



(Nutr Diet 2004;61:76-81)

Abstract

Objective: To determine whether current Australian dietetic dietetic /di·e·tet·ic/ (di?ah-tet´ik) pertaining to diet or proper food.

di·e·tet·ic
adj.
1. Of or relating to diet.

2.
 practice is consistent with research relating to relating to relate prepconcernant

relating to relate prepbezüglich +gen, mit Bezug auf +acc 
 maternal dietary restrictions for treatment and prevention of food allergy food allergy Allergy medicine A condition, the incidence of which–0.3-7.5%–is obscured by controversial data and differing disease definitions; food-induced reactions of immediate-hypersensitivity type are common and include anaphylaxis, angioedema,  in breastfed infants.

Design: Mail survey to benchmark practice and a systematic review of relevant studies and trials.

Subjects and setting: All 15 Australian specialist paediatric Adj. 1. paediatric - of or relating to the medical care of children; "pediatric dentist"
pediatric
 allergy dietitians were surveyed. The systematic review was confined to studies involving maternal dietary intervention followed by maternal dietary challenge for the treatment of breastfed infants with food allergy, trials investigating maternal dietary restriction during lactation lactation

Production of milk by female mammals after giving birth. The milk is discharged by the mammary glands in the breasts. Hormones triggered by delivery of the placenta and by nursing stimulate milk production.
 for allergy prevention, and studies where food proteins have been detected in human milk after the ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.

in·ges·tion
n.
1. The act of taking food and drink into the body by the mouth.

2.
 of a specific food challenge.

Main outcome measure: Assessment of current practice in relation to the level and quality of evidence on food allergy treatment and prevention in breastfed infants.

Results: The majority of dietitians (13 out of 15) surveyed follow recommendations of expert committees that breastfed infants with food allergy symptoms are trialled on maternal dietary restriction. However, the strength of published evidence in this area is limited and high quality randomised Adj. 1. randomised - set up or distributed in a deliberately random way
randomized

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 controlled trials are required to test the validity of current practice and recommendations. Maternal dietary restrictions to prevent food allergy were used by six of the 15 dietitians surveyed. No clinical trials have investigated maternal dietary restriction during breastfeeding with the specific outcome of reducing the development of food allergy.

Conclusion: Insufficient high quality evidence exists to determine the extent of benefit offered by maternal food avoidance diets to breastfed infants for the treatment and prevention of food allergy.

Key words: food allergy, human milk, food proteins, maternal diet, practice survey

**********

Introduction

Food allergy diagnosis requires the determination of a causal relationship between the improvement of symptoms after commencing a strict avoidance diet for a suspected food protein followed by the return of these symptoms on food challenge (1). The incidence of food allergy in exclusively breastfed infants, with symptoms of eczema, colic colic, intense pain caused by spasmodic contractions of one of the hollow organs, e.g., the stomach, intestine, gall bladder, ureter, or oviduct. The cause of colic is irritation and/or obstruction, and the irritant and/or obstruction may be a stone (as in the gall , diarrhoea and vomiting, is approximately 0.5% (2,3). For the treatment of these breastfed infants there is a consensus from both European and American expert committees that a trial of maternal dietary restriction should be undertaken (1,4).

Strategies to prevent food allergy in infants who are at high risk because of a strong atopic atopic /atop·ic/ (a-top´ik) (ah-top´ik)
1. ectopic.

2. pertaining to atopy; allergic.


atopic

1. displaced; ectopic.

2. pertaining to atopy.
 family history are controversial. Most recommendations include exclusive breastfeeding or use of a formula with confirmed reduced allergenicity for at least four to six months and not introducing solid foods before five to six months of age (1,4,5). The use of maternal dietary restriction during lactation to treat food allergy in breastfed infants led to the hypothesis that maternal dietary restriction during lactation may also prevent the development of food allergy in breastfed infants. The American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. , Committee on Nutrition (4) has recommended that mothers of high risk infants should eliminate peanuts and tree nuts, and also consider eliminating eggs, cow's milk and fish from their diets while breastfeeding. However some regard this approach as experimental (5).

In this paper we review current Australian dietetic practice and systematically examine the research regarding the use of maternal dietary restrictions to treat and prevent food allergy in breastfed infants.

Methods

Survey of current dietetic practice in Australia

A survey was mailed to all major paediatric hospitals in Australia This is a list of major hospitals in Australia. New South Wales
Public hospitals in New South Wales are organised into eight Area Health Services plus The Children's Hospital at Westmead.
 and other known specialist paediatric allergy dietitians at ACT Community Care. Flinders Medical Centre Flinders Medical Centre is a 500 bed public teaching hospital and medical school, co-located with Flinders University and Flinders Private Hospital located at Bedford Park, South Australia. It opened in 1976. , John Hunter Hospital The John Hunter Hospital (sometimes known as the JHH or more colloquially the John) is the principal referral centre and a community hospital for Newcastle, Lake Macquarie and Northern New South Wales. It is the main teaching hospital of the University of Newcastle. , Mater Health Services Mater Health Services is a public and private collocated health care provider located in Brisbane, Australia. Mater Health Services provides care for some 500,000 patients each year. The Mater was established in 1906 by the Sisters of Mercy.  Brisbane, Monash Medical Centre Monash Medical Centres (MMC) is a multicampus teaching hospital in Melbourne, Victoria, Australia. The Clayton campus is in Clayton, the Moorabbin Campus at East Bentleigh. It provides specialist care to the State's south-east. , Princess Margaret Hospital There are several Princess Margaret Hospitals :
  • Princess Margaret Hospital, Hong Kong
  • Princess Margaret Hospital, Toronto
  • Princess Margaret Hospital for Children in Perth
  • Princess Margaret Hospital, Christchurch
, Royal Children's Hospital The Royal Children's Hospital in Melbourne, Australia is the major specialist paediatric hospital for Victoria offering a full range of clinical services, tertiary care and health promotion and prevention programs for children and adolescents.  Brisbane, Royal Children's Hospital Melbourne, Royal Hobart Hospital The Royal Hobart Hospital (RHH or 'The Royal' as its often known) is the largest hospital in Tasmania, Australia. It is a public hospital managed by the Tasmanian Government. 'The Royal' is located in central Hobart. , Royal Prince Alfred Hospital RPA Hospital is sometimes confused with The Alfred Hospital in Melbourne, Victoria. The short form "PA Hospital" also refers to Princess Alexandra Hospital in Brisbane, Queensland. , Sydney Children's Hospital Sydney Children's Hospital is a hospital for children in the Eastern Suburbs of Sydney, New South Wales. The Sydney Children's Hospital is located approximately 6kms from the Sydney Central Business District in the suburb of Randwick. . The Children's Hospital A children's hospital is a hospital which offers its services exclusively to children. The number of children's hospitals proliferated in the 20th century, as pediatric medical and surgical specialties separated from internal medicine and adult surgical specialties.  at Westmead, The Murdoch Institute, plus two dietitians in private practice specialising in allergy. A total of 15 specialist dietitians were identified. This survey was constructed to determine the extent of maternal dietary restrictions advised by dietitians to breastfeeding mothers to treat or prevent food allergy in their infants. Where dietary restriction was used, questions were asked regarding circumstances, the extent of foods avoided and whether partial or complete avoidance of these foods was recommended. Where dietary restriction was not used, the reasons for this practice were also ascertained. The survey was approved by the Research Ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of  Committee of the Women's and Children's Hospital. A copy of the survey can be obtained on request from the corresponding author.

Literature review of evidence

The medline database was searched using terms: food protein (+cow's milk, nut, egg) and breast (human) milk; food allergy treatment; food allergy prevention; maternal food challenge; food allergy and breastfed infants. The search was limited to human subjects and English language English language, member of the West Germanic group of the Germanic subfamily of the Indo-European family of languages (see Germanic languages). Spoken by about 470 million people throughout the world, English is the official language of about 45 nations.  articles. The data of the last search was 19 March 2003. Research evidence retrieved and considered for this review included: studies involving maternal dietary restriction followed by maternal dietary challenge to treat breastfed infants with food allergy; trials investigating the use of maternal dietary intervention during lactation to prevent allergy in high-risk breastfed infants; studies where food proteins have been detected in human milk after the ingestion of a specific challenge dose of food. NHMRC NHMRC National Health and Medical Research Council  levels of evidence criteria were used to assess the quality of the study design (6).

Results and discussion

Survey of current dietetic practice in Australia: treatment of food allergy

All 15 major paediatric hospitals and other known specialist paediatric allergy dietitians surveyed responded. The majority of dietitians (13 out of 15) surveyed follow the recommendations of expert committees that breastfed infants with food allergy symptoms be trialled on maternal dietary restriction (1,4). There is also agreement that the foods most commonly restricted are cow's milk, egg, peanut and tree nuts. Nine out of 13 dietitians advise complete rather than partial dietary avoidance of these food proteins. Treatment was individualised Adj. 1. individualised - made for or directed or adjusted to a particular individual; "personalized luggage"; "personalized advice"
individualized, personalised, personalized
, and the most common circumstances for advising dietary interventions were if the food allergy symptoms commenced when the infant was exclusively breastfed and/or the breastfed infant had severe symptoms.

Literature review of evidence: treatment of food allergy

The treatment of suspected food allergy in breastfed infants with symptoms of atopic dermatitis/eczema, colic, diarrhoea and vomiting by maternal dietary restriction, and confirmation of this diagnosis and treatment effect with maternal dietary challenge has been described (2,7-14). Although results in some of these studies appear impressive, many are case series (2,7,8,12,14) where the dietary interventions were non-randomised and uncontrolled with open food challenges (NHMRC level of evidence IV) (6).

Only three studies in the area (9-11) (Table 1) were randomised trials of crossover design with double-blind food challenges (NHMRC level of evidence II (6)). The choice of an appropriate placebo challenge for such trials should be a non-allergenic food. Unfortunately two of these trials (9,11) used potentially allergenic Allergenic
A substance capable of causing an allergic reaction.

Mentioned in: Echinococcosis
 soy protein Soy protein is generally regarded as the storage protein held in discrete particles called protein bodies which are estimated to contain at least 60–70% of the total soybean protein.  for placebo challenges, which may explain the lack of difference in symptoms observed between challenge foods. This leaves only one randomised controlled trial conducted in 1983 (10), where nine out of 16 infants had colic symptoms following maternal ingestion of cow's milk capsules but not after the appropriate non-allergenic placebo of potato starch capsules. The mothers participating in this trial were, however, pre-selected after an initial period of colic symptom improvement following maternal cow's milk avoidance and symptom return on open maternal cow's milk challenge. This may have biased the results towards a more positive response than if any group of infants with colic symptoms were studied.

Thus, despite widespread recommendations and practice of maternal food protein avoidance to treat food allergy in breastfed infants, the strength of published trials is limited. Research evidence of improved quality is required from large, randomised, appropriately placebo controlled, double-blinded food exclusion and challenge trials to test the validity of current practice and substantiate recommendations.

Survey of current dietetic practice in Australia: prevention of food allergy

Nine out of 15 dietitians surveyed reported that they do not advise maternal dietary restrictions for lactating lac·tate 1  
intr.v. lac·tat·ed, lac·tat·ing, lac·tates
To secrete or produce milk.



[Latin lact
 women with a family history of allergy in order to prevent food allergy in their infant. The most common reason given was the lack of scientific evidence that food proteins in breast milk may adversely affect the infant. Six of 15 dietitians reported they would advise maternal dietary restrictions for food allergy prevention, especially if the infant has a sibling with food allergies Food Allergies Definition

Food allergies are the body's abnormal responses to harmless foods; the reactions are caused by the immune system's reaction to some food proteins.
. Again the advice was individualised, however all of these six dietitians would recommend that peanuts be completely avoided, in keeping with the recommendation from the American Academy of Pediatrics committee (4).

Literature review of evidence: prevention of food allergy

The use of maternal dietary restriction during lactation to prevent allergy in high-risk infants (due to an atopic family history) has been investigated in trials that are summarised in Table 2 (15-22). Three of these trials (15,16,20) were also included in the Cochrane Review on this topic (23). The main infant outcome measures in these trials were atopic disorders determined by clinical examination. Several of these trials demonstrated significant reductions in atopic dermatitis/eczema between groups following maternal and infant dietary interventions compared with control groups following unrestricted diets (15-17,19,20). To determine whether maternal dietary restriction during lactation prevents food allergy, the outcome measures should include double-blind, placebo-controlled food challenges. Skin prick testing to food allergens (17-19,22) or IgE levels specific to food allergens (21), as an indicator for food allergen allergen /al·ler·gen/ (al´er-jen) an antigenic substance capable of producing immediate hypersensitivity (allergy).allergen´ic

pollen allergen
 sensitisation Noun 1. sensitisation - the state of being sensitive (as to an antigen)
sensitization

irritation - (pathology) abnormal sensitivity to stimulation; "any food produced irritation of the stomach"
 were performed in five of these trials, however food challenges to confirm the diagnosis of food allergy were only done in two studies (18,19), with only one using double-blind, placebo-controlled food challenges (18).

Although the intervention in all trials included dietary restriction in lactating women, the type and number of foods avoided and length of dietary restriction varied (Table 2). In some cases dietary intervention began in pregnancy (18,19). Some trials also applied infant dietary interventions, through the use of hydrolysed formula when breastfeeding ceased (18-20). Others compared the introduction of solids guidelines (18,19). Therefore it is not possible to determine the relative importance of maternal food avoidance during lactation compared with the other infant interventions. Interestingly only three studies (17,21,22) specifically investigated maternal dietary restriction during lactation. These studies reported no significant differences in rates of specific food sensitisation measured by IgE levels or skin prick tests, but the presence of symptomatic food allergy was not documented by means of food challenges. Thus no trials to date specifically investigated maternal dietary restriction during breastfeeding alone and confirmed the final outcome of food allergy development by means of food challenge.

Detection of food proteins in human milk

The premise that maternal dietary restrictions during breastfeeding may benefit the infant assumes that ingested in·gest  
tr.v. in·gest·ed, in·gest·ing, in·gests
1. To take into the body by the mouth for digestion or absorption. See Synonyms at eat.

2.
 food proteins are absorbed and excreted antigenically intact into breast milk. Table 3 summarises those studies where food proteins have been detected in human milk after the ingestion of a specific challenge dose of food including: ovalbumin ovalbumin: see albumin; glycoprotein.  (egg) (24,25), bovine [beta]-lactoglobulin (cow's milk) (2,12,24,26-28), gliadin gliadin /gli·a·din/ (-din) a protein present in wheat; it contains the toxic factor associated with celiac disease.

gli·a·din
n.
 (wheat) (29) and Ara h 1 and Ara h 2 (peanut) (30). Results from these studies show that even after the ingestion of the same challenge dose of a particular food the frequency and concentration of detected food protein in breast milk varies (Table 3). The factors which account for this wide variation in the detection of food proteins in human milk remain unexplained but may be critical in understanding the effect of maternal dietary restriction during lactation for the treatment and prevention of food allergy.

[beta]-lactoglobulin from cow's milk (2,12,24,26-28) has been the most commonly studied food protein. However the measurement of bovine [beta]-lactoglobulin in human milk using polyclonal antibodies by enzyme linked immunosorbent immunosorbent /im·mu·no·sor·bent/ (-sor´bent) an insoluble support for antigen or antibody used to absorb homologous antibodies or antigens, respectively, from a mixture; the antibodies or antigens so removed may then be eluted in pure  assay (ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.

ELISA
n.
) or radioimmunoassay (RIA (Rich Internet Application) A Web-based application that approaches the speed and elegance of a local application. An RIA may refer to a browser-based application that uses AJAX or another enhanced coding technique. ) could lead to inaccurate results as these antibodies have been demonstrated to also detect the presence of human milk proteins such as lactoferrin lactoferrin
(lak´tōfer´in),
n an iron-binding protein found in the specific granules of neutrophils where it apparently exerts an antimicrobial activity by withholding iron from ingested bacteria and fungi.
, [beta]-casein and [alpha]-lactalbumin (31). In a study measuring gliadin in human milk (29) the concentration and frequency of detected gliadin decreased with increasing stage of lactation. This may relate to the decrease in total protein concentration in breast milk as lactation progresses (32). Table 3 illustrates the wide range of lactation stages in previous studies, which may account further for some of the variability in results observed. Repeat measures of the same ingested challenge dose on different days on the same woman would be necessary to determine intra-individual variation on the presence of food proteins in human milk. Previous studies have not addressed this issue.

Studies investigating a dose-related effect of food protein ingested on breast milk concentration have not yet been published. Thus current available evidence is lacking on the required extent of dietary avoidance of food proteins in the maternal diet. In agreement with an expert European committee (1), most of the Australian dietitians surveyed (nine out of 13) advise complete avoidance of the causal protein from the diet of the lactating mother to treat food allergy in breastfed infants. However, we should not forget that total dietary avoidance of one or more food proteins is difficult to achieve, can be nutritionally compromising, time consuming and socially restrictive for breastfeeding mothers. If complete maternal dietary avoidance is recommended for treatment, what about prevention? Kilburn (22) has proposed that exposure to low-dose food allergens via breast milk may produce tolerance rather than sensitisation. Breast milk contains immune components, such as IgA antibodies, which are thought to bind to to contract; as, to bind one's self to a wife s>.

See also: Bind
 food proteins to form immune complexes Immune complexes
Clusters or aggregates of antigen and antibody bound together.

Mentioned in: Wegener's Granulomatosis
 decreasing the chances of these food proteins from crossing the intestinal surface in a breastfed infant. Jarvinen (33) demonstrated that total IgA levels in breast milk were significantly lower in mothers who had infants with cow's milk allergy Milk allergy is an immunologically mediated adverse reaction to one or more cow's milk proteins.

In some people the ingestion of cow's milk can trigger the body into launching an inappropriate immune response to the proteins in milk resulting in an allergic reaction.
 compared to those without cow's milk allergy, suggesting that low maternal IgA levels in breast milk may be an important factor in infant allergy development. It is also possible that infants may be sensitised in utero in utero (in u´ter-o) [L.] within the uterus.

in u·ter·o
adj.
In the uterus.



in utero adv.
, either directly or by transplacental transplacental /trans·pla·cen·tal/ (-plah-sen´tal) through the placenta.

trans·pla·cen·tal
adj.
Relating to or involving passage through or across the placenta.
 passage of allergen, however the Cochrane Review (23) on maternal dietary antigen avoidance during pregnancy concluded that prescription of an antigen avoidance diet to a highrisk woman during pregnancy is unlikely to substantially reduce her child's risk of atopic diseases, and such a diet may adversely affect maternal and/or foetal foe·tal  
adj. Chiefly British
Variant of fetal.

Adj. 1. foetal - of or relating to a fetus; "fetal development"
fetal
 nutrition. Other possible routes of sensitisation for breastfed infants to food proteins may include contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object.
 hands (1), inhaled food proteins (1) or contact with inflamed skin (34).

Conclusion

Although on the surface it would appear to be a logical precaution for breastfed infants, evidence on the use of maternal dietary restriction to treat food allergy is of limited strength, and evidence on the use of maternal dietary intervention to specifically prevent food allergy has not been addressed. Furthermore, the current scientific literature does not address questions about the extent and duration of dietary food avoidance. It is also important to understand which factors may influence the presence of food proteins in human milk. This knowledge will aid the design of large, randomised, appropriately controlled, blinded trials to investigate the use of maternal diet restriction during lactation for both the treatment and prevention of food allergy in breastfed infants.
Table 1. Trials on maternal dietary restriction and challenge in
treatment of breastfed infants with food allergies

           Study design, sample
           size and level of          Maternal dietary
Study      evidence (a)               restrictions

Jakobsson  Randomised, crossover      cow's milk
1983 (10)  design with double-
           blind challenge,
           followed by an open
           challenge (n = 16) II (a)
Evans      Randomised, crossover      cow's milk
1981 (9)   design with double-
           blind challenge (n = 20)
           II (a)
Cant       Randomised, crossover      cow's milk, egg, chocolate, nuts,
1986 (11)  design with double-        wheat, fish, beef, chicken, citrus
           blind challenge (n = 19)   fruits, colourings & preservatives
           II (a)

           Maternal dietary
Study      challenge              Results of maternal diet challenges

Jakobsson  cow's milk vs potato   9 out of 16 infants with infantile
1983 (10)  starch capsules,       colic symptoms after cow's milk
           followed by open       capsules and cow's milk drink, but not
           challenge of 1/2 to 1  after placebo potato starch capsules.
           glass cow's milk 3
           times per day
Evans      600 ml flavoured soy   Maternal cow's milk avoidance resulted
1981 (9)   milk vs flavoured      in no reduction in infantile colic.
           300ml soy + 300 ml
           cow's milk drink
Cant       soy milk powder vs     Mean values of atopic eczema scores
1986 (11)  cow's milk and egg     not significantly different between
           powder (600 ml milk    soy vs cow's milk and egg challenges.
           and 1 egg per day)

(a) NHMRC levels of evidence (6).

Table 2. Trials on allergy prevention in breastfed infants with maternal
dietary restriction

Study      Study design                Sample size

Chandra    Randomised trial with       121 enrolled
1986 (15)  non-blinded examination     12 withdrew, D = 55 and
           II (a)                      ND = 54 completed
Chandra    Randomised trial with       112 enrolled
1989 (16)  blinded examination II (a)  15 withdrew, D = 49 and
                                       ND = 48 completed
Hattevig   Cluster trial of two towns  115 enrolled
1989 (17)  with non-blinded            6 withdrew, D = 65 and
           examination III-1 (a)       ND = 50 completed
Zeiger     Randomised trial with       379 enrolled
1989 (18)  blinded examination II (a)  91 withdrew, D = 103 and
                                       ND = 185 completed
Arshad     Randomised trial with       136 enrolled
1992 (19)  blinded examination II (a)  16 withdrew, D= 58 and
                                       ND = 62 completed
Lovegrove  Randomised trial with       44 enrolled
1994 (20)  blinded examination II (a)  6 withdrew, D = 12 and
                                       ND = 14 completed (12 non-
                                       atopic women)
Herrmann   Participants self-selected  150 enrolled
1996 (21)  their intervention group    12 withdrew, A = 30, B = 33
           with non-blinded            and C = 41 completed
           examination III-2 (a)       (34 mothers breastfed < 3
                                       months)
Kilburn    Participants self-selected  111 enrolled
1998 (22)  intervention group with     4 withdrew, D = 13 and
           blinded examination         ND = 94 completed
           III-2 (a)

Study      Maternal diet & infant interventions

Chandra    D = cow's milk, egg, beef, fish, peanut-free diet for
1986 (15)  mothers throughout pregnancy and lactation
           ND = no diet restrictions for mothers
Chandra    D = cow's milk, egg, fish, peanuts, soybean-free diet for
1989 (16)  mothers for first 6 months of lactation
           ND = no diet restrictions for mothers
Hattevig   D = cow's milk, fish, egg-free diet for mothers for first
1989 (17)  3 months of lactation
           ND = no diet restrictions for mothers
Zeiger     D = cow's milk, egg, peanut-free diet for mothers for
1989 (18)  last trimester of pregnancy and during lactation (d) +
           solid restrictions for infants
           ND = no diet restrictions for mothers or infants
Arshad     D = cow's milk, fish, nut, egg-free diet for mothers for
1992 (19)  first 9 months of lactation (d) + solid restrictions for
           infants and anti-house dust-mite measures
           ND = no diet restrictions for mothers or infants
Lovegrove  D = cow's milk-free diet for mothers during lactation (d)
1994 (20)  ND = no diet restrictions for mothers
Herrmann   A = cow's milk, egg-free diet for mothers for last
1996 (21)  trimester of pregnancy and during lactation (allowed
           goat and sheep milk)
           B = cow's milk, egg-free diet for mothers for lactation
           only (allowed goat and sheep milk)
           C = mothers consumed at least 1000 ml cow's milk and
           1 egg daily
Kilburn    D = cow's milk, egg, fish, nut-free diet for mothers
1998 (22)  during lactation
           ND = no diet restrictions for mothers

Study      Infant outcome measure            Main results

Chandra    Atopic eczema up to 12 months.    Atopic eczema up to 12
1986 (15)                                    months, D = 31% < ND = 44%.
Chandra    Atopic eczema up to 18 months.    Atopic eczema up to 18
1989 (16)                                    months, D = 22% < ND = 44%.
Hattevig   Atopic disorders at birth, 3, 6,  Atopic dermatitis at 3
1989 (17)  9, 12 & 18 months. SPT (b) at 9   months, D = 3% < ND = 22% &
           months to egg, cow's milk and     at 6 months,
           fish.                             D = 11% < ND = 28%.
                                             NS (c) for prevalence of
                                             atopic dermatitis at 9, 12
                                             & 18 months.
Zeiger     Atopic disorders at 4, 12 & 24    Atopic disorders at 12
1989 (18)  months. SPT at 4, 12 & 24 months  months, D = 16% < ND = 27%.
           to food and inhalant allergens.   NS for prevalence of atopic
                                             disorders at 4 & 24 months.
Arshad     Atopic disorders at 3, 6 & 12     Atopic disorders at 3
1992 (19)  months.                           months, D = 5% < ND = 18%,
           SPT to foods & environmental      at 6 months,
           allergens.                        D = 12% < ND = 32% & at 12
                                             months, D = 14% < ND = 40%.
Lovegrove  Atopic eczema at 6, 12 & 18       Atopic eczema at 18 months,
1994 (20)  months.                           D = 11% < ND = 50%.
                                             NS for prevalence of atopic
                                             eczema at 6 & 12 months.
Herrmann   Atopic dermatitis at 1, 3, 6 &    NS for prevalence of atopic
1996 (21)  12 months.                        dermatitis at 6 & 12
           IgE specific to cow's milk &      months.
           egg at 6 and 12 months.
Kilburn    Atopic disorders at 3, 6, 12 &    NS for incidence of atopic
1998 (22)  18 months. SPT at 6, 12 & 18      disorders at 3, 6, 12 & 18
           months to foods & inhalant        months.
           allergens.

(a) NHMRC levels of evidence (6).
(b) SPT = skin prick test.
(c) NS = no significant differences.
(d) Infants had hydrolysed formula when breastfeeding ceased.

Table 3. The detection of dietary food proteins in human milk after
challenge dose ingestion

Study &    Stage of         Challenge       Timing of
mothers    lactation        dose            samples

Kilshaw    1 week to 12     1/2 pint cow's  Prior to and at
1984 (24)  months           milk & 1 raw    2, 4 & 6 hours
n = 29                      egg             after challenge
Cant       < 6 months       1 raw egg       Prior to and at
1985 (25)  (most 3-4                        2, 4 & 6 hours
n = 19     months)                          after challenge
Troncone   1 week to 5      20 g gluten     2-4 hours
1987 (29)  months                           (Prior to and at
n = 53                                      2, 4 & 6 hours)
(n = 6)                                     after challenge
Cavagni    not clearly      1 cooked egg    3-5 hours after
1988 (12)  described        & 100 g         challenge
n = 13                      cow's milk
Host       not clearly      500 ml cow's    4 hours after
1988 (2)   described        milk            challenge
n = 19
Host       1-2 weeks        500 ml cow's    Prior to and at
1990 (26)  atopic & 8-19    milk            4, 8, 12 & 24
n = 20     weeks non-                       hours after
           atopic mothers                   challenge
Sorva      2-12 months      400 ml cow's    Prior to and at 1
1994 (27)  (median 7        milk            and 2 hours
n = 53     months)                          after challenge
Fukushima  4-10 months      200 ml cow's    1-3 hrs, 4-8 hrs
1997 (28)                   milk            and 9-15 hrs
n = 24                                      after challenge
Vadas      not clearly      50 g peanuts    Prior to and at
2001 (30)  described                        1, 2, 3, 4, 6, 8 &
n = 23                                      12 hrs after
                                            challenge

Study &    Detection        Sensitivity  Concentration
mothers    method           (ng/ml)      (ng/ml)

Kilshaw    RIA (a)          0.1-15       0.11-6.4 CM
1984 (24)                                0.26-6.17 egg
n = 29
Cant       RIA (a)          0.1-15       0.2-4.0
1985 (25)
n = 19
Troncone   ELISA (b)        5            5-95
1987 (29)
n = 53
(n = 6)
Cavagni    RIA (a)          0.01         results only
1988 (12)                                given as
n = 13                                   positive or
                                         negative
Host       ELISA (b)        0.3          0.5-45
1988 (2)
n = 19
Host       ELISA (b)        0.3          0.9-150
1990 (26)                                (median 4.2)
n = 20
Sorva      ELISA (b)        0.002        0.00-8.6? (not
1994 (27)                                clearly stated)
n = 53
Fukushima  ELISA (b)        0.1          up to 16.5
1997 (28)
n = 24
Vadas      ELISA (b)        Not          120-430
2001 (30)                   reported
n = 23

Study &    Detection         Peak
mothers    frequency         appearance

Kilshaw    52% CM            4 hours
1984 (24)  59% egg
n = 29
Cant       74% egg           2-4 hours
1985 (25)
n = 19
Troncone   68%               1 sample only
1987 (29)  gliadin           (at 2-4 hours)
n = 53
(n = 6)
Cavagni    62% CM (c)        1 sample only
1988 (12)
n = 13
Host       21% CM (c)        1 sample only
1988 (2)
n = 19
Host       95% CM (c)        4-24 hours
1990 (26)                    (median 8 hr)
n = 20
Sorva      75% CM (c)        only 1 mother
1994 (27)                    studied > 2
n = 53                       hours
Fukushima  63% CM (c)        not reported
1997 (28)
n = 24
Vadas      48%               1-2 hours
2001 (30)  peanut
n = 23

(a) RIA = radioimmunoassay.
(b) ELISA = enzyme linked immunosorbent assay.
(c) CM = cow's milk.


Acknowledgments

The authors would like to thank all the participating dietitians who volunteered their time to complete the survey of current practice. Part of this work was funded by grants from the Rural Industries Research and Development Corporation The Rural Industries Research and Development Corporation (RIRDC) is a statutory Corporation formed in July 1990 under the Primary Industries and Energy Research and Development (PIERD) Act 1989.  and the Women's and Children's Hospital Research Foundation. Maria Makrides was supported by a NHMRC RD Wright Fellowship.

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Child Health Research Institute, Women's and Children's Hospital, Adelaide The Women's and Children's Hospital is located on King William Road in North Adelaide, Australia. It is one of the major hospitals in Adelaide and is a teaching hospital of the University of Adelaide, the University of South Australia and Flinders University.  and Department of Paediatrics, The University of Adelaide Its main campus is located on the cultural boulevard of North Terrace in the city-centre alongside prominent institutions such as the Art Gallery of South Australia, the South Australian Museum and the State Library of South Australia.  

D.J. Palmer, BSc, BND BND

In currencies, this is the abbreviation for the Brunei Dollar.

Notes:
The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion.
, APD APD atrial premature depolarization (see atrial premature complex, under complex ); pamidronate. , PhD candidate

M. Makrides, BSc, BND, PhD, Head of Applied Nutrition Group and Senior Lecturer

Department of Paediatrics, The University of Adelaide

M.S. Gold, MBCHB, MD, FRACP FRACP Fellow of the Royal Australasian College of Physicians , Senior Lecturer

Correspondence: M. Makrides, Child Health Research Institute, Women's and Children's Hospital, 72 King William Road, North Adelaide SA 5006. Email: makridesm@mail.wch.sa.gov.au
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Publication:Nutrition & Dietetics: The Journal of the Dietitians Association of Australia
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