Treatment and prevention of food allergies in breastfed infants: practice and evidence.
(Nutr Diet 2004;61:76-81)
Objective: To determine whether current Australian dietetic dietetic /di·e·tet·ic/ (di?ah-tet´ik) pertaining to diet or proper food.
1. Of or relating to diet.
2. practice is consistent with research relating to relating to relate prep → concernant
relating to relate prep → bezüglich +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.
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
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
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)
2. pertaining to atopy; allergic.
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.
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 :
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)
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.
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.
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
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 the uterus.
in utero adv. , either directly or by transplacental transplacental /trans·pla·cen·tal/ (-plah-sen´tal) through the placenta.
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).
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.
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.
1. Host A, Koletzko B, Dreborg S, Muraro A, Wahn U, Aggett P, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European Society for Paediatric Allergology and Clinical Immunology Clinical immunology
A branch of clinical pathology concerned with the role of the immune defense system in disease. The subject encompasses diseases where a malfunction of the immune system itself is the basic cause, together with diseases where some external (ESPACI) Committee on Hypoallergenic hy·po·al·ler·gen·ic
Having a decreased tendency to provoke an allergic reaction.
adj Formulas and the European Society for Paediatric Gastroenterology gastroenterology
Medical specialty dealing with digestion and the digestive system. In the 17th century Jan Baptista van Helmont conducted the first scientific studies in the field; William Beaumont published his own observations in 1833. , Hepatology and Nutrition (ESPGHAN ESPGHAN European Society for Paediatric Gastroenterology Hepatology and Nutrition ) Committee on Nutrition. Arch Dis Child 1999;81:80-4.
2. Host A, Husby S, Osterballe O. A prospective study of cow's milk allergy in exclusively breast-fed breast·feed or breast-feed
v. breast-fed , breast-feed·ing, breast-feeds
To feed (a baby) mother's milk from the breast; suckle.
To breastfeed a baby. infants. Acta Paediatr Scand 1988;77:663-70.
3. Saarinen KM, Savilahti E, Infant feeding patterns affect the subsequent immunological features in cow's milk allergy. Clin Exp Allergy 2000;30:400-6.
4. American Academy of Pediatrics (Committee on Nutrition). Hypoallergenic infant formulas, Pediatries 2000;106:346-9.
5. Zeiger RS, Dietary aspects of food allergy prevention in infants and children. J Pediatr Gastrenterol Nutr 2000;30:77S-86S.
6. National Health and Medical Research Council The National Health and Medical Research Council (NHMRC) is Australia's peak funding body for medical research, with a budget of nearly A$500M a year . The Council was established to develop and maintain health standards and is responsible for implementing the . A guide to the development, implementation and evaluation of clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. . Canberra: Commonwealth of Australia Commonwealth of Australia: see Australia. ; 1999.
7. Matsumura T, Kuroume T, Oguri M, Iwasaki I, Kanbe Y, Yamada T et al. Egg sensitivity and eczematous manifestations in breast-fed newborns with particular reference to intrauterine intrauterine /in·tra·uter·ine/ (-u´ter-in) within the uterus.
Within the uterus.
Situated or occuring in the uterus. sensitisation. Ann Allergy 1975;35:221-9.
8. Gerrard J. Allergy in breast fed babies to ingredients in breast milk. Ann Allergy 1979;42:69-72.
9. Evans R, Fergusson D, Allardyce R, Taylor B, Maternal diet and infantile colic infantile colic,
n a health condition encountered in infants and small children; characterized by short, intensely painful intestinal spasms that often wake the distressed child. in breast-fed infants. Lancet 1981;1:1340-2.
10. Jakobsson I, Lindberg T. Cow's milk proteins cause infantile colic in breast-fed infants: a double-blind crossover study A crossover trial also referred to as a crossover study is one where patients are given all of the medications to be studied, or one medication and a placebo in random order. These studies are generally done on patients with chronic diseases to control their symptoms. . Pediatrics 1983;71:268-71.
11. Cant AJ, Bailes JA, Marsden RA, Hewitt D. Effect of maternal dietary exclusion on breast fed infants with eczema: two controlled studies. Br Med J 1986;293:231-3.
12. Cavagni G, Paganelli R, Caffarelli C, D'Offizi GP, Bertolini P, Aiuti F, et al. Passage of food antigens into circulation of breast-fed infants with atopic dermatitis Atopic Dermatitis Definition
Eczema is a general term used to describe a variety of conditions that cause an itchy, inflamed skin rash. Atopic dermatitis, a form of eczema, is a non-contagious disorder characterized by chronically inflamed skin and . Ann Allergy 1988;61:361-5.
13. Jarvinen K-M K-M Krauss-Maffei (German locomotive manufacturer) , Makinen-Kiljunen S, Suomalainen H. Cow's milk challenge through human milk evokes immune responses in infants with cow's milk allergy. J Pediatr 1999; 135:506-12.
14. De Boissieu D, Matarazzo P, Rocchiccioli F, Dupont C. Multiple food allergy: a possible diagnosis in breastfed infants. Acta Paediatr 1997;86:1042-6.
15. Chandra RK, Puri S, Suraiya C, Cheema PS. Influence of maternal food antigen avoidance during pregnancy and lactation on incidence of atopic eczema atopic eczema (āˈ·tˑ·pik egˑ·z in infants. Clin Allergy 1986;16:563-9.
16. Chandra RK, Puri S, Hamed A. Influence of maternal diet during lactation and use of formula feeds on development of atopic eczema in high risk infants. Br Med J 1989;299:228-30.
17. Hattevig G, Kjellman B, Sigurs N, Bjorksten B, Kjellman N, Effect of maternal avoidance of eggs, cow's milk and fish during lactation upon allergic manifestations in infants. Clin Exp Allergy 1989;19:27-32.
18. Zeiger RS, Heller S, Mellon MH, Forsythe AB, O'Connor RD, Hamburger RN, et al. Effect of combined maternal and infant foodallergen avoidance on development of atopy atopy /at·o·py/ (at´ah-pe) a genetic predisposition toward the development of immediate hypersensitivity reactions against common environmental antigens (atopic allergy), most commonly manifested as allergic rhinitis but also as in early infancy: A randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. study. J Allergy Clin Immunol 1989;84:72-89.
19. Arshad SH, Matthews S, Gant C, Hide DW. Effect of allergen avoidance on development of allergic disorders in infancy. Lancet 1992;339:1493-7.
20. Lovegrove JA, Hampton SM, Morgan JB. The immunological and long-term atopic outcome of infants born to women following a milk-free diet during late pregnancy and lactation: a pilot study. Br J Nutr 1994;71:223-38.
21. Herrmann M-E, Dannemann A, Gruters A, Radisch B, Dudenhausen J, Bergmann R, et al. Prospective study on the atopy preventive effect of maternal avoidance of milk and eggs during pregnancy and lactation. Eur J Pediatr 1996;155:770-4.
22. Kilburn SA, Pollard C, Bevin S, Hourihane JOB, Warner JO, Dean T, Allergens in mother's milk: tolerisation or sensitization sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun)
1. administration of an antigen to induce a primary immune response.
2. exposure to allergen that results in the development of hypersensitivity. . Nutr Res 1998;18:1351-61.
23. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy and/or lactation for preventing or treating atopic disease in the child (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons Ltd.
24. Kilshaw PJ, Cant AJ. The passage of maternal dietary proteins into human breast milk. Int Arch Allergy Appl Immunol 1984;75:8-15.
25. Cant A, Marsden RA, Kilshaw PJ. Egg and cows' milk hypersensitivity hypersensitivity, heightened response in a body tissue to an antigen or foreign substance. The body normally responds to an antigen by producing specific antibodies against it. The antibodies impart immunity for any later exposure to that antigen. in exclusively breast fed infants with eczema, and detection of egg protein in breast milk. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 1985;291:932-5.
26. Host A, Husby S, Hansen LG, Osterballe O. Bovine [beta]-lactoglobulin in human milk from atopic and non-atopic mothers. Relationship to maternal intake of homogenized ho·mog·e·nize
v. ho·mog·e·nized, ho·mog·e·niz·ing, ho·mog·e·niz·es
1. To make homogeneous.
a. To reduce to particles and disperse throughout a fluid.
b. and unhomogenized milk. Clin Exp Allergy 1990;20:383-7.
27. Sorva R, Makinen-Kiljunen S, Juntunen-Backman K. [beta]-Lactoglobulin secretion in human milk varies widely after cow's milk ingestion in mothers of infants with cow's milk allergy. J Allergy Clin Immunol 1994;93:787-92.
28. Fukushima Y, Kawata Y, Onda T, Kitagawa M. Consumption of cow milk and egg by lactating women and the presence of [beta]-lactoglobulin and ovalbumin in breast milk. Am J Clin Nutr 1997;65:30-5.
29. Troncone R, Scarcella A, Donatiello A, Cannataro P, Tarabuso A, Auricchio S. Passage of gliadin into human breast milk. Acta Paediatr Scand 1987;76:453-6.
30. Vadas P, Wai Y, Burks W, Perelman B, Detection of peanut allergens in breast milk of lactating women. JAMA JAMA
Journal of the American Medical Association 2001;285:1746-8.
31. Bertino E, Prandi GM, Fabris C, Cavaletto M, Di Martino S, Cardaropoli S, et al. Human milk proteins may interfere in ELISA measurements of bovine [beta]-lactoglobulin in human milk. Acta Paediatr 1996;85:543-9.
32. Suskind R, Lewinter-Suskind L. Textbook of pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. nutrition. 2nd ed. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Raven Press; 1993.
33. Jarvinen K-M, Laine ST, Jarvenpaa A-L, Suomalainen HK. Does low IgA in human milk predispose pre·dis·pose
To make susceptible, as to a disease. the infant to development of cow's milk allergy? Pediatr Res 2000;48:457-62.
34. Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy peanut allergy Immunology A common cause of anaphylactic reactions which, unlike some allergies, is rarely outgrown; PA is the most common cause of food allergy in the US, and a leading cause of food-induced anaphylaxis and death after accidental exposure in childhood. N Engl J Med 2003;348:977-85.
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.
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: firstname.lastname@example.org