HUNT313 - Allergies

What 2 factors during infancy have been associated with a reduced risk of coeliac disease?

(1) BF while introduction of gluten-containing foods; (2) increasing duration of BF.

What are the main 2 limitations of studies looking at late and early introduction of complimentary foods?

(1) available data is almost exclusively from observational studies; (2) mainly looking at infants who are at high risk of atopic disease.

A friend has asked me examples of appropriate food to feed her infant at 7-8 months. Give 3 recommendations.

-age appropriate infant cereals -continue to cook and puree meat, fish and vegetable alternatives -cooked and mashed egg -tofu -mashed vegetables and fruit (step up from purred) -use cow's milk (or suitable alternatives) in cooked food, e.g. custard or milk-based puddings -age-appropriate infant foods. -finger food in pieces that can be easily picked up by the infant e.g. slices of cheese, ripe banana

A friend has asked me examples of appropriate food to feed her infant at 8-12 months. Give 3 recommendations.

-breakfast cereals e.g. porridge -finely chopped or minced meat & mixed with mashed veges. -thin scraping of peanut butter (smooth) -add chopped soft fruit to yoghurt or custard -age-appropriate commercial foods. -slightly firmer finger foods e.g. soft ripe fruit like kiwifruit, grated carrot, toast fingers, tender meat.

A friend has asked me examples of appropriate food to feed her infant at 6-7 months. Give 3 recommendations.

-iron fortified baby cereal -cooked and pureed meat e.g. lamb -cooked and pureed vegetable alternatives e.g. legumes -pureed plain rice -cooked and pureed veges without skins, pips or seeds, e.g. pumpkin. -pureed fruit without skins, pips or seeds e.g. apple. -age-appropriate commercial infant foods.

What is the proposed criteria to assess the relationship between atopic disease and BF (which no studies currently fulfill)?

-nonreliance on late maternal recall of BF -sufficient duration of exclusive BF -strict diagnostic criteria for atopic outcomes -adequate statistical power

What are children predisposed to like/dislike in terms of food?

-prefer high-energy foods -to reject new foods -to learn the associations between food flavours and the postingestive consequences of eating.

When is starter formula recommended and what it's protein base?

0-6 months, whey-based like BM

How many <3 year olds affected by a peanut allergy and how many outgrow this?

0.8% prevalence and 20% outgrow it

Preferential use of low-fat cow's milk is appropriate when?

2-3 years old onwards

Poor growth in infancy was found with fat intakes below what percentage of EI?

22%

Fat intake should not actively be reduced before what age?

3 years.

Of the infants allergic to Cow's milk, what percentage are also allergic to soy?

47%

In relation to milestones of motor skill in infants feeding, describe expectations at 6, 8 and 9-12 months.

6 - can sit with support and sweep a spoon with their upper lip. 8 - improved tongue flexibility, can chew and swallow more lumpier foods in larger portions. 9-12 - most have the manual skill to feed themselves, drink from a standard cup holding with both hands, and eat food prepared for the rest of a family in appropriate manner (bite sized pieces, finger foods).

When should honey be introduced? Why?

>12 months of age. The consumption of honey has continually been associated with infant clostridium botulinum.

During complimentary feeding, what % of the infants iron intake should come from complimentary foods?

>90%

Allergy

A hypersensitivity reaction initiated by immunologic mechanisms.

Atopic dermatitis (eczema)

A pruritic, chronic inflammatory skin disease that commonly presents during early childhood and is often associated with a personal or family history of atopic diseases.

A friend has asked me examples of appropriate food to feed her infant at 12-24 months. Give 3 recommendations.

All previously mentioned. Can now include: -tender finely chopped meats -breads -small sandwiches with thin filling or spreads -finely chopped salad vegetables, e.g. cucumber -plain pasteurized whole milk or suitable alternatives.

Is soy formula a good option?

Although it may have a role in the treatment of GI conditions such as lactose intolerance and galactosemia, its use for allergy prevention is not recommended.

What advice would I give to a mother about ID and LCPUFA n complimentary feeding?

Although the evidence of moderate iron deficiency and a low intake of LCPUFA having adverse effects on neurodevelopment is not strong, I would advise to include good sources of iron (e.g. meat) and LCPUFA (e.g. oily fish) in complimentary feeding diet.

Asthma

An allergic-mediated response in the bronchial airways that is verified by the variation in lung function either spontaneously or after bronchodilating drugs.

Food allergy

An immunologically mediated hypersensitivity reaction to any food, including IgE-mediated and non-IgE-mediated allergic reactions.

Cow milk allergy

An immunologically mediated hypersensitivity reaction to cow milk, including IgE-mediated and non-IgE-mediated allergic reactions.

Do maternal dietary restrictions help prevent atopic disease?

At the present time there is a lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of atopic disease. Similarly, antigen avoidance during lactation does not prevent atopic disease (possibly excluding atopic eczema)

Atopy

Atopy (or atopic disease) is a personal or familial tendency to produce immunoglobulin E (IgE) antibodies in response to low-dose allergens, confirmed by a positive skin-prick test result. Includes atopic dermatitis (eczema), asthma, allergic rhinitis (hay fever) and allergic conjunctivitis.

At 3 months of age is there a difference between BF and formula fed babies?

BF infants typically show a deceleration of growth, compared with the growth acceleration of formula-fed.

Evidence surrounding exclusive BF and food allergens fed into breast milk?

BM contains intact food allergens and may induce both tolerance or sensitization in the infant, depending on maternal and infantile genetic factors, and levels of immune modulating compounds in BM (e.g. secretory IgA).

What has been assocoiated with an increased risk of coeliac disease in terms of complimentary feeding?

Both early (<3 months) and late (>7 months) introduction of gluten-containing cereals

What age are GI and renal systems mature enough to metabolise nutrients from complimentary foods?

By the age of 4 months

Atopic disease

Clinical disease characterised by atophy; typically refers to atopic dermatitis, asthma, allergic rhinitis, and food allergy.

What is the most common allergen for infants and toddlers?

Cow's milk

Should a mother be worried about her infants kidneys with cow's milk?

Cow's milk can increase the renal solute load secondary to high proportions of protein, Na, K and Cl in cow's milk compared to human milk. In order to handle this increased solute load, the infant must have sufficient fluid intake.

Main composition differences between Cow and Breast milk?

Cow's milk is higher in protein, minerals and SAFA. Also has a different composition of PUFA - low content of linolenic acid but a lower ratio of linoleic acid to a-linolenic ratio than most infant formulae.

Name the 8 allergens causing 90% of all reactions?

Cow's milk, Eggs, Peanuts, Tree nuts, Soy, Fish, Shellfish and wheat.

Define complimentary feeding and the target age.

Defined as the process starting when breast milk alone is no longer sufficient to meet nutritional requirements, and therefore other foods and liquids are needed along with breast milk, or formula. Target age: 6-12 months.

What is the evidence surrounding lactating and coeliac disease?

Evidence suggests small amounts gluten while infant is still BF may reduce the risk compared with those not BF. Recent evidence both early (<3 months) and late (>7 months) introduction of gluten-containing cereals in complimentary feeding may be associated with increased risk of Coeliac disease.

What is the key to food allergy and atopy prevention?

Exclusive BF for 4-6 months, use of hydrolysed formulae when BF is not possible and the delayed introduction of complimentary foods until the ages of 4-6 months,

What is responsive feeding?

Feed infants directly and assist older children when they can begin to feed themselves. Sensitise them to huger and satiety cues. Feed slowly and patiently, never force them to eat. If a child refuses to eat, experiment with different food combinations, flavours and textures.

What would be my advice to a mother wanting to feed her child Fully hydrolysed infant formula?

Fully-hydrolysed AA-based formula is, considered a treatment formula and not recommended for primary allergy prevention.

Evidence surrounding Amino-acid based formula?

Has been shown to be effective and nutritionally complete in the treatment of infants with CMA. However, its preventative effects on food allergy or atopic diseases has not been assessed. Extremely costly and may have disadvantages in immune maturation in the infant.

Does extensively or partially hydrolysed infant formula delay or prevent atopic dermatitis?

In infants at high risk of developing atopic disease who are NOT BF exclusively for 4-6 months there is modest evidence to suggest that feeding them partially or extensively hydrolysed infant formula, compared with cow's milk formula, may prevent or delay atopic dermatitis in early childhood.

Which infants are at risk of developing an allergy?

Infants with at least one first-degree relative (parent or sibling) with documented allergic disease.

What is the current evidence of partially hydrolysed infant formula?

It contains relatively intact cow's milk protein fragments. Shown to reduce incidence of CMA in high-risk infants, compared to CMF. Has similar preventative properties as extensively hydrolysed formula, but is not suitable for the treatment of infants with established CMA.

Is ID harmful to an infant?

It is unclear whether ID in the absence of anaemia has adverse effects on neurological outcomes. Until there is further evidence, it is advised to avoid ID.

Is there an influence of increased DHA during complimentary feeding in infants?

It may influence short-term visual function. However, further research is required to establish whether these effects persist and whether there are broader effects on cognitive function.

What is the main limitation with studies surrounding allergies?

Lack of RCT

Define baby-led weaning

Letting babies feed themselves from the very beginning of weaning.

What are probiotics?

Live microorganisms which, when administered in adequate amounts, confer a health benefit to the host.

Early introduction (before when) of Cow's milk causes what in an infant?

Microscopic bleeding of the GI tract (0.64 mL/day) due to possible antigenic challenge of the gut mucosa prior to proper immune development. This has not been seen beyond the age of 9 months.

Is soy good for allergy prevention?

No convincing evidence.

Is delaying solid food introduction beyond>4-6 months protective of atopic disease?

No current evidence convincing enough to suggest that delaying solid food introduction beyond 4-6 months has a protective effect on atopic disease development, regardless of formula fed or BF. This includes highly allergic foods too.

What is the current evidence surrounding Maternal elimination diets during pregnancy?

No evidence that elimination diets during pregnancy will prevent food allergies in high-risk infants, with the possible exception of peanut.

What is the current evidence surrounding lactose-free formula?

No preventative effect on food allergy. Although lactose-reduced, the cow's milk proteins remain intact and may sensitise the infant.

Does wheezing mean a child has asthma?

No, wheezing does not mean the child has asthma, and a child with asthma may not wheeze.

Should additional salt be added to food during infancy?

No.

What has early life soy exposure been associated with?

Not consistent throughout childhood, but has been associated with masculinized play in girls at 42 months of age.

Name the 3 types of hydrolysed formula

Partially hydrolysed formula - has longer protein chains than extensive. Extensively hydrolysed formula Free AA-based formula - peptide-free formula that contains mixtures of essential and nonessential AA.

What enhances an infants enjoyment of food in the early stages?

Prenatal and early postnatal exposure to flavours, that is in the amniotic fluid from what the mother has consumed or hints of it in the breast milk. Think of Lisa's example of garlic.

Differences in RBC DHA in infants fed Cow's milk compared to formula?

RBC docosahexaenoic acid (DHA) is more favorable in infants consuming cow's milk due to its lower ratio of a-linoleic to linolenic acid compared to infants fed formula not supplemented with DHA

Hypoallergenic

Reduced allergenicity or reduced ability to stimulate an IgE response and induce IgE-mediated reactions

What may be the issues for an infant restricted of fish in relation to concerns of an allergy?

Reduction in LCPUFA n-3 intake may have potential consequences on cognitive development and immune function.

What is a common first food in infants?

Rice cereal - easily digested and hypoallergenic

Recommended % fat intake during the ages of complimentary feeding?

Should be above, not below, 25% of EI. Higher levels may be required if the infant has a poor intake or an infection.

What are the current recommendations for introducing solid food to infants?

The European Academy of Allergology and Clinical Immunology recommends delayed introduction of solid foods for 4-6 months in BF or formula-fed infants. Also recommends cows milk to be delayed until 12 months of age.

Arachiodonic acid

The main LCPUFA of the n-6 series and well represented in the brain.

Does exclusive BF help infants at high risk of developing atopic disease?

There is evidence that exclusive BF for at least 3 months protects from wheezing in early life. However, the current evidence surrounding protection against allergic asthma developing >6 years of age in infants at high risk by exclusive BF is not convincing.

Should foods be restricted for allergy prevention?

There is no convincing evidence that avoidance or delayed introduction of potentially allergenic foods (e.g. fish and eggs), reduces allergies, in infants considered at risk or those who are not.

What us the evidence surrounding prebiotics in infant formulas?

They may enhance immunological benefits BUT may increase the risk of diarrhoea and eczema.

What is the main reason for delaying Cow's milk in infants diet?

To prevent iron deficiency as Cow's milk is a poor iron source.

When is follow-on formula recommended and what it's protein base?

Usually casein-based like cow's milk and recommended >6 months and beyond.

Exclusive BF beyond 6 months of age becomes insufficient for what nutrients?

energy, protein, iron, zinc and vitamins A + D

What are prebiotics?

food componants that arent digested in the small intestine oligosaccharides), but are used as food by colon bacteria to encourage their growth or activity.

In relation to allergens, what has the early (<4 months) introduction of >4 foods been associated with?

increased risk of atopic dermatitis both in the short-term and long-term (10 year) follow-up.

What is infant formula higher in?

iron, zinc and protein. Formula-fed infants also tend to ingest higher volumes.

What is the risk of an infant not getting introduced solid food before 10 months of age?

it may increase the risk of feeding difficulties later on. Therefore, it is important to give age-appropriate foods in the correct consistency and method for both developmental and nutritional reasons.

Over-consumption of En-dense complimentary foods may lead to what?

may induce excessive weight gain in infancy, which has been associated with a 2 to 3-fold higher risk of obesity in school age and childhood.

Are fish oil supplementation effective in infants?

no.

Measures that will help avoid ID in infants

promoting exclusive BF, using iron-fortified formula if formula is required, postponing the introduction of cow's milk and promoting iron-rich complimentary foods.

What is neophobia?

reluctance to try new foods. New foods may be offered 8-15 times before it is accepted.

If a lactating mother is a vegan and not taking nutritional supplements, what are the risks to the infant?

significant risk that the infant will experience severe cognitive impairment and the risk is increased further if the infant continues a diet containing no animal foods.