Recommendations for food allergen avoidance

There remains controversy about the stringency of allergen avoidance required in food allergies, recently reviewed by Zeiger.115 Two position statements have been published, by the American Academy of Pediatrics (AAP)99 and a joint statement by the European Society for Pediatric Allergology and Clinical Immunology (ESPACI) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).116 These statements deal with two areas of importance: the primary prevention of development of food allergies, and the treatment of the affected child.

With respect to primary prevention, there are areas of clear concordance, and both statements support the limitation of primary prevention to high-risk infants only, and the use of hypoallergenic formulas (ideally extensively hydrolyzed) but not soy milk for bottle-fed high-risk infants. High risk is defined on family history grounds rather than any perinatal testing, although the AAP defines a positive family history as two first-degree relatives with atopic disease and the ESPACI/ESPGHAN definition requires only one. Neither recommend maternal exclusion diets during pregnancy and both recommend exclusive breast feeding (AAP 6 months, ESPACI/ESPGHAN 4-6 months). While the European bodies do not recommend a maternal exclusion diet during lactation, the American body recommends exclusion of peanuts and nuts, and consideration of further exclusions. The European regulations are also less restrictive about the introduction of solid foods, suggesting introduction at 5 months, rather than the much later introduction of cow's milk and eggs suggested in the AAP report.

For treatment of established food allergies, both statements recommend complete exclusion of the causative antigen, and show broad consensus in the management of a formula-fed cow's milk-sensitized infant, with recommendation of an extensively hydrolyzed but not partially hydrolyzed formula. However, the AAP guidelines also suggest that soy is an alternative in this circumstance, which is not supported by the European guidelines. Both recommend an amino acid formula for the infant who is intolerant of hydrolysates. Neither support the use of unmodified goat's or sheep's milk. For the infant who becomes sensitized while breast fed, both statements concord in support of maternal exclusion of the relevant antigen, while the AAP further recommends weaning to an extensively hydrolyzed formula or soy milk. For the infant with concomitant malabsorption due to enteropathy, both recommend extensively hydrolyzed or amino acid formulas.

An important recent report from the German Infant Nutrition Intervention (GINI) study group117 assessed 2252 at-risk infants, who were randomly assigned at birth to receive one of four blinded formulas, either cow's milk-based, partially hydrolyzed whey, extensively hydrolyzed whey, or extensively hydrolyzed casein. The primary endpoint at 1 year of age was the presence of one or more of atopic dermatitis, gastrointestinal food allergy or urticaria. The drop-out rate was high, as 865 remained exclusively breast fed for 4 months, 304 left the study and 138 did not comply. Study of the 945 remaining treated infants showed a significant protective effect of extensively hydrolyzed casein compared to unmodified cow's milk (9% vs. 16% had allergies) and atopic dermatitis was significantly reduced with extensively hydrolyzed casein or partially hydrolyzed whey formulas. The protective effect of hydrolysates was attenuated in those with a strong family history of atopy.

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