4/5/2015 Jill Mallory, MD, IBCLC Wildwood Family Clinic Madison, WI Define a food allergy and a food intolerance. 20 yo living w/ her mom List 2 risk factors for the development of food First baby allergies in children? 10 lbs at birth! Describe the prognosis of food allergies in children. Vaginal delivery What is the role of lactation in the prevention of 41 weeks gestation food allergies? No complications What is the role of alteration in maternal diet in the allergic child? Took right to the breast Is weaning ever advisable in the setting of food 2 weeks old allergies or intolerances? Well above birth weight List 3 reasons why a nursing baby who has food allergies should continue to nurse. Exclusively breastfed Very colicky baby Her sister only breastfed Seems to be in pain all her daughter for 4 mo the time because she was so colicky. When she “About the only time he isn’t crying is when he’s switched to soy formula, asleep or nursing” it was like magic, and the baby was happy. Very runny, mucous stools Afraid of months of colic Grandmother can’t take “What’s wrong with my milk?” the crying and rec formula 1 4/5/2015 Definition: an adverse health effect arising Food allergies result in IgE-mediated from a specific immune response that occurs immediate reactions reproducibly on exposure to a specific food. (e.g., anaphylaxis) and several chronic diseases (e.g., enterocolitis syndromes, eosinophilic Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food esophagitis, etc), allergy: applications in the pediatric population. Pediatrics. 2011 in which IgE may not play an important role. Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10. Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food Gupta RS, et al. Childhood food allergies: current diagnosis, treatment, allergy: applications in the pediatric population. Pediatrics. 2011 and management strategies. Mayo Clin Proc. 2013 May;88(5):512-26 Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10. Gupta RS, et al. Childhood food allergies: current diagnosis, treatment, and management strategies. Mayo Clin Proc. 2013 May;88(5):512-26 In the nursling: GE reflux Bloody stools Eczema Colic In older children or adults: Itching in the mouth or swelling Vomiting, diarrhea, or abdominal cramps Hives or eczema Tightening of the throat and wheezing Drop in blood pressure Milk Egg Wheat Soy Peanut – affects 1-2% of children! Treenut Fish Shellfish 2 4/5/2015 IgE presence + symptoms = IgE mediated allergy Allergens are usually proteins http://www.ifr.ac.uk/protall/infosheet.htm Less well-defined In the United States, affects an estimated NOT IgE mediated 12% of children and 13% of adults (self- reported) Symptoms occur after eating a certain food Headaches In double-blind food challenges, incidence Muscle and joint aches and pains looks more like 3% for adults and children Tiredness Rise in prevalence in the past 20 years Abdominal pain and diarrhea No effective treatment exists Examples Management = avoidance Celiac disease Lactose intolerance Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10. Incidence is poorly defined Eczema and GI sxs most common 0.5-1% of EBF infant will develop allergy to Most common GI sx is bloody stools cow’s milk proteins excreted into mother’s Generally “well-appearing” milk Sxs can be present at birth 50-65% of allergic colitis in EBF infants is due Typically develop at 2-6 weeks of age to cow’s milk protein 19% to egg, 6% to corn, and 3% to soy ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant. EBF infants have significantly lower rates of Breastfeed Med. 2011 Dec;6(6):435-40. doi: 10.1089/bfm.2011.9977. Epub 2011 Nov 3. cow’s milk allergy than those exposed to formula ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant. Breastfeed Med. 2011 Dec;6(6):435-40. doi: 10.1089/bfm.2011.9977. Epub 2011 Nov 3. 3 4/5/2015 2-4 x more likely to have asthma, eczema, Biologic parents or siblings with a hx of respiratory problems allergic rhinitis, asthma, atopic dermatitis May co-exist with eosinophilic esophagitis (eczema), or food allergy. Food exposure may cause severe asthma Child themselves have other preexisting attacks or anaphylaxis allergic disease 37% of children with eczema have IgE- Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications mediated food allergy in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10. Burks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi: 10.1542/peds.2011-0539. Epub 2011 Oct 10. Difficult to predict by AAP Recommends Severity of past reactions At risk = at least 1 first degree relative, parent or Food specific IgE levels sibling with food allergy Wheal size in skin-prick testing All children at risk of should be exclusively breastfed Co-existence of asthma = If exclusive breastfeeding is not possible marker for severity of hydrolyzed infant formulas should be used food allergy Complementary food should not be restricted at 6 mo Intact proteins from the mother’s diet can Maternal gut cross the gut barrier and enter the breastmilk Infant gut These proteins can trigger an allergic response and symptoms in some infants. The crux of it all! Vadas P, et al. Detection of peanut allergens in breast milk of lactating women. JAMA 2001;285:1746-1748. Sorva R, et al. 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;93:787-792. Casas R, et al. Detection of IgA antibodies to cat, beta-lactoglobulin, and ovalbumin allergens in human milk. J Allergy Clin Immunol. 2000;105:1236-1240. Pittschieler K. Cow’s milk protein-induced colitis in the breastfed infant. J Pediatr Gastroenterol Nutr. 1990;10:548-549. 4 4/5/2015 A healthy gut Physical barriers – tight junctions Allows nutrients to pass from food into the Our bacteria friends bloodstream Oligosaccharides Prevents the entrance of pathogenic bacteria and toxins from the environment into the blood Breakdown of these barriers occur Large food particles pass into the blood stream and interact with the immune system This leads to the development of food allergies C. Perrier et al. Gut permeability and food allergies. Clinical & Experimental Allergy. Volume 41, Issue 1, pages 20–28, January 2011 Your body houses 10 x more bacterial cells May start prenatally? than human cells Modulated by mode of birth Further modulated by feeding method Thum C et al. Can nutritional modulation of maternal intestinal microbiota influence the development of the infant gastrointestinal tract? J Nutr. 2012 Nov;142(11):1921-8. 5 4/5/2015 Maternal gut bacteria are Our gut bacterial population = a hidden organ thought to contribute Breaks down our food towards the microbial, Biotransformation of bile acids metabolic, and Degradation of oxalate immunological Breakdown of plant polysaccharides Production of short chain programming of the fatty acids Synthesis of biotin, folate, child. and vitamin K • Lindsay K et al. Probiotics in pregnancy and maternal outcomes; a systematic review. J Matern Fetal Neonatal Med. 2013 Jan 11. [Epub ahead of print] O'Hara AM, Shanahan F. The gut flora as a forgotten organ. EMBO • Cilieborg MS et al. Bacterial colonization and gut Rep. 2006 Jul;7(7):688-93. development in preterm neonates. Early Hum Dev. 2012 Mar;88 Suppl 1:S41-9. Affects: A systematic review . Mucosal immunity 7 studies: 6 RCT’s and 1 prospective cohort . Intestinal disorder 33,399 women in the prospective cohort .Development of allergies Altered . Energy homeostasis Breast milk composition . Inflammation . Glucose metabolism Infant gut bacterial population Reduced: • Guarner F, et al. Gut flora in health and disease. Lancet 2003; 361:512-9. Infant allergic disease • Guarner F. Inulin and oligofructose:impact on intestinal diseases and disorders, Br J Nutr 2005;93:S61-5. • Hatakka K et al. Probiotics in intestinal and non-intestinal infectious disease – clinical evidence. Curr Pharm Des 2008;14:1351-67. • Cani PD et al. Interplay between obesity and associated metabolic disorders: new Lindsay, K et al. Probiotics in Pregnancy and Maternal Outcomes. The Journal of insights into the gut microbiota. Curr Opin Pharmacol 2009;9:737-43. Maternal-Fetal & Neonatal Medicine 2013 May;26(8):772-8. • Greiner T et al. Effects of the gut microbiota on obesity and glucose homeostasis. Trends Endocrinol Metab 2011;22:117-23. Infants born by c-section Infants who are exclusively breastfed have different gut develop a specific flora by 1 week bacteria than children born vaginally after birth that reaches dominance by 1 month. (Langhendries JP, et al.1995) Infants born by c-section have a higher incidence of Prebiotic factors in breast milk → a food allergy and other flora predominant in lactobacilli and atopic disease bifidobacteria (Balmer SE, et al.1989) Several factors in breastfed infants contribute to an intestine that favors proliferation of these healthy bacteria (Bernt KM, et al.1999) Koplin J, Allen K, Gurrin L, Osborne N, Tang ML, Dharmage S. Is caesarean delivery associated with sensitization to food allergens and IgE- mediated food allergy: a systematic review. 6 4/5/2015 The good microorganisms in breastmilk also This mixture of bacteria and prebiotics produce antibiotic molecules that directly alters the strength and permeability of prevent the growth of harmful organisms.