Review and feature article
Primary Prevention of Allergic Disease Through Nutritional Interventions

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With the rising prevalence of atopic disease, primary prevention may play a role in reducing its burden, especially in high-risk infants. With this in mind, the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology was charged with the task of developing recommendations for primary care physicians and specialists about the primary prevention of allergic disease through nutritional interventions according to current available literature and expert opinion. Recommendations that are supported by data are as follows. Avoidance diets during pregnancy and lactation are not recommended at this time, but more research is necessary for peanut. Exclusive breast-feeding for at least 4 and up to 6 months is endorsed. For high-risk infants who cannot be exclusively breast-fed, hydrolyzed formula appears to offer advantages to prevent allergic disease and cow’s milk allergy. Complementary foods can be introduced between 4 and 6 months of age. Because no formal recommendations have been previously provided about how and when to introduce the main allergenic foods (cow’s milk, egg, soy, wheat, peanut, tree nuts, fish, shellfish), these are now provided, and reasons to consider allergy consultation for development of a personalized plan for food introduction are also presented.

Section snippets

Maternal avoidance of highly allergenic foods during pregnancy

  • Maternal avoidance of cow’s milk and egg during pregnancy does not affect the incidence of allergic disease.8, 9, 10, 11, 12, 13

  • Earlier studies found no association between maternal peanut avoidance during pregnancy and lactation and the incidence of subsequent peanut allergy in their children.14, 15, 16 A small retrospective study of 25 subjects showed an increased risk of peanut allergy in the children with maternal consumption of peanut more than once per week during pregnancy.17 A more

Effect of breast-feeding on atopic dermatitis in the children

  • In a meta-analysis, exclusive breast-feeding for 3 months appears to reduce the incidence of atopic dermatitis in the children compared with conventional formula feeding.25 However, this effect was lost when a controversial study was removed from a more recent systematic review and meta-analysis.26

  • Reports are conflicting about whether exclusive breast-feeding longer than 3 months decreases, increases, or has no effect on the incidence of atopic dermatitis in the children.27, 28, 29, 30, 31, 32,

Cow’s milk formulas versus partial whey hydrolysate formulas

  • Studies suggest that partial whey hydrolysate formulas (pHFs) have a preventive effect on atopic disease and cow’s milk protein allergy.4, 57, 58, 59, 60, 61, 62, 63, 64

pHFs versus extensive casein or extensive whey hydrolysate formulas (ehF)

  • A meta-analysis of 2 studies found no significant difference between a pHF and an eHF in the development of infant allergic diseases, including asthma and food allergy.65, 66

  • One large study found that hydrolyzed formulas, especially the extensively hydrolyzed casein formulas, have the potential to reduce the risk of atopic

Timing of introduction

  • Between 4 and 6 months of age, complementary foods are necessary to support growth and to supplement nutritional needs. The introduction of complementary foods should be delayed, however, until the infant is able to sit with support and has sufficient head and neck control.71

  • The AAP recommends the introduction of complementary foods be delayed until the infant is at least 4 months old, but exclusive breast-feeding is preferred until 6 months of age.72 The expert panel from the European Academy

General advice for complementary food introduction for all children regardless of predisposition to develop allergic disease

  • Most pediatric guidelines suggest first introducing single-ingredient foods between 4 and 6 months of age, at a rate not faster than one new food every 3 to 5 days.71

  • Complementary foods in the United States are typically rice or oat cereal, yellow/orange vegetables (eg, sweet potato, squash, and carrots), fruits (eg, apples, pears, and bananas), green vegetables, and then age-appropriate staged foods with meats.92

  • It is common for acidic fruits (eg, berries, tomatoes, citrus fruits, and

Avoidance diets

  • Maternal avoidance diets during pregnancy and lactation are not recommended at this time on the basis of current data; more research is necessary to generate a recommendation about maternal avoidance of peanut.

Breast-feeding

Exclusive breast-feeding is recommended for at least 4 months and up to 6 months of age

  • To possibly reduce the incidence of atopic dermatitis for those younger than the age of 2 years,

  • To reduce early onset wheezing before age 4 years, and

  • To reduce the incidence of cow’s milk allergy in the

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    No external funding was received for this report.

    Conflicts of interest: J. M. Spergel has received consultancy fees from Danone and Abbott, has received research support from Nutricia, and is on the medical advisory boards for APFED and the International Assoc Food Protein Induced Enterocolitis. The rest of the authors declare that they have no conflicts of interest.

    Cite this article as: Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol: In Practice 2013;1:29-36. http://dx.doi.org/10.1016/j.jaip.2012.09.003.

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