Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
2
Food Allergy in the Past 7 Years
Prevalence of food allergy highest in infants and
toddlers
Cows milk allergy incidence: 2.5% of infants
Up to 8% of children under 3 years have allergy to a
limited number of foods:
Cows milk Wheat
Egg Shellfish
Soy Fish
Peanut Tree nuts
For every child who actually had a food allergy, over three
more children were believed wrongly by their parents to suffer
from the condition
______________
Venter et al 2008 3
Age Relationship Between Food Allergy and Atopy
Effect of Food Allergens Effect of Air-borne Allergens
Asthma
Rhinitis
Relative Incidence
Eczema
Food Allergy
Anaphylaxis
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
4
Age (in years)
Historical Perspective
Sensitization to food allergens was thought to
be the start of the allergic march
Food allergy
Atopic dermatitis/eczema
Asthma
Rhinitis
Reducing sensitization to foods was therefore
considered the essential first step in allergy
prevention
5
Historical Perspective
Measures of prevention were all designed to avoid
sensitization to allergens during what were
considered the most vulnerable periods:
Intra-uterine life
From birth to 2-3 years
This meant reduction in exposure to highly allergenic
foods:
Mothers diet during pregnancy and lactation
Delay in introduction of highly allergenic foods during
weaning
In spite of these stringent measures to prevent allergy,
incidence of all types of allergies have increased
significantly
6
Change in Direction During the Past
Five Years
Understanding of the importance of immunological
sensitization and tolerance
Recognition that tolerance not sensitization is the
critical step in allergy prevention
Finding that exposure to the allergenic food at an
optimum stage is probably a critical step in allergy
prevention
Recognition that tolerance can be induced after
allergy has been established leading to important
measures for allergy management
7
Allergy is a Response of the Immune System
10
Role of T-helper Cell Subtypes
Th1 triggers the protective response to a
pathogen such as a virus or bacterium
IgM, IgG, IgA antibodies are produced
11
T cells involved in Oral Tolerance
T cell response depends on the type of T helper cell
that is activated
Latest research indicates that T cells that produce a
cytokine called TGF- are important in inducing oral
tolerance
Sometimes called Th3 cells
T cells that produce IL-10 and IL-13 may also be
involved in tolerance
These also regulate immune response to resident
microflora, preventing the usual immune
inflammatory response to microorganisms
___________________
Strobel and Mowat 2006 12
Oral Tolerance
_____________
Jones et al 2000
16
Does Atopic Disease Start in Fetal Life?
(continued)
17
Does Atopic Disease Start in Fetal Life?
(continued)
18
Significance in Practice
19
Immune Response of the Allergic Mother
_______________
Kramer et al 2006 21
Breast-feeding and Allergy
__________________
Kirjavainen et al 2002 22
Breast-feeding and Allergy
Other studies are in conflict with these
conclusions:
Some report no improvement in symptoms
Some suggest symptoms get worse with breast-
feeding and improve with feeding of
hydrolysate formulae
Japanese study suggests that breast-feeding
increases the risk of asthma at adolescence
Why the conflicting results?
_______________
Miyake et al 2003
23
Immunological Factors in Human Milk that
may be Associated with Allergy:
Cytokines and Chemokines
_________________________________ __________________________
30
Osborn and Sinn 2009 Cochrane Review Von Berg et al GINI Study 2009
Infant Formulae for the Allergic Baby
Current Recommendations
_____________ _______________
1Kull et al 2006 2Calvani et al 2006
36
Introduction of Fish
Study (n= 5,000); 20.9% developed eczema by 1 year:
Babies who were fed fish before nine months of age
were 24% less likely to develop eczema by age 1 year
Omega-3 content of fish did not seem to influence the
outcome
The age at which egg and milk were introduced did
not affect development of eczema
Breast-feeding did not have any significant impact on
development of eczema
____________ ____________________________
Alm et al 2009 Hibbeln et al 2007 ALSPAC study 37
The Natural History of Food Allergy
Food allergy most often begins in the first 1 to
2 years of life
Child is sensitized to the food protein by the
immune system developing allergen-specific
IgE to that protein
Sensitization does not necessarily mean that
the child will develop symptoms when that
food is eaten
Over time most food allergy is lost
_________
Wood 2003 38
Prognosis
Most children outgrow early food allergy
Johns Hopkins Childrens Center USA
Milk allergy outgrown:
20% by 4 years
42% by 8 years
79% by 16 years
Egg allergy outgrown:
4% by 4 years
37% by 10 years
68% by 16 years
Allergy to some foods more often than others persists into
adulthood:
Peanut Tree nuts Seeds
Shellfish Fish
______________
Skripak et al 2007
39
Induction of Oral Tolerance
Tolerance to a specific food can be induced by
oral administration of the offending food by
process of low dose continuous exposure
Designated (SOTI: specific oral tolerance
induction)
Starting with very low dosages
Gradually increasing daily dosage up to the
equivalent of the usual daily intake
Followed by daily maintenance dose
__________________ _____________
Niggemann et al 2006 Calvani et al 2010 40
Desensitization to
Cows Milk
18 children with confirmed CMA >4 years of age
underwent SOTI
Starting dose 0.05 ml cows milk
Increased to 1 ml on first day
Increasing dosage weekly up to a daily dose of 200-
250 ml
Results: 16/18 tolerated 200-250 ml milk
Length of process median 14 weeks (range 11-17
weeks)
Tolerance has been maintained for >1 year
_______________
Zapatero et al 2008 41
Oral Tolerance Induction to
Milk, Egg, and Peanut
48
Take Home Message
49
Take Home Message
Provision of complete balanced
nutrition by substituting foods of equal
nutritional value
Monitoring the childs response at
intervals to determine when the food
allergy has been outgrown
Maintenance of tolerance by feeding
tolerated foods regularly
50
Invitation to Further Information
www.allergynutrition.com
51