Food Allergies In The Lactation Dyad - MPHI
4/5/2015Jill Mallory, MD, IBCLCWildwood Family ClinicMadison, WI Define a food allergy and a food intolerance.List 2 risk factors for the development of foodallergies in children? Describe the prognosis of food allergies inchildren. What is the role of lactation in the prevention offood allergies? What is the role of alteration in maternal diet inthe allergic child? Is weaning ever advisable in the setting of foodallergies or intolerances? List 3 reasons why a nursing baby who has foodallergies should continue to nurse. 20 First Very Hercolicky babyto be in pain allthe time “About the only time heisn’t crying is when he’sasleep or nursing” Very runny, mucousstools “What’s wrong with mymilk?” Seemsyo living w/ her mombaby 10 lbs at birth! Vaginal delivery 41 weeks gestation No complications Took right to the breast 2 weeks old Well above birth weight Exclusively breastfedsister only breastfedher daughter for 4 mobecause she was socolicky. When sheswitched to soy formula,it was like magic, andthe baby was happy. Afraid of months of colic Grandmother can’t takethe crying and recformula1
4/5/2015 Definition:an adverse health effect arisingfrom a specific immune response that occursreproducibly on exposure to a specific food. Foodallergies result in IgE-mediatedimmediate reactions Burks AW, et al. NIAID-sponsored 2010 guidelines for managing foodallergy: applications in the pediatric population. Pediatrics. 2011Nov;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(e.g., anaphylaxis) andseveral chronic diseases(e.g., enterocolitis syndromes, eosinophilicesophagitis, etc), inwhich IgE may not play an important role.Burks AW, et al. NIAID-sponsored 2010 guidelines for managing foodallergy: applications in the pediatric population. Pediatrics. 2011Nov;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 Inthe nursling:GE reflux Bloody stools Eczema Colic In older children or adults:Itching in the mouth or swellingVomiting, diarrhea, or abdominal crampsHives or eczemaTightening of the throat and wheezingDrop in blood pressure Milk Egg Wheat Soy Peanut– affects 1-2% of children! Treenut Fish Shellfish2
4/5/2015 IgEpresence symptoms IgE mediatedallergy Allergens are usually proteinshttp://www.ifr.ac.uk/protall/infosheet.htm Lesswell-definedIgE mediated Symptoms occur after eating a certain food NOTHeadachesMuscle and joint aches and pains Tiredness Abdominal pain and diarrhea Examples Celiac diseaseLactose intoleranceis poorly definedof EBF infant will develop allergy tocow’s milk proteins excreted into mother’smilk 50-65% of allergic colitis in EBF infants is dueto cow’s milk protein Inthe United States, affects an estimated12% of children and 13% of adults (selfreported) In double-blind food challenges, incidencelooks more like 3% for adults and children Rise in prevalence in the past 20 years No effective treatment exists Management avoidanceBurks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applicationsin the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:10.1542/peds.2011-0539. Epub 2011 Oct 10. Incidence Eczema 0.5-1% Most 19% to egg, 6% to corn, and 3% to soy EBFinfants have significantly lower rates ofcow’s milk allergy than those exposed toformulaand GI sxs most commoncommon GI sx is bloody stools Generally “well-appearing” Sxs can be present at birth Typically develop at 2-6 weeks of ageABM 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.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 2-4x more likely to have asthma, eczema,respiratory problems May co-exist with eosinophilic esophagitis Food exposure may cause severe asthmaattacks or anaphylaxisBurks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applicationsin the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:10.1542/peds.2011-0539. Epub 2011 Oct 10. Biologicparents or siblings with a hx ofallergic rhinitis, asthma, atopic dermatitis(eczema), or food allergy. Child themselves have other preexistingallergic disease 37% of children with eczema have IgEmediated food allergyBurks AW, et al. NIAID-sponsored 2010 guidelines for managing food allergy: applicationsin the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. doi:10.1542/peds.2011-0539. Epub 2011 Oct 10. Difficultto predict bySeverity of past reactions Food specific IgE levels Wheal size in skin-prick testing Co-existenceof asthma marker for severity offood allergy Intactproteins from the mother’s diet cancross the gut barrier and enter thebreastmilk These proteins can trigger an allergicresponse and symptoms in some infants. AAPRecommendsAt risk at least 1 first degree relative, parent orsibling with food allergy All children at risk of should be exclusivelybreastfed If exclusive breastfeeding is not possiblehydrolyzed infant formulas should be used Complementary food should not be restricted at6 mo Maternal InfantgutgutThe crux of it all!Vadas P, et al. Detection of peanut allergens in breast milk of lactating women. JAMA2001;285:1746-1748.Sorva R, et al. Beta-lactoglobulin secretion in human milk varies widely after cow’s milkingestion in mothers of infants with cow’s milk allergy. J Allergy ClinImmunol.1994;93:787-792.Casas R, et al. Detection of IgA antibodies to cat, beta-lactoglobulin, and ovalbuminallergens in human milk. J Allergy Clin Immunol. 2000;105:1236-1240.Pittschieler K. Cow’s milk protein-induced colitis in the breastfed infant. J PediatrGastroenterol Nutr. 1990;10:548-549.4
4/5/2015 Ahealthy gutAllows nutrients to pass from food into thebloodstream Prevents the entrance of pathogenic bacteria andtoxins from the environment into the blood Physicalbarriers – tight junctionsbacteria friends Oligosaccharides OurBreakdown of thesebarriers occur Large food particles passinto the blood streamand interact with theimmune system This leads to thedevelopment of foodallergies C. Perrier et al. Gut permeability and foodallergies. Clinical & Experimental Allergy.Volume 41, Issue 1, pages 20–28, January 2011Your body houses 10 x more bacterial cellsthan human cellsMay start prenatally?Modulated by mode of birth Further modulated by feeding method Thum C et al. Can nutritional modulation of maternal intestinal microbiota influence thedevelopment of the infant gastrointestinal tract? J Nutr. 2012 Nov;142(11):1921-8.5
4/5/2015Maternal gut bacteria arethought to contributetowards the microbial,metabolic, andimmunologicalprogramming of thechild. Lindsay K et al. Probiotics in pregnancy and maternaloutcomes; a systematic review. J Matern FetalNeonatal Med. 2013 Jan 11. [Epub ahead of print]Cilieborg MS et al. Bacterial colonization and gutdevelopment in preterm neonates. Early Hum Dev.2012 Mar;88 Suppl 1:S41-9. Affects: Mucosal immunity Intestinal disorder Development of allergies Energy homeostasis Inflammation Glucose metabolism Guarner F, et al. Gut flora in health and disease. Lancet 2003; 361:512-9.Guarner F. Inulin and oligofructose:impact on intestinal diseases and disorders, Br JNutr 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: newinsights into the gut microbiota. Curr Opin Pharmacol 2009;9:737-43.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-sectionhave different gutbacteria than childrenborn vaginally Infants born by c-sectionhave a higher incidence offood allergy and otheratopic disease Koplin J, Allen K, Gurrin L, Osborne N, Tang ML,Dharmage S. Is caesarean delivery associatedwith sensitization to food allergens and IgEmediated food allergy: a systematic review. Ourgut bacterial population ahidden organ Breaks down our food Biotransformation of bile acidsDegradation of oxalateBreakdown of plant polysaccharidesProduction of short chainfatty acidsSynthesis of biotin, folate,and vitamin KO'Hara AM, Shanahan F. The gut flora as a forgotten organ. EMBORep. 2006 Jul;7(7):688-93. A 7 systematic reviewstudies: 6 RCT’s and 1 prospective cohort33,399 women in the prospective cohort Altered Breast milk compositionInfant gut bacterial population Reduced: Infant allergic diseaseLindsay, K et al. Probiotics in Pregnancy and Maternal Outcomes. The Journal ofMaternal-Fetal & Neonatal Medicine 2013 May;26(8):772-8. Infantswho are exclusively breastfeddevelop a specific flora by 1 weekafter birth that reaches dominanceby 1 month. (Langhendries JP, et al.1995) Prebiotic factors in breast milk aflora predominant in lactobacilli andbifidobacteria (Balmer SE, et al.1989) Several factors in breastfed infantscontribute to an intestine that favorsproliferation of these healthybacteria (Bernt KM, et al.1999)6
4/5/2015 Thegood microorganisms in breastmilk alsoproduce antibiotic molecules that directlyprevent the growth of harmful organisms. Thismixture of bacteria and prebioticsalters the strength and permeability ofthe barrier between the intestinal lumenand the circulating bloodDai D, Walker WA. Protective nutrients and bacterial colonization in the immaturehuman gut. Adv Pediatr 1999; 46:353-82. Incontrast, in newborns whoreceive formula at birth anintestinal flora develops that ishigh in enterobacteria and gramnegative organisms. Tight junctions do not developproperly in these babies.Majamas H, Isolauri E. Probiotics: A novel approach in themanagement of food allergy. J Allergy Clin Immunol 1997; 99:17885.Isolauri E, Majamas H, Hrvola T, et al. Lactobacillus casei strainreverses increased intestinal permeability induced by cow's milk insuckling rats. Gastroenterology 1993; 105:1643-50 Whendamage to the gut barrier occurs fromone exposure to formula, it takes a fullmonth of exclusive breastfeeding to heal it. The intestinal permeability increases withexposure to formula in a dose-relatedmanner C-section formula exposureTaylor SN, et al. Intestinal permeability in preterm infants by feeding type: mother'smilk versus formula. Breastfeed Med. 2009 Mar;4(1):11-5.7
4/5/2015 Poormaternal gut health in pregnancyAllows larger food particles to cross the placentaand get into fetal circulation Affects what bacteria are passed to babyprenatally, at birth, postpartum Affects what bacteria are present in thebreastmilk A mechanism for inheritance of allergicdisease? HistoricallyMDs recommended stoppingbreastfeeding in: Severely allergic infantsBlood in the stool Started on hydrolyzed or elemental formulasGenerally a benign and self-limiting disorderNot an automatic dx of cow’s milk proteinallergyArvola T, Ruuska T, Keränen J, Hyöty H, Salminen S, Isolauri E. Rectal bleeding ininfancy: clinical, allergological, and microbiological examination. Pediatrics. 2006Apr;117(4):e760-8. Hypothesis: Both decline in gut healthinfant and maternalRise in c-sectionsDecrease in exclusive breastfeedingAntibiotic and pharmaceutical exposureProcessed foodsPoor dietsChemical exposureEnvironmentStress Thisresolved symptoms BUT . . .the mother and infant of thebenefits of breastfeeding AND . . . Will make the leaky gut issue worse Specialized formulas are very expensive! Deprived Mostcommon cause: breastmilkoversupply Anal tear (fissure) from baby strainingwith the passage of the stool Mom has a cracked nipple or otherbleeding, then baby may ingest someblood from mom Mucous and/or blood in the stool afterstarting vitamin/fluoride drops Infectious: C. Difficile, campylobacter?8
4/5/2015 Incidenceis 0.5-1% in breastfed infants% in infants overall in the first year of life Most develop sxs before 1 mo of age Prognosis 2-3 Remission rate of45-50% by 1 year of age60-75% by 2 years of age 85-90% by 3 years of age 50% will develop allergies to other foods as well 50-80% will develop environmental allergicreactions such as asthma and rhinoconjunctivitis If GI sxs are the only sxs, remission rates are high Often within 1 week of exposure to formula 50-60% GI sxs 50% rash 20-30% wheezing Høst A. Frequency of cow's milk allergy in childhood. Ann Allergy Asthma Immunol.2002 Dec;89(6 Suppl 1):33-7.Høst A. Frequency of cow's milk allergy in childhood. Ann Allergy Asthma Immunol.2002 Dec;89(6 Suppl 1):33-7.Proteins are made of chains of amino acidsSome other mammalian milks are similar tobreastmilk Some research suggests that exposure toproteins of other mammals may trigger an actualhuman milk protein allergy Sx: poor weight gain, GI sxs, not resolving withhypoallergenic diet This may be one food allergy situation whereweaning is advisable Restani P, et al. Evaluation of the presence of bovine proteins in human milk as apossible cause of allergic symptoms in breast-fed children. Ann Allergy AsthmaImmunol.1999;84:353-360.Bernard H, et al. Molecular basis of IgE cross-reactivity between human beta-casein andbovine beta-casein, a major allergen of milk. Mol Immunol 2000;37:161-167. Hemoglobinor albumin levels droppingof hypoallergenic formula may beadvisable while awaiting pediatric GIevaluation Put mom on hypoallergenic diet (rice, lamb,pears, squash) for 2 weeks If baby still symptomatic, may need to wean Use Ruleof 3’s:3 weeks of age More than 3 hours of crying 3 days a week or more Lasts for more than 3 weeks 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 3.9
4/5/2015 Behavioral theoryCrying results from a disequilibrium in thematernal/infant interaction/bond Immunologic modelPossible allergens in breastmilk or infant formulaas a causative agent Otherthings to consider Infantshould be assessed by a medicalprofessional for:GERDMalrotation of the intestine Intussuscetion Malabsorption syndromes Blood in stools Oversupply, undersupply Other medical conditions The family should also be assessedDietFood allergies in mom or other familyAsthmaEczemaEnvironmental allergiesAtopic disease Othercommon foods that can cause colicsymptoms in nurslings: Eliminationof cow’s milk protein (CMP) fromthe maternal diet has led to a decrease incolicky symptoms in a large number ofinfants A positive challenge test is considereddiagnostic For some infants, multiple foods may be theculpritIacovou, Marina et al. Dietary Management of Infantile Colic: A Systematic ReviewMatern Child Health J (2012) 16:1319–1331PeanutsEggsSoyWheatTree nutsCornStrawberries Onehigh quality RCT (n 90) reported areduction 37% (95% CI 15–56%) of colicsymptoms when mothers changed from astandard diet to a hypoallergenic dietElimination of dairy, eggs, peanuts, tree nuts,wheat, soy, and fish For seven days Otherstudies have had mixed resultsIacovou, Marina et al. Dietary Management of Infantile Colic: A Systematic ReviewMatern Child Health J (2012) 16:1319–133110
4/5/2015 Mom RAST Considerand baby to be evaluated by MDallergy testing - controversial Mom and baby to start probiotic and eatplenty of prebiotics IgE Burdock, raw chicory root, raw jerusalemartichoke , raw dandelion greens, garlic, leek,onion, wheat bran, banana OKto go ahead and advise mom to start anelimination diet while awaiting MDevaluation testing – no longer recommendedtestingFalse negativesFalse positives Foodchallengetesting IgG testing - not recommended Applied kinesiology – not recommended Skin Overused Varyingdegrees of successmay resolve within 48-72 hours,but may take up to 2 weeks There may be a big decrease in symptomswithout 100% resolution Burdensome on mothersemotionally Nutritional risks Financial risks Lots of education needed Symptoms Startwith dairyelimination: two weeks,followed by re-introduction Consider soy, corn, egg Lastly: citrus, nuts, wheat,strawberries, chocolate Once problem foods areidentified, they should beeliminated for at least 6mo Avoid until 9-12 mo of age Mothertakes 2 tablets of pancrease MT4strength tablets with each meal or snack Pancrease is a digestive enzyme that furtherbreaks down fats, proteins, and carbohydratesbefore they enter the mother’s bloodstream. First phase of elimination:Dairy, soy, nuts, strawberries, chocolate Second phase of elimination:Wheat, eggs, corn11
4/5/2015 Decreasedsymptoms of colicblood in infant’s stool 13/16 were able to continue lactationwithout use of specialized formulas Decreased Whatmight be causing Leo’scolic Should she wean? Why not? What should she try instead?Repucci A. Resolution of stool blood in breast-fed infants with maternal ingestion ofpancreatic enzymes. J Pediatr Gastroenterol Nutr. 1999;29:500A. Doesit play a role in some of our “low milksupply” cases? Case study Baby #4, exclusively BFMom had no hx low supplyFailure to thrive at 6mo“Whimpy nurser”Happy babyEczemaFood allergy testing: dairyMaternal elimination - growth Nobenefit to limiting exposureto non-food allergens (e.g.,dust mites or pollen) Insufficient evidence torecommend allergy testing inat-risk children withoutsymptoms, prior to foodintroduction Varied maternal diet may behelpful Nobenefit todelaying allergenicfoodsThat’s right! Start eggs, dairy,fish, nut butters,soy, strawberries,citrus, wheat allright at 6 mo whenother foods areintroduced12
4/5/2015 Studieson allergic food elimination inpregnant women are conflicting Restriction of maternal diet during pregnancyor lactation is not recommended AAP recommends all children with riskfactors for food allergy be exclusivelybreastfed for 4-6 months Therole of breastfeeding in prevention isdebated, mainly due to problems with thequality of studies Why? ManyGreer FR et al. Effects of early nutritional interventions on the development of atopicdisease in infants and children: the role of maternal dietary restriction, breastfeeding,timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics.2008 Jan;121(1):183-91. Theyreally should be thinking from theperspective of formula exposure as a gutbarrier disruptordon’t look at exclusivity and think interms of breastmilk exposure as a magicbullet 12 criteria for a valid studyNon-reliance on late maternal recall ofbreastfeedingSufficient duration of exclusive breastfeedingStrict diagnostic criteria for allergyAssessment of effects of children at high risk ofallergiesAdequate statistical power Unfortunately,no studies to date havecompletely fulfilled these criteria.Kramer MS. Does breast feeding help protect against atopic disease? Biology,methodology, and golden jubilee of controversy. J Pediatr. 1988;112:181–190 In order to decrease the risk:Avoid both early ( 4 months) and late ( 7 months)introduction of gluten Introduce gluten while the infant is still beingbreastfed Probiotics Present in breastmilkReview of 10 studies Szajewska H et al. Systematic review: early infant feeding and the prevention ofcoeliac disease. Aliment Pharmacol Ther. 2012 Oct;36(7):607-18. doi:10.1111/apt.12023. Epub 2012 Aug 21.Given to pregnant and postpartum women or newbornsreduces incidence of allergiesGiven to children with eczema, reduced the severityDid not specify feeding typeFoolad N, et al. Effect of nutrient supplementation on atopic dermatitis in children: asystematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol.2013 Mar;149(3):350-5. Review.13
4/5/2015 Prebiotics –oligosaccharides (OS) Present in breastmilk Formula fed kids whowere supplementedwith OS had adecreased risk ofdeveloping eczema(50% reduction)Foolad N, et al. Effect of nutrientsupplementation on atopic dermatitis inchildren: a systematic review of probiotics,prebiotics, formula, and fatty acids. JAMADermatol. 2013 Mar;149(3):350-5. Review. FormulaexposureUse of soy formula is not beneficial in preventionof dairy allergy There is no evidence that suggests use ofhydrolyzed formulas offer any preventativebenefit over breastmilk FormulaexposureAt least 25% of BF infants are exposed to formulaby day #2 of life in the US By 3 mo of age, that is up to 80% in some studies Typeof FormulaMixed results on the benefits of amino acid orhydrolyzed formulas over standard cow’s milkformulas There may be a benefit in prevention of dairyallergy FattyacidsUS pregnant and lactating women have thelowest DHA levels in the developed world Gamma-linolenic acid (GLA) and omega-3’s bothcomponents of breastmilk If a mother has allergic disease, GLAsupplementation in pregnancy may reduceseverity of allergic disease in infants Foolad N, et al. JAMA Dermatol. 2013 Mar;149(3):350-5. Effect of nutrientsupplementation on atopic dermatitis in children: a systematic review ofprobiotics, prebiotics, formula, and fatty acids. FattyacidsGLA also appears to reduce severity when givento infants Infants and mother’s supplemented with omega3’s had lower incidence of allergic disease Black currant seed oil GLA omega 3’s,beneficial in incidence reduction Again, does not specify feeding method Foolad N, et al. JAMA Dermatol. 2013 Mar;149(3):350-5. Effect of nutrientsupplementation on atopic dermatitis in children: a systematic review of probiotics,prebiotics, formula, and fatty acids.Hibbeln, Joseph. NIH14
4/5/2015 Likelyto occur over time with dairy, soy, eggand wheat Kids with peanut, tree nut, fish and shellfishallergies are less likely to outgrow them Younger children may be re-tested annually SublingualImmunotherapy (SLIT)Liquid or tabs placed under the tongue More research needed OralImmunotherapy (OIT)May lessen the severity of reactions More research needed 1. Keet CA, Frischmeyer-Guerrerio PA, Thyagarajan A, et al. Thesafety and efficacy of sublingual and oral immunotherapy for milkallergy. J Allergy Clin Immunol 2012;129(2)448-‐55,455.e1‐5.2. Burks AW, Jones SM, Wood RA, et al. Oral Immunotherapy fortreatment of egg allergy in children. N Engl J Med2012;367(3):233‐43 FoodAllergy and Anaphylaxis Networkwww.foodallergy.org Consortium of Food Allergy Research’sonline educational Program.htm The Whole Life Nutrition /whole-life-nutrition-cookbook AAPSection on Allergy and Immunologywww.aap.org/sections/allergy American Academy of Allergy, Asthma &Immunology(AAAAI) www.aaaai.org/ American College of Allergy, Asthma andImmunology(ACAAI) www.acaai.org/ Asthma and Allergy Foundation of America(AAFA)www.aafa.org/ FoodAllergy Initiative (FAI)www.faiusa.org/ Kids With Food Allergies (KFA)www.kidswithfoodallergies.org/ National Institute of Allergy and InfectiousDiseases (NIAID)www.niaid.nih.gov/ InfantProctocolitis – printable handouts!http://infantproctocolitis.org/15
4/5/2015 1 Jill Mallory, MD, IBCLC Wildwood Family Clinic Madison, WI Define a food allergy and a food intolerance. List 2 risk factors for the development of food allergies in children? Describe the prognosis of food
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