The Role of the Maternal and Infant Diet in Prevention of Childhood Allergic Disease
by Anne Eglash MD, IBCLC, FABM
This week’s CQW focuses on the American Academy of Pediatrics (AAP) recent update of their 2008 report on the role of maternal and early infant diet on the prevention of allergic diseases, which include atopic dermatitis, asthma and food allergies. This report does not include research on the role of probiotics, vitamin D or fatty acids in allergic disease.
The AAP reports that food allergies and atopic dermatitis have become more common from 1997 to 2011. The good news is that much more research with longer followups now exists on this topic since 2008; for example, there are 64 more recent studies on the relationship between asthma and breastfeeding. Therefore the AAP has revised some of their recommendations which are summarized in the abstract. Check your knowledge first!
- Excluding highly allergenic foods such as fish, peanuts and eggs during pregnancy can prevent childhood allergies to these foods.
- Excluding highly allergenic foods such as fish, peanuts and eggs during breastfeeding can prevent childhood allergies to these foods.
- Exclusive breastfeeding for at least 3-4 months decreases the risk of eczema for the first 2 years of life.
- Exclusive breastfeeding for 6 months is more likely to prevent childhood allergy diseases as compared to exclusive breastfeeding for 3-4 months.
- Infants exclusively breastfed for at least 3 months decreases wheezing in early life.
- Longer duration of any breastfeeding is associated with less asthma after age 5.
- Infants with severe eczema and/or egg allergy should be introduced to peanuts between 4-6 months of age, as long as they test negative for peanut allergy.
- Infants with severe eczema who take formula should receive elemental formula with no cow’s milk protein.
- Withholding peanuts until 15 months of age is a good idea for an infant who has no eczema, but does have a family history of peanut allergy.
See the Answer
This clinical report updates and replaces a 2008 clinical report from the American Academy of Pediatrics, which addressed the roles of maternal and early infant diet on the prevention of atopic disease, including atopic dermatitis, asthma, and food allergy. As with the previous report, the available data still limit the ability to draw firm conclusions about various aspects of atopy prevention through early dietary interventions. Current evidence does not support a role for maternal dietary restrictions during pregnancy or lactation. Although there is evidence that exclusive breastfeeding for 3 to 4 months decreases the incidence of eczema in the first 2 years of life, there are no short- or long-term advantages for exclusive breastfeeding beyond 3 to 4 months for prevention of atopic disease. The evidence now suggests that any duration of breastfeeding $3 to 4 months is protective against wheezing in the first 2 years of life, and some evidence suggests that longer duration of any breastfeeding protects against asthma even after 5 years of age. No conclusions can be made about the role of breastfeeding in either preventing or delaying the onset of specific food allergies. There is a lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease. There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease. There is now evidence that early introduction of peanuts may prevent peanut allergy.
As per the abstract, withholding allergenic foods such as fish, eggs and peanuts, during pregnancy, lactation, or after 4-6 months of life will not prevent childhood allergic diseases. I have had breastfeeding infants in my practice who had resolution of their eczema when mom stopped the offending food in her diet, such as peanut, egg, milk or fish. I don’t mean to imply that mom’s diet caused the allergy, but merely just want to raise the point that the authors don’t address trials of maternal dietary restriction of the most common allergens when infants have eczema or other allergic symptoms.
According to the authors, there is no evidence that exclusive breastfeeding beyond 3-4 months affords more protection from eczema and other allergic diseases. In fact, any duration of breastfeeding beyond 3-4 months will reduce wheezing early in life. Prolonged breastfeeding (duration not defined), not necessarily exclusive, is associated with less asthma over the age of 5.
One change from 2008 is that hydrolyzed formula is no longer considered protective of atopic dermatitis among infants who take formula.
An important take away for clinical practice is that if an infant has severe eczema and/or egg allergy, it is important to test the infant for peanut allergy before introducing peanuts.