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introduced. In infants with a positive family his- tory of allergy who are not exclusively breastfed, the use of infant formulae based on hydrolyzed cow’s milk proteins reduces the risk of atopic ec- zema. Delayed introduction of complementary feeding has no proven benefit.
Maternal Diet and Avoidance of Allergenic Foods during Pregnancy and Lactation Maternal dietary allergen exclusion during preg- nancy has been proposed as a potential strategy for reducing allergy risk in the offspring, but the available data do not support any beneficial ef- fects [1] . In human milk, food antigens derived from cow’s milk, egg, wheat and other foods can be detected a few hours after maternal consump- tion of the respective foods. The concentration of cow’s milk protein in breast milk is found to be 100,000 times lower than that in cow’s milk and does not correlate with the amount of antigen in- gested by the mother. Whether these low amounts of antigen in breast milk induce sensitization or tolerance is not clear. In a randomized controlled trial, no beneficial effect of avoidance of egg and milk consumption by lactating women was found with regard to the development of allergic disease in children up to 5 years of age [2] . Maternal ex- clusion diets bear the risk of inadequate supply of certain nutrients. In the absence of beneficial evi- dence, maternal exclusion diets during pregnan- cy and lactation for allergy prevention are not rec- ommended. However, there is some evidence that consumption of oily fish by the mother during pregnancy and breastfeeding reduces the risk of allergic diseases in the offspring [3] .
Breastfeeding
Breastfeeding is preferred for infants because of its nutritional, immunological and psychological benefits. The potential allergy-preventive effect of
exclusive or partial breastfeeding has not been properly assessed because randomization of breastfeeding is not possible for ethical reasons.
Mothers who breastfeed exclusively differ mark- edly from those who feed formula with regard to education, socioeconomic factors, smoking, keeping pets at home, introduction of other foods, and many other factors which may influence the incidence of allergy. Inverse causality may occur in nonrandomized studies, i.e. mothers of infants with the highest degree of heredity or signs of at- opy within the first months of life may tend to prolong exclusive and total breastfeeding.
However, evidence from a cluster randomized trial of the promotion of breastfeeding in the Re- public of Belarus [4] and from a recent meta-anal- ysis of the effect of breastfeeding on allergy in the offspring support that exclusive breastfeeding for 3 months or longer confers a protective effect against atopic dermatitis during infancy [5] .
Feeding Hydrolyzed Infant Formulae
Several intervention trials evaluated infant for- mulae based on partially or extensively hydro- lyzed proteins compared with standard cow’s milk formula, often with nonrandomized breast- fed reference groups. All randomized trials pub- lished were performed on infants with an in- creased atopy risk, based on one parent or sibling affected by allergy, both parents affected, elevated cord blood IgE or other criteria. Therefore, the results cannot be generalized to infants with non- atopic parents. Some of the studies included ad- ditional cointerventions such as maternal dietary or environmental restrictions, or delayed intro- duction of complementary feeding.
A recent Cochrane review on these studies concluded that there is limited evidence that the use of hydrolyzed formulae reduces the risk of in- fant and childhood allergy and infant cow’s milk allergy when compared with using a standard cow’s milk formula [6] . In this analysis, many
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 113–117 DOI: 10.1159/000360328
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studies even of high quality were excluded be- cause of dropout rates of more than 20%. For this and other reasons, the Cochrane review has been criticized, and the conclusions were challenged by an international panel of allergy experts [7] .
The German Infant Nutritional Intervention study is by far the largest double-blind, random- ized, controlled intervention trial in this area, and the only trial sponsored by a governmental grant rather than by industry funds [8, 9] . The trial eval- uated allergy-preventive effects of three hydro- lyzed formulae compared with a cow’s milk for- mula in high-risk infants provided during the first 4 months of life. Among different atopic manifes- tations (atopic dermatitis, asthma, gastrointestinal manifestations, allergic rhinitis and urticaria), only the risk of atopic dermatitis was reduced by the hydrolyzed formulae. Compared with the cow’s milk formula, both an extensively hydro- lyzed casein formula and a partly hydrolyzed whey formula significantly reduced atopic dermatitis. In contrast, the risk reduction with the extensively hydrolyzed whey formula did not reach signifi- cance. The effect developed in the first year of live and persisted until the age of 10 years ( fig. 1 ). No significant effect was observed on asthma, allergic rhinitis or sensitization pattern.
Protein Sources other than Cow’s Milk in Infant Feeding
The use of unmodified mammalian milk protein, including unmodified sheep, buffalo, mare or goat’s milk, or unmodified soy or rice milk, is not recommended for infants because their composi- tion is inadequate to serve as the sole food source for infants. Moreover, these milks are not recom- mended for infants with suspected or proven cow’s milk protein allergy because of the risk of possible allergenic cross-reactivity. A Cochrane review concluded that infant formulae based on soy protein do not reduce allergy risk, including food allergy [10] . There is no evidence to support
allergy-preventive effects of infant formulae based on protein sources other than hydrolyzed cow’s milk proteins.
Complementary Foods
Most available data originate from large cohort studies. Very early introduction of solid food within the first 3 months of life seems to increase the risk of eczema, and possibly also of food al- lergy. However, delaying the introduction of solid foods beyond the 6th month of life has no protec- tive effect and may even increase the risk of dif-
45
CMFeHF-W pHF-W eHF-C 40
35 30
15 109 87 6
0 1
Physician-diagnosed eczema (adj. %)
25 20
2 3 4
Age (years)
5 6 7 8 9 10
Fig. 1. Cumulative incidence of parent-reported, physi- cian-diagnosed atopic dermatitis in 988 infants who were fed 1 of 4 study formulae during the first 4 months of life and were followed until 10 years of age (per-pro- tocol analysis). Results are adjusted (adj.) for sex, BMI at birth, parental education, biological siblings at birth, study region, maternal smoking during pregnancy and/
or during the child’s first 4 months, smoking in the pres- ence of the child during the child’s first 4 months, furry pets in the home during the child’s first year of life, and age of mother at birth. CMF = Cow’s milk formula; pHF- W = partially hydrolyzed whey formula; eHF-W = exten- sively hydrolyzed whey formula; eHF-C = extensively hydrolyzed casein formula [9] .
116 Koletzko
ferent allergic diseases [11] . This effect was also found for allergenic foods such as hen’s egg, cow’s milk, fish and wheat [12–14] . A high diversity of complementary foods seems to decrease the risk of allergies [15] . Thus it is recommended that complementary foods should not be introduced before the 17th week of life or later than the 26th week of life, regardless of the familial risk of al- lergy [16, 17] .
Probiotics and Prebiotics
The impact of maternal supplementation with probiotics during pregnancy on atopic eczema in childhood was investigated by a recent meta- analysis including 7 randomized, double-blind, placebo-controlled trials [18] . The authors con- clude that there is some evidence for lactobacilli – but not for different mixtures of probiotics – to reduce the risk of eczema in the offspring.
Several studies investigated the effect of probi- otics given to infants either as a supplement or as a component of the infant formula. A recent posi- tion paper of the World Allergy Organization re- viewed the evidence and concluded that with the current knowledge, probiotics have no established role in the prevention or treatment of allergy [19] .
Similarly, a Cochrane review on the addition of prebiotics to infant formulae concluded that certain prebiotic mixtures of galacto- and fruc-
tooligosaccharides have shown some beneficial effect in reducing eczema in infants [20] . How- ever, the heterogeneity of these studies with re- gard to their design and target groups does not allow any generalized recommendations on sup- plementation for reducing the risk of allergy.
Conclusions
• Maternal exclusion diet during pregnancy and lactation has no allergy-preventive effect and is not recommended
• Exclusive breastfeeding for the first 4 months of life and continuous breastfeeding while gradually introducing solid foods is recom- mended for all infants
• In populations with low infection risks, solid foods should not be introduced before the 17th or after the 26th week of life, regardless of the hereditary risk of allergy
• If infant formulae are given during the first 4 months of life to infants with a family history of allergy, a protein hydrolysate formula should be used
• Formulae based on other milk proteins (sheep, buffalo, mare or goat’s milk), as well as soy or rice protein, have no demonstrated allergy- preventive effect and are not recommended • Probiotics and prebiotics do not have an estab-
lished role in the prevention of allergy
4 Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al: Promotion of Breastfeeding Inter- vention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001; 285: 413–420.
5 Kramer MS: Breastfeeding and allergy:
the evidence. Ann Nutr Metab 2011;
59(suppl 1):20–26.
References
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3 Dotterud CK, Storrứ O, Simpson MR, Johnsen R, ỉien T: The impact of pre- and postnatal exposures on allergy re- lated diseases in childhood: a controlled multicentre intervention study in pri- mary health care. BMC Public Health 2013; 13: 123.
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8 von Berg A, Koletzko S, Grübl A, Fili- piak-Pittroff B, Wichmann HE, Bauer CP, et al: The effect of hydrolyzed cow’s milk formula for allergy prevention in the first year of life: the German Infant Nutritional Intervention Study, a ran- domized double-blind trial. J Allergy Clin Immunol 2003; 111: 533–540.
9 von Berg A, Filipiak-Pittroff B, Kramer U, Hoffmann B, Link E, Beckmann C, et al: Allergies in high-risk schoolchildren after early intervention with cow’s milk protein hydrolysates: 10-year results from the German Infant Nutritional Intervention (GINI) study. J Allergy Clin Immunol 2013; 131: 1565–1573.
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2 Nutrition of Healthy Infants, Children and Adolescents
Key Words
Dietary guidelines, food-based ã Dietary habits ã Food preference ã Food choice ã Feeding skills ã Meals
Key Messages
• Toddlers and children should participate in family meals
• Toddlers do not need specially prepared commer- cial foods for particular nutritional uses. The use of such meals is determined by convenience
• Food-based dietary guidelines for children should name basic food groups, give approximate amounts to be consumed and provide exemplary recipes ac- cording to local habits
• Nutrient supplements and fortified foods should be used only when indicated
• Beverages of no or low energy content should ac- company meals © 2015 S. Karger AG, Basel
Introduction
The age range of 1 to approximately 12 years in- cludes very different phases of development.
With increasing motor skills, toddlers – some of which are still partly breastfed – will feed them- selves with an increasing variety of foods as part
of the family diet. Food preferences developed in the first year of life tend to persist but are modi- fied under the influence of parents, siblings and playmates. Preschool and school children in- crease both the frequency and variety of social contacts outside the home, and thereby food and meal choices [1] .
A healthy diet for children should be devised on the basis of both scientific and practical con- siderations. Scientific criteria are adequacy of in- take in comparison with recommendations on energy and nutrient intake to support normal growth and development, taking into account the preventive effects of an adequate diet on chronic diseases in adulthood [2] . Practical criteria are re- gional or national dietary habits, availability and cost of foods, and taste preferences of children.
Food-based dietary guidelines for children have been devised. As an example, the so-called
‘optimized mixed diet’ [3, 4] developed in Ger- many is described. Such guidelines can be easily adapted to different typical eating habits, meal schedules and differences in locally available ba- sic foods. They are based on commonly available foods to be prepared at home, but leave room for the integration of ready-to-eat products and foods preferred by many children, such as ‘fast foods’ and sweets.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 118–121 DOI: 10.1159/000360329