PREVENTING ALLERGY BY NUTRITIONAL INTERVENTION Sibylle Koletzko Dr. v.

Haunersches Kinderspital, Ludwig-Maximilians University of Munich, Germany In face of the rising incidence of allergic diseases over the last decades, preventive measures are of increasing importance. Since it has been recognized that early contact to food allergens plays a major role for the development of both, tolerance and sensitization to food antigens, nutritional interventions strategies have been thought for primary allergy prevention.

Maternal elimination diets during pregnancy and lactation have been proven in randomized controlled trials (RCT) to be of no benefit to reduce the risk of allergy in the offspring (1). There is some evidence for protective effect of fish consumption during pregnancy and breast-feeding for development of atopic diseases in offspring.

Breastfeeding is preferred for infants after birth because of 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 considerations. Recent meta-analyses do no demonstrate a protective effect of breastfeeding for reducing allergy risk. However, breastfeeding is strongly recommended because of its other benefits for all healthy infants, irrespective of atopic risk.

In case of insufficient breast feeding during the first 4 months, cows milk formula (CMF) is the standard formula for infants. In infants with a familiar predisposition for allergies formulae based on partially or extensively hydrolyzed proteins have been investigated in randomized trials compared to cows milk formula (CMF). By far the largest trial, the German birth cohort study GINIplus, includes 5991 children. A non-interventional arm (N = 3739) followed children with or without familial predisposition (2-5). Predisposed children whose parents agreed to participate in the double-blind intervention (N = 2252) were randomly assigned at birth to one of four formulae: partially (pHF-W), or extensively hydrolysed whey (eHF-W), extensively hydrolysed casein (eHF-C) or standard CMF. Compared CMF, the eHF-C and pHF-W significantly reduced AD, while the eHF-W was ineffective. The effect developed in the 1st year of live and persisted until 6 years. Predisposed children without nutritional intervention had a 2.1 times higher risk for AD [95% confidence interval (CI) 1.62.7] than children without a familial predisposition. The risk was smaller with nutritional intervention, with a HR of 1.3 (95% CI 0.91.9) in children fed eHF-C formula, which was not significant different to children without familiar allergy risk. It is concluded that some, but not all hydrolyzed formulae can reduce the risk for AD.The results cannot be generalized to infants without familiar risk for allergies (6). In contrast, a soy based formula can not be recommended for allergy prevention (7)

Solid foods should not be introduced before the 5th months of life, however, delaying solid food introduction beyond 7 months in children at risk for allergy, may even increase the risk of atopic dermatitis and food allergy. This applies also to high allergic foods such as diary products, hens egg, fish and wheat.

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Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2006;3:CD000133. Berg v A, Koletzko S, Grubl A 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 randomized double-blind trial. J Allergy Clin Immunol 2003;111:533-40. Berg v A, Filipiak-Pittroff B, Kramer U et al. Preventive effect of hydrolyzed infant formulas persists until age 6: long-term results from the German Infant Nutritional Intervention Study GINI. J Allergy Clin Immunol 2008;121:1442-7.

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Berg v A, Kramer U, Link E et al. Impact of early feeding on childhood eczema: development after nutritional intervention compared with the natural course - the GINIplus study up to the age of 6 years. Clin Exp Allergy 2010. Berg-v A, Koletzko S, Filipiak-Pittroff B et al. Certain hydrolyzed formulas reduce the incidence of atopic dermatitis, but not of asthma: Three year results of the GINI-Study. J Allergy Clin Immunol 2007;119:718-22. Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006;CD003664. Osborn DA, Sinn J. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2004;CD003741.