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Module No.

Allergy Immunology Working Group

Primary Prevention
of Allergic Disease

Learning objective

Review the allergic march


Identify children at risk for allergic disease
Discuss those who need primary prevention
Review various recommendation for primary
prevention of allergy

Natural history of allergic disease


Allergic
march

Contributing Factors for allergy


development
Environment
inducer:
Cows milk,
HDM, cat,
cockroach

Environment
trigger:
Cold air
passive smoke

Environment
Enhancer:
DEP, PAH,
Fluorene, Viruses

Which children
are at risk for having
allergy?

Those who have first degree family


history
Low risk
No family history
of allergy

Moderate risk
1 family history
of allergy

High risk
2 or more family
history of
allergy

Family history
Newborn (100
population)

% risk of infant
having allergy
No. of newborn
with allergy risk
= population x
% allergy risk

Number of newborn
at risk

Number of newborn
at risk

Pre natal sensitization

Warner JO. Early life origin


of asthma. ADC
2004;89:97-102

Prenatal sensitization
Amniocentesis: Lymphocyte specific activation
at gestational age 20-24 weeks
House dust and egg allergen detected in
amniotic fluid
Warner JO.

Cord blood IgE:


Food allergen more frequent than inhalant
Ultrasensitive detection methods: differentiate
maternal blood and cord blood shows IgE and
IgA detected in cord blood is of fetal origin
2012;130:113-27

Kamemura N. JACI

Development of Allergy: the 3


phase

Allergy Mechanism

SENSITIZATION

ENHANCEMENT

Fireman P, Slavin RG. Atlas of Allergies,

TRIGGERING
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Allergy development can be


prevented
1. Primary Prevention:
Before any IgE mediated disease
has occurred
2. Secondary Prevention:
Further sensitivities once IgE mediated
disease has developed
3. Tertiary Prevention:
Prevention manifestation of allergic disease
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Allergy prevention
Is an important part in the management of
allergy, since allergy can be fatal, OR,
experienced throughout life
Primary prevention: is the most effective
Before sensitization to occur
Period: prenatal first 6 month of life
Target: all population with allergy risk
Tool for detection: Allergy trace card
should be done before the pregnancy ended
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To identify infant at risk


Allergy Trace card: IDAI-POGI

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where appropriate and give score


Family

Diagnos Suspect No
ed
ed
history

Score

Mother
Father
Sibling
Total
score
Givie Score
2 if diagnosed by physician
1 if suspected by family
0 if no history of allergy

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Risk of allergy for the fetus


High when total score 4-6
Moderate when total score 1-3
Low risk when total scoire 0

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Management of infant at
risk
Breastfeeding exclusively for 4-6
month

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Management of infant at
risk
Recommendation AAP-IDAI
During
pregnancy
Probiotics
Avoid
smoke
No diet
restriction

Soon After birth


Exclusive breastfeeding
Probiotics
Hydrolysed cows milk
formula
Avoid tobaco smoke

Vaginal

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Exclusive Breastfeeding
Exclusive BF for 4-6 month reducing the rate of allergic
disease in early childhood
Kemp.AS. MJA 2003 www.mja.com.au

the extent of the preventive effect remains


controversial
Finish study: prolonged > 6 month was associated with
lower rates of eczema & food allergy at 1 & 3 years,
also lower score of respiratory allergy up to 17 years
of age compared with cows milk formula fed individuals
Lancet 1999

Sarinen,

Danish study: exclusively 4 month ; No restriction


during lactation. : 1.3% cows milk allergy
S. Pediatr Allergy Immunol.2000

Halkens

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Maternal avoidance
Maternal food antigen avoidance (cows
milk, egg, HDM) infant IgE, SPT, allergic
ds : no difference
Faith-Magnusson JACI 1992

Metaanalysis from 4 trials (451 subjects)


maternal food antigen avoidance (cows
milk, peanuts, egg and chocolates) :
does not support protection

Kramer MS, Kakuma R. The Cochrane


Library 2004
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the prophylactic-treated group : mother avoid cow's


milk, egg, and peanut during the last trimester of
pregnancy & lactation. Infant avoided cow's milk until
age 1 year (casein hydrolysate before age 1), egg
until age 2 years, and peanut and fish until age 3
years.
At 2 year: CMA < , at 7 years not differ
Atopic diseases/parameters at age 7 years associated
with male gender, maternal nonwhite ethnicity and
asthma, and household smoking
Zeiger, JACI 1995;95:117990
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Breatfeeding and avoidance


No need for
avoidance
Only when baby has
allergy: mother can
avoid the triggering
food.
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When breastfeeding is not possible


Partially' and 'extensively'
Hydrolysed
Molecular weight :
may have different preventive or treatment
effects
less predictive value than suggested

Peptide chain length distribution

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Intact Protein

Partial
Hidrolysed

Extensively
Hidrolysed

Allergenicity

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24 12/29/16

Amino acid

partially hydrolysed whey versus


cow's milk formula
Meta-analysis for prevention
a significant reduction in infant allergy (six
studies, 1391 infants; typical RR 0.79, 95% CI
0.65, 0.97) but not childhood allergy, or infant or
childhood asthma, eczema or rhinitis.

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Probiotics
L rhamnosus GG : 4 weeks prior to delivery
infant high risk for allergy: in first 6 month of
life
Atopic eczema diagnosed in 46 of 132 (35%)
of aged 2 years. The frequency in probiotic
vs placebo group was 23% vs 46%, RR 0.55
(95%CI 0.32-0.85)
Kaliomaki M et al. The Lancet
2001;357-61
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Incidence of eczema at 2
years in children given
probiotics from birth

Kalliomaki M, Lancet. 2001; 27


357:1076

Pediatric Atopic dermatitis and


probiotics
Meta analysis
21 AD prevention
10 RCT
6 prevention pre
and post natal
4 treatment

Prevention:effect
sizes of 0.69 (0.57,
0.83) and 0.66
(0.49, 0.89)
The treatment trial:
SCORAD score
reduction by -6.64
points (-9.78, -3.49)
and -8.56 (-18.39,
1.28)

supporting probiotics' PAD


Jouhei Lee, et al. JACI
prevention
2008;121:116-21

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Cigarette-smoke exposure

Risk of asthma and poor lung


function

Associated with higher levels of IgE


specific for HDM in children
Risk factor for allergic disease in
children
JAMA. 2010;303(18):1848-56.
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J Allergy Clin Immunol. 2009;123: 1012

Delayed Introduction to Solid


Food??
Systematic review (2006):
Early solid feeding may increase the risk
of eczema.
Little data supporting an association
between early solid feeding and other
allergic conditions.
Arch Pediatr Adolesc Med 2006;160:502
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Recommendation of Allergy Prevention


RECOMMENDATION

EBM

Breastfeeding
A
Maternal nutrition during pregnancy and/or A and B
breastfeeding
Feeding of children at risk with mothers milk A
substitutes
Introduction of solid food and child nutrition A and B
in the first year
Nutrition after the first year
A
Pets
B
Housedust mites
B
Mold and damp
B
Exposure to tobacco smoke
A
Indoor air pollutants
B
Vaccinations
A
Body weight
A
Motor vehicle emissions
B
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Effect of Muche-Boroswki,
probioticset al, 2009. Dtsch Arztebl Int. 106(39): 625631.

Recommendations for Primary Prevention of FA by AAP and


ESPACI/ESPGHAN
Parameter
AAP, 20005
Espaci/Espghan, 1996
High-risk infants
Maternal pregnancy
diet
Exclusive
breastfeeding
Maternal lactation
diet

Yes: biparental; parent

Yes: affected parent

and sibling
Not recommended with
possible exception of
peanut
6mo

or sibling
Not recommended

Eliminate peanuts and nuts


(consider eliminating eggs,
CM, fish)
Yes

Not recommended

Supplemental Ca & Vit.


During
Restrictied lactation diet
Avoid soy formulas
Yes
Hypoallergenic formula for
Yes: use a hypoallergenic
bottle-fed high-risk infant
(extensive) or possibly
PHs when not
breastfeeding

46 mo

Not discussed

Yes
Yes: use formula
with confirmed
reduced
allergenicity 33

Thank
you

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