Prevention of allergic diseases
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PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC PREVENTION OF ALLERGIC DISEASEDISEASEDISEASEDISEASEDISEASEDISEASEDISEASEDISEASE
CHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD
Outline Outline
�� Food allergen avoidanceFood allergen avoidance
�� HDM avoidanceHDM avoidance�� HDM avoidanceHDM avoidance
�� Multiple interventionMultiple intervention
Food allergen avoidanceFood allergen avoidance
High risk High risk
Definitions/Definitions/interventionsinterventions
AAP 2008 AAP 2008 Clinical Clinical ReportReport
AAP 2000AAP 2000recommendrecommendationsations
‘‘High risk’’‘‘High risk’’ Parent or Parent or BiparentalBiparental or or
Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20082008;;122122::2929--3333..
‘‘High risk’’‘‘High risk’’ Parent or Parent or sibling withsibling withdocumented documented allergicallergicdiseasedisease
BiparentalBiparental or or parent plusparent plussibling history sibling history of allergyof allergy
Atopic risk scoreAtopic risk score
Type and degree of allergy symptomsType and degree of allergy symptomsFamilyFamily Major*Major* Minor**Minor** TotalTotal
OvertOvert ProbableProbable AbsentAbsent OvertOvert ProbableProbable AbsentAbsent
FatherFather 22 11 00 11 0.50.5 00 4.54.5MotherMother 33 22 00 11 0.50.5 00 6.56.5
J. J. NgamphaiboonNgamphaiboon et al Asian Biomedicine 2009; 3:121et al Asian Biomedicine 2009; 3:121--126.126.
MotherMother 33 22 00 11 0.50.5 00 6.56.5SiblingSibling 22 11 00 11 0.50.5 00 4.54.5
*asthma, atopic dermatitis, allergic rhinitis, *asthma, atopic dermatitis, allergic rhinitis, CMA.CMA.****urticariaurticaria, drug allergy, other food allergies , drug allergy, other food allergies except CMA, allergic conjunctivitis.except CMA, allergic conjunctivitis.
P. P. BagerBager et al Clinical and Experimental Allergy 2008;38:634et al Clinical and Experimental Allergy 2008;38:634––642.642.
LiemLiem et al J Allergy et al J Allergy ClinClin ImmunolImmunol 2007;119:12032007;119:1203--9.9.
R. E. Bergmann R. E. Bergmann et al Clinical and Experimental Allergy et al Clinical and Experimental Allergy 19971997;;2727: : 752752--760760..
Allergic marchAllergic march
www.theallergymarch.comwww.theallergymarch.com
Maternal avoidance diet during Maternal avoidance diet during pregnancypregnancy
�� Maternal avoidance cow’s milk and egg Maternal avoidance cow’s milk and egg during pregnancy not affect incidence of during pregnancy not affect incidence of allergic diseaseallergic diseaseallergic diseaseallergic disease
�� No association between maternal peanutNo association between maternal peanut
avoidance during pregnancy and incidenceavoidance during pregnancy and incidence
of peanut allergy in their childrenof peanut allergy in their children
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
Definitions/Definitions/interventionsinterventions
AAP 2008 AAP 2008 Clinical Clinical ReportReport
AAP 2000AAP 2000recommendrecommendationsations
Pregnancy Pregnancy avoidanceavoidance
Lack of Lack of evidenceevidence
Possibly Possibly peanutpeanut
Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol 2008;122:29J Allergy Clin Immunol 2008;122:29--33.33.
Kramer MS et al Cochrane Database of Systematic Reviews Kramer MS et al Cochrane Database of Systematic Reviews 20062006..
�� No significant benefit to childrenNo significant benefit to children
Maternal avoidance diet during Maternal avoidance diet during lactationlactation
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..
Definitions/Definitions/interventionsinterventions
AAP 2008 AAP 2008 Clinical Clinical ReportReport
AAP 2000AAP 2000recommendrecommendationsations
Maternal Maternal lactationlactationavoidance of avoidance of
Some Some evidence for evidence for reducedreduced
Peanuts, tree Peanuts, tree nuts andnuts and‘‘consider’’ ‘‘consider’’
Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol 2008;122:29J Allergy Clin Immunol 2008;122:29--33.33.
avoidance of avoidance of allergensallergens
reducedreducedatopic atopic dermatitisdermatitis
‘‘consider’’ ‘‘consider’’ egg, milk, egg, milk, fish,fish,and ‘‘perhaps and ‘‘perhaps other foods’’other foods’’
Kramer MS et al Cochrane Database of Systematic Reviews Kramer MS et al Cochrane Database of Systematic Reviews 20062006..
�� Exclusive breastExclusive breast--feeding for feeding for 3 3 months months
reduce incidence of atopic dermatitis in reduce incidence of atopic dermatitis in
Effect of breastEffect of breast--feeding on feeding on atopic dermatitisatopic dermatitis
reduce incidence of atopic dermatitis in reduce incidence of atopic dermatitis in
childrenchildren
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
Effect of breastEffect of breast--feeding on feeding on asthmaasthma
�� Exclusive breastExclusive breast--feeding for 3feeding for 3--4 months 4 months
reduces number of early, upper respiratory reduces number of early, upper respiratory
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
reduces number of early, upper respiratory reduces number of early, upper respiratory
infectioninfection--associated wheezingassociated wheezing
episodes before age of 4 yearsepisodes before age of 4 years
�� HighHigh--risk infants exclusive breastrisk infants exclusive breast--feeding feeding
at least at least 4 4 months lowered risk of cow’s months lowered risk of cow’s
Effect of breastEffect of breast--feeding on feeding on food allergyfood allergy
at least at least 4 4 months lowered risk of cow’s months lowered risk of cow’s
milk allergy (but not food allergy inmilk allergy (but not food allergy in
general)general)
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..
�� Not clearNot clear
Effect of breastEffect of breast--feeding on feeding on allergic rhinitisallergic rhinitis
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
�� Cow’s milk formulas & partial whey Cow’s milk formulas & partial whey
hydrolysatehydrolysate formulasformulas
Infant formula for primary prevention Infant formula for primary prevention of allergic disease of allergic disease 11
pHFspHFs preventive effect on atopic disease preventive effect on atopic disease
and cow’s milk protein allergyand cow’s milk protein allergy
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..
�� pHFspHFs & extensive casein or extensive & extensive casein or extensive
whey whey hydrolysatehydrolysate formulas (formulas (ehFehF))
Infant formula for primary prevention Infant formula for primary prevention of allergic disease 2of allergic disease 2
No significant difference between No significant difference between pHFpHF and and
eHFeHF in development of infant allergic in development of infant allergic
diseasesdiseases
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
�� Soy formula & amino acid based Soy formula & amino acid based
formulasformulas
Infant formula for primary prevention Infant formula for primary prevention of allergic disease 3of allergic disease 3
-- Advantage of soy formula not show Advantage of soy formula not show
-- Amino Amino acidebasedacidebased formulas lacking formulas lacking
studiesstudies
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..
Definitions/Definitions/interventionsinterventions
AAP 2008 AAP 2008 Clinical Clinical ReportReport
AAP 2000AAP 2000recommendrecommendationsations
Prevention formulasPrevention formulas Compared with Compared with wholewholecow’s milk protein,cow’s milk protein,evidence for certainevidence for certain
‘‘Hypoallergenic ‘‘Hypoallergenic formula’’formula’’(extensive (extensive hydrolysatehydrolysate,,
Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20082008;;122122::2929--3333..
evidence for certainevidence for certainextensive extensive hydrolysateshydrolysates,,partial partial hydrolysateshydrolysates, but, butnot soynot soy
hydrolysatehydrolysate,,possibly partialpossibly partialhydrolysatehydrolysate); not ); not soysoy
I I BrockowBrockow et al et al J Investig Allergol Clin Immunol J Investig Allergol Clin Immunol 20092009;;1919: : 180180--187187..
Introduction of complementary foods Introduction of complementary foods 11
�� Expert panel from European Academy of Expert panel from European Academy of
AllergologyAllergology and Clinical Immunology and Clinical Immunology
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice 2013;1:29: In Practice 2013;1:29--36.36.
recommends introduction of recommends introduction of
complementary foods between complementary foods between 4 4 and and 6 6
months of agemonths of age
Introduction of complementary foods 2Introduction of complementary foods 2
�� Feeding solids before Feeding solids before 4 4 months of age months of age
higher incidence of atopic dermatitishigher incidence of atopic dermatitis
David M. Fleischer et al J Allergy David M. Fleischer et al J Allergy ClinClin ImmunolImmunol: In Practice : In Practice 20132013;;11::2929--3636..
�� No current evidence suggests that delay of No current evidence suggests that delay of
introduction of solid foods beyond introduction of solid foods beyond 4 4 to to 6 6
months of age prevent allergic diseasemonths of age prevent allergic disease
Definitions/Definitions/interventionsinterventions
AAP 2008 AAP 2008 Clinical Clinical ReportReport
AAP 2000AAP 2000recommendrecommendationsations
Types of Types of ‘‘solids’’ and‘‘solids’’ andcomplementarycomplementary
Evidence to Evidence to wait 4 (to 6)wait 4 (to 6)mo; lack of mo; lack of
Solids held to Solids held to 6 mo6 moDairy Dairy
Scott H. Scott H. SichererSicherer et al et al J Allergy Clin Immunol 2008;122:29J Allergy Clin Immunol 2008;122:29--33.33.
complementarycomplementary
foodsfoodsmo; lack of mo; lack of convincingconvincingevidence for evidence for avoidingavoidingspecific specific allergenic allergenic foodsfoods
Dairy Dairy products, age products, age 1 y1 yEgg, age 2 yEgg, age 2 yPeanuts, Peanuts, nuts, fish, nuts, fish, age 3 yage 3 y
HDM avoidanceHDM avoidance
Study on Prevention of Allergy inStudy on Prevention of Allergy inChildren in Europe (SPACE)Children in Europe (SPACE)
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
Newborn Newborn 696696
BirthBirth Mattress Mattress cover cover
Allergic Allergic sensitizationsensitization
11y allergic y allergic sensitizationsensitization
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..
696696 cover cover and and general general adviceadvice
sensitizationsensitization sensitizationsensitization
22y no y no effecteffect
Toddler Toddler 636636
22--4 4 yy 11y allergic y allergic sensitizationsensitization
School School children children 242242
55--7 7 yy
Manchester Asthma and Allergy Manchester Asthma and Allergy StudyStudy
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
620620 PrenatalPrenatal Extensive Extensive --Allergic Allergic HDM HDM
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.
620620 PrenatalPrenatal Extensive Extensive HDM HDM avoidanceavoidance--covercover--HEPA filterHEPA filter--hardwood hardwood flooringflooring--use of use of AcarosanAcarosan
--Allergic Allergic sensitizationsensitization
--WheezeWheeze--Airway Airway resistanceresistance
HDM HDM allergen allergen levelslevels11Y: only Y: only severe severe wheezewheeze
Prevention and Incidence of Prevention and Incidence of Asthma and Mite Allergy (PIAMA)Asthma and Mite Allergy (PIAMA)
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention MainMain
outcomeoutcome
Reduction Reduction inin
810810 PrenatalPrenatal Mattress Mattress --Total Total HDM HDM
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.
810810 PrenatalPrenatal Mattress Mattress covers covers and and general general adviceadvice
--Total Total IgEIgE--Specific Specific IgEIgE--Cough, Cough, wheezewheeze--Atopic Atopic dermatitisdermatitis
HDM HDM allergenallergenlevelslevels22y: y: nocturnal nocturnal coughcough
Multiple interventionMultiple intervention
Isle of Wight prevention studyIsle of Wight prevention study
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
120120 BirthBirth Food and Food and HDM HDM avoidanceavoidance
-- Allergic Allergic sensitizationsensitization-- AsthmaAsthma-- Allergic Allergic rhinitisrhinitis-- Atopic Atopic
HDM HDM allergen allergen levellevel1 1 y:y:Asthma,ADAsthma,ADallergic allergic
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..
-- Atopic Atopic dermatitisdermatitis-- Food Food allergyallergy
allergic allergic sensitizationsensitization22Y:AD Y:AD allergic allergic sensitizationsensitization44Y:AD Y:AD allergic allergic sensitizationsensitization88Y:asthma, Y:asthma, allergic allergic sensitizationsensitization
Prevention of atopic allergyPrevention of atopic allergy
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
531531 BirthBirth Diet Diet exclusive exclusive BF or BF or
-- Asthma Asthma -- ADAD-- RhinitisRhinitis
44y :any y :any allergyallergy
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.
BF or BF or soya soya formula formula and and environmental environmental
HDM and HDM and ETS ETS avoidanceavoidance
-- RhinitisRhinitis--UrticariaUrticaria
Canadian Asthma Primary Canadian Asthma Primary Prevention StudyPrevention Study
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
545545 PrenatalPrenatal Diet : breast Diet : breast feeding, feeding, delayed delayed
-- Allergic Allergic sensitizationsensitization-- AsthmaAsthma
HDM HDM allergen allergen levelslevels
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..
delayed delayed introduction introduction of solids and of solids and environment environment reductionreductionHDM and HDM and pet pet exposure exposure and ETS and ETS
-- AsthmaAsthma-- Allergic Allergic rhinitisrhinitis
levelslevels1 Y: asthma 1 Y: asthma and allergic and allergic rhinitisrhinitis2Y :asthma2Y :asthma
Childhood Asthma Prevention Childhood Asthma Prevention StudyStudy
NumberNumber Intervention Intervention
started atstarted atInterventionIntervention Main Main
outcomeoutcome
Reduction Reduction inin
616616 PrenatalPrenatal -- HDM HDM avoidanceavoidance-- Diet : Diet :
-- CoughCough-- AAsthma sthma --AAllergic llergic
11..5 5 y :diet y :diet group; group; wheeze wheeze
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..
-- Diet : Diet : omega omega 3 3 PUFAPUFA-- CombinedCombined
--AAllergic llergic sensitizationsensitization--Total Total IgEIgE at at age age 18 18 monthsmonths
wheeze wheeze HDM groupHDM groupno effectno effect3 3 y diet y diet group;coughgroup;coughHDM group HDM group sensitization sensitization to HDMto HDM
OmegaOmega--3 PUFAs3 PUFAs
�� Dietary modifications of supplementation Dietary modifications of supplementation
with fish oil with fish oil ((rich inomegarich inomega--3 3 PUFAsPUFAs)) might might
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.
be some benefitbe some benefit
�� ProspectiveProspective observational study indicate observational study indicate
introduction of fish into infant’s diet reduces introduction of fish into infant’s diet reduces
occurrence of rhinitis but notoccurrence of rhinitis but not asthmaasthma
ProbioticsProbiotics
�� LactobaccilusLactobaccilus GG given during pregnancy GG given during pregnancy
to mothers with a family history of to mothers with a family history of atopyatopy
for 6 months resulted in significant for 6 months resulted in significant
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol 2005;116:3J Allergy Clin Immunol 2005;116:3--14.14.
for 6 months resulted in significant for 6 months resulted in significant
reduction in atopic dermatitis up to thereduction in atopic dermatitis up to the
age of 2 yearsage of 2 years
VaccinationVaccination
�� No clinical trials to assess No clinical trials to assess
immunomodulatoryimmunomodulatory effect ofeffect of
SyedSyed HasanHasan ArshadArshad J Allergy Clin Immunol J Allergy Clin Immunol 20052005;;116116::33--1414..
immunomodulatoryimmunomodulatory effect ofeffect of
vaccination in primary prevention of allergyvaccination in primary prevention of allergy
Take Home Message 1Take Home Message 1
�� Maternal avoidance diets during Maternal avoidance diets during
pregnancy and lactation not pregnancy and lactation not
recommended at this timerecommended at this timerecommended at this timerecommended at this time
�� Exclusive breastExclusive breast--feeding recommended feeding recommended
for at least 4 months and up to 6 for at least 4 months and up to 6
months of agemonths of age
Take Home Message 2Take Home Message 2
�� BreastBreast--feeding reduce incidence of feeding reduce incidence of
atopic dermatitis, reduce early onset atopic dermatitis, reduce early onset
wheezing before age wheezing before age 4 4 years and years and wheezing before age wheezing before age 4 4 years and years and
reduce incidence of cow’s milk allergy reduce incidence of cow’s milk allergy
in the first in the first 2 2 years of lifeyears of life
Take Home Message Take Home Message 33
�� No conclusive evidence supports No conclusive evidence supports
formula over breastformula over breast--feeding to prevent feeding to prevent
atopic diseaseatopic diseaseatopic diseaseatopic disease
�� Complementary foods can be Complementary foods can be
introduced between 4introduced between 4––6 months of age6 months of age
Take Home Message 4Take Home Message 4
�� Preventive effect of HDM avoidance for Preventive effect of HDM avoidance for
sensitization or respiratory allergy not sensitization or respiratory allergy not
compelling compelling compelling compelling
�� Combining food and aeroallergen Combining food and aeroallergen
avoidance reducing early childhoodavoidance reducing early childhood
wheeze and atopic dermatitis laterwheeze and atopic dermatitis later
asthmaasthma
THANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOU
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