The need for prevention
There is general consensus that the prevalence of asthma and other atopic diseases, including food allergies, is increasing. A history of allergic disease in the immediate family (atopic heredity) is the most important risk factor. Recent studies indicate that exposure to allergens in utero and in the first few months of life is critical in the development of allergic disease in children with an atopic heredity. In children at high risk, reduction in exposure to allergen should lead to a decline in disease prevalence. Food proteins are important allergens in early childhood. A hypoallergenic diet has therefore been suggested as a means of preventing the development of allergy.
Experimental evidence indicates that the child can be sensitised in utero. It is sometimes advised that an atopic mother should avoid highly allergenic foods during pregnancy. However, there is concern that this might adversely affect the growth of the foetus. Avoidance of allergens during early infancy has been shown to reduce the development of allergy in at-risk infants. Among food allergens, cow's milk is an important allergen at this stage, and exclusive breastfeeding has been advocated. As protein ingested by the lactating mother can be secreted in the breast milk (a potential source of sensitisation), a maternal diet excluding allergenic foods during lactation has been advised. eHF may be used, if required, as a replacement or supplement to breast milk and by pregnant and lactating women if cow's milk is excluded from their diet. There are, however, problems designing suitable hydrolysates that are low in antigenicity and palatable in taste.
Six months' delay in the introduction of solid foods and a further 1-2 years' delay for more allergenic foods such as eggs, fish and nuts have also been recommended. This requires supervision by a qualified dietitian so that replacement foods are suggested and nutritional adequacy of the diet is ensured. Any primary preventive programme for infants at high risk requires highly motivated parents and close cooperation with the physician and other healthcare workers.
In infants at risk of developing allergies, maternal avoidance of hypoallergenic foods during lactation, exclusive breast-feeding for 4-6 months, use of eHF if required, and introduction of solids after four months of age reduce the incidence of atopic syndromes, particularly atopic dermatitis and food allergy in early childhood. There is also evidence of reduced sensitisation, i.e. the number of positive skin prick tests and level of specific IgE antibody.9
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