ASCIA Guidelines for Infant Feeding and Allergy Prevention

Healthy foods from the food groups image

By Sandra Vale, ASCIA Education Officer

Ever wondered why there has been an increased focus on allergic diseases in recent years? Allergic diseases have more than doubled in western countries over the last 25 years. The most common allergic conditions in children are food allergies, eczema, asthma and hay fever (allergic rhinitis). The number of hospital presentations for anaphylaxis (severe allergic reactions) has increased and many children with food allergy are not outgrowing their allergies, resulting in an increase in food allergies in the adult population.  Up to 2 in 5 children in Australia and New Zealand are affected by allergic conditions at some time during childhood.

Allergic conditions are often life-long and although treatable, there is currently no cure.  As a result, there has been an increasing focus on allergy prevention in infants.

The reason for the continued rise in allergic diseases in developed countries is complex and research in this area is ongoing. Although children with a family history of allergy have a higher risk of allergy, many children with no family history of allergy also develop allergies.

A number of factors appear to increase the risk of developing allergic conditions. We have no control over some risk factors, such as family history, whilst there are other environmental factors that we might be able to influence.  Identified risk factors for developing an allergic condition include:

  • Family history of allergy in a parent or sibling (family history of allergy in both parents OR a parent and a sibling is associated with a further increased risk).
  • Introduction of cow's milk or soy milk formula before 3-4 months of age (an increased risk for eczema and food allergy).
  • Introduction of solid foods before 3-4 months of age (an increased risk for eczema and food allergy).
  • Birth in spring - a risk for seasonal allergic rhinitis (hay fever).
  • Passive exposure to cigarette smoke (a risk for increased respiratory symptoms).

We currently do not have a clear explanation as to why food allergy seems to have increased so rapidly in recent years, particularly in young children. Proposed explanations include:

  • Hygiene hypothesis, which proposes that less exposure to infections in early childhood is associated with an increased risk of allergy.
  • Changes in microbiome - a complex set of micro-organisms that colonise the human body.
  • Delayed, compared to earlier, introduction of allergenic foods (e.g. egg, peanut, tree nuts) where introduction later in life might reduce the development of oral tolerance.
  • Methods of food processing (e.g. roasting makes peanuts more allergenic). 
  • Development of allergy to food by skin exposure (e.g. use of unrefined nut oil based moisturisers, goat’s milk products).
  • Vitamin D deficiency in first year of life.
  • Medication to suppress gastric acid production.

Earlier this year, the Australasian Society of Clinical Immunology and Allergy (ASCIA), the peak body for allergy and critical immunology in Australia, updated its Guidelines for infant feeding advice and allergy prevention.  These guidelines are relevant for all families not just those with a family history of allergy and aim to provide families with a summary of evidence-based information about infant feeding.

Many previous allergy prevention strategies have been ineffective, including delayed introduction of allergenic foods.

Based on recent evidence the guidelines address important issues with a focus on maternal diet during pregnancy, breastfeeding and the introduction of complementary foods to infants.

Key recommendations from the guidelines include:

  • Up to 3 serves of oily fish per week during pregnancy and breastfeeding may be beneficial in preventing eczema in early life.
  • There is no consistent, convincing evidence to support that hydrolysed formulas (usually labelled HA or hypoallergenic) assists in allergy prevention in infants or children.
  • Introduce solid foods from around 6 months, but not before 4 months (whilst breastfeeding), when the infant is ready.
  • Allergenic foods should not be avoided and there is some benefit to introducing these foods in the first year of life while the infant is still being breastfed.
  • There is evidence that for infants at high risk of food allergies, such as those with severe eczema or who already had a food allergy reaction to egg, introduction of regular peanut before 12 months of age can reduce subsequent peanut allergy.
  • It is not recommended that infants are fed raw egg, however there is moderate evidence for the introduction of cooked egg into the diet of infants with a family history of allergy before 8 months of age to try and reduced the risk of egg allergy.

Other important issues addressed in the ASCIA guidelines include dietary advice for the mother whilst pregnant and breastfeeding.

Full versions of the ASCIA Guidelines for Infant Feeding and Allergy Prevention, including frequently asked questions, are available from the ASCIA website:

www.allergy.org.au/patients/allergy-prevention

References

1. Boyle RJ et al. Hydrolysed formula and risk of allergic or autoimmune disease: a systematic review and meta-analysis. BMJ. 2016;352:i974 | doi: 10.1136/bmj.i974
2. Du Toit G et al. Effect of avoidance on peanut allergy after early peanut consumption. N Engl J Med. 2016. DOI: 10.1056/NEJMoa1514209
3. Du Toit G et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015 Feb 26;372(9):803-13.
4. Fiocchi A et al. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics. World Allergy Organ J. 2015 Jan 27;8(1):4.
5. Fleischer DM, et al. J Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants. J Allergy Clin Immunol. 2015 Aug;136(2):258-61.
6. Gunaratne AW et al. Maternal prenatal and/or postnatal n-3 long chain polyunsaturated fatty acids (LCPUFA) supplementation for preventing allergies in early childhood. Cochrane Database Syst Rev. 2015 Jul 22;7
7. Kramer MS et al. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2012 Sep 12;9.
8. Lodge CJ et al , Allen KJ, Lowe AJ, Dharmage SC. Overview of evidence in prevention and aetiology of food allergy: a review of systematic reviews. Int J Environ Res Public Health. 2013 Nov 4;10(11):5781-806.
9. Osborn DA et al. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. 2006 Oct 18;(4).
10. Palmer DJ et al. Early regular egg exposure in infants with eczema: A randomized controlled trial. J Allergy Clin Immunol. 2013 Aug;132(2):387-92.
11. Perkin MR et al. Randomised trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016. DOI: 10.1056/NEJMoa151421