Issue 137 Preventing food allergy in higher risk infants

PAEDIATRIC

PREVENTING FOOD ALLERGY IN HIGHER RISK INFANTS Mary Feeney Paediatric Allergy Dietitian, King’s College London

This article reports on BSACI/BDA FASG guidance for UK healthcare professionals (HCPs) on preventing food allergy in higher risk infants.

Mary has worked as the FASG Project Dietitian funded by a joint grant from the BDA GET and Anaphylaxis Campaign to develop guidance and dietetic resources in three areas of food allergy management through evaluation of research literature, current practice and dietetic consensus. Mary is also a research dietitian and is currently working on the LEAP Trio Study.

The UK Scientific Advisory Committee on Nutrition (SACN) has recently published a review on feeding in healthy term infants aged 0-12 months: Feeding in the First Year of Life. This report forms part of a comprehensive risk assessment of infant and young child feeding up to five years (60 months).1 To inform their work, an examination of evidence relating to ‘the influence of infant diet on development of food allergy and atopic and autoimmune disease’ was carried out by the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT).2 In April 2018, a SACN-COT working group, established to carry out a benefit-risk assessment on the timing of introduction of peanut and hen’s egg into the infant diet and to provide integrated recommendations to the UK Health Departments, published a joint statement.3 This statement recommended: • exclusive breastfeeding for around the first six months of life; • the introduction of complementary foods in an age-appropriate form from around six months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child; • foods containing peanut and hen’s egg need not be differentiated from other complementary foods; • the deliberate exclusion of peanut or hen’s egg beyond six to 12 months of age may increase the risk of allergy to these foods.

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These recommendations relate to healthy term infants. Included in the SACN-COT statement was an acknowledgement that HCPs may need to take into account different clinical scenarios, and targeted advice may be appropriate for infants at a higher risk of developing food allergy. SACN-COT also advised that families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing peanut or hen’s egg.3 GUIDANCE FOR HCPS

To support UK HCPs, particularly those working in primary care to provide individualised advice to families of higher risk infants, guidance has been developed by the Paediatric Advisory Group of the British Society of Allergy and Clinical Immunology (BSACI) and the Food Allergy Specialist Group (FASG) of the BDA.4-5 This guidance document, Preventing food allergy in higher risk infants: guidance for healthcare professionals, provides scientific background and practical information for HCPs and parents/caregivers and is designed to complement the SACNCOT joint statement (see Figure 1

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FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies

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TO CONTAIN GOS/FOS PREBIOTICS

Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to five years1–3

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cows’ milk allergy is extensively hydrolysed formula†

References: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the fi rst two years of life. J Nutr. 2008;138:1091-5. 2. Arslanoglu S et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the fi rst 5 years of life. J Biol Regul Homeost Agents. 2012;26:49-59. 3. Pampura AN et al. Ros Vestn Perinatol Paediat 2014;4:96-104

IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. † For the management of mild to moderate IgE-moderated cows’ milk allergy the iMAP guideline recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.

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Preventing food allergy in higher risk infants: summary for healthcare professionals

PAEDIATRIC

The'UK'health'departments'advise'exclusive'breastfeeding'until'around'six'months'of'life, and'to'continue'breastfeeding'throughout'the'first'year.

Figure 1: The management of infants with a known risk factor for food allergy

Infants'with'a'known'risk'factor'for'food'allergy:

• •

Eczema* Existing'food'allergy'in'your'baby

Avoid'any'foods'the'baby'is'known'to'be'allergic'to

These'children'may'benefit'from'the'earlier'introduction' of'cooked'egg'(and'then'peanut),'alongside'other'solids

When'the'baby'is'ready,'consider'introducing'solid' foods'– including'cooked'egg and'then'peanut – from'age'4'months,'followed'by'other'allergenic'foods§ *Some infants will already be allergic to these foods: infants with moderateOsevere eczema are at greatest risk. To date, no lifeOthreatening reactions have been reported in this context.

Allergy tests can help identify individual infants at higher risk, but systematically screening all infants with more severe eczema is not currently available in most areas and may not be effective.

Families may wish to seek advice from a healthcare professional with expertise in allergy; this should not delay introduction of common allergenic foods beyond 12 months of age.

Infants'with'a'household' member'with'food'allergy

No'risk'factors' for'food'allergy

Consider'how'to'introduce'the'food' into'the'baby’s'diet'whilst'keeping' the'foodOallergic'person'safe.

Some'families'may'benefit'from' reassurance'from'an'allergy' specialist'but'this'should'not delay' introduction'of'allergenic'foods.

When'the'baby'is'ready,'introduce'solid'foods'at around'6'months'of'age'(but'not'before'4'months).'

Include'peanut,'egg'and'other'foods§ that'are' eaten'as'part'of'the'family’s'normal'diet Screening'allergy'tests'are'not routinely' recommended'prior'to'introducing'solids § Common'foods'which'can'cause'food'allergy'include:'egg,' peanut'and'other'nuts,'dairy'foods,'fish/seafood'and'wheat

The'UK'health'departments'advise'that'breastfeeding'should'continue This figure has been edited. The complete figure includes advice on allergy symptoms and management. Click here for the full pdf throughout'the'first'year'of'life,'at'the'same'time'as'introducing'solid'foods.

for a summary). It was developed following which is also summarised within the guidance Monitor'for'any'symptoms'of'an'allergic'reaction: a consultation process involving BSACI and document.9 ImmediateCtype'food'allergy BDA members, HCPs including health visitors DelayedCtype'food'allergy Infants with a household member with a Typically'happen'within'30'minutes'of'eating'the'food: Symptoms'occur'hours'after'the'trigger'food: and general practitioners, parents and patient food allergy, who have no other risk factors MildOmoderate'symptoms: Gut'symptoms: support groups. allergy, are also recommended to follow • Swollen'lips,'face'or'eyes •for Recurrent'abdominal'pain,'worsening'vomiting/reflux This document, directed towards HCPs, •current UK infant feeding advice. This is with • Itchy'skin'rash'e.g.'“hives”,'urticaria Food'refusal'or'aversion • Abdominal'pain,'vomiting Loose/frequent'stools'(>6O8 provides background information on the •the proviso that some times'per'day)'or'''''''' families will benefit from constipation'/'infrequent'stools'(2 or'fewer'per'week) RARELY**: Severe'symptoms'(anaphylaxis): randomised trials investigating the timing the reassurance of an allergy specialist and Skin'symptoms: AIRWAY:' Swollen tongue,'persistent'cough,'hoarse'cry of introduction of allergen foods for allergy •allergy testing before introducing allergen foods.

Skin'reddening'or'itch'over'body BREATHING:' Difficult'or'noisy'breathing,'wheezing •However, Worsening'eczema prevention, including the LEAP and EAT studies. this should not delay introduction of CONSCIOUSNESS:'Pale'or'floppy,'unresponsive/unconscious It also considers**risk'estimated'to'be'1O2'per'1000'babies'at'higher'risk.' the impact of implementing earlier NB:'DelayedOtype'allergy'cannot'trigger'anaphylaxis allergen foods. introduction of egg and peanut on preventing these allergies in different population groups: general Existing food allergy • Stop'the'trigger'food,'symptoms'should'resolve'after' • If'any'severe'symptoms'(anaphylaxis),''''''' and infants with moderate-severe eczema.6-8 Infants with a known risk factor for food allergy a'few'days. immediately'dial'999'for'assistance. ‘higher risk infants’ are defined as those with •orIf'symptoms'are'not'severe,'consider'trying'the'food' • Avoid'the'trigger'food,'do NOT reintroduce. again'1O2'weeks'later.

Infant• feeding eczema (particularly moderate-severe eczema GP'review'recommended.

• Seek'GP'review'If'symptoms'recur'or'are'severe.

A single-page summary includes an algorithm or early-onset beginning in the first three (Figure 1) outlining the management of infants months of life), or an existing food allergy. It with •a GP'advised'to'take'allergyOfocused'history:' known risk factor for food allergy, •is GP'advised'to'take'allergyOfocused'history:' advised that such infants may benefit from https://www.nice.org.uk/guidance/cg116 https://www.nice.org.uk/guidance/cg116 infants with a household member with a food •earlier introduction of foods containing egg (if Seek'advice'from'a'dietitian'with'appropriate' • Referral'to'secondary'or'specialist'care'is'recommended' competencies,'if'needed allergy and infants with no risk factors for food part of the family’s diet) and peanut, i.e. from for'all'infants'presenting'with'symptoms'of' Refer'any'child'with'persistent'delayedOtype' allergy. immediateOtype,'IgEOmediated'food'allergy.

Breastfeeding is advised for all infants •four months alongside other complementary symptoms'(not'responding'to'single'food'elimination)' 10 throughout the first year of life, alongside foods.

It is recommended that these allergen and/or'faltering'growth'to'specialist'clinic

introduction of complementary solids as per foods are introduced as an age-appropriate the UK health departments' recommendations, texture to avoid risk of choking, i.e. no whole regardless of allergy risk. For infants with no nuts or chunks of peanut butter. Egg should be risk factors for food allergy, it is advised that given in cooked form, as the use of pasteurised they follow current UK infant feeding advice raw egg was associated with significant allergic 34

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Table 1: Introducing egg and peanut into a baby’s diet Egg (both egg white and yolk

Choose British Lion stamped eggs, then you can offer your baby scrambled egg, omelette, soft or hard-boiled egg. You can mash egg into other foods, e.g. pureed fruit/veg, yoghurt, or baby cereals such as rice. Aim for at least one egg over the course of a week.

If you are not using British Lion-stamped eggs, only give well-cooked or hard-boiled egg.

Peanut

Never give whole nuts, coarsely-chopped nuts or chunks of peanut butter to children under five years of age, as these are a choking risk.

You can use smooth peanut butter, ‘puffed peanut’ snacks, or grind whole peanuts to a fine powder. Mix with pureed fruit/veg, yoghurt, porridge, baby cereals etc, or add to baby’s milk.

Suggested recipe: Mix 1 teaspoon of smooth peanut butter with 1 tablespoon of warm water (boiled), or baby’s milk, or some pureed fruit/veg. Aim for a total of 2 level teaspoons per week.

reactions during a German study of early egg introduction.11 Practical advice, including recipes and tips for introduction, are provided in the accompanying information for parents/ caregivers.

Screening Systematic screening of all higher risk infants is not routinely recommended prior to introducing egg or peanut; this decision related to current limited availability of allergy testing and the lack of prompt access to supervised food challenges which would be needed should screening tests be positive. Negative allergy tests are highly predictive of the absence of IgE-mediated (immediate-type) allergy symptoms. Positive allergy tests are less predictive of allergy and require confirmation by a supervised food challenge to identify whether the infant is sensitised but tolerant, or already allergic.

The guidance aims to support HCPs to help parents/caregivers make an informed decision, weighing up the benefits of allergy testing prior to introduction against the possibility that a delay in introduction may increase the risk of their infant developing a food allergy. To date, no lifethreatening reactions have been reported in infants related to the introduction of allergenic foods.

Screening is not generally offered in those countries where peanut is introduced in infancy and this has not caused major public health concerns. However, some infants will already be allergic when these

foods are introduced and so information on allergy symptoms and how to manage them is included on the front page of both the HCP guidance and the information for parents/caregivers.

Referral Onward referral for specialist advice is recommended for all infants with a diagnosed IgE-mediated (immediate) food allergy and also for those with eczema that is poorly controlled or requires longer term or potent steroid use.

'PREVENTING FOOD ALLERGY IN YOUR BABY: INFORMATION FOR PARENTS'

The accompanying information for parents/ caregivers incorporates public health messages from the UK health departments for mothers during pregnancy and after birth, alongside more specific allergy prevention advice. Allergen avoidance during pregnancy and breastfeeding, omega-3 fatty acids, probiotics, healthy eating and the use of partial or extensively hydrolysed infant formula milks for allergy prevention, are discussed as well as the timing of introduction of egg and peanut.12-13 This information sheet includes practical advice about suitable textures and recipes for introducing peanut and egg (Table 1), how to spot an allergic reaction and how to manage it, as well as how to introduce these foods if someone else in the household is allergic. Further sources of information and recipes are also provided.

The new guidance is available to download at: www.bsaci.org/about/early-feeding-guidance or www.bda.uk.com/regionsgroups/groups/foodallergy/allergy_prevention_guidance www.NHDmag.com August/September 2018 - Issue 137

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