NHD CPD eArticle Vol 8.14

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Volume 8.14 - 11th October 2018

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

This is an independent article reproduced from NHD issue 137 and is free from industry funding and editorial influence.

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.

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

The difference IS IN THE DETAIL

Must only be used under medical supervision and after full consideration of the feeding options available, including breastfeeding.

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

NHD CPD eArticle

Volume 8.14 - 11th October 2018 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.

throughout'the'first'year'of'life,'at'the'same'time'as'introducing'solid'foods.

may be appropriate for infants at a higher risk a consultation process involving BSACI and Monitor'for'any'symptoms'of'an'allergic'reaction: of developing food allergy. SACN-COT also BDA members, HCPs including health visitors ImmediateCtype'food'allergy advised that families of infants with a history DelayedCtype'food'allergy and general practitioners, parents and patient Typically'happen'within'30'minutes'of'eating'the'food: Symptoms'occur'hours'after'the'trigger'food: of early-onset eczema or suspected food support groups.

MildOmoderate'symptoms: Gut'symptoms: allergy wish to seek medical advice before • Recurrent'abdominal'pain,'worsening'vomiting/reflux This document, directed towards HCPs, • may Swollen'lips,'face'or'eyes introducing peanut or hen’s egg.3 background information on the • Itchy'skin'rash'e.g.'“hives”,'urticaria •provides Food'refusal'or'aversion • Abdominal'pain,'vomiting •randomised Loose/frequent'stools'(>6O8 times'per'day)'or'''''''' trials investigating the timing constipation'/'infrequent'stools'(2 or'fewer'per'week) RARELY**: Severe'symptoms'(anaphylaxis): GUIDANCE FOR HCPS of introduction of allergen foods for allergy Skin'symptoms: AIRWAY:' Swollen tongue,'persistent'cough,'hoarse'cry To support UK HCPs, particularly those working •prevention, including the LEAP and EAT studies.

Skin'reddening'or'itch'over'body BREATHING:' Difficult'or'noisy'breathing,'wheezing •It also Worsening'eczema in primary care to provide individualised advice considers the impact of implementing earlier CONSCIOUSNESS:'Pale'or'floppy,'unresponsive/unconscious to families of higher risk infants, guidance has NB:'DelayedOtype'allergy'cannot'trigger'anaphylaxis introduction of egg and peanut on preventing these **risk'estimated'to'be'1O2'per'1000'babies'at'higher'risk.' been developed by the Paediatric Advisory allergies in different population groups: general Group of the British Society of Allergy and and infants with moderate-severe eczema.6-8 • Stop'the'trigger'food,'symptoms'should'resolve'after' • If'any'severe'symptoms'(anaphylaxis),''''''' Clinical Immunology (BSACI) and the Food a'few'days. immediately'dial'999'for'assistance.

4-5 Allergy Specialist Group (FASG) of the BDA. feeding •Infant If'symptoms'are'not'severe,'consider'trying'the'food' • Avoid'the'trigger'food,'do NOT reintroduce.

This guidance document, Preventing food allergy A again'1O2'weeks'later. single-page summary includes an algorithm • GP'review'recommended.

• Seek'GP'review'If'symptoms'recur'or'are'severe. in higher risk infants: guidance for healthcare (Figure 1) outlining the management of infants professionals, provides scientific background and with a known risk factor for food allergy, • GP'advised'to'take'allergyOfocused'history:' GP'advised'to'take'allergyOfocused'history:' practical information for HCPs and parents/ •infants with a household member with a food https://www.nice.org.uk/guidance/cg116 https://www.nice.org.uk/guidance/cg116 caregivers and is designed to complement •allergy and infants with no risk factors for food Seek'advice'from'a'dietitian'with'appropriate' • Referral'to'secondary'or'specialist'care'is'recommended' competencies,'if'needed the SACN-COT joint statement (see Figure 1 allergy.

Breastfeeding is advised for all infants for'all'infants'presenting'with'symptoms'of' Refer'any'child'with'persistent'delayedOtype' for a summary).

It was developed following •throughout the first year of life, alongside immediateOtype,'IgEOmediated'food'allergy. symptoms'(not'responding'to'single'food'elimination)' and/or'faltering'growth'to'specialist'clinic

Why might some eHFs show better clinical outcomes for symptom resolution?1–4

Must only be used under medical supervision and after full consideration of the feeding options available, including breastfeeding.

Copyright © 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use 2of CPD activities for personal use.

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The difference

IS IN THE DETAIL Why might some eHFs show better clinical outcomes for symptom resolution?1–4 Our analyses of eHF samples from manufacturers around the world – which compared peptide size and residual protein content – showed that eHFs may have different allergenic potentials.4–6 Althéra® is proven to have a consistent, very low allergenic potential which may make all the difference in the dietary management of your CMA patients.4–8

Allergenicity analysis (peptide molecular weight & BLG residual protein)6 Peptides >1200 Da (%)

35 30 25 20 15 10 5 0

0

500

1000

1500

2000

2500

Allergenicity (µg BLG/g protein) Althéra®

Randomly selected eHF brands

Learn more about our latest research and clinical trials: www.nestlehealthscience.co.uk/althera IMPORTANT NOTICE: Mothers should be encouraged to continue breastfeeding even when their infants have CMA. This usually requires qualified dietary counselling to completely exclude all sources of cows’ milk protein from the mothers’ diet. If a decision to use a special formula intended for infants is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. Formula for special medical purposes intended for infants must be used under medical supervision. Althéra® and Alfamino® are for complete nutritional support from birth or supplementary feeding from 6 months and up to 3 years of age for the dietary management of CMA and/or multiple food protein allergies.

Abbreviations: BLG, ß-lactoglobulin; CMA, cows’ milk allergy; Da, Daltons; eHF, extensively hydrolysed formula. References: 1. Dupont et al. BJN, 2012; 107(3): 325–338. 2. Chauveau et al. Pediatr Allergy Immunol, 2016; 27(5): 541–543. 3. Petrus, N.C. et al. Eur J Pediatr. 2015; 174(6): 759–765. 4. Kuslys M, et al. EMJ Allergy and Immunol. 2017; 2(1): 46–51. 5. Nutten S, et al. EMJ Allergy and Immunol. 2018; 3(1): 50–59. 6. Nutten S, et al. Abstract. EAACI Congress, 26-30 May, 2018. 7. Niggemann, B. et al. Pediatr Allergy Immunol. 2008; 194(4): 348–354. 8. Data on file. 9. Nowak-Węgrzyn A, et al. Clin Pediatr (Phila). 2015;54(3): 264–272.

Version: ALLER51_August2018. For healthcare professionals only.

Explore the rest of our portfolio: Alfamino® is our non-allergenic amino acid formula for the effective dietary management of severe CMA.9 Learn more: nestlehealthscience.co.uk/alfamino

NHD CPD eArticle

Volume 8.14 - 11th October 2018

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.

introduction of complementary solids as per the UK health departments' recommendations, regardless of allergy risk. For infants with no risk factors for food allergy, it is advised that they follow current UK infant feeding advice which is also summarised within the guidance document.9 Infants with a household member with a food allergy, who have no other risk factors for allergy, are also recommended to follow current UK infant feeding advice. This is with the proviso that some families will benefit from the reassurance of an allergy specialist and allergy testing before introducing allergen foods.

However, this should not delay introduction of allergen foods.

Existing food allergy Infants with a known risk factor for food allergy or ‘higher risk infants’ are defined as those with eczema (particularly moderate-severe eczema or early-onset beginning in the first three months of life), or an existing food allergy. It is advised that such infants may benefit from earlier introduction of foods containing egg (if part of the family’s diet) and peanut, i.e. from four months alongside other complementary foods.10 It is recommended that these allergen

foods are introduced as an age-appropriate texture to avoid risk of choking, i.e. no whole nuts or chunks of peanut butter. Egg should be given in cooked form, as the use of pasteurised raw egg was associated with significant allergic 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

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 Copyright © 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use.

Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

NHD CPD eArticle 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.

Volume 8.14 - 11th October 2018 '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.

References 1 Scientific Advisory Committee on Nutrition (SACN): ‘Feeding in the first year of life’. Available here: www.gov.uk/government/publications/ feeding-in-the-first-year-of-life-sacn-report 2 Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) (2016). Statement on the timing of introduction of allergenic foods to the infant diet and influence on the risk of development of atopic outcomes and autoimmune disease. https://cot.food.gov.uk/ cotstatements/cotstatementsyrs/cot-statements-2016/statement-on-the-timing-of-introduction-of-allergenic-foods-to-the-infant-diet-and-influence-onthe-risk-of-development-of-atopic-outcomes-and-autoimmune-disease 3 Assessing the health benefits and risks of the introduction of peanut and hen’s egg into the infant diet before six months of age in the UK. A Joint Statement from the Scientific Advisory Committee on Nutrition and the Committee on Toxicity of Chemicals in food, Consumer products and the Environment. https://cot.food.gov.uk/sites/default/files/jointsacncotallergystatement-april2018.pdf 4 Preventing food allergy in higher risk infants: guidance for healthcare professionals. Available at: www.bsaci.org/about/early-feeding-guidance or www. bda.uk.com/regionsgroups/groups/foodallergy/allergy_prevention_guidance 5 Preventing food allergy in your baby: information for parents. Available at: www.bsaci.org/about/early-feeding-guidance or www.bda.uk.com/ regionsgroups/groups/foodallergy/allergy_prevention_guidance 6 Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S et al. Randomised trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372: 803-13 7 Perkin MJ, Logan K, Tseng A, Raji B. Ayis S et al. Randomised trial of introduction of allergenic foods in breastfed infants. N Engl J Med 2016; 374: 1733-43 8 Turner PJ, Campbell DE, Boyle RJ, Levin ME. Primary Prevention of Food Allergy: Translating evidence from clinical trials to population-based recommendations. J Allergy Clin Immunol Pract. 2018 Mar-Apr; 6(2): 367-375 9 www.nhs.uk/start4life/baby/first-foods 10 Ierodiakonou D, Garcia-Larsen V, Logan A, Groome A, Cunha S et al. Timing of allergenic food introduction to the infant diet and risk of allergic or autoimmune disease: A Systematic Review and Meta-analysis. JAMA 2016 Sep 20; 316(11): 1181-1192 11 Bellach J, Schwarz V, Ahrens B, Trendelenburg V, Aksünger Ö et al. Randomised placebo-controlled trial of hen’s egg consumption for primary prevention in infants. J Allergy Clin Immunol. 2017 May;139(5): 1591-1599.e2 12 Garcia-Larsen V, Ierodiakonou D, Jarrold K, Cunha S, Chivinge J et al. Diet during pregnancy and infancy and risk of allergic or autoimmune disease: A systematic review and meta-analysis. PLoS Med 2018 Feb; 15(2): e1002507 13 Boyle RJ, Ierodiakonou D, Khan T, Chivinge J, Robinson Z et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ 2016; 352:i974

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NHD CPD eArticle NETWORK HEALTH DIGEST

Volume 8.14 - 11th October 2018

Questions relating to: Preventing food allergy in higher risk infants Type your answers below, download and save or print for your records, or print and complete by hand.

Q.1

What were the four key recommendations in the joint statement from the SACN-COT working group with regards to feeding healthy term infants 0-12 months?

A

Q.2

What feeding regime should HCPs recommend for infants who have a household member with a food allergy?

A

Q.3

How do you define an infant with a known risk factor for food allergy?

A

Q.4

Describe the recommended feeding regime for infants with a known risk factor for food allergy.

A

Q.5

Why isn’t systematic screening of all higher risk infants routinely recommended?

A

Q.6

Give the reasons why whole nuts should not be given to children under five years of age.

A

Q.7

What is recommended for all infants diagnosed with IgE-mediated food allergy and for those with poorly controlled eczema?

A

Please type additional notes here . . .

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