A review of recent literature published in 2008 related to the timing of the introduction of solids Diana Langton IBCLC FCHN B.Health ScienceRM,RN

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1 Concerns and Controversies A review of recent literature published in 2008 related to the timing of the introduction of solids Diana Langton IBCLC FCHN B.Health ScienceRM,RN WHO Recommendation 2001 Recommended period of exclusive Breastfeeding changed from 4-6 months to 6 months This recommendation was aimed at reducing morbidity from gastrointestinal infectious diseases in developing countries 2008 Draft of Practice Guidelines of the PMH Department of Immunology and Allergy for the prevention of allergic disease Stressed that early and regular exposure to foods from 4 months is important for the development of normal immune tolerance Continued breastfeeding during the period that foods are first introduced appears to promote tolerance Draft references Agostini et al Medical Position Paper Complementary feeding :a commentary by the ESPGHAN Committee on Nutrition. J.Paediatr Gastroenterol Nutr : Greer FR et al Effects of early nutritional interventions on the development of atopic disease in infants and children : the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolized formulas. Paediatrics 2008;121: Prescott S. The importance of early complementary feeding in the development of oral tolerance :Concerns and Controversies Paediatr Allergy Immunol 2008 Feb 9 Agostini et al [ESPGHAN] Medical Position Paper on Complementary feeding 2008 Exclusive Breastfeeding for about 6 months is a desirable goal Complementary feeding should not be introduced before 17 weeks and all infants should start complementary feeding by 26 weeks 1

2 Rising Rates of food allergies in early childhood reflect increasing failure of early immune tolerance mechanisms Since 1980 s advice has been to delay the introduction of foods such as cow s milk,eggs, peanuts and fish Maternal allergen avoidance in pregnancy and lactation Use of hypoallergenic formulas for infants with a family history of atopia Tolerance to food allergens appears to be driven by regular,early exposure to these proteins during a critical early window of development Once a food has been introduced and tolerated,a future allergy to that food is less likely if it is given regularly Continued breastfeeding during the period that foods are first introduced appears to promote tolerance No clear evidence that trying to avoid potentially allergenic foods [eggs,peanuts,nuts,fish]will prevent allergies to these foods Maturity of gastro-intestinal and renal functions Available data suggests that GI and Renal functions are sufficiently mature by around 4 months of age to allow infants to process some complementary foods To a large degree GI maturity is driven by the food ingested Breastfeeding whilst introducing gluten>4m and <7 m may reduce the risk of: Coeliac disease Type 1 diabetes Wheat Allergy Conclusion of Medical Position Paper There is a range of ages at which infants can attain the necessary motor skills to cope safely with complementary feedings By around 6 months most infants can sit with support and can sweep a spoon with their upper lip as opposed to sucking semisolids off a spoon Greer FR et al Effects of early nutritional interventions on the development of atopic disease in infants and children : 1. the role of maternal dietary restriction in pregnancy and lactation, 2. Breastfeeding and timing of introduction of complementary foods 3. Use of hydrolized formulas in infants with a family history of atopia. 2

3 Atopic Diseases have a clear genetic basis Environmental factors are assumed to have an important influence on their development Atopy is a personal or familial tendency to produce IgE antibodies in response to low-dose allergens In studies of infants at high risk of developing atopic disease, atopic dermatitis is delayed or prevented by exclusive breastfeeding for at least 4 months or use of an extensively hydrolized formula if breastfeeding not possible Insufficient studies and the lack of proven efficacy does not indicate that the approach of pregnancy and lactation avoidance diets is disproved [Greer et al 2008] Evidence does not allow one to conclude that there is a strong relationship between the timing of the introduction of complementary foods and development of atopic disease which raises questions about the benefit of delaying cow s milk,fish,eggs and peanuts beyond 4-6 months Solid food should not be introduced before 4-6 months of age For infants at high risk of developing Atopic disease exclusive breastfeeding for at least 4 months will decrease the cumulitive incidence of atopic dermatitis and cow s milk allergy in the first 2 years of life Types of formula for those high risk infants who are not breastfed exclusively to 6 months Extensively hydrolised formula is most effective Soy formulas are not proven to be effective Partially hydrolised formulas are not effective in preventing atopia in the high risk infant The Importance of early complementary feeding in the development of oral tolerance;concerns and controversies Prescott S.et al Paediatric Allergy and Immunology

4 Prescott emphasises a preference for the introduction of solids at 4 months throughout her article emphasis that the development of normal immune tolerance to foods depends on early and regular exposure to foods {from 4 months} Strong recommendation that breastfeeding continue during the introduction of solids at 4 months 2001USA,UK & Australia Adopted the recommendation of 6 months exclusive breastfeeding based on a theoretical concern for increased gut permeability and immaturity of mucosal immunity in infants HOWEVER Growing concern that the introduction of solids AFTER six months of age MAY increase allergic disease Although the timing of the window period is not clear,current evidence suggests it is between weeks No completed studies give any evidence for introducing solids at 4 months There have been no changes in National or International policies exclusive breastfeeding to 6 months is still the recommendation Further Research is ongoing Dec 2008 Australasian Society of Clinical Immunology and Allergy (ASCIA) published guidelines for Infant feeding based on the best evidence that is currently available as at September 2008 The change from previous guidelines is based on some recent studies suggesting that avoiding allergenic foods does not appear to reduce allergies and may even be associated with an increased risk. ASCIA Infant Feeding Advice December Key points: Breastfeeding; Introduction of Solids Practical Advice on : Breastfeeding for at least six months; Before 4 months; From 4-6 months 4

5 ASCIA: Infant Feeding Advice Key Points:Breastfeeding Breastfeeding during the period that foods are first introduced may help to prevent allergy to those foods Breastfeeding for at least six months and as long as mother and infant wish If infant formula is used in the first months of life hydrolysed formula may reduce the risk of allergies in the high risk infant ASCIA:No particular foods that need to be avoided Some children will develop allergies.if there is a reaction to any food,seek medical advice and avoid that food until child is reviewed by a medical practitioner with experience in food allergy Infants who have eczema are at higher risk of allergies Introduction of Solid Foods ASCIA Infant feeding Advice More Research needed to determine the optimal time to start complementary solid foods There is little evidence that delaying the introduction of solid foods beyond 6 months reduces the risk of allergy That the delaying of solids after 6 months causes an increase in allergies is NOT PROVEN at this stage Insufficient evidence to support previous advice to specifically delay or avoid potentially allergenic foods. This also applies to infants with siblings who have allergies to these foods ASCIA Practical Advice Breastfeed for at least 6 months and continue as long as mother and infant desire If formula is required before 4 months a standard cow s milk infant formula should be used,unless there is a family history of allergies Soy milk or Goats milk are not recommended for allergy prevention ASCIA Infant Feeding Advice from 4-6 months When your child is ready, consider introducing a new food every 2-3 days according to what the family usually eats Give one new food at a time so that reactions can be clearly identified.if a food is tolerated continue to give it as part of a varied diet Breastmilk or an appropriate infant formula should remain the main source of milk until 12 months of age,although cow s milk can be used in cooking or with other foods References for the ASCIA GUIDELINES Prescott S. The importance of early complementary feeding in the development of oral tolerance :Concerns and Controversies Paediatr Allergy Immunol 2008 Feb 9 Sicherer SH et al Maternal and infant s diets for the prevention of allergic diseases ; Understanding menu changes in J. Allergy Clin Immunology 2008 ;122:29-33 Snijders BE et al Age at first introduction of cows milk products and other food products in relation to infant atopic manifestations in the first 2 years of life :The KOALA Birth Cohort Study. Paediatrics 2008 ;122:e115-e122 5

6 Agostini et al Complementary feeding :a commentary by the ESPGHAN Committee on Nutrition. J.Paediatr Gastroenterol Nutr : Allen CW et al Food Allergy:is strict avoidance the only answer? Paediatr Allergy Immunol 2008 Sep 15 Greer FR et al Effects of early nutritional interventions on the development of atopic disease in infants and children : the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolized formulas. Paediatrics 2008;121: Host A et al Dietary prevention of allergic diseases in infants and small children. Paediatr Allergy Immunol 2008 Feb 19 [1] :1-4 A pregnant woman with many allergies asks about infant feeding. Your best response is; a. a baby is never allergic to it s mothers milk,but he may be sensitive to foods in the mother s diet b. since many allergic tendencies are inherited,there is nothing you can do to reduce your baby s chances of being allergic c.the hypoallergenic formulas will prevent any allergic reaction in your baby d.whether you breastfeed or not, you should delay solid foods until 6 months or later to help your baby avoid allergies Smith Linda D002 p nd ed 2 nd a.exclusive Breastfeeding for about 6 months is the best strategy to reduce the baby s risk.the mothers avoidance of known allergens during pregnancy may also reduce the baby s risks of allergy. Delaying solid foods does not address the baby s more likely early exposure to to cow s milk and soy proteins, which are common allergens in humans An exclusively breastfed baby s risk of food allergies is; a.decreased,because few food allergens pass through the mother s milk b.decreased,because the mother s milk makes passage of allergenic proteins through the baby s gut less likely c.increased,because allergens pass readily through the mother s milk d.increased,because the mother s milk increases the permeability of the baby s gut Smith,Linda D005 p nd Ed b. Breastmilk optimises the environment in the babies gut.allergens may be present in Breastmilk and may create problems for a sensitive baby,but the risk of allergies is significantly reduced through breastfeeding A 3 week old exclusively breastfed baby with a strong family history of allergy has a severe reaction the first time he is fed with a cow s milk based formula. The LEAST likely explanation for this is a.the baby was sensitised by intact cow s milk protein that passed into his mothers milk b.the baby was given a bottle of formula in the hospital nursery c.the mother consumed large amounts of dairy products during pregnancy d.the allergic reaction was more likely due to the latex in the bottle teat than the cow s milk 6

7 Smith,Linda DN nd Ed d. Although sudden,severe latex allergies are possible,the reaction is more likely to be caused by an ingested allergen,especially cow s milk protein.all of the other choices are possible sources or routes of sensitisation The rash on this baby s face appeared when he began receiving supplements of cow s milk based formula.what is the most likely cause: a.normal infant acne b.reaction to non-human protein in the formula c.presence of bovine antigen in the mothers milk d.allergic reaction to latex in the bottle teat Smith,Linda DP B. Facial rashes are a common allergic reaction to cow s milk proteins.direct exposure from artificial baby milk is the most likely trigger This exclusively breastfed baby is gaining weight well and is healthy.for the condition pictured,your best recommendation to the mother is : a.try eliminating dairy products from your diet for a week to rule out an allergic response b.give the baby water in between breastfeeds because her urine is too concentrated c.start supplementing with soy formula because your milk supply is inadequate d.ask the baby s paediatrician to prescribe an antifungal ointment for the baby s skin 7

8 Smith,Linda dp A. The baby is entirely healthy and thriving except for an allergic diaper rash caused by dairy in her mother s diet. The other options are inappropriate and incorrect.there are no signs of fungal infection on the baby in this picture 8