Dietary interventions in children to prevent atopic disease- Updated AAP recommendations

The American Academy of Pediatrics (AAP) has released an updated version of its 2008 recommendations of the dietary interventions to prevent atopic disease including atopic dermatitis, asthma, and food allergy. The updated report from the Committee on Nutrition and Section on Allergy and Immunology provides some new recommendations based on reviews of expert guidelines, systematic reviews, meta-analyses and studies published since the AAP's 2008 report was issued.

The report is published in the journal Pediatrics.

Evolution of recommendations

In 2000, an AAP policy suggested that the approach to allergy prevention in infants at high risk of allergy based on family history of atopic disease could include the use of hydrolyzed infant formulas; maternal avoidance of peanut and other allergenic foods; and delayed introduction of milk, egg, peanut, nuts and fish beyond age 1 year. Those recommendations were based on limited data. Over the subsequent eight years, mounting evidence suggested that delaying introduction of allergens was not preventive.

The 2008 clinical report replaced the prior recommendations with more tentative comments about the impact of hydrolyzed formulas and made no recommendations on restricting food allergens in the maternal diet during pregnancy or lactation. The report presented a comprehensive review of the infant diet including breastfeeding and the timing of introduction of solid foods on outcomes of numerous atopic conditions, including asthma, atopic dermatitis, and food allergy. Since then, accumulating evidence has further informed the field, resulting in the following new conclusions and recommendations.

Key Recommendations:

• There is a lack of evidence to support maternal dietary restrictions either during pregnancy or during lactation to prevent atopic disease. This conclusion is unchanged from the 2008 report.


• The evidence regarding the role of breastfeeding in the prevention of atopic disease can be summarized as follows:
  
  
  
  • There is evidence that exclusive breastfeeding for the first 3 to 4 months decreases the cumulative incidence of eczema in the first 2 years of life. This conclusion is unchanged from the 2008 report;
  
  
  • There are no short- or long-term advantages for exclusive breastfeeding beyond 3 to 4 months for prevention of atopic disease. This conclusion is unchanged from the 2008 report;
  
  
  • The evidence now suggests that any duration of breastfeeding beyond 3 to 4 months is protective against wheezing in the first 2 years of life. This effect is irrespective of the duration of exclusivity. This conclusion differs slightly from the 2008 report, which stated that exclusive breastfeeding for at least 3 months protects against wheezing early in life;
  
  
  • unlike the 2008 report, there is now some evidence that longer duration of any breastfeeding, as opposed to less breastfeeding, protects against asthma, even after 5 years of age; and
  
  
  • similar to the 2008 report, no conclusions can be made about the role of any duration of breastfeeding in either preventing or delaying the onset of specific food allergies.
  
  
  
  


• There is a lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease in infants and children, even in those at high risk for allergic disease. This is a change from the 2008 report, in which the AAP concluded that there was modest evidence that hydrolyzed formulas delayed or prevented atopic dermatitis in infants who were formula fed or not exclusively breastfed for 3 to 4 months.


• This report describes the means to prevent or delay atopic disease through early dietary intervention. For the child who has developed atopic disease, treatment may require specific identification and restriction of causal food proteins; this topic is not addressed in this report.


• The current evidence for the importance of the timing of the introduction of allergenic foods and the prevention of atopic disease can be summarized as follows:
  
  
  
  • There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease. This conclusion has not changed from the 2008 report
  
  
  • There is now evidence that the early introduction of infant-safe forms of peanuts reduces the risk of peanut allergies. Data are less clear for the timing of introduction of eggs; and
  
  
  • The new recommendations for the prevention of peanut allergy are based largely on the LEAP trial and are endorsed by the AAP. An expert panel has advised peanut introduction as early as 4 to 6 months of age for infants at high risk for peanut allergy (presence of severe eczema and/or egg allergy). The recommendations contain details of implementation for high-risk infants, including appropriate use of testing (specific IgE measurement, skin-prick test, and oral food challenges) and the introduction of peanut-containing foods in the health care provider's office versus the home setting, as well as amount and frequency. For infants with mild to moderate eczema, the panel recommended introduction of peanut-containing foods at around 6 months of age, and for infants at low risk for peanut allergy (no eczema or any food allergy), the panel recommended introduction of peanut-containing food when age appropriate and depending on family preferences and cultural practices (ie, after 6 months of age if exclusively breastfeeding).
  
  
  
  

Courtesy American Academy of Paediatrics

For detailed recommendations follow the link: https://pediatrics.aappublications.org/content/early/2019/03/15/peds.2019-0281