1. Allergy prevention through nutrition interventionAbdulwahab TelmesaniFRCPC, FAAPAssociate prof of PediatricsCollege of Medicine and Medical scienceUmm Al-Qura University

2. غراء فرعاء مصقول عوارضهـا تمشى الهوينا كما يمشى الوجى الوحل _________يكاد يقتلها لـــــولا تشددهــــــــا اذ تقوم الى جـــــــاراتهــا الكســـــــــلألأعشى(صناجة العرب)

3. اْْن المتانة فى الأجسم يصحبها متانة العقل والتفكير والحــــــلم ________ ماذا يسرك من جرداء ناحلة كأنها ريشة تزهو على عـــــــلم ________ ما المرأة الحق الا من اذا درجت يكاد يهتز وجه الأرض للقدم شاعر معاصر

7. EVE PBUH • Had no formulas • Had no infants cereals • No blenders

11. Recent trends in infant nutrition NO For Early infant feeding Aggett PJ et al a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2001

12. Incidence of allergies increases Incidence of allergy over the last 20 years S H Downs et al Arch Dis Child 2001;84:20–23.

13. Food Allergy

14. Small Gut & Allergy • Main Target Organ • Main Port of Entry

15. Food Allergy Level of Contact • G.I 50 - 80% • Skin 20 - 40% • Respiratory 10- 25%

16. Gut is a major lymphoid organ • Network of Macrophages • Mast Cells • Ig producing Cells • T- cells

17. Immune response Antigen exposure (e.g.bacteria,pollen,protein) Mucosal barrier (e.g.skin,gut) Immunologic processing Allergy Protection Tolerance

18. Pathogenesis • Type I allergy: Degranulation of mast cells • Type III allergy: Immune-complex mediated Spread from G.I to distant organs e.g. skin, kidney etc. • Type IV: T-cells + Antigens = Production of cytokines (IL-4, interferon-γ, TNF- α etc.), Esinophilic gastroenteritis

19. T Cell Balance Th1 ________ Th0 _________ Th2

20. Hygiene hypothesis Infections stimulate Th 1 response Th1 cytokines inhibit Th 2 function lack of microbial exposure due to improved hygiene is responsible for the observed increase in allergies

21. T Cell Balance Th1 ________ Th0 _________ Th2

22. T Cell Imbalance Th1 ___ Th0 _______Th2

24. REVIEW Distinct differences between CMP-specific T cell reactivity in the blood of infants with or with out CMA, especially expressed by the release of Th2 cytokines R. P. Schade et al clin. Exp. Allergy 2003

25. POSPECTIVE COHORT STUDY We conclude that in infants at atopic risk, exclusive breast-feeding for at least 4 months is effective in reducing atopic dermatitis Schoetzau et al Pediatr Allergy Immunol 2002

26. How about when breastfeeding is not possible ?

27. AN EXTENSIVE REVIEW BY AN EXPERT GROUP In infants, breast-feeding with avoidance of solid food and cow’s milk for at least 4-6 months is the most effective preventive regimen. In the absence of breast milk, formula with documented reduced allergenicity for at least 4-6 months should be used Section on Pediatrics, European Academy of Allergology and Immunology Muraro et al Pediatr. Allergy Immunol 2004

28. Frequency of Atopic Symptoms in Infants With a Family Risk of Allergy Y. VANDENPLAS et al. J Pediatr 1995

29. Predisposition to food allergy • Family history (atopy, asthma etc.) • Immune deficiency (IgA) • Gut barrier defect • Early antigen exposure • Antigen provocation

30. G.I Manifestations • Vomiting • Diarrhea • Malabsorption • Esinophilic gastroenteritis • Allergic colitis • FTT

31. Skin Manifestations • Atopic Dermatitis -12% Prevalence in School children -80% Have high IgE and positive skin test to food antigens

32. Respiratory Manifestations • Allergic Rhinitis • Asthma

33. Diagnosis • Elimination and Challenge • Skin testing • G.I. Biopsy

34. Therapy

35. Food allergy is a a diagnosis frequently entertained, occasionally evaluated and rarely established Franz Ingelfiger

36. Therapy • Elimination Diet • Medical e.g. Ketotifen, SCG, Stroids etc.

37. Brake

39. Therapy • Elimination Diet • Medical e.g. Ketotifen, SCG, Stroids etc.

40. Prevention

41. Prevention • Identify infants at risk • Exclusive BREST MILK for 4-6/12 • Hydrolyzed (partial, extensive) formula as an alternative to B.M when truly not possible • Delay solid food after 6 months • Avoid Cows milk and Eggs in the first year

42. Prevention cont. • Remove house hold allergens -Smoking -Pets -Mite/Molds • Avoid early day care centers -decreases respiratory infections

43. Cow’s milk protein avoidance and development of childhood wheeze in children with family history of atopy Ram FSF, Ducharme FM, Scarlett J Background: In infants with a family history of atopy, food allergen avoidance has been advocated as means of preventing the development of atopic disease. When breast-feeding is not possible or supplemental feeding is needed, alternative choices include soy based and hydrolysed cows milk formulas. (Cochrane Review)

44. Authors' conclusions: Breast-milk should remain the feed of choice for all babies. In infants with at least one first degree relative with atopy, hydrolysed formula for a minimum of four months combined with dietary restrictions and environment measures may reduce the risk of developing asthma or wheeze in the first year of life. There is insufficient evidence to suggest that soya-based milk formula has any benefit. (Cochrane Review)

46. Probiotic (For Life)

47. Probiotic Lactobacillus Bacteria Bifidobacteria spp

48. Porbiotic or no probiotic ?

49. Porbiotic Recent current research and publications are more pro probiotic

50. Probiotics & Allergy managementEczema severity (SCORAD score) Isolauri E et al. Probiotics in management of atopic eczema..Clin Exp Allergy 2000;30:1604-1610