Allergies, besides obesity and cardiovascular diseases, are one of the main noncommunicable diseases that can develop in the first 1000 days postpartum. In the last several decades, the incidence of asthma, atopic dermatitis and food allergies has increased, a fact that represents a problem for all the clinicians who provide healthcare for pregnant women and newborns. Currently, there are evidence that support the idea that breastfeeding, compared with feeding formula with intact cow milk protein, for at least four months, delays or prevents the occurrence of cow milk allergies and atopic dermatitis. In regard to hydrolyzed formulas, there are comparative studies that indicate that not all formulas have the same protective benefit. Exclusive breastfeeding seems to have a preventive effect on the development of allergic disease (asthma, atopic dermatitis) up to 2 years of age. Some probiotics, prebiotics and synbiotics have the ability to influence the response of the immune system. The underlying immunological mechanism of the effects of the three aforementioned products continues to be discovered, with new findings for dendritic cells, effector lymphocytes, T regulatory cells, natural killer T cells and B cells. There are three keys periods that can train and stimulate the development of immune system: pregnancy, breast feeding period and early childhood. The aim of this clinical report is to review the dietary options during pregnancy, lactation and the first year of life that can affect the development of atopic disease in early life.
maternal diet, breast feeding, food allergies, atopic dermatitis, prebiotics
Alergiile, pe lângă obezitate sau bolile cardiovasculare, sunt printre principalele boli netransmisibile care pot apărea în primele 1000 de zile post-partum. În ultimele decenii, incidenţa astmului, a dermatitei atopice şi a alergiilor alimentare a cunoscut o creştere semnificativă, devenind astfel o problemă pentru toate specialităţile medicale implicate în îngrijirea femeile gravide şi a nou-născuţilor. În prezent, există dovezi care susţin ideea că alăptarea, în comparaţie cu formulele ce conţin proteine din lapte de vacă integrale, timp de cel puţin patru luni, întârzie sau previne apariţia alergiilor la proteina laptelui de vacă şi a dermatitei atopice. În ceea ce priveşte formulele hidrolizate, există studii comparative care indică faptul că nu toate formulele au acelaşi grad de protecţie. Alăptarea exclusivă pare să aibă un efect preventiv asupra dezvoltării bolilor alergice (astm, dermatită atopică) de până la doi ani. Unele probiotice, prebiotice şi sinbiotice au abilitatea de a influenţa răspunsul sistemului imunitar. Mecanismele imunologice care stau la baza efectelor probioticelor, prebioticelor şi sinbioticelor continuă să fie din ce în ce mai bine definite, noi mecanisme fiind descrise pentru celulele dendritice, celule epiteliale, celulele T regulatoare, limfocite, celulele T „natural killer” şi celulele B. Există trei perioade-cheie care pot antrena şi stimula dezvoltarea sistemului imunitar: sarcina, perioada de alăptare şi perioada de sugar. Scopul acestui articol este de a revizui opţiunile alimentare din timpul sarcinii, lactaţiei şi din primul an de viaţă care pot determina dezvoltarea bolilor atopice în copilărie.
It is by now recognized that the earliest nutritional influence on atopic disease in infants is the nutritional diet of the pregnant woman. However, not all studies have supported the protective effect of a maternal exclusion diet (including the exclusion of cow milk and eggs) on the development of atopic disease in infants, as summarized in a 2006 Cochrane review(3,4,5).
Although data is still conflicting, there is no demonstrated significant benefit for children whose mothers had a restrictive diet during breastfeeding(6,7,8). There was found a possible reduction of the incidence of atopic dermatitis in children in their first two years of life in some studies, but no difference after two years(9).
Short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides (GOS/FOS) supplementation of the partially hydrolysed cow’s milk formula influences the immune system by lowering IgE, that is directly involved in the allergic mechanism, and also by lowering the IgG1, IgG2 and IgG3, whereas no effect on IgG4 was observed. The IgG1 value of the cow’s milk protein decreases significantly when prebiotics are added to the fomula(10).
The use of prebiotics is one of the tree strategies used in manipulating the intestinal microbiota. Prebiotics are undigestible food ingredients that stimulate selectively the proliferation or/and the activity of the already existing bacterial population. This strategy offers more advantages than the use of antibiotics or probiotics (Table 1).
Recent studies have brought more and more evidence that suggests that early colonization of the intestinal tract by an appropriate intestinal microbiota is very important for the healthy maturation of the immune system(11). Although it is well known that the only food that satisfies the nutritional needs of a newborn is human milk, there are cases when breastfeeding is interrupted and babies are fed with infant formula, or cases of mothers who don’t produce enough milk in order to fulfill the nutritional needs of the baby and they add infant formula. There are several studies which reported that the oligosaccharides found in human milk acted as prebiotics(12,13).
Particularly, studies have shown that by adding prebiotics (galactooligosaccharides and fructooligosaccharides) mixtures to the infant formula, the growth of bacilli and Bifidobacteria is being stimulated(14), which lead to a change in the chain of fatty acids, making their biological profile closer to the one observed in infants who were breastfed, and also reduces the incidence of infections and allergic events during the first two years of life(15).
The positive effects of using probiotics have stimulated an intense interest in determining if the same results can be achieved by using prebiotics. Some animal feeding studies have demonstrated that prebiotics can induce the immune response of Th1, re-balance Th2 biased responses, and also suppress allergenic synthesis of IgE. Currently, there have been reports from different randomized controlled studies which concluded that prebiotics may be able to replicate the exact benefits that have been seen for probiotics in the prevention of allergies(16).
Prebiotics added to infant formula rarely produce any side effects. Among the minor effects that can appear, we can mention flatulence or abdominal bloating, but only for doses greater than 20 g per day, and diarrhea and abdominal cramps for doses greater than 50 g per day(17).
Although World Allergy Organization (WAO) recommends the use of prebiotic supplements in not exclusively breastfed infants and not using the prebiotic supplement in exclusively breastfed infants, a recent study, made by Boyle et al.(18), concluded that the use of pHF-prebiotic formula showed a persistent immune-modulatory effect and, possibly, also reduced the occurrence of allergic manifestations in infants to whom solids were introduced in the diet according to guidelines (>18 weeks).
Despite some studies that showed an increased risk of allergic disease with exclusive breast-feeding, the overall benefits of breastfeeding on the general health of the child are likely to outweigh the potential drawbacks, regardless of the allergic status of the mother or child.
The prevention of allergy symptoms is very important in order to reduce the risk of chronic disease in the adult life. Although the current guidelines do not recommend the use of prebiotics, more targeted studies have shown beneficial effects, mostly in reducing the occurrence of allergic manifestations in infants to whom solids were introduced in the diet according to guidelines.
1. Eichenfield LF, Hanifin JM, Beck LA, et al. Atopic dermatitis and asthma: parallels in the evolution of treatment. Pediatrics. 2003; 111:608–616.
2. Kull I, Wickman M, Lilja G, et al. Breast feeding and allergic diseases in infants – a prospective birth cohort study Archives of Disease in Childhood 2002; 87:478-481.
3. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy and/or lactation for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2006; (3): CD000133.
4. Falth-Magnusson K, Kjellman NI. Allergy prevention by maternal elimination diet during late pregnancy: a 5-year follow-up of a randomized study. J Allergy Clin Immunol. 1992; 89: 709–713.
5. Lilja G, Dannaeus A, Foucard T, Graff-Lonnevig V, Johansson SG, Oman H. Effects of maternal diet during late pregnancy and lactation on the development of IgE and egg- and milkspecific IgE and IgG antibodies in infants. Clin Exp Allergy. 1991; 21:195–202.
6. Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy in childhood N Engl J Med, 348 (2003), pp. 977–985.
7. Herrmann ME, Dannemann A, Gruters A, Radisch B, Dudenhausen JW, Bergmann R, et al. Prospective study of the atopy preventive effect of maternal avoidance of milk and eggs during pregnancy and lactation Eur J Pediatr, 155 (1996), pp. 770–774.
8. G Hattevig, N Sigurs, B Kjellman Effects of maternal dietary avoidance during lactation on allergy in children at 10 years of age Acta Paediatr, 88 (1999), pp. 7–12.
9. Muraro A, Dreborg S, Halken S, et al. Dietary prevention of allergic diseases in infants and small children. Part III: critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol. 2004; 15:291–307.
10. van Hoffen E, Ruiter B, Faber J, M’Rabet L, Knol EF, Stahl B, Arslanoglu S, Moro G, Boehm G, Garssen J. A specific mixture of short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides induces a beneficial immunoglobulin profile in infants at high risk for allergy; Allergy. 2009 Mar; 64(3):484-7. doi: 10.1111/j.1398-9995.2008.01765.x. Epub 2008 May 27.
11. Lahtinen S, Ouwehand A, Collado MC, Salminen S, Vesterlund S, Tang M and Satokari R (2008). Mechanisms of Probiotics, in Handbook of Probiotics and Prebiotics, Second Edition (eds Y. K. Lee and S. Salminen), John Wiley & Sons, Inc., Hoboken, NJ, USA. doi: 10.1002/9780470432624.ch5
12. Bode L. Human milk oligosaccharides: Prebiotics and beyond Nutrition Reviews, 67 (s2) (2009), pp. S183–S191.
13. MB Engfer, B Stahl, B Finke, G Sawatzki, H Daniel. Human milk oligosaccharides are resistant to enzymatic hydrolysis in the upper gastrointestinal tract American Journal of Clinical Nutrition, 71 (6) (2000), pp. 1589–1596.
14. XM Ben, J Li, ZT Feng, SY Shi, YD Lu, R Chen, et al. Low level of galacto-oligosaccharide in infant formula stimulates growth of intestinal Bifidobacteria and Lactobacilli World Journal of Gastroenterology, 14 (42) (2008), pp. 6564–6568.
15. S Arslanoglu, GE Moro, J Schmitt, L Tandoi, S Rizzardi, G Boehm. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first two years of life Journal of Nutrition, 138 (6) (2008), pp. 1091–1095.
16. Lee, Yuan Kun, and Seppo Salminen. Andbook of Probiotics and Prebiotics. New Jersey: Wiley, 2009.
17. Randi J Bertelsen, Elizabeth T Jensen, Tamar Ringel-Kulk. Use of probiotics and prebiotics in infant feeding, Best Practice & Research Clinical Gastroenterology, Volume 30, Issue 1, February 2016, Pages 39-48, http://doi.org/10.1016/j.bpg.2016.01.001.
18. Boyle et al. Partially hydrolysed, prebiotic supplemented whey formula for the prevention of allergic manifestations inå high risk infants: a multicentre double-blind randomised controlled trial. Clinical and Translational Allergy 2015 5(Suppl 3):P30.