Dojčenie a ekzém

Výsledky viacerých štúdii naznačujú, že výživa materským mliekom chráni deti do určitej miery pred rozvojom atopických ochorení. Protektívny efekt pretrváva aj po skončení dojčenia, podľa niektorých autorov až do obdobia adolescencie. Naopak privčasné zavádzanie príkrmov a kontakt s bielkovinami kravského mlieka riziko atopie zvyšuje, a to najmä u detí s pozitívnou rodinnou anamnézou.

Is the breast best for children with a family history of atopy? The relation between way of feeding and early childhood morbidity. 
van den Bogaard C, van den Hoogen HJ, Huygen FJ, van Weel C 
Department of Family Medicine, University of Nijmegen, The Netherlands.
BACKGROUND: Previous studies reported that breast-feeding protects children against a variety of diseases, but these studies were generally conducted on "high-risk" or hospitalized children. This paper describes the results of our study on the effects of breast-feeding on rate of illness in normal children with a family history of atopy. METHODS: A historic cohort approach of 794 children with a family history of atopy was used to assess the effects of breast-feeding on illness rates. Family history of atopy was based on allergic diseases in family members as registered by the family physician. Illness data from birth onwards were available from the Continuous Morbidity Registration of the Department of Family Medicine. Information on breast-feeding was collected by postal questionnaire. We then compared rates of illness between children with a family history of atopy who were and who were not breast-fed. RESULTS: Breast-feeding was related to lower levels of childhood illness both in the first and the first three years of life. In the first year of life they had fewer episodes of gastroenteritis, lower respiratory tract infections, and digestive tract disorders. Over the next three years of life they had fewer respiratory tract infections and skin infections. CONCLUSIONS: Our results suggest a protective effect of breast-feeding among children with a family history of atopy that is not confined to the period of breast-feeding but continues during the first three years of life. Breast-feeding should be promoted in children with a family history of atopy.

Five-year follow-up of high-risk infants with family history of allergy who were exclusively breast-fed or fed partial whey hydrolysate, soy, and conventional cow's milk formulas. 
Chandra RK 
Department of Pediatrics, Memorial University of Newfoundland, Canada.
BACKGROUND: Allergy is a common cause of illness. The effect of feeding different infant formulas on the incidence of atopic disease and food allergy was assessed in a prospective randomized double-blind study of high-risk infants with a family history of atopy. METHODS: 216 high-risk infants whose mothers had elected not to breast-feed were randomized to receive exclusively a partial whey hydrolysate formula or a conventional cow's milk formula or a soy formula until 6 months of age. Seventy-two high risk infants breast-fed for > or = 4 months were also studied. RESULTS: Follow-up until 5 years of age showed a significant lowering in the cumulative incidence of atopic disease in the breast-fed (odds ratio 0.422 [0.200-0.891]) and the whey hydrolysate (odds ratio 0.322 [0.159-0.653) groups, compared with the conventional cow's milk group. Soy formula was not effective (odds ratio 0.759 [0.384-1.501]). The occurrence of both eczema and asthma was lowest in the breast-fed and whey hydrolysate groups and was comparable in the cow's milk and soy groups. Similar significant differences were noted in the 18-60 month period prevalence of eczema and asthma. Eczema was less severe in the whey hydrolysate group compared with the other groups. Double-blind placebo-controlled food challenges showed a lower prevalence of food allergy in the whey hydrolysate group compared with the other formula groups. CONCLUSIONS: Exclusive breast-feeding or feeding with a partial whey hydrolysate formula is associated with lower incidence of atopic disease and food allergy. This is a cost-effective approach to the prevention of allergic disease in children.

Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. 
Saarinen UM, Kajosaari M 
Children's Hospital, Helsinki, Finland.
Atopic diseases constitute a common health problem. For infants at hereditary risk, prophylaxis of atopy has been sought in elimination diets and other preventive measures. We followed up healthy infants during their first year, and then at ages 1, 3, 5, 10, and 17 years to determine the effect on atopic disease of breastfeeding. Of the initial 236 infants, 150 completed the follow-up, which included history taking, physical examination, and laboratory tests for allergy. The subjects were divided into three groups: prolonged (> 6 months), intermediate (1-6 months), and short or no (< 1 month) breastfeeding. The prevalence of manifest atopy throughout follow-up was highest in the group who had little or no breastfeeding (p < 0.05, analysis of variance and covariance with repeated measures [ANOVA]). Prevalence of eczema at ages 1 and 3 years was lowest (p = 0.03, ANOVA) in the prolonged breastfeeding group, prevalence of food allergy was highest in the little or no groups (p = 0.02, ANOVA) at 1-3 years, and respiratory allergy was also most prevalent in the latter group (p = 0.01, ANOVA) having risen to 65% at 17 years of age. Prevalences in the prolonged, intermediate, and little or no groups at age 17 were 42 (95% CI 31-52)%, 36 (28-44)%, and 65 (56-74)% (p = 0.02, trend test) for atopy, respectively, and 8 (6-10)%, 23 (21-25)%, and 54 (52-56)% (p = 0.0001, trend test) for substantial atopy. We conclude that breastfeeding is prophylactic against atopic disease--including atopic eczema, food allergy, and respiratory allergy--throughout childhood and adolescence.

Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up. 
Marini A, Agosti M, Motta G, Mosca F 
1st Department of Paediatrics, University of Milan, Italy.
A prospective case-control study is presented to assess an allergy prevention programme in children up to 36 months of age. Infants born at three maternity hospitals were followed from birth: 279 infants with high atopic risk (intervention group) were compared with 80 infants with similar atopic risk but no intervention (non-intervention group). The intervention programme included dietary measures (exclusive and prolonged milk feeding diet followed by a hypoantigenic weaning diet) and environmental measures (avoidance of parental smoking in the presence of the babies, day care > 2 years of life). Mothers in this group who had insufficient breast milk were randomly assigned to one of two coded formulas: either a hydrolysed milk formula (Nidina HA, Nestle) or a conventional adapted formula (Nan, Nestle). Other environmental measures remained the same as for the breastfeeding mothers. The non-intervention group were either breastfed or received the usual Italian milk feeding and weaning diet, without environmental advice. The main outcome measures were anthropometric measurements and allergic disease manifestations. Normal anthropometric data were observed both in the intervention group and in the non-intervention group. The incidence of allergic manifestations was much lower in the intervention group than in the non-intervention group at 1 year (11.5 versus 54.4%, respectively) and at 2 years (14.9 versus 65.6%) and 3 years (20.6 versus 74.1%). Atopic dermatitis and recurrent wheezing were found in both the intervention group and the non-intervention group from birth up to the second year of life, while urticaria and gastrointestinal disorders were only present in the non-intervention group in the first year of life. Conjunctivitis and rhinitis were present after the second year in both the intervention group and the non-intervention group. Relapse of the same allergic symptom was less in the intervention group (13.0%) than in the non-intervention group (36.9%). In comparison to the non-intervention group, there were fewer intervention group cases with two or more different allergic symptoms (8.7 versus 32.6%), and they were more likely to avoid steroid treatment (0 versus 10.8%) and hospital admission (0 versus 6.5%). Babies in the non-intervention group fed with adapted formula were more likely to develop allergies than breastfed babies in the same group. In the intervention group the breastfed infants had the lowest incidence of allergic symptoms, followed by the infants fed the hydrolysed formula (ns). Infants in the intervention group fed the adapted formula had significantly more allergies than the breastfed and hydrolysed milk fed infants, although less than their counterparts in the non-intervention group. Of the affected subjects in the intervention group, 80.4% were RAST and/or Prick positive to food or inhalant allergens. Total serum IgE values detected at birth in the intervention group were not predictive, but at 1 and 2 years of age, IgE values more than 2 SD above the mean in asymptomatic babies were found to predictive for later allergy. In breastfed babies the total IgE level at 1 and 2 years of age was lower than in the other two feeding groups. Of the various factors tested in the non-intervention group, the following were the most important in the pathogenesis of allergic symptoms: (i) formula implementation begun in the first week of life; (ii) early weaning (< 4 months); (iii) feeding beef (< 6 months); (iv) early introduction of cow's milk (< 6 months); and (v) parental smoking in the presence of the babies and early day care admission (< 2 years of life). All the preventive measures used in this study (exclusive breastfeeding and/or hydrolysed milk feeding, delayed and selective introduction of solid foods, and environmental advice) were effective at the third year of follow-up, greatly reducing allergic manifestations in high atopic risk babies in comparison with those not receiving these interventions.

Breast-feeding of allergic infants. 
Isolauri E, Tahvanainen A, Peltola T, Arvola T 
Department of Pediatrics, University of Turku, Finland.
OBJECTIVE: Infants may have allergic disease even during exclusive breast-feeding. The aim of this study was to evaluate whether allergic infants should continue breast-feeding. STUDY DESIGN: We studied 100 infants who had atopic eczema during exclusive breast-feeding. The extent and severity of the eczema, allergic sensitization, and the patients' growth and nutrition were assessed during and after cessation of breast-feeding. RESULTS: The mean body length SD score decreased at the onset of allergic disease, and an association was seen between the duration of symptoms and poor growth (r = -.23, P =.04). Some improvement could be achieved by strict elimination diet by the mothers. The atopic eczema improved significantly after breast-feeding was stopped: SCORAD score 20 (range 15 to 27) during and 7 (range 4 to 11) after breast-feeding; t = 5.38, P <.0001, and the relative length of patients increased, in parallel with improved nutritional parameters. CONCLUSIONS: Breast-feeding should be promoted for primary prevention of allergy, but breast-fed infants with allergy should be treated by allergen avoidance, and in some cases breast-feeding should also be stopped. This particularly applies to infants with atopic eczema who also have impaired growth.

Early diet of preterm infants and development of allergic or atopic disease: randomised prospective study. 
Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF 
MRC Dunn Nutrition Unit, Cambridge.
OBJECTIVE--To study the effect of early diet on the development of allergic reactions in infants born preterm. DESIGN--Two randomised prospective trails. In trail A infants were randomly allocated banked donor milk or preterm formula as their sole diet or (separately randomised) as a supplement to their mother's expressed breast milk. In trial B infants were allocated term or preterm formula. A blind follow up examination was done 18 months after the expected date of birth. SETTING--Neonatal units of hospitals in Cambridge, Ipswich, King's Lynn, Norwich, and Sheffield. Outpatient follow up. PARTICIPANTS--777 Infants with a birth weight less than 1850 g born during 1982 to 1984. MAIN OUTCOME MEASURES--Development of eczema, allergic reactions to food or drugs, and asthma or wheezing by nine and 18 months after term. Whenever possible the observations were confirmed by rechallenge or clinical examination. RESULTS--At 18 months after term there was no difference in the incidence of allergic reactions between dietary groups in either trial. In the subgroup of infants with a family history of atopy, however, those in trial A who received preterm formula rather than human milk had a significantly greater risk of developing one or more allergic reactions (notably eczema) by 18 months (odds ratio 3.6; 95% confidence interval 1.4 to 9.1). CONCLUSIONS--Feeding neonates on formulas based on cows' milk, including those with a high protein content, did not increase the overall risk of allergy. Nevertheless, in the subgroup with a family history of atopy early exposure to cows' milk increased the risk of a wide range of allergic reactions, especially eczema.

Breast feeding as prophylaxis for atopic eczema: a controlled study of 368 cases. 
Shohet L, Shahar E, Davidson S 
The present study was undertaken in an attempt to draw data whether breast-feeding is beneficial in prevention of atopic eczema. Three-hundred and sixty-eight babies given different feeding modalities were examined for the presence of atopic eczema at the age of three and six months. Seven percent of breast-fed infants developed eczema compared to 10% of formulae-fed and 6% of mixed breast and formulae-fed infants. No difference in the severity of atopic eczema was recorded in the three study groups. Our experience demonstrates the absence of a protective effect of breast-feeding against the development and severity of atopic eczema.

Does breast feeding help protect against atopic disease? Biology, methodology, and a golden jubilee of controversy. 
Kramer MS 
Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Quebec, Canada.
To help shed some light on the 50-year-old controversy concerning the possible protective effect of breast feeding on subsequent atopic disease, I developed 12 standards pertaining to both biologic and methodologic aspects of exposure (infant feeding), outcome (atopic conditions), and statistical analysis for studies of atopic eczema, asthma, allergic rhinitis, cow milk allergy, and other food allergy. Among the published studies on atopic eczema, the nine claiming a protective benefit of breast feeding performed less well than the 12 not making such a claim on "methodologic" standards relating to strict diagnostic criteria and blind ascertainment of outcome. The positive studies were somewhat stronger, however, on the "biologic" standards bearing on sufficient duration and exclusivity of breast feeding and on separate analysis of children at high risk. For the other atopic conditions, there were no important differences between positive and negative studies. In few negative or positive studies was there adequate control for confounding variables or examination of potential benefits relating to the severity or age at onset of atopic disease. To avoid another 50 years of unresolved controversy, future studies should improve both the biologic and methodologic aspects of their design and analysis.