Divezzamento ed allergie: quali alimenti quando, ma soprattutto perchè.

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1 Divezzamento ed allergie: quali alimenti quando, ma soprattutto perchè.

2 Definition of weaning To accustom an infant or other young mammal to food other than milk Thompson D, Fowler HW, Fowler FG, editors. The concise Oxford dictionary. 9th ed. London: BCA/Oxford University Press, The process of accustoming an infant to a full adult diet (while maintaining breastfeeding) Savage King F, Burgess A. Nutrition for developing countries. 2nd ed. Oxford, United Kingdom: Oxford University Press, 1996:123.

3 WHO definition of weaning complete cessation of breastfeeding WHO/UNICEF. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: World Health Organization, WHO/NUT/98.1,1998.

4 WHO recommandations on weaning a. timely - foods introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding; b. adequate - foods provide sufficient energy, protein, and micronutrients to meet a growing child s nutritional needs; c. safe - meaning that foods are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats; d. properly fed - meaning that foods are given consistent with a child s signals of appetite and satiety, and that meal frequency and feeding method - actively encouraging the child to consume sufficient food using fingers, spoon or self-feeding - are suitable for age. WHO. Complementary feeding. Report of the global consultation. Geneva, December accessed February 6th, 2005

5 L epoca di introduzione degli alimenti solidi nel bambino normale secondo l OMS è: 1. 3 mesi (60 giorni) 2. 4 mesi (90 giorni) 3. 5 mesi (120 giorni) 4. 6 mesi (150 giorni) 5. Nessuna delle precedenti

6 WHO recommandations on weaning (2001) WHO Expert Consultation: exclusive breastfeeding for six months then introduction of complementary foods and continued breastfeeding thereafter breastfeeding continue until 12 months of age (thereafter as long as mutually desired). breastfeeding can continue beyond 12 months WHO. Complementary feeding. Report of the global consultation. Geneva, December accessed February 6th, 2005

7 Age of introduction of complementary feeding Introduction of solids 4-6 months. Report of a WHO Expert Committee, Technical Report Series 854. Geneva, World Health Organisation, Breastfeeding at 6 months (180 days). Introduction of solids around 6 months American Academy of Pediatrics. Breastfeeding and use of Human milk. Pediatrics 1997; 100:1035-9World Health Organization s Programme of Nutrition. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva, World Health Organisation, 1998

8 WHO recommandations on weaning Late introduction of solid foods: Reduced growth [breast milk alone is insufficient after 6 months] Immune protection compromised Micronutrient deficiencies Motor skills such [chewing] delayed Infant unwilling to accept new tastes and textures WHO. Complementary feeding. Report of the global consultation. Geneva, December accessed February 6th, 2005

9 WHO recommandations on timing Early introduction of solid foods Less time on the breast, maternal milk production may decline the infant will reject the spoon (a hard object) Food allergies can develop Pathogens diarrhoeal diseases WHO. Complementary feeding. Report of the global consultation. Geneva, December accessed February 6th, 2005

10 Age of introduction of complementary feeding After six months of age: it is difficult to meet nutrient needs from human milk alone infants are developmentally ready for other foods infants are beginning to actively explore their environment Naylor AJ, Morrow AL. Developmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods. Linkages/Wellstart International, 2001 Lanigan JA. Systematic review concerning the age of introduction of complementary foods to the healthy full-term infant. Eur J Clin Nutr 2001;55:

11 L epoca di introduzione degli alimenti solidi nel bambino normale secondo l OMS è: 1. 3 mesi (60 giorni) 2. 4 mesi (90 giorni) 3. 5 mesi (120 giorni) 4. 6 mesi (150 giorni) 5. Nessuna delle precedenti

12 Il primo alimento solido da introdurre secondo le linee guida statunitensi è: 1. Mela 2. Riso e cereali senza glutine 3. Frutta fresca 4. Tutte le precedenti 5. Nessuna delle precedenti

13 Weaning of infants Brazil Step 1- human milk exclusive up to 6 months. No water, tea or any other kind of food. Step 2 - After 6 months, solid food. Keep providing human milk up to 2 years or longer. Step 3 Start with cereals, vegetables, meat, fruits three times a day if the child is being breastfed, five times a day if the child is no longer breastfed Step 4 - Complementary food must be offered on demand, always respecting the child's appetite.. Brasil/Ministério da Saúde/Organização Pan-Americana da Saúde. Guia alimentar para crianças menores de 2 anos. Serie A. Normas e manuais técnicos no 107. Brasília, DF, Ministério da Saúde; 2002.

14 Weaning of infants 4-6 months - UK 1. Baby rice mixed with the infant s normal milk 2. Vegetables 3. Fruits 4. Cheese 5. Yoghurt or fromage frais 6. Lean meat, all in pureed form. Foote KD. Weaning of infants. Arch Dis Child 2003;88:

15 Weaning of infants - UK 7 8 months: wheat and soy After 9 months of age: egg - fish After 12 months: nut products Foote KD. Weaning of infants. Arch Dis Child 2003;88:

16 Weaning timing in Australia Dietary guidelines for children and adolescents in Australia. Australian National Health and Medical Research Council, endorsed 10 April 2003

17 Il primo alimento solido da introdurre secondo le linee guida statunitensi è: 1. Mela 2. Riso e cereali senza glutine 3. Frutta fresca 4. Tutte le precedenti 5. Nessuna delle precedenti

18 Weaning timing in Australia Foods should be introduced individually Initially, new foods should be offered no more often than each five to 10 days, to avoid confusion and rule out the (remote) possibility of food allergy or sensitivity. Dietary guidelines for children and adolescents in Australia. Australian National Health and Medical Research Council, endorsed 10 April 2003

19 Schema classico 1. la precocità di introduzione determina allergie 2. il ritardo riduce il tasso di allergie Il pediatra detta i tempi 3. è meglio non introdurre troppi alimenti troppo presto 4. è bene introdurre gli alimenti uno alla volta.

20 Schema alternativo 1. non importa dare gli alimenti presto o tardi 2. possiamo introdurre gli alimenti anche tutti insieme Tempi e modi del 3. non è rischioso divezzamento esporre il dettati bambino a dal molteplicità di allergeni in epoca precoce farmacista? Dal supermercato? 4. non è necessario alcun timing di introduzione degli alimenti se non quello dettato dalla tradizione

21 A step-by-step introduction of solid foods: theorical framework can an early introduction of solid foods anticipate the development of food allergy? can their avoidance prevent the development of food allergy? are some foods more allergenic than other foods? are some food allergies more persistent than others?

22 La precoce introduzione degli alimenti solidi 1. incrementa il rischio di dermatite atopica a due anni 2. incrementa il rischio di dermatite atopica a dieci anni 3. si associa con il rischio di allergia respiratoria successiva 4. tutte le precedenti 5. nessuna delle precedenti

23 Can an early introduction of solid foods anticipate the development of food allergy? 1265 New Zealand neonates Prospectively followed-up - solid foods introduced to 4 months / eczema by 2 years - solid foods introduced to 4 months / recurrent/chronic eczema by 10 years Fergusson DM. Early solid food feeding and recurrent childhood eczema: a 10-year longitudinal study. Paediatrics 1990; 86:541-6

24 Can an early introduction of solid foods anticipate the development of food allergy? A prospective observational study Effect of different time of introduction of foods on weight gastrointestinal diseases respiratory illness napkin dermatitis eczema up to 24 months of age Forsyth JS. Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life. BMJ. 1993;306:

25 Can an early introduction of solid foods anticipate the development of food allergy? Solid food at an early age (< 8 weeks or 8-12 weeks) respiratory illness at weeks of age persistent cough at and weeks of age eczema Forsyth JS. Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life. BMJ. 1993;306:

26 Eczema and early solid feeding 257 preterm infants Follow-up one year Number and type of solid foods and risk of eczema Morgan J. Eczema and early solid feeding in preterm infants. Arch Dis Child. 2004;89:309-14

27 Eczema and early solid feeding Morgan J. Eczema and early solid feeding in preterm infants. Arch Dis Child. 2004;89:309-14

28 La precoce introduzione degli alimenti solidi 1. incrementa il rischio di dermatite atopica a due anni 2. incrementa il rischio di dermatite atopica a dieci anni 3. si associa con il rischio di allergia respiratoria successiva 4. tutte le precedenti 5. nessuna delle precedenti

29 A step-by-step introduction of solid foods: theorical framework can an early introduction of solid foods anticipate the development of food allergy? can their avoidance prevent the development of food allergy? are some foods more allergenic than other foods? are some food allergies more persistent than others?

30 Tutte le seguenti affermazioni sono vere eccetto: 1. L introduzione precoce di alimenti incrementa il rischio di allergia alimentare 2. Evitare un alimento previene il rischio di diventarvi allergici 3. Assumere probiotici riduce il rischio di allergia alimentare 4. Alcuni alimenti sono più allergenici 5. Alcune allergie sono più pericolose

31 Eczema and early solid feeding 642 term infants Follow-up 5½ years Delayed introduction of solid foods no lower risk of eczema Zutavern A. The introduction of solids in relation to asthma and eczema. Arch Dis Child 2004: 89:303-8

32 Eczema and early solid feeding a. Late egg risk for eczema b. Late egg risk for preschool wheezing c. Late milk risk for eczema Reverse causality? results do not support the guidelines for the prevention of asthma and allergy in general populations stating that the introduction of solids should be delayed for at least 4 6 months. Zutavern A. The introduction of solids in relation to asthma and eczema. Arch Dis Child 2004: 89:303-8

33 Can avoidance of solid foods prevent the development of food allergy? 135 bambini con familiarità allergica, al seno fino a 6 mesi gruppo a (70) - a 6 mesi: verdure cotte, mela, pera, cereali a 8 mesi: carne, pesce a 10 mesi: uovo gruppo b (65) - a 3 mesi: patata, carota cotta, cereali, carne a 4 mesi: uovo, pesce a 5 mesi: frutti diversi, "commercial foods" a 6 mesi: dieta libera ed estesa eczema a < b allergia alimentare a < b Saarinen UM, Kajosaari M Prophylaxis of atopic disease: role of infant feeding. Lancet i: , 1980 Kajosaari M, Saarinen UM Prophylaxis of atopic disease by six months' total solid foods elimination. Acta Paed Scand 72:411, 1983

34 GINI (German Infant Nutritional Intervention Study Group) 2252 newborns enrolled ( ) 945 formula-fed vs. 865 breastfed Randomised to four formulae: CMF: 16% incidence of atopic manifestations OR = 1 ehf W: 14% incidence of atopic manifestations OR = 0.86 phf W: 11% incidence of atopic manifestations OR = 0.65 ehf C: 9% incidence of atopic manifestations OR = 0.51 Von Berg A, J Allergy Clin Immunol 2003; 111:533-40

35 A step-by-step introduction of solid foods: theorical framework can an early introduction of solid foods anticipate the development of food allergy? can their avoidance prevent the development of food allergy? are some foods more allergenic than other foods? are some food allergies more persistent than others?

36 Directive 2000/13/EC (amended by Directive 2003/89/EC) 1. Cereals containing gluten 2. Crustaceans 3. Eggs 4. Fish 5. Peanuts 6. Soybeans 7. Milk and products thereof (including lactose) 8. Nuts i. e. Almond, Hazelnut, Walnut, Cashew, Pecan nut, Brazil nut, Pistachio nut, Macadamia nut and Queensland nut 9. Celery 10. Mustard 11. Sesame seeds

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38 IFAV EU 5 FW. RedAll project - Preliminary data. Perceived Food Allergies. A Report on a representative telephone survey in 10 European countries Foods reported to induce a FA (adults) Adults ,2 28,6 20, ,1 5,4 10,9 6,6 8,3 6,0 16,1 13,7 0 Fish Seafood Wheat Meat Eggs Milk Fruit Legumes Vegetables Nuts Others Valid cases: N=1290 in % IFAV/REDALL

39 IFAV EU 5 FW. RedAll project - Preliminary data. Perceived Food Allergies. A Report on a representative telephone survey in 10 European countries Foods reported to induce a FA (children) Children 40 38, , ,4 3,0 11,4 7,0 19,0 6,7 13,5 9,7 18,1 0 Fish Seafood Wheat Meat Eggs Milk Fruit Legumes Vegetables Nuts Others Valid cases: N=438 in % IFAV/REDALL

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41 Clinical tolerance of homogenised kiwifruit 20 children (challenge-confirmed) SPT+ with kiwi Fresh - Steam-cooked - Homogenised [scalding at 90 C for 5 minutes - purée extraction at 115 C for 15 seconds - stabilisation at 110 C for 15 seconds - pasteurisation for 21 minutes at 65 C] Double-blinded placebo-controlled food challenge Steam-cooked Neg 19/20 Homogenized Neg 20/20 Fiocchi A. Tolerance of heat-treated kiwi by children with kiwifruit allergy. Pediatr Allergy Immunol. 2004;15:454-8.

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43 Perceived Food Allergies. A Report on a representative telephone survey in 10 European countries Allergy to meat and meat products in children Swizerland Slovenia Poland 8,7 9,3 10,2 Italy 15,2 Greece 10,4 Germany 4,8 Finland 1 Denmark Belgium 4,5 4,7 Austria IFAV EU 5 FW. RedAll project - Preliminary data.

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45 A step-by-step introduction of solid foods: theorical framework can an early introduction of solid foods anticipate the development of food allergy? can their avoidance prevent the development of food allergy? are some foods more allergenic than other foods? are some food allergies more persistent than others?

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47 Natural history of egg allergy Tolerance reached in: 44% of case at 2.5 years 31% - 51% at 8 years 50% at 35 months 66% after 5 years Ford RPK, Taylor B. Natural history of egg hypersensitivity. Arch Dis Child 1982;57: García Ara MC. Therapeutic aprroach to and prognosis of food allergy. Allergol Immunopathol 1996;24(suppl 1):31-5 Boyano-Martinez T. Prediction of tolerance on the basis of quantification of egg white-specific IgE antibodies in children with egg allergy. J Allergy Clin Immunol. 2002;110:304-9

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49 Natural history of peanut allergy A permanent affliction? Bock SA. The natural history of peanut allergy. J Allergy Clin Immunol 1989;83:900-4 Infants can outgrow their peanut allergy 10% at 3 years 30% at 6 years 18% at 5 years 21.5% at 7 years. Spergel JM. Resolution of childhood peanut allergy. Ann.AllAsthma Immunol 2000;85: Tariq SM. Cohort study of peanut and nut sensitisation by age of 4 years. BMJ 1996; 313: Hourihane JO. Resolution of peanut allergy: case-control study. BMJ. 1998;316: Skolnick HS. The natural history of peanut allergy. J Allergy Clin Immunol 2001;107: Pucar F. Peanut challenge: a retrospective study of 140 patients. Clin Exp Allergy 2001;31:40-6. Fleischer DM. The natural progression of peanut allergy: Resolution and the possibility of recurrence. J Allergy Clin Immunol. 2003;112:183-9

50 Natural history of peanut allergy it is not possible to establish an half-life for a diagnosis of nut allery. These allergens should be considered as giving indefinitely persistent allergies. Sicherer SH. Clinical update on peanut allergy. Ann Allergy Asthma Immunol. 2002;88:350-61

51 Clinical course of cow's milk protein allergy/intolerance and atopic diseases in childhood 1-year birth cohort 1,749 newborns 39 CMA (2.22%) Age (years) Tolerance 95% CI 1 22 (56 %) (77 %) (87 %) (92 %) (92 %) (97 %) Høst A. Pediatric Allergy and Immunology 2003; 13 (s15), 23-8

52 APLV: risultati Pazienti confermati: 197 (91 M, 56 F) Età media alla diagnosi: 7 mesi ± 9 Vita media della diagnosi: 42 ± 21 mesi

53 Tutte le seguenti affermazioni sono vere eccetto: 1. L introduzione precoce di alimenti incrementa il rischio di allergia alimentare 2. Evitare un alimento previene il rischio di diventarvi allergici 3. Assumere probiotici riduce il rischio di allergia alimentare 4. Alcuni alimenti sono più allergenici 5. Alcune allergie sono più pericolose

54 La tempistica di introduzione degli alimenti nel bambino allergico. Tutte queste affermazioni sono vere eccetto: 1. Il pesce è stato indicato dopo i 12 mesi 2. L arachide è stata indicata dopo i 36 mesi 3. Il kiwi è stato indicato dopo i 12 mesi 4. L uovo è stato indicato dopo i 12 mesi 5. Non vi sono documenti ufficiali

55 Solid foods in children at risk of allergy Source Egg Fish Peanuts Zeiger 24 months 36 months 36 months Arshad 12 months 12 months 12 months Chandra 18 months 18 months?? Von Berg 12 months 12 months 12 months Fiocchi A. Dietary Primary Prevention of Food Allergy. Ann Allergy, Asthma & Immunology 2003; 91: 3-13

56 Weaning of the infant at risk of allergy Recommandation Solids CM Egg Nuts, fish Time 6 months 12 months 24 months 36 months Zeiger RS. Food allergen avoidance in the preventionof food allergy in infants and children. Pediatrics 2003; 111:

57 La tempistica di introduzione degli alimenti nel bambino allergico. Tutte queste affermazioni sono vere eccetto: 1. Il pesce è stato indicato dopo i 12 mesi 2. L arachide è stata indicata dopo i 36 mesi 3. Il kiwi è stato indicato dopo i 12 mesi 4. L uovo è stato indicato dopo i 12 mesi 5. Non vi sono documenti ufficiali

58 Alcune considerazioni 1. L epidemiologia indica che l esposizione precoce si associa ad allergia specifica 2. L epidemiologia indica che ci sono nuove allergie anche in Italia 3. Non ci sono evidenze che un carico allergenico sia tollerogeno in epoca postnatale 4. Evitare gli alimenti ritarda o riduce la sensibilizzazione e l allergia 5. Gli alimenti processati possono essere meno allergizzanti 6. In assenza di evidenze, vale il principio di precauzione.

59 Considerations to be factored when calculating an allergenicity index for each food in a given population Sensitisation Allergy Persistence Personal risk Sensitised/exposed Symptomatic/sensitised Persistent/allergic Familiarity

60 Schema classico 1. la precocità di introduzione determina allergie 2. il ritardo riduce il tasso di allergie Il pediatra detta i tempi 3. è meglio non introdurre troppi alimenti troppo presto 4. è bene introdurre gli alimenti uno alla volta.

61 Dal mito alla realtà Milano, gennaio 2006