Article

Cochrane in context: Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child

McGill University, Faculty of Medicine, 1020 Pine Avenue West, Montreal, Quebec, Canada H3A 1A2.
Cochrane database of systematic reviews (Online) (Impact Factor: 5.94). 02/2006; 9(3):CD000133. DOI: 10.1002/14651858.CD000133.pub2
Source: PubMed

ABSTRACT Some breastfed infants with atopic eczema benefit from elimination of cow milk, egg, or other antigens from their mother's diet. Maternal dietary antigens are also known to cross the placenta.
To assess the effects of prescribing an antigen avoidance diet during pregnancy or lactation, or both, on maternal and infant nutrition and on the prevention or treatment of atopic disease in the child.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2006) and contacted researchers in the field.
All randomized or quasi-randomized comparisons of maternal dietary antigen avoidance prescribed to pregnant or lactating women. We excluded trials of multimodal interventions that included manipulation of the infant's diet other than breast milk or of nondietary aspects of the infant's environment.
We extracted data from published reports, supplemented by additional information received from the trialists we contacted.
The evidence from four trials, involving 334 participants, does not suggest a protective effect of maternal dietary antigen avoidance during pregnancy on the incidence of atopic eczema during the first 18 months of life. Data on allergic rhinitis or conjunctivitis, or both, and urticaria are limited to a single trial each and are insufficient to draw meaningful inferences. Longer-term atopic outcomes have not been reported. The restricted diet during pregnancy was associated with a slightly but statistically significantly lower mean gestational weight gain, a nonsignificantly higher risk of preterm birth, and a nonsignificant reduction in mean birthweight.The evidence from one trial, involving 26 participants, did not observe a significant protective effect of maternal antigen avoidance during lactation on the incidence of atopic eczema during the first 18 months.One crossover trial involving 17 lactating mothers of infants with established atopic eczema found that maternal dietary antigen avoidance was associated with a nonsignificant reduction in eczema severity.
Prescription of an antigen avoidance diet to a high-risk woman during pregnancy is unlikely to reduce substantially her child's risk of atopic diseases, and such a diet may adversely affect maternal or fetal nutrition, or both. Prescription of an antigen avoidance diet to a high-risk woman during lactation may reduce her child's risk of developing atopic eczema, but better trials are needed. Dietary antigen avoidance by lactating mothers of infants with atopic eczema may reduce the severity of the eczema, but larger trials are needed.

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    ABSTRACT: ENGLISH ABSTRACT: Background Adverse reactions to food are frequently suspected in daily clinical practice yet the knowledge of health care workers regarding correct diagnosis and management remains limited. This is compounded by few allergy consultants and may contribute to patient dissatisfaction and self‐diagnoses. The primary treatment modality for food hypersensitivity remains strict but nutritionally adequate elimination of offending food allergens based on accurate diagnosis. Nutritional misconceptions and incorrect diagnosis may lead to inappropriate dietary restriction resulting in nutritional deficiencies, malnutrition, growth retardation, and feeding difficulties in children. Elimination diets thus require supervision and monitoring similar to drug treatments, being reviewed regularly for possible food re‐challenges. 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Ethics approval was obtained from the University of Stellenbosch, Faculty of Health Sciences Committee of Human Research. Results Even though valuable insights were obtained, poor response from all three groups (N=82) compromised the strength of significant findings. There was limited knowledge regarding appropriate diagnosis, dietary intervention and allergy prevention strategies. 98% of respondents believed they needed more education and training in management of allergies. Approximately 50% reported use of complementary therapy by patients prior to and while using conventional medicine. Dietitians weren't consulted for nutritional management by 72% General Practitioners and 45% Specialists. For allergy prevention, over 50% of health professionals advised extensive food avoidance for the first year in high risk infants. Dietitians recommended multiple food avoidance for the longest period of time per food in infants, pregnant and lactating women to prevent allergy. Advice for infant feeding and introduction of solid foods was not evidence‐based. Goat's milk, soya formula and breast milk with maternal dietary avoidance were advised for allergy prevention. 54% of medical doctors and 31% of Dietitians provided no guidance for implementing an elimination diet. Only 15% of respondents did growth assessment of allergic patients. 99% of all participants recognised a need for South African specific 'best practice' guidelines. Conclusion The study highlighted a need in South Africa, at undergraduate and post graduate levels, for better education and training of food allergy, in particular diagnosis, dietary management and prevention strategies. This will create a platform for the achievement of minimum levels of competency in allergy care. It should also provide motivation for the establishment of South African specific guidelines, allergy support networks and better public awareness. AFRIKAANSE OPSOMMING: Agtergrond Afwykende reaksies tot voedsel word dikwels by gesondheidsorg instellings verdag. Nieteenstaande, bestaan daar steeds beperkte kennis oor allergië. Die tekort aan allergie konsultante vererger sake en het dikwels ontevrede pasiënte en self‐diagnose tot gevolg. Die primêre modaliteit van behandeling van voedsel hipersensitiwiteit behels doelmatige verwydering van die oorsaaklike voedsel allergene deur middel van 'n streng dog voedingswaardige dieet. Ontoepaslike bestuur van, en die verkeerde implementering van die uitskakelings dieet mag egter lei tot komplikasies by kinders soos hongersnood, groei vertraging en voedings probleme. Daar is tans beperkte navorsing om die peil van kennis van voedsel allergië en die bestuur van die probleem te meet. Geen sodanige navorsing ten opsigte van dieëtkundiges is al gedoen nie. Slegs beperkte inligting is beskikbaar tot welke mate huidige behandelings praktyk konformeer met die mees onlangse bewys‐gebaseerde aanbevelings, veral met betrekking tot allergie voorkomende strategië. Doelstelling Die doelstelling van hierdie opname was om die kundigheid en bestuur van voedsel verwante allergië deur medici en dieëtkundiges te bepaal. Metodologie Dwarsprofiel analiese was gedoen met respondente wat onwillekeurig gekies was uit profesionele mediese en dieëtkundige praktisyns uit die drie grootste provinsies in Suid Afrika, Gauteng, Wes‐Kaap en Kwazulu Natal (N=660). Deelnemers was versoek om vraelyste met 'n samestelling van aspekte van voedsel allergie diagnose en bestuur te voltooi. Deelnemers is huidiglik werksaam in Suid Afrika en was verteenwoordigend van drie kategorië, naamlik Algemene Praktisyns, Dieetkundiges en Mediese Spesialiste. Etiese goedkeuring was bekom van die Universiteit Stellenbosch se Fakulteit Gesondheidswetenskappe Navorsingsetiek komitee. Bevindinge Desnieteenstaande insiggewende inligting is die bevindinge gekompromitteer deur beperkte respons (N=82). Kennis met betrekking tot diagnose, dieëtkundige intervensie en allergie voorkomings strategië, is beperk. 88% van respondente versoek meer opleiding in die bestuur van allergië. 53% beweer dat pasiënte komplementêre terapie aanwend voor en gelyktydig met die gebruik van konvensionele medikasie. Interdisiplinêre konsultasie is beperk. Dieëtkundiges word nie geraadpleeg deur 72% van algemene praktisyns en 54% mediese spesialiste nie. Meer as 50% gesondheidsorg praktisyns beveel algemene voedsel ontwyking aan by hoë risiko kleuters gedurende die eerste lewensjaar. Dieëtkundiges se allergie voorkomings aanbevelings aan kleuters, swanger en lakterende vrouens was vir die langste periode. Advies vir kleuter voeding was nie bewys‐gebaseerd nie. Bokmelk, soya formule en borsmelk van moeders met dieëtkundige beperkinge word aanbeveel vir die voorkoming van allergië by kleuters. 54% mediese en 31% dieëtkundiges voorsien geen voorkomings dieët riglyne nie. Slegs 15% respondente takseer kleuter groei van allergie pasiënte. 99% van al die respondente ondersteun die vestiging van spesifieke 'beste praktyk' riglyne vir Suid Afrika. Gevolgtrekking Die bevindinge van die studie beklemtoon die behoefte in Suid Afrika vir verbeterde en doelgerigte voedsel allergie onderrig en opleiding, vir voorgraadse en nagraadse onderrig. Meer doeltreffende diagnose, dieëtkundige bestuur en allergie voorkomings strategië word aanbeveel. Daar word 'n doelwit geskep vir die bereiking van minimum vaardigheids vlakke vir allergie versorging. Die inligting motiveer ook die vestiging van doelgerigte Suid‐Afrikaanse riglyne, allergie ondersteunings bronne en beter, openbare bewuswording van allergië. 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