Asthma Management Handbook

Infant feeding and asthma prevention

Recommendations

Recommend breastfeeding where possible for its health benefits, but do not advise prolonged exclusive breastfeeding (as recommended in the past for allergy prevention) specifically for the purpose of reducing the child’s risk of developing asthma. Instead, recommend the introduction of a variety of solid foods at around 6 months (but not before 4 months), while continuing to breastfeed.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Australasian Society of Clinical Immunology and Allergy, 20161

For infants at high risk of asthma (e.g. family history of asthma and allergies), do not recommend the use of hydrolysed formula or soy formula in preference to breast milk for the purpose of reducing the child’s risk of developing asthma.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Australasian Society of Clinical Immunology and Allergy, 20102
  • Osborn and Sinn, 20063
  • Osborn and Sinn, 20064
  • Prescott and Tang, 20055
  • Scott et al. 20126
  • Szajewska and Horvath, 20107

Do not recommend dietary restrictions for breastfeeding women for the purpose of reducing the child’s risk of developing asthma.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Kramer and Kakuma, 20068
  • Prescott and Tang, 20055

Do not routinely recommend dietary supplements (e.g. probiotics, vitamins, fish oil) for breastfeeding women or infants specifically for the purpose of reducing the child’s risk of developing asthma.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Azad et al. 20139
  • Arslanoglu et al. 201210
  • D'Vaz et al. 201211
  • Kalliomäki et al. 200712
  • Kopp et al. 200813
  • Kuitunen et al. 200914
  • Nurmatov et al. 201115
  • Osborn and Sinn, 201316
  • Paul et al. 201217
  • Prescott and Tang, 20055

More information

Breastfeeding and allergy prevention

Earlier evidence suggested that the risk of asthma was reduced by exclusive breastfeeding in the first months of life. The reduction in risk was thought to be greatest in children at high risk of asthma, but small in other children.5 However, recent studies did not confirm that prolonged exclusive breastfeeding protected against development of asthma,18 allergic rhinitis,18 or other allergic disease such as atopic dermatitis (eczema).19

Limited evidence from observational or poor quality studies suggests that breastfeeding while solid foods are introduced may help reduce the infant's risk of developing allergies.1 The Australasian Society of Clinical Immunology and Allergy (ASCIA) current guidelines for Infant feeding and allergy prevention recommend breastfeeding for at least 6 months for its range of benefits, with complementary foods introduced at around 6 months (but not before 4 months) while continuing to breastfeed.1

Exclusion of allergenic foods from the maternal diet has not been shown to prevent allergies.1 ASCIA does not recommend maternal dietary restrictions while breastfeeding.1

ASCIA’s guidelines for Infant feeding and allergy prevention contain practical advice for mothers.2 For updates on ASCIA advice, refer to the ASCIA website (www.allergy.org.au).

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Hypoallergenic infant formula and allergy prevention

Infant formulas available in Australia

Hydrolysed formulas are cow’s milk-based formulas that have been processed to break down most of the proteins associated with allergies. They include partially and 'extensively' hydrolysed formulas. Partially hydrolysed formulas (usually labelled ‘HA’ or ‘hypoallergenic’) are no longer recommended by the Australasian Society of Clinical Immunology and Allergy (ASCIA) as part of allergy prevention, if breastfeeding is not possible. In Australia and New Zealand, extensively hydrolysed formulas are only available on prescription, and only for children with cow’s milk allergies or enteropathies.2

Partially hydrolysed formula

Meta-analyses of randomised controlled trials suggest that infant feeding with partially hydrolysed formula does not reduce the risk of wheeze or asthma in children, compared with control formulas.731

Extensively hydrolysed formula

Hypoallergenic formulas have also been combined with other allergen avoidance measures in multifaceted interventions. Extensively hydrolysed formula (or breastfeeding with mothers on low-allergen diet) was one component of allergen avoidance (along with house dust mite avoidance strategies) in a randomised controlled clinical trial which recorded asthma and atopy rates at ages 1, 2, 4, 8 and 18 years. Compared with a control group whose mothers received standard advice, the intervention group showed a lower prevalence of asthma at age 18 years, and a lower overall prevalence over the entire follow-up period (taking into account children who had developed asthma that did not persist to age 18).6

However, there is not consistent or sufficient high-quality evidence that extensively hydrolysed formula is effective in preventing asthma, eczema, food allergy or allergic rhinitis in infants or children.1

Soy formula

A meta-analysis of studies assessing soy-based formulas found that these were not protective against asthma during infancy or childhood.4

Goat's milk

Goat's milk has not been shown to reduce the risk of allergies, compared with cow's milk.1

General recommendations for allergy prevention

Current ASCIA guidelines on Infant feeding and allergy prevention recommend that, if breastfeeding is not possible, infants can be fed conventional cow’s milk formula.1

ASCIA’s guidelines on Infant feeding and allergy prevention contain practical advice for mothers.2 For updates on ASCIA advice, refer to the ASCIA website (www.allergy.org.au).

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Dietary supplementation during pregnancy and in newborns

Folic acid

Observational studies have reported conflicting findings on the association between folic acid supplementation during pregnancy and asthma.20 Various studies have reported either that folic acid supplementation late in pregnancy (but not early) was associated with increased risk of childhood asthma, that folic acid supplementation early in pregnancy (but not late) was associated with increased risk of childhood wheeze, or no association between folic acid supplementation and infant wheeze.20

Note: folic acid supplementation before and during pregnancy is recommended for the prevention of neural tube defects.21

Probiotics

Probiotic or prebiotic supplementation of mothers during late pregnancy and lactation, or of non-breastfed infants, does not appear to prevent asthma,9221413121016 although infant feeding with prebiotics may reduce atopic dermatitis (eczema) risk.16

Supplementation with probiotics during pregnancy and breastfeeding cannot be recommended to reduce risk of allergies or asthma in infants because there is not enough evidence to identify the optimal choice of species and dose.1

Vitamins

A meta-analysis of observational cohort studies observed that high maternal dietary vitamin D and E intakes during pregnancy were associated with reduced risk of wheezing.15 However, there is insufficient evidence from intervention studies demonstrating protective effects of vitamins to recommend supplementation.1517

Fish oil

Fish oil has a range of anti-inflammatory properties.23

Overall, evidence from studies assessing the effectiveness of fish oil supplementation in preventing allergy suggest that protective effects are probably greatest in pregnancy (i.e. earlier in development).23 Epidemiological studies suggest that dietary fish oil in pregnancy and early childhood may protect against asthma and allergic disease.2324 However, there is insufficient evidence from randomised controlled intervention studies to determine whether supplementation during pregnancy should be recommended to reduce asthma risk in children.

Studies in which fish oil supplementation was commenced in early childhood have not shown reductions in asthma risk.23, 11

 

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References

  1. Australasian Society of Clinical Immunology and Allergy (ASCIA). Infant feeding and allergy prevention. ASCIA, Sydney, 2016. Available from: http://www.allergy.org.au/images/pcc/ASCIAguidelinesinfantfeedingandallergyprevention.pdf
  2. Australasian Society of Clinical Immunology and Allergy (ASCIA). Infant feeding advice. ASCIA, Sydney, 2010. Available from: http://www.allergy.org.au/health-professionals/papers/ascia-infant-feeding-advice
  3. Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane database of systematic reviews. 2006; Issue 4: CD003664. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003664.pub2/full
  4. Osborn DA, Sinn J. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. 2006; Issue 4: CD003741. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003741.pub4/full
  5. Prescott SL, Tang ML. The Australasian Society of Clinical Immunology and Allergy position statement: summary of allergy prevention in children. Med J Aust. 2005; 182: 464-467. Available from: https://www.mja.com.au/journal/2005/182/9/australasian-society-clinical-immunology-and-allergy-position-statement-summary
  6. Scott M, Roberts G, Kurukulaaratchy RJ, et al. Multifaceted allergen avoidance during infancy reduces asthma during childhood with the effect persisting until age 18 years. Thorax. 2012; 67: 1046-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22858926
  7. Szajewska H, Horvath A. Meta-analysis of the evidence for a partially hydrolyzed 100% whey formula for the prevention of allergic diseases. Curr Med Res Opin. 2010; 26: 423-37. Available from: http://informahealthcare.com/doi/full/10.1185/03007990903510317
  8. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2006; Issue 3: CD000133. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000133.pub2/full
  9. Azad MB, Coneys JG, Kozyrskyj AL, et al. Probiotic supplementation during pregnancy or infancy for the prevention of asthma and wheeze: systematic review and meta-analysis. BMJ. 2013; 347: f6471. Available from: http://www.bmj.com/content/347/bmj.f6471?view=long&pmid=24304677
  10. Arslanoglu S, Moro GE, Boehm G, et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the first 5 years of life. J Biol Regul Homeost Agents. 2012; 26: 49-59. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23158515
  11. D'Vaz N, Meldrum SJ, Dunstan JA, et al. Postnatal fish oil supplementation in high-risk infants to prevent allergy: randomized controlled trial. Pediatrics. 2012; 130: 674-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22945403
  12. Kalliomaki M, Salminen S, Poussa T, Isolauri E. Probiotics during the first 7 years of life: a cumulative risk reduction of eczema in a randomized, placebo-controlled trial. J Allergy Clin Immunol. 2007; 119: 1019-21. Available from: http://www.jacionline.org/article/S0091-6749(06)03800-0/fulltext
  13. Kopp MV, Hennemuth I, Heinzmann A, Urbanek R. Randomized, double-blind, placebo-controlled trial of probiotics for primary prevention: no clinical effects of Lactobacillus GG supplementation. Pediatrics. 2008; 121: e850-856. Available from: http://pediatrics.aappublications.org/content/121/4/e850
  14. Kuitunen M, Kukkonen K, Juntunen-Backman K, et al. Probiotics prevent IgE-associated allergy until age 5 years in cesarean-delivered children but not in the total cohort. J Allergy Clin Immunol. 2009; 123: 335-341. Available from: http://www.jacionline.org/article/S0091-6749(08)02212-4/fulltext
  15. Nurmatov U, Devereux G, Sheikh A. Nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis. J Allergy Clin Immunol. 2011; 127: 724-733. Available from: http://www.jacionline.org/article/S0091-6749(10)01738-0/fulltext
  16. Osborn DA, Sinn JK. Prebiotics in infants for prevention of allergy. Cochrane Database Syst Rev. 2013; Issue 3: CD006474. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006474.pub3/full
  17. Paul G, Brehm JM, Alcorn JF, et al. Vitamin D and asthma. Am J Respir Crit Care Med. 2012; 185: 124-32. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3297088/
  18. Kramer MS, Matush L, Vanilovich I, et al. Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial. BMJ. 2007; 335: 815. Available from: http://www.bmj.com/content/335/7624/815
  19. Flohr C, Nagel G, Weinmayr G, et al. Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two. Br J Dermatol. 2011; 165: 1280-1289. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2011.10588.x/full
  20. Sharland E, Montgomery B, Granell R. Folic acid in pregnancy – is there a link with childhood asthma or wheeze?. Aust Fam Phys. 2011; 40: 421-424. Available from: http://www.racgp.org.au/afp/201106/42664
  21. The Women's Health Committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy. amended May 2015. RANZCOG, Melbourne, 2008. Available from: https://www.ranzcog.edu.au/college-statements-guidelines.html
  22. Dotterud CK, Storro O, Johnsen R, Oien T. Probiotics in pregnant women to prevent allergic disease: a randomized, double-blind trial. Br J Dermatol. 2010; 163: 616-23. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2010.09889.x/full
  23. Prescott S, Nowak-Wegrzyn A. Strategies to prevent or reduce allergic disease. Ann Nutr Metab. 2011; 59 Suppl 1: 28-42. Available from: http://www.karger.com/Article/FullText/334150
  24. Olsen SF, Osterdal ML, Salvig JD, et al. Fish oil intake compared with olive oil intake in late pregnancy and asthma in the offspring: 16 y of registry-based follow-up from a randomized controlled trial. Am J Clin Nutr. 2008; 88: 167-75. Available from: http://www.ajcn.org/content/88/1/167.long