powerpoint presentation - healthed€¦ · mice with antacid had higher ige and immediate skin...
TRANSCRIPT
24-May-16
1
What does allergy prevention,
constipation, colic and mastitis
have in common
A/Professor John Sinn
MBBS (Syd), D Paed, DCH, M Med(Clin Epi), FRACP
Consultant Neonatologist and Infant Allergist
The Paediatric Centre, St LeonardsThe University of Sydney
The Children’s Hospital, Westmead
Royal North Shore Hospital
Man/ Woman’s best friend: 3000 cohort study in Melbourne
Less allergies if have dog inside house p 0.043 compared
to outside p 0.66
More siblings the less allergy
Probiotics
Produce lactic acid- lowers the pH of intestines and inhibiting bacterial villains such as Clostridium, Salmonella, Shigella, E. coli, etc.
Aid absorption of minerals, esp Ca, increased intestinal acidity.
Production of β- D- galactosidase enzymes that break down lactose.
Produce vitamins (especially Vitamin B and vitamin K)
Act as barriers to prevent harmful bacteria from
colonizing the intestines
Gastric pH and Gut flora
Mice with antacid had higher IgE and immediate skin reactivity cf to without antacid
In Humans had a 25% increase of allergy associated with Antacid ingestion after 3 months
Proton pump inhibitors: causes more pathogenic organism: Salmonella, Clostridia
Bavishi, DuPont: AP&T 2011;34 (11-12), p1269-1281
24-May-16
2
Microbiome LSCS vs NVD
Vagina: lactobacillus, provotella, sneathia
LSCS: is hospital organism Staph and C Difficule
Lower bifidobacterium in neonate and lower bacteria
diversity
High fat diet affects the intestinal microbiome
Increase non pathogenic campylobacter in the infant
Kaplan-Meier analysis of cumulative incidence of chronic asthma.
Roduit C et al. Thorax 2009;64:107-113
Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
Caesarian vs Normal vaginal delivery and
Asthma Rates
Immuno-modulation factors:
Potential Good Bugs
Lactobacillus GG or Rhamnosus
Allergy prevention
L. Reuteri
Colic
L. Fermentus / Salivarius
Mastitis
L. paracasei: obesity
B. Breve Breast milk probiotic, allergy
Infloran: L. acidophillis /B. Bifidum: NEC
PROPREM: ABC: B Infantis, S. thermaphilus, B lactis: NEC
Saccharomyces boulardii, L.acidophilus and B bifidum: Diarrhoea
Probiotic versus no probiotic:
Infant eczema: 13 trials, 1911 infants
Heterogeneity: P = 0.37; I² = 8%
Test for overall effect:
P = 0.001 RR 0.79, 95%CI 0.68, 0.91
24-May-16
3
Soluble fibre
Can be a prebiotics
Some causes bloating and colic
eg FOS, inulin
Metamucil is a insoluble fibre (psyllium) is not a good
prebiotics and not recommended to kids < 13 yrs
Prebiotics are indigestable fibre
Benefibre is soluble and can be used after 1 year of age.
Is 100% wheat dextrin: is a prebiotic
Established PREbiotics Breast Milk oligosaccharides
Milk 20 gm/l in colostrum & 12- 14 gm/ in mature milk.
Polydextrose
Inulin Wheat, banana, onions, garlic, leek, chicory.
FOS (Fructo-oligosaccharides or oligofructose) plants.
GOS (Galacto-oligosaccharides) milk.
Lactulose
(Journal of the American Dietetic
Assosciatio,2008)
Short chain fatty acids (SCFAs) are the products of colonic bacterial degradation of unabsorbed starch
Acetate, Propionate, and Butyrate and Lactic acid.
Colonocyte (Proliferation / Differentiation)
& Function (Tight Colonic Junction
/ Inflammatory Suppression).
POSTbiotics
• SCFA facilitate absorption of water and electrolytes
• Acetate increases colonic blood flow and enhances ileal motility.
SCFA help improve Water & Electrolyte Absorption
24-May-16
4
Butyrate
provides fuel for colonic epithelial cells,
Help heal
LOW Fiber Diet low SCFA
high occurrence of colonicdisorders.
SCFA support the critical
Gut mucosal barrier: Keeping Gut integrityPrebiotic versus no prebiotic:
Infant eczema incidence
4 trials, 1218 infants
RR = 0.68, 95% CI 0.48, 0.97; p=0.03
Heterogeneity: I2 = 34%
Adapted from Mihatsch WA et al. Acta Paediatrica 2006;95:843-8.
GIT transitional TimeStool consistency
Preterm infants
Antibiotic-associated Diarrhea
Systematic review: 9 RCT (2 in children):
60% reduction in duration of diarrhea compared with placebo (P<0.01) 2002
9/10 pediatric trials (different products) favored probiotics (RR 0.49; 95% CI 0.32 to 0.74).
Johnston BC. Cochrane Database Syst Rev, 2007
D’Souza et al. BMJ, 2002
Diarrhoea
Probiotics/ prebiotics,
Electrolyte
Lactose Intolerance. Reducing substance > 2% required
LF formula or Soy
24-May-16
5
Probiotics: constipation
Meta-analysis of 5 RCTs (3 adults n = 266;
2 children,
n = 111
In children, L. casei rhamnosus Lcr35,
showed a beneficial effect.
but not L. rhamnosus GG,
Chmielewska A. World J Gastroenterol, 2010
ConstipationBreast milk less due to the prebiotics
Infant formula:
More whey
HA is 100% whey
Stage 1 has 60-70% whey
Stage 2 has 50-60% whey
Stage 3 has 20-30% whey
Probiotics: soften stools
Prebiotics: increase transient times
AR formula or thickener associated with constipation
Constipation: other treatment
Benefibre
Prune juice:
Paraffin
Movacol ‘iso-osmotic’ solution –Macrogol
Suppository:
Glycerine
microlax
Colic
22 studies
Benefit with hydrolysed formula
Benefit with maternal elimination diet
24-May-16
6
Probiotics and colic: Systematic
review
3 trials
220 breast fed infants
L reuteri
Significant better compared to placebo
NNT 1:2
Anabree: 2013 BMC Pediatrics
Colic and irritable baby
HA: increase transit time
Probiotic: L reuteri
prebiotic formula
Cow milk intolerance
Proton pump inhibitor or H2 receptor
antagonist:
Simeticone Drops
RCT show no difference
Anti-Foaming agent silicon Dioxide and dimethylsioxane
C2H6)Si.Si02, Not metabolised, break gas bubbles
Decrease gas, antiflatulant
It has no reported adverse effects, and the simple act of being able to give their baby something may help parents cope better with the crying.
AntiflatulentBreastfed or bottle fed: Simeticone 40mg/ml oral suspension sugar freeGive one drop (0.5ml) before each feed. Increase to two drops (1ml) if required. Supply 50 ml.Age: under 6 months
Reflux
AR formula Casein dominant
Increase constipationWhey 100% less constipation
Thickener to breast milkNot use antacid as high Aluminium
content
Omega 3 and allergy prevention
Systematic review of polyunsaturated fatty acid supplementation in infancy for the prevention of allergy Schindler T1, Osborn DA2, Sinn J2
9 studies enrolling 2704 infants reported allergy outcomes. 2 years FU
All allergy: no difference (1 study, 323 infants; RR 0.96, 95% CI 0.73, 1.26),
asthma (3 studies, 1162 infants; RR 1.04, 95% CI 0.80, 1.35),
dermatitis/eczema (7 studies, 1906 infants; RR 0.93, 95% CI 0.82, 1.06)
food allergy (3 studies, 915 infants; RR 0.81, 95% CI 0.56, 1.19).
allergic rhinitis (2 studies, 594 infants; RR 0.47, 95% CI 0.23, 0.96).
2-5 years, meta-analyses found no difference in incidence or prevalence of all allergic disease, asthma, dermatitis/eczema, allergic rhinitis or food allergy.
Conclusions: no significant effect of higher infant PUFA intake on infant or childhood allergy, asthma, dermatitis/eczema or food allergy.
There is insufficient evidence to determine an effect on allergic rhinitis.
Vit D
Currently conflicting evidence of role of Vit D and
prevention of allergy.
Difficult to have RCT on this.
Supplementation decrease Atopic eczema and Asthma
24-May-16
7
LEAP Study (Learning Early about Peanut allergy)
640 infants with severe eczema, egg allergy or both to
consume or avoid peanuts until 60months
From 4-11 months
Results: Peanut allergy at 60 months
Nut group 1.9% vs avoidance 13.7% ITT
Prevalence nut group 10.6% vs 35% in avoidance gp
Leap
1303 Breast fed infants UK
RCT: 3/12 vs 6/12 allergenic foods (peanuts, egg, CM, sesame, white fish and wheat)
Results: Early vs late
2.4% vs 7.3% food allergy
0 vs 2.5% peanut allergy 2g per week
No difference milk. sesame, fish, wheat
EAT
24-May-16
8
Allergy Prevention CEFAL: Centre for Food & Allergy Research (NHMRC)
When your infant is ready at around 6 months but not before 4 months, start to introduce a variety of complementary foods, starting with iron rich foods, whilst continuing breastfeeding
All infants should be given allergenic solids foods including peanut paste, cooked egg and wheat products in the first year of life. This includes those at high risk of allergy
Hydrolysed (partially or extensively) infant formula are not recommended for prevention of allergic disease
Others:
Probiotics/ Prebiotics esp if interventions
Omega 3, Vit D
Importance oral exposure
Eg topical creams with any food oils and proteins
Breast feeding Mastitis
Dysbiosis
Single strain of pathogenic bacteria
Lactobacillus disappear
Most common organism is Staph Aureus, Staph Epi esp
chronic infection
L Fermentum
L Salivarius
24-May-16
9
RCT n 352
A) L. fermentum CECT 5716 (n=127)
B) L. salivarius CECT 5713 (n=124)
C) Antibiotics (n=101)
Inclusion:
breast inflammation,
painful breastfeeding
milk bacterial count 14 log10 (CFU)/mL
milk leukocyte count 16 log10
cells/mL.
74 had fissures
:
Bacterial Count
Lactobacillus vs AntibioticsResults
Breast pain reduction similar between the 2 probiotics
Bactrim is the most effective
Augmentin is next
Amoxil and Flucluxacillin was less effective
88% Grp A L Fer and 85% Gp B L Sal complete recovery
Stop breast feeding and vaginal candidiasis only in antibiotic
Gp
Mechanism is related to probiotic stimulating the immune
system
Summary
Gut flora important to regulate the immune system not to
overreact and become allergic to food or aeroallergen
Ensuring good microbiome is the key for prevention of
allergy and also childhood infections
Breast Fed as long as possible
Infant formula with prebiotic or probiotics
Supplementation with probiotics during pregnancy,
lactation and to infant as per WAO
Obesity
High protein intake in infancy
Rapid weight gain in infancy
High energy intake
24-May-16
10
Protein in Breast milk vs Formula
Higher protein intake proposed to play a role
14 – 16 g Protein/L
Protein
HypothesisProtein intake in excess
may lead to:
9 – 13 g Protein/L
Long-Term
Risk of obesity?
Weight gain Weight for Length
Short-Term
Insulin IGF-1
Circulating amino
acids
Term
Infant
Formula
Mature
Breast
Milk
Koletzko Germany, Poland, Belgium, Italy, Spain
1.7 to 2.2 g protein /100kcal Vs 2.9 and 4.4g
2yr follow up
323 higher protein 313 lower protein
298 breast fed control
Lower protein still higher weight increase compared to
breast milk
Formula fed intake 14 to 20g/d at 3 and 6 months
Breast fed 7g/d
Catch up growth
IUGR
postnatal catch up growth
increase central fat
Systematic review of 24 studies
Outcome: obesity at any age after infancy
Infants who grow more rapidly are increased
risk of obesity
OR = 1.35 to 9.38 times
Born from 1927 to 1994Baird J, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ.
2005 Oct 22;331(7522):929.
Dietary energy at 4/12
predict postnatal weight gain
and BMI SGA consume larger volumes than normal birth weight
Compensatory rapid postnatal weight gain
Associated with obesity
Ong et al Pediatric vol 117, 3, e503 2006
Summary: Prevention
Obesity Prevention Breast Feeding
Microbiota
Reduce Protein
Reduce excess Growth
Vit D
Allergy Prevention Breast feeding
Prebiotics/ probiotics
Vit D
Introduce allergens before 12 months
24-May-16
11
Atopic eczema
Associated with high levels of IgE to
milk, egg and peanut
Egg is the most frequently involved allergen, followed by cows milk protein.
IgE antibodies have been implicated in most cases of cows milk protein- induced eczema, about 10% of cases are not IgE associated.
Sleep disturbances
For the severe eczema 35 % would benefit from Food elimination
Ideally do skin prick test on eczema children with a 45% chance of positive food response
CM protein induced enteropathy
Not IgE
Diarrhoea
Vomiting, irritability
80% respond to EHF
20% chance of cross reactivity to soy
Mx: mother avoid CMP. And soy initially.
Size of the molecule
Allergen 10000-70000 daltons
Intact Soy 28000 daltons
Partial hydrolysed 1100-10000 daltons
Extensive hydrolysed < 1500
Can be Allergenic if >1300 daltons
Amino acid < 1000 daltons
2 Human, 3 CM 4 Donkey
Natural history of food allergy
IgE-mediated allergy:- Egg 66% remit after 5 yrs- Peanut 20% may remit (8% may recur)- Treenut, seafood typically persist
Declining/low levels of specific-IgE predictive
Non-IgE-associated GI allergy food intolerance
- Infant forms resolve 1- 3 years- Toddler/adult forms more persistent
Resolution of CMA
1yr 56%, 2yr 77% 3yr 87% 5yr 92% 15yr 97%
Delayed reaction vs immediate
2yr 64%: 31% 3yr 92%: 53% 4yr 96%: 63%
A 99% reduction of IgE to CMP is associated with a 94% drop in CMP. Resolution occurs in most infants with IgE-CMA.
Persistency:
Infants reacting to <10 mL of milk
larger wheal size on SPT, are at increased risk for persistence.
J Pediatr. 2012 Apr 4.
Nutrient requirements for
breastfeeding women
24-May-16
12
Micronutrient
Micronutrients affected by
maternal diet /
depletion7,8,9
Micronutrients unaffected
by maternal diet /
depletion7,8,9
Vitamin A Folate
Vitamin B1 Calcium
Vitamin B2 Iron
Vitamin B6 Copper
Vitamin B12 Zinc
Vitamin D
Selenium
Iodine
Benefits to
BABY
Benefits to
MOTHER
The Paediatric Centre
St LeonardsOUR SERVICES
Paediatric Allergy: Allergy testing and Immunotherapy
Neonatology
Allied Health
Clinical Psychologist, Occupational therapist; Physiotherapist, Speech
therapist, Dietician,
Any practical advice on your patient care please email or telephone:
[email protected] Tel: 94052386 Fax 94052387
www.thepaediatriccentre.com.au