Nutricia Paediatric Allergy Symposium 24th May 2016 The speaker had sole editorial control over the content in this slide deck. Any views, opinions or recommendations expressed in the slides are solely those of the speaker and do not necessarily represent those of Nutricia.

MULTISYSTEM DISEASE IN ALLERGY

& HOW

SYNBIOTICS CAN TARGET MICROBIAL DYSBIOSIS

Dr Louise Michaelis Consultant Paediatrician in Immunology and Allergy Great North Children’s Hospital United Kingdom

The Baltic - Newcastle upon Tyne 24th May2016

DISCLOSURES

I have no disclosures to state in relation to this lecture

Industry and NIHR Collaborative Research Grant

Non IgE mediated cow’s milk allergy - ASSIGN

IgE mediated cow’s milk allergy - PRESTO

QUESTION

How often do you see Non IgE mediated cow’s milk allergy in your clinic?

A. Weekly

B. Monthly

C. Annually

D. Rarely

E. Never

QUESTION

In the management of the baby would you consider any of the following:

A. A change in cow’s milk formula

B. Referral to a dietician

C. Referral to a dermatology

D. Referral to a general paediatrician

E. Referral to allergy

F. Introduction of a synbiotic

G. All of the above

H. None of the above

QUESTION

Which cow’s milk formula would you recommend or change?

A. No change in formula

B. Another regular cow’s milk formula

C. Soya formula

D. An extensively hydrolysed formula

E. An amino acid formula

F. No idea - refer to an allergy clinic

OBJECTIVES

To demonstrate that children with cow’s milk allergy might present with multi-system allergic disease

In so doing to show altered mechanisms of induction of sensitisation and tolerance

To understand recent advances in the understanding of Non IgE mediated allergy

To discuss the effect of synbiotics on the microbiota and subsequent immune modulation in clinical trials: ASSIGN

DEFINITION OF NON IGE MEDIATED FOOD ALLERGY IN CHILDHOOD

Boyce et al JACI 2010; 126 S1-58.

WHAT IS ATOPY AND MULTI-SYSTEM ALLERGIC DISEASE

An exaggerated propensity in genetically predisposed individuals to produce IgE and Non IgE responses to common environmental triggers Atopic spectrum

• Atopic Dermatitis • Food Allergy • Atopic Asthma • Allergic Rhinitis • Gastrointestinal disease

Wahn 1998, Illi 2004 , Hamelmann 2007 ,2008

Eczema Food allergies Rhinitis Asthma

IMPACT OF BARRIER MICROBES ON ORGAN BASED INFLAMMATION

Garn H, Neve s JF, Blumberg RS, Renz H JACI 2013

THE SKIN

IgE- mediated Non-IgE-mediated

Pruritus Pruritus Erythema Erythema Acute urticaria – localised or generalised

Atopic suppuritive eczema

Acute angioedema – most commonly of the lips, face and around the eyes

Image reproduced with kind permission of parent and child

THE GASTROINTESTINAL SYSTEM

IgE- mediated Non-IgE-mediated

Angioedema of the lips, tongue and palate

Gastro-oesophageal reflux disease

Oral pruritus Loose or frequent stools Nausea Blood and/or mucus in stools Colicky abdominal pain Abdominal pain Vomiting Infantile colic Diarrhoea Food refusal or aversion

Constipation Perianal redness Pallor and tiredness

Faltering growth Faltering growth

Meyer et al Curr all Cl Imm March 2012 Fiocchi et al, 2010;Gibbons et al, 2012 Heine, 2015

FOOD PROTEIN INDUCED SYNDROMES

FPI Proctocolitis

FPI dysmotility

FPI enteritis syndrome

FPI enteropathy

Age onset Newborn Newborn infant

Infant Infant toddler

Duration <12 months 12-24 months 12-48 months 12-24 months Symptoms signs

Well Blood mucus in stool

Regurgitation Vomiting Food refusal Colic Constipation Faltering growth

Diarrhoea (blood) Vomiting Collapse Hypothermia Shock

Diarrhoea Abdominal pain Growth faltering

Slide courtesy of Dr Su Bunn

THE RESPIRATORY SYSTEM

IgE- mediated Non-IgE-mediated

Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea or congestion [with or without conjunctivitis])

Persistent wheeze NO MENTION OF ASTHMA

Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)

SENSITISATION VERSUS TOLERANCE

Image reproduced with kind permission of authors G du Toit and G Lack 2016

Du Toit J Allergy Clin Imm 137 (4) 2016

FcεRII

IgE

Treg

Sensitization Tolerance

Sensitization

MLN

FcεRI

IgE

Th2 B Cell Th0

B Cell

IL-4

IgE IgG

IgA

Mast Cell Macrophage

ILC

IL-4

CD103+ DC

CX3CR1+ DC

IL-33 TSLP IL-25

Skin Epithelium

Filaggrin

Intestinal Epithelium

DC

Microbiota? Adjuvants Staph toxins (SEB)

Injury Antigen Staph?

IDO RA

TGF- β

IL-10

NKT Cell IL-10

Antigen

Th2

Image reproduced with kind permission of author Prof Paul Bryce 2015

Histamine

TNF

IL-33

IL-9 IL-6 IL-13 CXCL2 CXCL10

PAF

PAF TNF

IL-4

Early Phase Late Phase

FcεRI

IgE

Fcγ?

IgG

Mast Cell

FcεRI

IgE

IgG Fcγ?

Basophil

IgG

FcγRIII

Macrophage

IgG

IgG

FcγRIII

FcγRIV

Neutrophil

Neutrophil

Eosinophil

ILC

?

?

Treg Ti

ssue

B

lood

Neutrophil

Image reproduced with kind permission of author Prof Paul Bryce 2015

FOOD ALLERGY AND THE GUT MICROBIOTA

• Cow’s milk allergy (CMA) affects 2-5% of infants and children in Western counties

• (Fiocchi 2010, DuBoissieu 1997, Isolauri 1995)

• The GI tract plays an important role in allergy

• (Takahashi 1999, MacDonald 2005)

• Allergic disease is associated with an altered microbiota

• (Husby 2000, Ouwehand 2001, Bisgaard 2011, Azad 2015, Berni Canani 2016)

GUT MICROBIOTA HOMEOSTASIS

Eubyosis : Balance between beneficial and harmful bacteria

Oligosaccharides

• Stimulate growth and activity of bacteria

• Modulate the immune system.

Increase in faecal anaerobes:

• Bifidobacteria

• Lactobacilli

Enhance epithelial barrier function & maintain the balance

Dysbiosis: In inflammatory, metabolic and allergic conditions

Triggered by mode of delivery, type of nutrition, timing of introduction of solids

Decrease in Bifidobacteria and B.breve & increase in pathogenic bacteria

Synbiotics in formula milks may benefit infants resulting in facultative anaerobic fermentation.

DEVELOPMENT OF CORE MICROBIOTA – A GRADUAL TRANSITION FROM INFANT TO ADULT-LIKE

Cheng et al., 2016 ISMEJ

FISH-probe: Bif164m: Representing “infant-like” microbiota

FISH-probe: Erec482: Representing “adult-like” microbiota

SYNBIOTICS

Prebiotics Indigestible food compounds with OS Direct effect on the immune system by reducing antigen presentation and absorption to the GIT Counteract infections Alter faecal microbiota

Probiotics Live organisms colonise the gut and exert beneficial effects Bifidobacterium and lactobacillus Also reduce antigen presentation and absorption Synbiotic: B.breve sc-FOS and lc-FOS

Boehm G , Stahl B et al J Clin Gastro 2004 Kalliomaki M et al lancet 2001

PREBIOTIC AND PROBIOTIC (SYNBIOTIC) IN THE MANAGMENT OF COW’S MILK ALLERGY

• Prebiotic and probiotic (synbiotic) ingredients have been shown to affect the early life gut microbiota (Van der Aa 2011, Veereman- Wauters 2011, Fuller 1997, Moro 2003)

• Studies suggest eHF + probiotics and/or synbiotics may have beneficial effect in allergy management (Berni Canani et al. 2012, Grüber et al. 2010, Van de Aa et al. 2010 & 2011)

• Effects on growth tolerance and hypoallergenicity of an amino-acid based formula with synbiotics. (Harvey et al.2014 Ped Research)

• Synbiotics-supplemented amino acid-based formula supports adequate growth in

cow’s milk allergic infants (Burks et al 2015 PAI)

No data regarding Non-IgE mediated allergic infants receiving AAF+/- Synbiotics

ASSIGN STUDY TO ASSESS THE EFFECT OF AN AMINO ACID BASED FORMULA (AAF) WITH A SYNBIOTIC BLEND ON GUT MICROBIOTA IN NON –IGE CMA Exploratory: Clinical symptoms in suspected GI Non-IgE mediated CMA • Control product: Commercially available AAF

• Test product: AAF + synbiotics*; mixture of short and longchain fructo-

oligosaccharides, Bifidobacterium breve M-16V

Gut microbiota Immune modulation

Clinical effectiveness

ASSIGN OVERVIEW

Control product for 8 weeks

Test product for 8 weeks n=68

n=34

n=34

Test product optional

Control product optional

No study product Healthy breastfed group

Non-IgE CMA infants group T8wks T26wks

FUP T12wks

FUP

Methods: • DB-RCT, 68 non-IgE med. CMA infants (0-13 months) 8 wks intervention Safety: • Adverse events, medication use, growth Primary objective: • Faecal Bifidobacteria and E. rectale / C. coccoides cluster (FISH) Secondary objectives: • Stool, gut immune health markers Exploratory obejctives: • Sequencing of faecal bacteria, clinical symptoms, follow-up at 12 & 26 wks

Confidential

STUDY OUTCOME PARAMETERS

Primary: Percentage of Bifidobacteria and Eubacterium rectale / Clostridium coccoides Secondary: Stool characteristics, gut health and immune status (e.g. secretory IgA and short chain fatty acids) Exploratory: Allergic clinical symptoms, stool and saliva microbiota (sequencing method), additional parameters of gut health and immune status (e.g. calprotectin, eosinophilic cationic protein)

First results will be presented at ESPGHAN/EAACI 2016 Second results will be presented at FAAM 2016 Final results will be presented at WCPGHAN ‘16

PRESTO: IGE MEDIATED CMA

• Tolerance to cow’s milk (by DBPCFC) (12, 24 & 36 months)

• Gut health & gut immune defence (Bifidobacteria, SCFAs, Ig’s)

• Clinical effectiveness in IgE-med. CMA (skin, respiratory, GI)

• Follow-up: incidence & frequency of other allergies

scre

enin

g

base

line Test

Control Follow-up

Follow-up

0 1yr 2yr 3yr Milk challenge

n=170 n=85

n=85

Germany

Hospital PI Charite Hospital, Berlin Prof. Kirsten Beyer St. Marien Hospital, Bonn Dr. Lars Lange St. Josef Hospital Bochum Prof. Uwe Schauer Ev. Krankenhaus Bielefeld Prof. Eckard Hamelmann

UK

Hospital PI Royal Victoria Infirmary, Newcastle Dr. Louise Michaelis St. Thomas Hospital London Dr. Adam Fox Royal London Hospital (Barts) Dr. Lee Noimark Southampton General Hospital Dr. Mich Lajeunesse Leicester Royal Infirmary Dr. Gary Stiefel

Italy Hospital PI University Hospital Padua Dr. Antonella Muraro

Verona University Hospital/Clinico G.B. Rossi Prof. A. Boner

SGP Hospital PI KK Women's and Children's Hospital Dr. Rajeshwar Rao National University Hospital Prof. Seng Hock Quak

Thailand

Hospital PI King Chulalongkorn Memorial Hosp. A/Prof. Pantipa Chatchatee Ramathibodi Hospital Prof. Suwat Benjaponpitak Prince of Songkla Hospital Dr. Pasuree Sangsupawanich

USA

Hospital PI Mt Sinai, NY Dr. Anna Nowak-Wegrzyn

Texas Children's Hospital, Houston Dr. Carla Davis

Arkansas Children's Hospital Dr. Robbie Pesek

PRESTO: SITES AND INVESTIGATORS

(http://www.nutriciaresearch.com/research-study/presto/)

CASE PRESENTATION AND SYMPTOMS

Presented at 6 months of age - Normal delivery and weight

Severe atopic dermatitis since birth – recurrent infections

Poor weight gain (<0.4th centile)- not weaned

Trial multiple cow’s milk formulas - worsening of eczema

Symptoms • >5 stools a day; Severe gastro-oesophageal reflux symptoms;

Abdominal pain, back arching, difficult to settle

• Anti-reflux medication - worse on lactose free milk

• Partially breast fed, porridge, soya ,potato only

All skin prick and specific IgE tests negative

QUESTION

What would your working diagnosis be?

A. IgE mediated food allergy

B. IgE mediated sensitisation

C. Non IgE mediated food allergy

D. Both IgE and Non IgE mediated food allergy

E. Lactose Intolerance

F. None of the above

G. Don’t know

EMERGENCY ADMISSION

Presented to ED at 7 months • Given cow’s milk formula

• Held & kissed by father eating peanuts

• Developed erythema, urticaria and lip swelling

• Admitted overnight due to severe eczema, wheeze and swelling of the face

• Antihistamine given – resolved

• Normal Blood pressure - no Adrenaline

RESULTS

FOOD IgE (kAU/L)

Total 4677 Cow’s milk

<0.35

Egg >100 Peanut >100 Cod <0.35 Soya 93.8 Wheat <0.35 Cat <0.35

FOOD SKIN PRICK TEST (mm)

Positive 4 Negative 0 House Dust Mite

0

Cat 0 Cod 0 Cow’s milk 0 Wheat 5 Sesame 6 Peanut 0 Soya 4 Egg 5

QUESTION

Now …..what would your working diagnosis be?

A. IgE mediated food allergy

B. IgE mediated sensitisation

C. Non IgE mediated food allergy

D. Both IgE and Non IgE mediated food allergy

E. Lactose Intolerance

F. None of the above

G. Don’t know

QUESTION

In the management of the baby would you consider any of the following:

A. A change in cow’s milk formula

B. Referral to a dietician

C. Referral to a dermatology

D. Referral to a general paediatrician

E. Referral to allergy

F. Introduction of a synbiotic

G. All of the above

H. None of the above

DIAGNOSIS AND MANAGEMENT

Diagnosis • IgE mediated food allergy (peanut) - Anaphylaxis?

• IgE mediated sensitisation (egg, soya, sesame, wheat)

• Non IgE mediated food allergy (cow’s milk)

Management • STOP current formula milks & change to eHF and subsequent amino

acid formula

• Cow’s milk, egg, soya, nut, sesame free diet

• Iron, vitamin D and calcium supplements

• Wheat food challenge/feed

• Optimise eczema management with emollients, steroid creams, skinnies and garments

CLINICAL OUTCOME

Resolution of clinical symptoms within 10 days

Regained weight to 50th centile

Introduction of baked cow’s milk products -9 months of age

Introduced full cow’s milk - 12 months

Introduced baked egg - 18 months

Wheat remained in diet

Nuts & sesame excluded- awaiting challenges

ACKNOWLEDGEMENTS

The research team of Dr. Louise Michaelis Dr Quentin Campbell-Hewson Phil Woodsford Claire Simmister Evelyn Thomas Anne McDonnell Prof. David Candy, Royal Alexandra Children’s Hospital, UK Dr. Assad Butt, Royal Alexandra Children’s Hospital, UK Dr. Adam Fox, Guy’s & St Thomas’ Hospital, UK Dr. Lee Noimark, Barts / Royal Hospital, UK Prof Antonella Muraro, University Hospital Padova, IT Dr. Diego Peroni, University Hospital Verona, IT Prof. Yvan Vandenplas, University Hospital Brussels, BE Prof. Francoise Smets, U.C.L. Saint-Luc, BE Dr. Sandra Mullier, HUDERF Brussels, BE Prof. Christina West, Umeå University, SE

Nutricia Research: Marleen van Ampting Lucien Harthoorn Ewa Latko Manon Oude Nijhuis Barbara Mourmans Reina den Hollander Willemien Sinke Marjolein Alvares Heidi Sonnemans Rob Slump

Prof Jan Knol, Harm Wopereis, Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands

11-14th June 2016