A systematic review of infant feeding food allergy prevention guidelines – can we AGREE?

Abstract

Food allergy is a significant issue worldwide, particularly in Westernised countries. There is no clear explanation why food allergy appears to have increased so rapidly in recent years, particularly in young children, hence ongoing research to identify effective primary prevention strategies. Food allergy prevention guidelines for health professionals have been developed based on existing clinical trial evidence for effective translation and implementation. As these guidelines underpin clinical practice, it is important to ensure robust processes of development. We conducted a systematic review to identify food allergy prevention guidelines for health professional use; to compare the recommendations made by the identified guideline documents; and to assess the quality of the identified guideline documents. We searched Medline, EMBASE, CINAHL, Scopus, Global Health and Guidelines International Network for the period 1990 to 13 August 2019, to identify articles referring to English-language food allergy prevention guidelines or the guidelines themselves. A grey literature search of Google Scholar and reference checking was also undertaken. The guidelines were compared for recommendation similarities and differences. An Appraisal Guidelines for Research and Evaluation (AGREE II) appraisal was undertaken to assess guideline quality. The electronic database search yielded 1121 publications and reference checking identified an additional 16 publications. After title, abstract and full text screening, data extraction was undertaken on 156 publications and with additional reference checking, 28 food allergy prevention guidelines and advice documents were identified. Comparison of the recommendations within the guidelines and advice documents indicated the greatest variation in recommendations related to exclusive breastfeeding and timing of solid food introduction. Eight of the 10 guidelines and none of the 18 advice documents met the quality threshold set by the reviewers. Overall, documents specifically termed "guidelines" scored better than advice documents when assessed using the AGREE II tool. Variation in recommendations may create confusion for health professionals and result in inconsistent advice being provided to parents, and less translation of the evidence into actual food allergy reduction in the population. Appraisal using the AGREE II tool identified that there is considerable room for improvement in the development of guidelines and advice documents for food allergy prevention. The AGREE II appraisal identified common areas of poorer quality development and/or documentation of processes to inform future guideline development. Based on this study, we recommend the use of validated guideline development tools, to direct food allergy prevention guideline review or development. Use of the AGREE II tool, to direct the review and development of guidelines, is very likely to improve guideline quality.

Alternatives to Cow’s Milk-Based Infant Formulas in the Prevention and Management of Cow’s Milk Allergy

“…The use of soy-based infant formulas in the prevention of atopic diseases in high-risk infants seems controversial [ 339 , 347 ], with studies showing some prophylactic effect of soy-based infant formulas when compared to cow’s milk-based formulas [ 353 , 354 ], whereas other studies did not show such effect [ 355 , 356 ]. Yet, in a meta-analysis, Osborn and Sinn concluded that soy-based infant formulas cannot be recommended for use in the prevention of food allergies in high-risk infants [ 357 ], which is generally supported by most guidelines [ 358 ]. For example, EAACI recommends against using soy-based formula in the first 6 months of life as a means of preventing food allergy [ 81 ].…”

Mucosal Mast Cells as Key Effector Cells in Food Allergies

“…In some non-IgE-mediated allergies, such as pseudo-allergies, mast cell activation also plays an important role in the onset of allergic symptoms [3][4][5]. In developed countries, the prevalence of food allergies is 6% to 10% in infants and 2% to 5% in adults [6][7][8][9], indicating that they are more common in children. However, it has recently been demonstrated that some patients with irritable bowel syndrome (IBS) have abdominal pain caused by local IgE-mediated food allergy reactions [10].…”

Relevance of Early Introduction of Cow’s Milk Proteins for Prevention of Cow’s Milk Allergy

“…One of the key questions in relation to food allergy is when potentially allergenic foods should be introduced into the diet of infants to induce tolerance. As a result of several intervention trials on early introduction of food allergens, such as peanut and egg, there is increasing scientific consensus that earlier introduction of these foods can be recommended [11].…”

“…As a result of all these new insights, guidelines have been updated in many different countries. These guidelines have been reviewed in a systematic review by Vale et al [11]. These changes are also illustrated in the policy document of the American Academy of Pediatrics [35,36] that shifted from the statement that "there are insufficient data to document a protective effect of any dietary intervention beyond 4 to 6 months of age for the development of atopic disease" in 2008 [35] to "There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease.…”