Preventing immediate‐onset food allergy in infants, children and adults: Systematic review protocol

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Background This guideline from the European Academy of Allergy and Clinical Immunology (EAACI) recommends approaches to prevent the development of immediate‐onset / IgE‐mediated food allergy in infants and young children. It is an update of a 2014 EAACI guideline. Methods The guideline was developed using the AGREE II framework and the GRADE approach. An international Task Force with representatives from 11 countries and different disciplinary and clinical backgrounds systematically reviewed research and considered expert opinion. Recommendations were created by weighing up benefits and harms, considering the certainty of evidence and examining values, preferences and resource implications. The guideline was peer‐reviewed by external experts, and feedback was incorporated from public consultation. Results All of the recommendations about preventing food allergy relate to infants (up to 1 year) and young children (up to 5 years), regardless of risk of allergy. There was insufficient evidence about preventing food allergy in other age groups. The EAACI Task Force suggests avoiding the use of regular cow's milk formula as supplementary feed for breastfed infants in the first week of life. The EAACI Task Force suggests introducing well‐cooked, but not raw egg or uncooked pasteurized, egg into the infant diet as part of complementary feeding. In populations where there is a high prevalence of peanut allergy, the EAACI Task Force suggests introducing peanuts in an age‐appropriate form as part of complementary feeding. According to the studies, it appears that the most effective age to introduce egg and peanut is from four to 6 months of life. The EAACI Task Force suggests against the following for preventing food allergy: (i) avoiding dietary food allergens during pregnancy or breastfeeding; and (ii) using soy protein formula in the first 6 months of life as a means of preventing food allergy. There is no recommendation for or against the following: use of vitamin supplements, fish oil, prebiotics, probiotics or synbiotics in pregnancy, when breastfeeding or in infancy; altering the duration of exclusive breastfeeding; and hydrolysed infant formulas, regular cow's milk–based infant formula after a week of age or use of emollients. Conclusions Key changes from the 2014 guideline include suggesting (i) the introduction of peanut and well‐cooked egg as part of complementary feeding (moderate certainty of evidence) and (ii) avoiding supplementation with regular cow's milk formula in the first week of life (low certainty of evidence). There remains uncertainty in how to prevent food allergy, and further well‐powered, multinational research using robust diagnostic criteria is needed.

Section: Methodsmentioning

confidence: 99%

EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update)

Halken

Muraro²,

Silva³

et al. 2021

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308

302

“…The methods are briefly described here. Details are available in the published protocol 12 and via the International Prospective Register of Systematic Reviews: CRD42019127457.…”

Section: Methodsmentioning

confidence: 99%

“…The published review protocol 12 specified that meta‐analysis to quantify effect size would be undertaken for outcomes with three or more studies about the same intervention in the same risk‐profile population. No intervention met the criteria for meta‐analysis, so results about each intervention were summarized using narrative synthesis.…”

Section: Methodsmentioning

confidence: 99%

Preventing food allergy in infancy and childhood: Systematic review of randomised controlled trials

Silva¹,

Halken

Singh³

et al. 2020

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148

140

Background: This systematic review of ways to prevent immediate-onset/IgEmediated food allergy will inform guidelines by the European Academy of Allergy and Immunology (EAACI). Methods: The GRADE approach was used. Eleven databases were searched from 1946 to October 2019 for randomized controlled trials (and large prospective cohort studies in the case of breastfeeding). The studies included heterogeneous interventions, populations, and outcomes and so were summarized narratively. Results: Forty-six studies examined interventions to reduce the risk of food allergy in infancy (up to 1 year) or early childhood. The following interventions for pregnant or breastfeeding women and/or infants may have little to no effect on preventing food allergy, but the evidence is very uncertain: dietary avoidance of food allergens, vitamin supplements, fish oil, probiotics, prebiotics, synbiotics, and emollients. Breastfeeding, hydrolyzed formulas, and avoiding cow's milk formula may not reduce the risk of cow's milk protein allergy; however, temporary supplementation with cow's milk formula in the first week of life may increase the risk of cow's milk allergy. Introducing well-cooked egg, but not pasteurized raw egg, from 4 to 6 months probably reduces the risk of hen's egg allergy. Introducing regular peanut consumption into the diet of an infant at increased risk beginning from 4 to 11 months probably results in a large reduction in peanut allergy in countries with a high prevalence. These conclusions about introducing peanut are based on moderate certainty evidence, from single trials in high-income countries. Conclusions: Sixty percent of the included studies were published in the last 10 years, but much still remains to be understood about preventing food allergy. In particular, 2 | ME THODS The systematic review was conducted by a task force made up of allergy, gastroenterology, primary care and dietetic clinicians,

mentioning

confidence: 99%

“…A number of review papers have been published focusing on maternal diet during pregnancy, lactation, or early life [8][9][10][11] and allergy prevention. [8][9][10][11][12] Our review follows and extends a recent systematic review and meta-analysis by Garcia-Larsen et al, 13 who summarized the evidence up to December 2017. Garcia-Larsen et al 13 considered dietary intake not only during pregnancy, but also in lactation and infancy; their main conclusions 13 were that maternal omega-3 fatty acid supplementation during pregnancy and lactation may reduce the risk of allergic sensitization to egg and peanut.…”

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confidence: 99%

Dietary factors during pregnancy and atopic outcomes in childhood: A systematic review from the European Academy of Allergy and Clinical Immunology

Venter

Agostoni

Arshad

et al. 2020

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116

Rationale: Allergic diseases are an increasing public health concern, and early life environment is critical to immune development. Maternal diet during pregnancy has been linked to offspring allergy risk. In turn, maternal diet is a potentially modifiable factor, which could be targeted as an allergy prevention strategy. In this systematic review, we focused on non-allergen-specific modifying factors of the maternal diet in pregnancy on allergy outcomes in their offspring. Methods: We undertook a systematic review of studies investigating the association between maternal diet during pregnancy and allergic outcomes (asthma/wheeze, hay fever/allergic rhinitis/seasonal allergies, eczema/atopic dermatitis (AD), food allergies, and allergic sensitization) in offspring. Studies evaluating the effect of food allergen intake were excluded. We searched three bibliographic databases (MEDLINE, EMBASE, and Web of Science) through February 26, 2019. Evidence was critically appraised using modified versions of the Cochrane Collaboration Risk of Bias tool for intervention trials and the National Institute for Clinical Excellence methodological checklist for cohort and case-control studies and meta-analysis performed from RCTs. Results: We identified 95 papers: 17 RCTs and 78 observational (case-control, crosssectional, and cohort) studies. Observational studies varied in design and dietary intakes and often had contradictory findings. Based on our meta-analysis, RCTs showed that vitamin D supplementation (OR: 0.72; 95% CI: 0.56-0.92) is associated with a reduced risk of wheeze/asthma. A positive trend for omega-3 fatty acids was observed for asthma/wheeze, but this did not reach statistical significance (OR: 0.70; 95% CI: 0.45-1.08). Omega-3 supplementation was also associated with a non-significant decreased risk of allergic rhinitis (OR: 0.76; 95% CI: 0.56-1.04). Neither vitamin D nor omega-3 fatty acids were associated with an altered risk of AD or food allergy. Conclusions: Prenatal supplementation with vitamin D may have beneficial effects for prevention of asthma. Additional nutritional factors seem to be required for modulating the risk of skin and gastrointestinal outcomes. We found no consistent evidence regarding other dietary factors, perhaps due to differences in study design and host features that were not considered. While confirmatory studies are required, there is also a need for performing RCTs beyond single nutrients/foods.