eSign Food Allergy Chart Made Easy

Esign food allergy chart

thank you for the introduction Mikael and also thank you for the opportunity to present here I just so my topic is atopic dermatitis and food allergy and as you can see it's not a topic that spans back as the hot topic for the past 75 years but maybe let's say for the past two decades ahead certainly has been a topic of great interest and of debate as well disclosures I should mention that I'm an employee of nefler health science as a medical director very early onset atopic dermatitis is an important starting point for food allergy but also for asthma and atopic rhinos or allergic rhinitis it affects a large number of infants after 20% of infants are affected by their in degrees of eczema and it's characterized by impaired barrier function increased transdermal water loss and th2 type chronic inflammation the mechanisms involved in eczema are getting more and more unraveled and we know as a genetic genetic susceptibility loci and we also recognize the close association with food allergy in IgE mediated food allergy in particular I'm not a dermatologist and please forgive me we first a high level and maybe in the interest of time that's also okay what you can I use the mouse maybe what you can see here is normal skin and you can see like in the guts barrier function is paramount to maintain health and integrity of the skin so you will see that there is commensal bacteria and that there is a multi-layered barrier function here fantastic I'm getting old as well so you in the middle here you see not even Alexa muskan but despite being non lesion all you can see that the barrier function is severely disrupted you can see that allergens antigens and in cephalo corpus aureus in particular can get in and cause inflammation and mayhem which is then also reflected by chronic inflammation in the subject ethereal spaces either as an acute lesion or it's a chronic lesion one of the barrier maintenance genes that's very well studied and closely involved is the flagrant gene which is on chromosome 1 and you can see that there are multiple mutations that are known both with European variants and Asian variants so these are very closely associated with eczema and to some extent also associated with food allergy and I'll show you that the work here from Earvin which was published over six years ago or seven years ago in the New England Journal showing that peanut allergy and eczema were closely associated with allegra mutations and asthma was also associated in the presence of eczema and we also know many of the gene loci that are associated you can see that these and this is a recent paper which is very useful because it distinguishes between genes and sociated with the atopic March so the progression from eczema to food allergy to asthma to allergic rhinitis and some of the genes were exclusively limited to eczema and some also to asthma and for example here you can see the genome-wide Association scan and you can see that the filigree gene here on chromosome 1 is clearly visible similar to other chronic diseases and they are now different phenotypes that emerge and the one that I'm going to focus on is the barely very early onset eczema with onset in infancy with or without remission later in life and this condition is very crucial as in setting the path of the atopic march to towards respiratory allergies later in life this is data from Melbourne from the health nut study which is a large cohort study and they looked at challenged proven food allergy and risk factors and what they could show is that one and two infant with early onset eczema that requires corticosteroids has a 50% risk of peanut allergy or food allergy so infants with any eczema were 11 times more likely to develop peanut allergy and six times more likely to have egg allergy per 12 months and from the same study I can show you now that if you don't have eczema your peanut allergy risk food allergy risk is in the order of three or four percent and Melbourne has one of the highest food allergy rates in the world so so that might seem high to you but and that's actually from for Melbourne circumstances reasonably low but as you look now surrogate markers for severity no topical treatment moisturizers only over-the-counter topical steroids and prescription corticosteroids you can see that those with early onset eczema at three months have a higher rate and it gets higher and higher as the severity increases so early onset severe eczema is a precursor to food allergy so can we prevent eczema if we prevent eczema in the hope is that we might also prevent food allergy we might prevent asthma or allergic rhinitis although the prevention of respiratory allergies has so far been more elusive from looking back into history the past decades we've been mainly been preoccupied with these four interventions for prevention of eczema partially hydrolyzed formulas extensively hydrolyzed formulas as well I should say probiotics prebiotics and long-chain polyunsaturated fatty acids many of you will know the data from the Genie study which is now 10 years post-completion and you can see the follow up data here which was presented a few years back and you can see that extensively hydrolyzed casein based formula and partially hydrolyzed whey based formula have a preventive effect compared to cows in the formula-feeding and this difference was sustained to ten years and this was also found in other studies so there is a meta-analysis and yet another meta-analysis I should say but this meta-analysis was a little bit criticized because a it didn't include a large study and it was then superseded by a more recent meta-analysis by my Boyle and co-workers from from England who questioned that extensively or partially hydrolyzed formulas have a role in the prevention of X mind you can see that the effect sizes here span has been one so that there was no discernible significant effect difficulty was that the interventions were quite heterogeneous the study designs were heterogeneous and also the the type of formulas was quite heterogeneous so it within partially hydrolyzed formulas there was a great difference so in this form review here you can see that partially hydrolyzed formulas are subsidized and it's not distinguished between whey and casein formulas so to overcome that limitation potentially as there was another meta-analysis by professor CSKA which showed that yes if you limit the analysis to two-way based partially hydrolyzed formulas there is a benefit for x-ray at least at some time points but you can also see all these colorful annotations on the side which highlight that there's potential bias that there's potentially lower quality of data so it's a very difficult field to to navigate and I think we have to just accept that there may be a small benefit which is difficult to prove because of problems in the quality of the data to some extent but the recommendation and that it is a useful strategy for those who can't breastfeed remains at least for the first four months of life as supported also by the European area Academy apology what about probiotics the I think the evidence for probiotics is much clearer and you can see here from another meta-analysis and I'm guilty of showing you all these meta analyses in the interest of time you can see that there is a protective but you have to be very careful about which probiotic you use because they're also probiotics which go the other way and increase your risk of allergy and this is the study from from pers which used acidophilus and which went the wrong way so that there's some bacterial probiotic bacteria which have a benefit and some which don't so you have to be careful but the effect of probiotics in prevention of allergic disease is now also supported by the world allergy organization and I encourage you to read this review which is much more detailed and will give you a better overview prebiotics I will just mention for completeness this is a study on the formula of randomized trial who looking at Unser plummeted cow's milk formula versus formula supplemented with three prebiotics and should compare to a reference breast milk here in in blue and you can see that the prebiotic supplemented group co-located with breastfeeding where there was a clear difference to formula-fed infants so at least at 12 months there appeared to be a benefit also from prebiotic supplementation but long-term data are not available finally moving on to DHA and EPA supplementation this is an Australian study from Debbie Palmer and Maria McCready's group showing looking at the effect of omega-3 supplementation in pregnant women this is the study design it was a large study of him about 700 infants who were randomized to receive either DHA 800 milligrams of 100 milligrams of EPA compared to vegetable oil and this was given to the pregnant mothers from 21 weeks gestation and followed up to birth and then the infants were followed to 12 months and worked up for food allergy with regard to sensitization to skin testing and interestingly there was an effect on eczema but only if it was an association with IG sensitive so I GE associated eczema was significantly reduced and so was sensitization to egg but disappointingly on food allergy itself so beyond sensitization there was no discernible effect and this is a limitation that we often run into that we can show that sensitization patterns change but the outcome finally food allergy is unchanged I had given this talk 20 years ago as going down the the history or memory lane I would have said these are the allergens and this is the recommendation avoid all these allergens and milk until 12 months and egg until 2 years and nuts until 3 years please don't take photos because this is obsolete and this is one of the problems it stays in memory line and people still resistant to change because they should really tune in to new evidence that's coming and I'm actually going forward and I'm looking into the future here and I'm hoping that we can change the atopic march and the and the incidence of food allergy next month so it started pretty much with them Gideon Lacs hypothesis or dual allergen hypothesis that prolonged avoidance of food allergens might counter be counterproductive and increase food allergy and the reason behind that is that the best you can do is actually oral exposure to food allergens because this will program the immune system generally to tolerance contact by our inflamed skin will trigger a th2 memory response and lead to allergy and while you're avoiding the food you're very prone to be sensitized by a skin because you have not yet been colorized this led to a large randomized trial the the leap study which most of you will know which was published in the New England Journal a few years back and this study randomized children who had eczema or egg allergy so high-risk infants for peanut allergy to either start peanut from four months or to avoid after until 12 months and then they looked at the effect on peanut allergy and I just maybe in the interest of time concentrate on the the right group with the skin test positive and negative groups were lumped together and you can see that there's an 80% or above 80% reduction in the incidence of peanut allergy in these infants who introduced introduced peanut early and when you looked at the effect when was the best time to introduce there was really no clear signal so somewhere between 4 and 11 months is maybe good enough but if you already were sensitized had a positive skin test of peanut if you did not introduce you can see how your risk of peanut allergy goes up to 50% at if you had a 4-millimeter skin prick test compared to maybe 10% or so risk if you introduced early so a highly highly significant effect in these high-risk infants and it gets even more interesting the Canadian group who did an asthma study followed up further and did a retrospective analysis of their data for the leap type approach and looked at where were mothers breastfeeding and when was peanut introduced and in this Canadian cohort what they found is if the mother consumed peanut wild breastfeeding and the baby introduced early this group actually had the best preventive effect if both weren't eating it it was about 5% but if only the mother was eating it and not the child or only the child and not the mother rates of peanut allergy were very high which means peanut antigen in breast milk is there for a reason potentially and passive exposure by a breastfeeding is an important precursor to inform the immune system of the baby towards tolerance I'm just going to change tact a little bit and I've got a few minutes left just to talk about the skin as a tiger and this moves a little bit away from my brief of nutritional intervention but I just wanted to show you that we maybe should not be solely focused on nutritional interventions throughout with that we should also think about the skin as a treatment target and this is a nice review from the Australian from the Melbourne we'll begin looking at the effect of regular emollient use on eczema in babies the idea is that if you have a disruptive barrier which allows invasion of antigens in the bacteria if you could maybe curb this effect if you can put a emollient barrier onto the skin that prevents penetration of antigens into the deeper layers and that prevents the infection over the past years there have been three randomized control trials looking at this actually one study from North America and UK one study from Japan and one study from Australia and all three studies came to the same conclusion that regular emollient use in babies from birth or from the first week of life to about six months reduces eczema by fifty percent and this is a huge effect as you can realize this is data from the Japanese study and you can see that the amoliant group and the control group had different rates of eczema with the hazard ratio of roughly 50% but disappointingly when they looked at egg sensitization rates for the intervention group in the control group there were no differences between group so egg allergy aligned with eczema no x-bar but not with the intervention groups which was disappointing however and the subsequent study in Australia called the the pebble study which is now in the Phase two stage or has completed Phase two looked at a intervention where this product Epis Aram a lipid mix emollient which is slightly acidic in pH was applied and daily for six months from about two to three weeks and this is a per protocol analysis and you can see at 12 months there were big differences between standard skin care and application of this topical barrier cream you can see that none of the babies here in the group who had at least five applications per week per protocol analysis were sensitized in any way so this is complete protection for food allergy so I'm putting my forward thinking hat hat on and put all these interventions that I've shown you into one diagram and what so what can we do we've got a window before birth so maybe Elsie proofer supplementation maybe probiotics supplementation of mothers we should encourage breastfeeding but if that's not possible perhaps use partially hydrolyzed formula we should bring in complementary diet from about four months which is in breach of whu-oh guidelines but that may be still what's required for allergy prevention and not hold back on the introduction of food allergens and in addition and that's what I'm hoping might actually provide further benefits is concentrate on skin interventions in conjunction with nutritional interventions and I'm hoping that if someone comes back in ten years and gives the 85th birthday at all that that we have some good news to to share so my conclusions and a limit myself to three points as instructed so there are several targeted interventions during light pregnancy and and and/or lactation that have been shown to reduce the incidence of eczema and high-risk infants and this is important it's only in high-risk infants with the family history of allergic diseases so these way based partially hydrolyzed formulas probiotics prebiotics and maternal DHA or EPA supplements importantly as a recent development over the past decade maybe the introduction of allergic foods from four to 11 months reduces the risk of subsequent food allergies and this is something that's been shown for peanut and egg conclusively but in principle it should only work should also work for other food allergens the question is whether this should become policy or whether there might also be risks with the early introduction in trees that have a low prevalence of food allergies and you might actually cause paradoxically food allergies so this is all to be sorted out and we need to know what is the best approach in this but definitely the leap study approach in high risk population looks highly highly promising and finally I've maybe got you aware that skin interventions may also be an important part of prevention strategies and we probably see this incorporated into future prevention strategies going forward combining nutritional and skin interventions I might leave it here and thank you very much [Applause]